NIHR Signal Group rehabilitation activities improve walking after stroke

Published on 12 September 2017

Group-based circuit class therapy (CCT) focused on repetitive mobility, and functional tasks improved walking ability in people after stroke. People walked on average 61m further during six minutes than those receiving comparison interventions. CCT involves stroke survivors practising different activities at workstations in sight of each other.

This Cochrane review identified 17 trials of group-based CCT, given at least weekly for four weeks, compared with other physical therapies or no intervention. Those receiving CCT showed clinically meaningful improvements in walking distance and speed, as well as independence and balance.

Regular multidisciplinary team rehabilitation is a central component of post-stroke care. However, there are no specific recommendations around the format of rehabilitation. Cost effectiveness was not assessed, but it is possible that group-based physical rehabilitation programmes could reduce staff resources and offer cost savings.

Local availability may be an issue. There is also the question of whether it would be practical and appropriate for individuals to attend group sessions, depending on their stroke severity.

Group rehabilitation activities improve walking after stroke

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Why was this study needed?

There are more than 100,000 strokes in the UK each year. In England alone, stroke is estimated to cost the economy around £7 billion per year, comprised of costs to the NHS, social care, disability and loss of productivity.

Stroke survivors are often left with long term impairment, caused by loss of blood supply to part of the brain. Most report upper or lower limb weakness, which can affect daily activities and cause difficulty walking and balancing.

Circuit class therapy (CCT) is a group physical therapy where participants have the chance to repeatedly practice everyday functional tasks and activities at workstations in sight of each other, encouraging people to see how things are done. These group-based sessions are also used for other conditions such as chronic obstructive pulmonary disease in pulmonary rehabilitation centres. Most studies to date have focused on the effects of CCT for improving mobility. Therefore, this updated Cochrane review focused on the question of whether mobility-tailored CCT can improve the ability to walk and balance.

What did this study do?

This review identified 17 randomised controlled trials assessing circuit class therapy (CCT) in 1,297 adults with any severity of stroke or stage of rehabilitation. Time since stroke varied considerably between trials.

CCT had to involve a sequence of functional tasks aimed at improving mobility and impairment, rather than just strength or fitness. Sessions had to be group-based, with a staff-to-client ratio of no more than 1:3, and given a minimum of once-weekly for at least four weeks. Conventional therapy included individual physiotherapy and education as well as other physical therapy methods, or no intervention.

The main outcome was distance walked during the Six Minute Walk Test. Other outcomes included the ability to walk independently and have confidence in their balance.

Two studies came from the UK. Four were conducted in inpatient settings, the rest in the community. Selective reporting of outcomes was the most likely source of bias.

What did it find?

  • People who received mobility-related circuit class therapy (CCT) walked further than the comparison group on the Six Minute Walk Test (mean difference [MD] 60.86 m, 95% confidence interval [CI] 44.55 to 77.17m; 10 moderate quality studies, 835 people). This was a clinically meaningful difference (threshold MD 34.4m).
  • The CCT group had faster-walking speed over a short distance (MD 0.15 m/s, 95% CI 0.10 to 0.19; eight moderate quality studies, 744 people). This was also considered clinically meaningful.
  • Five low-quality studies looked at balance and mobility as measured by time to stand up, walk and return to sitting, finding the CCT group quicker than the comparison group (MD -3.62 seconds, 95% CI -6.09 to -1.16; 488 people).
  • Three moderate quality studies also found that people receiving CCT were more likely to be able to walk independently without assistance ability (odds ratio 1.91, 95% CI 1.01 to 3.62; 469 people).
  • Low-quality evidence from eight studies (815 people) found no significant difference between groups in the reported number of falls (roughly 13 per 100 in the CCT group vs nine per 100 with controls).

What does current guidance say on this issue?

NICE guidelines on stroke rehabilitation (2013) recommend that post hospital discharge people receive rehabilitation from a specialist stroke team in the community. This should be multidisciplinary, including physiotherapists and occupational therapists. NICE recommend at least 45 minutes of each relevant rehabilitation therapy on at least five days a week for as long as necessary.

Repetitive task training for both the upper limbs (e.g. manipulating objects) and lower limbs (e.g. sit-to-stand transfers and using stairs) is specifically recommended. Treadmill training is one option that may be considered for people who can walk with or without assistance.

NICE does not make any recommendations about the form in which it is delivered, for instance, whether rehabilitation should be individual or group-based.

What are the implications?

Group circuit class therapy (CCT) focusing on mobility seems to give meaningful improvements in walking ability, speed and independence, although the reasons for the success - for example peer support - may need further exploration. Cost-effectiveness was not assessed, but group-based rehabilitation in the community or hospital centres has potential to require less staff resource than seeing people individually, particularly in their own home.

The time since stroke varied, so the most effective timing of CCT is unclear. There may also be practical considerations as some patients might find travelling to a group session difficult.

Citation and Funding

English C, Hillier SL, Lynch EA. Circuit class therapy for improving mobility after stroke. Cochrane Database Syst Rev. 2017;6:CD007513.

This research was funded by Cochrane UK and the Cochrane Stroke Group.

Bibliography

NHS Choices. Stroke. London: Department of Health; 2017.

NICE. Stroke rehabilitation in adults. CG162. London: National Institute for Health and Care Excellence; 2013.

NICE. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. CG68. London: National Institute for Health and Care Excellence; 2008.

Lawrence ES, Coshall C, Dundas R, et al. Estimates of the prevalence of acute stroke impairments and disability in a multiethnic population. Stroke. 2001;32(6):1279-84.

Saka RO, McGuire A, Wolfe CDA, et al. Economic burden of stroke in England. King’s College London. 2005.

Stroke Association. State of the nation: stroke statistics. London: Stroke Association; 2017.

Why was this study needed?

There are more than 100,000 strokes in the UK each year. In England alone, stroke is estimated to cost the economy around £7 billion per year, comprised of costs to the NHS, social care, disability and loss of productivity.

Stroke survivors are often left with long term impairment, caused by loss of blood supply to part of the brain. Most report upper or lower limb weakness, which can affect daily activities and cause difficulty walking and balancing.

Circuit class therapy (CCT) is a group physical therapy where participants have the chance to repeatedly practice everyday functional tasks and activities at workstations in sight of each other, encouraging people to see how things are done. These group-based sessions are also used for other conditions such as chronic obstructive pulmonary disease in pulmonary rehabilitation centres. Most studies to date have focused on the effects of CCT for improving mobility. Therefore, this updated Cochrane review focused on the question of whether mobility-tailored CCT can improve the ability to walk and balance.

What did this study do?

This review identified 17 randomised controlled trials assessing circuit class therapy (CCT) in 1,297 adults with any severity of stroke or stage of rehabilitation. Time since stroke varied considerably between trials.

CCT had to involve a sequence of functional tasks aimed at improving mobility and impairment, rather than just strength or fitness. Sessions had to be group-based, with a staff-to-client ratio of no more than 1:3, and given a minimum of once-weekly for at least four weeks. Conventional therapy included individual physiotherapy and education as well as other physical therapy methods, or no intervention.

The main outcome was distance walked during the Six Minute Walk Test. Other outcomes included the ability to walk independently and have confidence in their balance.

Two studies came from the UK. Four were conducted in inpatient settings, the rest in the community. Selective reporting of outcomes was the most likely source of bias.

What did it find?

  • People who received mobility-related circuit class therapy (CCT) walked further than the comparison group on the Six Minute Walk Test (mean difference [MD] 60.86 m, 95% confidence interval [CI] 44.55 to 77.17m; 10 moderate quality studies, 835 people). This was a clinically meaningful difference (threshold MD 34.4m).
  • The CCT group had faster-walking speed over a short distance (MD 0.15 m/s, 95% CI 0.10 to 0.19; eight moderate quality studies, 744 people). This was also considered clinically meaningful.
  • Five low-quality studies looked at balance and mobility as measured by time to stand up, walk and return to sitting, finding the CCT group quicker than the comparison group (MD -3.62 seconds, 95% CI -6.09 to -1.16; 488 people).
  • Three moderate quality studies also found that people receiving CCT were more likely to be able to walk independently without assistance ability (odds ratio 1.91, 95% CI 1.01 to 3.62; 469 people).
  • Low-quality evidence from eight studies (815 people) found no significant difference between groups in the reported number of falls (roughly 13 per 100 in the CCT group vs nine per 100 with controls).

What does current guidance say on this issue?

NICE guidelines on stroke rehabilitation (2013) recommend that post hospital discharge people receive rehabilitation from a specialist stroke team in the community. This should be multidisciplinary, including physiotherapists and occupational therapists. NICE recommend at least 45 minutes of each relevant rehabilitation therapy on at least five days a week for as long as necessary.

Repetitive task training for both the upper limbs (e.g. manipulating objects) and lower limbs (e.g. sit-to-stand transfers and using stairs) is specifically recommended. Treadmill training is one option that may be considered for people who can walk with or without assistance.

NICE does not make any recommendations about the form in which it is delivered, for instance, whether rehabilitation should be individual or group-based.

What are the implications?

Group circuit class therapy (CCT) focusing on mobility seems to give meaningful improvements in walking ability, speed and independence, although the reasons for the success - for example peer support - may need further exploration. Cost-effectiveness was not assessed, but group-based rehabilitation in the community or hospital centres has potential to require less staff resource than seeing people individually, particularly in their own home.

The time since stroke varied, so the most effective timing of CCT is unclear. There may also be practical considerations as some patients might find travelling to a group session difficult.

Citation and Funding

English C, Hillier SL, Lynch EA. Circuit class therapy for improving mobility after stroke. Cochrane Database Syst Rev. 2017;6:CD007513.

This research was funded by Cochrane UK and the Cochrane Stroke Group.

Bibliography

NHS Choices. Stroke. London: Department of Health; 2017.

NICE. Stroke rehabilitation in adults. CG162. London: National Institute for Health and Care Excellence; 2013.

NICE. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. CG68. London: National Institute for Health and Care Excellence; 2008.

Lawrence ES, Coshall C, Dundas R, et al. Estimates of the prevalence of acute stroke impairments and disability in a multiethnic population. Stroke. 2001;32(6):1279-84.

Saka RO, McGuire A, Wolfe CDA, et al. Economic burden of stroke in England. King’s College London. 2005.

Stroke Association. State of the nation: stroke statistics. London: Stroke Association; 2017.

Circuit class therapy for improving mobility after stroke

Published on 3 June 2017

English, C.,Hillier, S. L.,Lynch, E. A.

Cochrane Database Syst Rev Volume 6 , 2017

BACKGROUND: Circuit class therapy (CCT) offers a supervised group forum for people after stroke to practise tasks, enabling increased practice time without increasing staffing. This is an update of the original review published in 2010. OBJECTIVES: To examine the effectiveness and safety of CCT on mobility in adults with stroke. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (last searched January 2017), CENTRAL (the Cochrane Library, Issue 12, 2016), MEDLINE (1950 to January 2017), Embase (1980 to January 2017), CINAHL (1982 to January 2017), and 14 other electronic databases (to January 2017). We also searched proceedings from relevant conferences, reference lists, and unpublished theses; contacted authors of published trials and other experts in the field; and searched relevant clinical trials and research registers. SELECTION CRITERIA: Randomised controlled trials (RCTs) including people over 18 years old, diagnosed with stroke of any severity, at any stage, or in any setting, receiving CCT. DATA COLLECTION AND ANALYSIS: Review authors independently selected trials for inclusion, assessed risk of bias in all included studies, and extracted data. MAIN RESULTS: We included 17 RCTs involving 1297 participants. Participants were stroke survivors living in the community or receiving inpatient rehabilitation. Most could walk 10 metres without assistance. Ten studies (835 participants) measured walking capacity (measuring how far the participant could walk in six minutes) demonstrating that CCT was superior to the comparison intervention (Six-Minute Walk Test: mean difference (MD), fixed-effect, 60.86 m, 95% confidence interval (CI) 44.55 to 77.17, GRADE: moderate). Eight studies (744 participants) measured gait speed, again finding in favour of CCT compared with other interventions (MD 0.15 m/s, 95% CI 0.10 to 0.19, GRADE: moderate). Both of these effects are considered clinically meaningful. We were able to pool other measures to demonstrate the superior effects of CCT for aspects of walking and balance (Timed Up and Go: five studies, 488 participants, MD -3.62 seconds, 95% CI -6.09 to -1.16; Activities of Balance Confidence scale: two studies, 103 participants, MD 7.76, 95% CI 0.66 to 14.87). Two other pooled balance measures failed to demonstrate superior effects (Berg Blance Scale and Step Test). Independent mobility, as measured by the Stroke Impact Scale, Functional Ambulation Classification and the Rivermead Mobility Index, also improved more in CCT interventions compared with others. Length of stay showed a non-significant effect in favour of CCT (two trials, 217 participants, MD -16.35, 95% CI -37.69 to 4.99). Eight trials (815 participants) measured adverse events (falls during therapy): there was a non-significant effect of greater risk of falls in the CCT groups (RD 0.03, 95% CI -0.02 to 0.08, GRADE: very low). Time after stroke did not make a difference to the positive outcomes, nor did the quality or size of the trials. Heterogeneity was generally low; risk of bias was variable across the studies with poor reporting of study conduct in several of the trials. AUTHORS' CONCLUSIONS: There is moderate evidence that CCT is effective in improving mobility for people after stroke - they may be able to walk further, faster, with more independence and confidence in their balance. The effects may be greater later after the stroke, and are of clinical significance. Further high-quality research is required, investigating quality of life, participation and cost-benefits, that compares CCT with standard care and that also investigates the influence of factors such as stroke severity and age. The potential risk of increased falls during CCT needs to be monitored.

Expert commentary

Mobility is central to many personal and social activities and to regain mobility is a key aspect of recovery after illness. One of the big challenges after stroke is ensuring that survivors can regain and maintain their mobility. Circuit class therapy might be delivered to groups of individuals living in the community. It can help stroke survivors to walk further, faster and with more independence and confidence. Uncertainties remain about whether we can deliver such classes safely and efficiently across the whole country. However, the information available at present looks promising.

Peter Langhorne, Professor of Stroke Care, University of Glasgow

Categories

  •   Stroke, Physical therapy