Stroke Practice Guideline

TSR 13:2, Spring 2006Contents vii viii x 1 Foreword Information for Authors Letters to the Editors Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation 3 Method 4 4 5 5 7 7 9 9 Target population Literature search Study inclusion/exclusion criteria Post-stroke rehabilitation interventions Outcomes Statistical analysis Reviewing the guidelines Results of literature search 10 Results 10 Clinical practice guidelines for therapeutic exercises 14 Summary of trials 14 Efficacy 20 Strength of published evidence compared with other guidelines 20 Clinical recommendations compared with other guidelines Clinical practice guidelines for task-oriented training 24 Summary of trials 24 Efficacy 27 Strength of the published evidence compared with other guidelines 27 Clinical recommendations compared with other guidelines Clinical practice guidelines for biofeedback 30 Summary of trials 30 Efficacy 32 Strength of published evidence compared with other guidelines 33 Clinical recommendations compared with other guidelines Clinical practice guidelines for gait training 36 Summary of trials 37 Efficacy 40 Strength of published evidence compared to other guidelines 40 Clinical recommendations compared with other guidelines Clinical practice guidelines for balance training 43 Summary of trials 43 Efficacy 45 Strength of the published evidence compared with other guidelines 45 Clinical recommendations compared with other guidelines 21 28 34 41 THOMAS LAND PUBLISHERS, INC. 45 Clinical practice guidelines for sensory interventions 46 Summary of trials 46 Efficacy 48 Strength of the published evidence compared with other guidelines 48 Clinical recommendations compared with other guidelines Clinical practice guidelines for constraint-induced movement therapy 49 Summary of trials 49 Efficacy 50 Strength of published evidence compared with other guidelines 50 Clinical recommendations compared with other guidelines Clinical practice guidelines for shoulder subluxation 52 Summary of trials 52 Efficacy 53 Strength of published evidence compared with other guidelines 54 Clinical recommendations compared with other guidelines Clinical practice guidelines for electrical stimulation 56 Summary of trials 57 Efficacy 59 Strength of published evidence compared with other guidelines 60 Clinical recommendations compared with other guidelines Clinical practice guidelines for transcutaneous electrical nerve stimulation (TENS) 61 Summary of trials 62 Efficacy 63 Strength of published evidence compared with other guidelines 63 Clinical recommendations compared with other guidelines Clinical practice guidelines for therapeutic ultrasound 64 Summary of trials 64 Efficacy 64 Strength of the published evidence compared with other guidelines 64 Clinical recommendations compared with other guidelines Clinical practice guidelines for acupuncture 65 Summary of trials 66 Efficacy 67 Strength of the published evidence compared with other guidelines 67 Clinical recommendations compared with other guidelines Clinical practice guidelines for intensity and organization of rehabilitation 74 Summary of trials 75 Efficacy 83 Strength of published evidence compared with other guidelines 83 Clinical recommendations compared with other guidelines 48 51 54 61 64 65 68 84 Discussion 86 87 88 88 91 91 Therapeutic exercises Task-oriented training Biofeedback Gait training Balance training Sensory interventions v 91 92 93 94 94 95 95 Constraint-induced movement therapy Shoulder subluxation Electrical stimulation TENS Therapeutic ultrasound Acupuncture Intensity and organization of rehabilitation 96 97 97 Conclusion Acknowledgments References 119 Appendixes All figures and tables cited in this issue are included in the CD attached to the inside back cover. This CD also includes an electronic version of the full text of this issue with embedded hyperlinks to the figures and tables. Additional copies can be ordered at www.thomasland.com vi Foreword The concept of developing and implementing clinical practice guidelines has received considerable attention in recent years among many medical professionals, clinical leaders, payers, and policy makers. It is interesting to note that adoption of these tools has been considerably less enthusiastic among rehabilitation programs and practitioners than among many other disciplines and professionals. Reasons for the slower utilization of guidelines are many, including concern that they might limit the important role of creativity and ingenuity in the clinical practice of rehabilitation, relative deficiency of sufficient evidence supporting many prevailing rehabilitation practices, and an apparent lack of compelling reasons for clinicians to examine the possibility of changing existing practices. There also is limited interest in the development and use of guidelines among rehabilitation professionals and a general lack of awareness of their usefulness among clinicians and their leaders. Although there are some notable prominent exceptions, clinical practice guidelines are in their infancy in rehabilitation. There is a school of thought that asserts that the experience of developing these guidelines is as important and beneficial as the actual implementation of these tools. The opportunity to thoroughly and critically review existing medical literature and assess its implications for clinical practice often is a unique and favorable collaborative experience for clinicians and scholars. However, it is in their roles in education and in promoting both quality and consistency of care that clinical practice guidelines demonstrate their greatest benefits. For trainees and for junior clinicians with minimal practical experience, these tools can be used as an effective training device. For all practitioners, they can be used as a template to ensure that favorable evidence-driven practices are being implemented. This is a method to improve quality of care. These documents are tools and, like other instruments used by clinicians, they serve to support and facilitate successful rehabilitation; they do not replace the role of originality and they do not reduce the value of hands-on, interactive, collaborative problem-solving by clinicians and patients that often is the hallmark of team-driven clinical stroke rehabilitation. Topics in Stroke Rehabilitation recently has published several Clinical Practice Guidelines (TSR 10:1 and 10:2 [2003], 11:4 [2004]). The frequency with which these documents are being published at this time reflects the emerging interest among thought leaders and practitioners in the performance and dissemination of comprehensive reviews of literature and in the implementation of clinical practices that are based on strong evidence, where it exists. In the present issue, Dr. Lucie Brosseau and her colleagues in Ottawa, Ontario, Canada, have conducted an exhaustive review of the literature, employed rigorous grading measures to rate the quality of the research studies, developed and applied a systematic method for organizing key points from the manuscripts that they reviewed, and created an extensive set of guidelines for clinical stroke rehabilitation practices that derive directly from these findings. The product focuses on 147 specific recommendations concerning 13 rehabilitation interventions. Practicing according to these guidelines can be expected to enhance the quality of care that is provided by clinicians and to improve the level of functioning that is experienced by patients. Dr. Brosseau and her team are to be congratulated for the enormous effort that was put into the production of this document, not only for their rigorous reviews and clear writing, but also because of the way in which the information is presented. Because the volume of material is potentially overwhelming, it could be somewhat unwieldy for most practitioners. This is one reason that the organization of the material is so relevant in order to facilitate understanding and use of the recommendations and their foundation. The managing editor, Mary Killion, also should be recognized for her extensive contribution to the layout and formatting of the data. The use of the CD-ROM is a novel approach. Displaying information in a tabular format is a sound way to promote understanding and learning. The enormity of the material necessitated an alternative additional method to disseminate the figures and tables of the reviewed literature. Using a CDROM seemed a sensible method to provide this material to you. Your comments on the text (and the format) are welcome. However, the true test of the success of the product is whether these guidelines are actually adopted in daily practice and the extent to which the content forms a basis of clinical practice in stroke rehabilitation. —Elliot J. Roth, MD Co-Editor-in-Chief Topics in Stroke Rehabilitation Chicago, IL, USA January 2006 vii Special Issue Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation The Ottawa Panel* Background and Purpose: The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA). Method: Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale. Results: The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation. Discussion and Conclusion: The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke. Key words: clinical practice guidelines, CVA, epidemiology, evidence-based practice, outcomes, physical rehabilitation, stroke troke is the third cause of mortality in North America.1 Although approximately two thirds of stroke patients survive an initial stroke, nearly one half of survivors have physical disabilities as a result.2 Furthermore, while severe stroke incidence has decreased, milder stroke incidence with minimal and moderate deficits has increased. The individuals surviving a stroke S require rehabilitation that includes varying degrees of medical care, rehabilitation, nursing, and other health professional care.3 Stroke survivors present sensorimotor, musculoskeletal, perceptual, and cognitive system deficits.4 Their impairments, disabilities, and handicaps can lead to devastating personal consequences as well as consequences for the health care system and society at large. *Ottawa EBCPGs Development Group: Lucie Brosseau, PhD,1 George A. Wells, PhD,2,3 Hillel M. Finestone, MD,6 Mary Egan, PhD,1 Claire-Jehanne Dubouloz, PhD,1 Ian Graham, PhD,4 Lynn Casimiro, MA, Vivian A. Robinson, MSc,3 Martin Bilodeau, PhD,1 and Jessie McGowan, MLIS.3 External Panel Members: Robert Teasell, MD,10 Johanne Desrosiers, PhD,5 Susan Barreca, MSc,8 Lucie Laferrière, MHA,9 Joyce Fung, PhD,7 Hélène Corriveau, PhD, MHA,5 Gordon Gubitz, MD,11 Michael Sharma, MD,9 and Mr. S. U.12 Assistant Manuscript Writers: Amole Khadilkar, MD,1 Karin Phillips, MA,1 Nathalie Jean,1 Catherine Lamothe,1 Sarah Milne, MSc,1 and Joanna Sarnecka, MSc.1 School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada; 2Department of Epidemiology and Community Medicine, Univer1 sity of Ottawa, Ottawa, Ontario, Canada; 3Centre for Global Health, Institute of Population Health, Ottawa, Ontario, Canada; 4School of Nursing Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada; 5Research Centre on Aging and Sherbrooke University, Sherbrooke, Québec, Canada; 6Sisters of Charity of Ottawa Health Service, Ottawa, Ontario, Canada; 7Department of Physical Therapy, McGill University, Montreal, Québec, Canada; 8Hamilton Health Sciences, Hamilton, Ontario, Canada; 9Regional Stroke Centre, Ottawa Hospital, Ottawa (Ontario), Canada; 10University of Western Ontario, London, Ontario, Canada; 11Division of Neurology, Dalhousie University, Halifax (Nova Scotia), Canada; 12Patient who had a stroke. Top Stroke Rehabil 2006;13(2):1–269 © 2006 Thomas Land Publishers, Inc. www.thomasland.com 1 17 robot-aided training. Evidence-based clinical practice guidelines (EBCPGs) have been defined as systematically developed statements to help practitioners and patients with decisions about appropriate health care for specific clinical circumstances.46–48 Finally. They also failed to use a rigorous grading system to .. However.16. nurses. Functional electrical stimulation (FES) has also been systematically reviewed for post-stroke patients. Post-stroke physical rehabilitation interventions are mostly noninvasive interventions that present very few adverse side effects and contraindications as compared with a large number of pharmacologic interventions. and the results of most of these reviews also need to be updated in order to be included in the development of EBCPGs. the methodology used in these reviews needs to be standardized (e.7. physiotherapists.49 examined the use of EMG-BFB to improve lower extremity function after stroke.51 Moreover.68. Both Barclay-Goddard35 and Pollock36 have systematically reviewed balance training.5 EBCPGs are a rapidly emerging technology with considerable potential to alter the clinical decision-making process in fundamental ways. the Agency for Health Care Policy and Research’s (AHCPR’s) EBCPGs were developed for limited clinical practice areas. One examined EMG-BFB for neuromuscular reeducation. Despite the fact that significant progress has been made in the clinical management of stroke over the last decade. require updating because of the rapidly growing number of scientific articles published on the effectiveness of EMG-BFB. mobility. (Summarized comparative results of these reviews are included in the Discussion section.37–44 Several meta-analyses.64–67 However. The appropriate use of guidelines has been demonstrated to improve both the process of care and patient health outcomes. Cochrane Collaboration).20–23 Four meta-analyses have been published24–27 for the effect of the intensity of rehabilitation following stroke. physical fitness. there is an urgent need for physicians. while reviews on different aspects of gait training.52–60 A recent review was conducted on the management of shoulder pain and subluxation. no published systematic review exists concerning the efficacy of therapeutic electrotherapy modalities. Several multidisciplinary EBCPGs have been published on post-stroke rehabilitation.70–78 However.45 and others looked at EMG-BFB for the improvement of upper extremity function.. Furthermore. one of the studies45 has been criticized for failing to perform a sensitivity analysis on the control group.61– 63 Meta-analyses on post-stroke pain management were done for acupuncture as an adjuvant therapy in stroke rehabilitation. several trials of electroanalgesia could have been added to this review.70 They did not provide a clear definition of physiotherapy or review specific physical rehabilitation interventions.15 progressive strengthening exercise.69 To our knowledge.) Trials on the efficacy of the following types of therapeutic exercises for stroke survivors have been systematically reviewed: physical fitness.9–14 task-oriented training.49 Follow-up of drop-outs was also lacking.49 EMG-BFB constitutes a small but effective part of lower extremity physical rehabilitation in stroke patients. walking ability.19 and constraint-induced movement therapy. There are currently many systematic reviews and meta-analyses on the effectiveness of poststroke physical rehabilitation interventions in the scientific literature.6 EBCPGs allow stroke patients to benefit maximally from the physical rehabilitation treatment that they are receiving.2 TOPICS IN STROKE REHABILITATION/SPRING 2006 Post-stroke physical rehabilitation interventions have been used to reduce pain and spasticity. as well as to increase range of motion (ROM). functional status.g. the efficacy of organization and intensity of stroke rehabilitation has been examined through systematic reviews.50. and literature reviews have been conducted over the last 7 years on the effectiveness of EMG biofeedback (EMG-BFB).8 therapeutic exercise. systematic reviews. and quality of life.29–35 have also been done. occupational therapists. muscle force.g.28 such as the use of the treadmill combined with body support.18. Moreland et al. selection criteria) and quantified (e. It is evident that the post-stroke physical rehabilitation literature has been exhaustively reviewed. These publications. and other rehabilitation specialists to provide the most efficient and effective treatments for their patients. though recent. occupational therapy.D.). and outcomes to allow the research staff to select the most relevant material as evidence for the effectiveness of various rehabilitation interventions for post-stroke patients.) are members of the Canadian Stroke Network. transcutaneous electrical nerve stimulation (TENS). and intensity and organization of rehabilitation. H.T. S. J..L. sensory interventions. and physical therapy.. rigorously developed EBCPGs on physical poststroke rehabilitation interventions suggest the need for the development of better quality EBCPGs for these interventions. Method The development process of these EBCPGs was similar to that of the Philadelphia Panel90 and to previous Ottawa Panel publications. L. the evaluation of the evidence is based upon descriptive conclusions of the primary studies rather than a quantitative analysis of the raw data. balance training. These guidelines are aimed at various users. These analyses are also not pooled to specific outcome measures. asked professional associations interested in the care of stroke patients to suggest individuals with both clinical expertise in the management of stroke and familiarity with EBCPGs. J. in addition to all the members of the OMG. M..B.U. stroke rehabilitation interventions.G. The advantage of the proposed Ottawa Panel EBCPGs80–82 on post-stroke physical rehabilitation interventions is that they offer graded. The OMG also made sure that the Ottawa Panel EBCPGs were methodologically .79 Other EBCPGs72–78 are also available for rehabilitation specialists. the OMG chose nine experts (R. the Ottawa Methods Group (OMG). physicians. J.B....F. The Ottawa Panel consisted of these nine experts.83 and high-quality84 recommendations that indicate the treatment time for which a specific intervention is optimally effective for a specific outcome for a particular stroke population.T. A. The OMG then established an a priori set of inclusion criteria for the study designs.82 except that a different target population was used. Furthermore... Briefly.D. quantitative. treatment of shoulder subluxation. From among the suggestions. evidence suggests that quality of care can be improved through the use of EBCPGs... Although the review of the literature and selection of stroke topics is exhaustive in these guidelines. S. constraint-induced movement therapy (CIMT). such as proposed by the Cochrane Collaboration methodology.91 while some had already developed post-stroke rehabilitation EBCPGs (R. G.T..S.B. S. The OMG assembled a research and support staff with expertise in meta-analyses. These guidelines use a grading system that takes the research design of the studies into account.H. a group of 10 methodologists with experience in developing EBCPGs. Except for the guidelines from the Heart and Stroke Foundation of Ontario. This article discusses only post-stroke physical interventions such as therapeutic exercises. subject samples. The professional experts were recruited from multidisciplinary disciplines such as physical medicine. task-oriented training.) to serve as panel members. J. biofeedback.81. The conclusions of most of these EBCPGs concerning the effectiveness of the selected post-stroke interventions are often imprecise and difficult to apply to the daily practice of rehabilitation practitioners. neurology.Clinical Practice Guidelines 3 assess the evidence. electrical stimulation. including physical therapists. gait training. therapeutic ultrasound. occupational therapists.. and patients. research methods.. This a priori protocol guided separate systematic reviews of the literature for each intervention. G.85–89 The purpose of developing these guidelines is to promote the appropriate use of various physical rehabilitation interventions in the management of stroke survivors. Guidelines were based mainly on committee opinions and have not been recently updated. Several experts (R. The generally positive (small-to-large effect sizes from quantitative reviews) results from the recent meta-analyses coupled with the lack of up-to-date..71 these EBCPGs do not base their assessment of the level of evidence on a quantitative synthesis using the raw data of the studies of interest.G.F.B. S. interventions. or the development and assessment of EBCPGs. acupuncture. L. The OMG also reviewed the inclusion criteria to ensure that the approach to the study selection was reproducible and systematic. but not the clinical significance of the outcomes..C. Seven percent of the abstracts needed the consultation of the senior reviewer and an additional review of the problematic article. or (7) psychiatric conditions. If the reviewers were uncertain about a particular article after having read the abstract. or subdural hematomas were excluded because of the numerous and varied associated signs and symptoms.. a comparison of their individual lists was performed. The search was organized around the condition and interventions rather than the outcomes because it was an a priori search. subarachnoid hemorrhages. The patients had to be medically stable and able to follow simple instructions and to interpret and respond to feedback signals.org) criteria. (2) cardiac conditions. EMBASE. the pairs of reviewers retrieved articles selected for inclusion from the first round and inde- . according to AGREE (www. Current Contents. Finally.4 TOPICS IN STROKE REHABILITATION/SPRING 2006 developed at high level of quality. Further inclusion and exclusion criteria are exhibited in Table 1. These tables were used as the basis for making the Ottawa Panel recommendations. she searched the reference lists of all of the included trials for relevant studies and contacted content experts for additional studies. and post-acute (from 6 weeks to 6 months) to chronic (from 6 months) as defined by the Canadian Stroke Network (Appendix 3: Characteristics of Included Studies). study selection. Further exclusion criteria included studies whose patients presented with one of the following conditions: (1) cancer or other oncological conditions. For the second round of the inclusion and exclusion process. and the University of Ottawa EBCPGs Web site. Parkinson’s. (5) serious cognitive deficits or severe communication problems.84 The research staff reviewed articles and created draft evidence tables. two trained independent reviewers appraised the titles and abstracts of the literature search. the Physiotherapy Evidence Database (PEDro). brain tumors.B. cohort.g. checked the two independent lists of articles and the reasons for inclusion or exclusion to determine potential inconsistencies. She also searched the registries of the Cochrane Field of Rehabilitation and Related Therapies. For each pair of reviewers. individuals independently read the title and abstract of each article and created a list of all of the articles in the database along with a reason for either including or excluding each article. In the first round of study inclusion or exclusion. (3) dermatologic conditions. using a checklist with the a priori defined selection criteria (Table 1). and non-randomized studies and conducted the search in the electronic databases of MEDLINE. we had no control over the outcomes that the authors of the primary studies decided to measure (Appendix 1: Literature Search Results). and the Cochrane Controlled Trials Register up to December 2004. A senior reviewer. Before deciding whether to include or exclude the article.91 Patients who had been identified as having multiple CVAs.). and data extraction and synthesis. Thus. which the nine clinical experts received in preparation for their consensus meeting with the OMG. the Cumulative Index to Nursing and Allied Health (CINAHL). the Cochrane Musculoskeletal Group. a methodologist and a clinical expert (L.agreecollaboration. they ordered the article and read it in full before making a determination. Target population The target population was adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic CVA. other neurological problems (e. (4) healthy normal subjects. subacute (from the first to 6th week). acute (first week following a stroke). Studies that included patients with bilateral neurological signs were also excluded. The mean duration since stroke onset varied from hyper-acute (the first 12 hours). The library scientist expanded the search strategy to identify case control. Literature search The library scientist developed a structured literature search based on the sensitive search strategy recommended by The Cochrane Collaboration92 and modifications to that strategy proposed by Haynes et al. (6) major medical problems that could interfere with the rehabilitation pfOcess or incapacitate functional status. traumatic brain injury).93 The Cochrane Collaboration method minimizes bias through a systematic Z proach to the literature search. Abstracts were excluded if they contained insufficient data for analysis and additional information could not be obtained from the authors. and the use of the overhead pulley. Proprioceptive neuromuscular facilitation was identified as the use of mostly reflex-inhibiting patterns. which had been created for multiple diagnoses. as were eligible studies with greater than a 20% *Controlled clinical trials are considered the same as randomized control trials (RCTs). and acupuncture. gait training. Individual components of the larger task were then practiced until the patient was able to complete the component adequately. biofeedback. treatment of shoulder subluxation.95 They are defined as follows. kinetron.90 This list of criteria.94 CCTs are either not randomized or have not been appropriately randomized. No limitations based on methodological quality were imposed a priori with regard to the selection of comparative controlled studies. passive range of motion exercises. Studies where patients served as their own controls were excluded. Study inclusion/exclusion criteria drop-out rate or a sample size of fewer than 5 patients per group. Crossover studies were included. proprioceptive neuromuscular facilitation. However. allocation concealment. the quality of the studies was considered when grading the recommendations resulting from our analysis. balance training. controlled clinical trials (CCTs). Bobath technique was defined as a neurodevelopmental technique using inhibitory posture and movement to inhibit spasticity and synergies. This consensus served to support the reliability of data obtained with the article selection process. Resistance training was defined as active exercise done against a resistance. . according to the Jadad Scale. resistance training. therapeutic ultrasound. Post-stroke rehabilitation interventions were identified as therapeutic exercises. The reviewers resolved differences in data extraction and quality assessment through consensus with the senior reviewer. and case-control studies. however. All original comparative controlled studies that evaluated relevant physical rehabilitation interventions in stroke patients were included: randomized controlled trials (RCTs). Bobath technique. sensory information.94 a 5-point scale with reported reliability and validity that assigns 2 points each for randomization and double blinding and 1 point for description of withdrawals. and outcomes. CIMT. Aerobic training is considered to be activities to increase endurance and cardiovascular function. Post-stroke rehabilitation interventions related to therapeutic exercises were identified as aerobic training.Clinical Practice Guidelines 5 pendently assessed the full articles for inclusion or exclusion in the study. usually in isokinetic mode. Post-stroke rehabilitation interventions The inclusion/exclusion criteria were based upon previous criteria used by the Philadelphia Panel.* cohort studies. details of the interventions. but to avoid potential confounding carry-over effects the data from only the first part of the study (before crossing) was analyzed. Rehabilitation interventions related to task-oriented training were identified as treatments that involved dividing activities of daily living into component parts. TENS. The pairs of reviewers assessed the methodological quality of the studies using the Jadad Scale.83. because of the additional time and resources required for translation. was adapted and approved by the OMG for use with patients post stroke (Table 1). Using predetermined extraction forms. electrical stimulation. task-oriented training. For further exclusion criteria. while facilitating normal movements. the pairs of reviewers independently extracted from included articles data on the population characteristics. Intensity and organization of rehabilitation was also included as an intervention related to stroke rehabilitation. Uncontrolled cohort studies (studies with no comparison group) and case series were excluded. Passive range of motion exercises were defined as physiological mobilization done by the therapist without any effort from the patient. trial design. see Table 1. Trials published in languages other than French and English were not analyzed. Kinetron training was defined as training with this resistive lower extremity machine. Neuromuscular electrical stimulation (NMES) was defined as electrical . Treadmill training was defined as ambulation on a treadmill adjusted to patient’s comfortable walking speed or highest speed as possible for the patient. and functional lower extremity training. Rehabilitation interventions associated with gait training were identified as treadmill training. Post-stroke rehabilitation interventions related to electrical stimulation were identified as FES. EMG-BFB was defined as an intervention that allows a patient to monitor his or her muscle activity through electrodes with a visual or audible feedback signal. Video feedback was considered to be a visual cue from a monitor after the action was done. video feedback. We included interventions such as base of support training and platform training. such as gait training. Strapping methods were defined as strapping used to keep the glenohumeral joint in normal position. Functional exercises were given to the patient to improve the function of the affected arm. rhythmic auditory facilitation training. EMGbiofeedback-relaxation training.6 TOPICS IN STROKE REHABILITATION/SPRING 2006 Component parts were then combined. Functional lower extremity training was defined as functional tasks such as sitting. strapping. backward. EMGtriggered electrical muscle stimulation. FES was defined as electrical stimulation of a specific muscle or nerve such as supraspinatus or middle deltoid with functional purpose resulting in the reduction of shoulder subluxation. Force feedback was defined as feedback related to the moment of force. body weight support training. Post-stroke rehabilitation interventions related to biofeedback were identified as EMG-BFB.95 We included tasks such as seated reaching tasks. Rhythmic auditory facilitation training was defined as imposed rhythm to improve gait rhythm and frequency. while an overhead harness supported a percentage of the body weight. Rehabilitation interventions related to balance training were identified as any intervention that contributes to the enhancement of equilibrium and balance in post-stroke patients. Electrogoniometric feedback training was defined as auditory feedback during gait training when patient was compensating in hyperextension or flexion. FES. FES was defined as electrical stimulation of a specific muscle or nerve such as tibialis anterior or peroneal nerve for a functional purpose – to improve swing phase or stance phase during gait. and repetitive elbow joint movements. rhythmic positional biofeedback. Audio and visual feedback were identified as any cue received by the patient during or after the exercise.95 Rhythmic positional biofeedback was defined as a usual biofeedback intervention with auditory or visual stimuli aimed at increasing the rhythm of movement. FES was defined as the electrical stimulation of a specific muscle or nerve such as tibialis anterior and gastrocnemius for a functional purpose. positional feedback stimulation training. adapted games. Post-stroke rehabilitation interventions related to treatment of shoulder subluxation were identified as FES. and the overall skill was practiced with repetition. perceptual learning exercises. and rocking chair stimulation. brace-assisted walking. and force feedback. and sideways or going up and downstairs. Brace-assisted walking was defined as use of hemibar and ankle-foot orthosis (AFO) or any other type of brace if necessary. Support methods were defined as any use of an external support such as orthosis or sling to prevent shoulder subluxation. audio and visual feedback. Rehabilitation interventions associated with CIMT were defined as the restriction of the nonparetic upper extremity by a sling or hand splint to encourage the use of the paretic limb. supports methods. neuromuscular electrical stimulation (NMES). overground training. Any intervention that divided required tasks into individual skills was included. Body weight support training was defined as treadmill training. Rehabilitation interventions related to sensory interventions were identified as any retraining of the sensory and visuo-spatial function to correct posture and perceptual problems after stroke. and shoulder positioning. climbing stairs. and TENS. Shoulder positioning was defined as a position induced by the physiotherapist to protect the structures around the weak hemiplegic shoulder in order to avoid shoulder pain and shoulder subluxation. transfers. and gait with a focus on the recovery of stability and gait performance.95 such as passive vestibular stimulation. Overground training was defined as gait training on an even surface with propulsion forward. standing. electrogoniometric feedback training. stride length. variability or difference in estimated effects between studies) was tested using the chi-square statistic. global patient assessment. the relative risk is “the ratio of risk in the intervention group to the risk in the control group. When heterogeneity was not significant. quality of life. frequency and rigor of any physical rehabilitation intervention or combination of interventions in the treatment of post-stroke patients. enhanced physical therapy. Disability and Health. Post-stroke rehabilitation interventions related to the intensity and organization of rehabilitation were identified as “examining the rate. and indirectly for ROM. enhanced occupational therapy. complexity. functional status. and cardiopulmonary function. gait status.. probability.” 98 Heterogeneity (i.” 98 Dichotomous data or data with only two classifications98 were analyzed using relative risks. postural status. usually for pain. which involved the concepts of body function. EMG-triggered electrical muscle stimulation was defined as electrical stimulation of a muscle triggered by EMG activity of this muscle. Studies were included if any one of the aforementioned outcomes was measured. or use of educational pamphlets. endurance. cadence. and environmental factors. where the weight is the inverse of the variance. Concurrent therapies (such as medication) were accepted only if they were provided to both the experimental and control groups.97 Continuous data. A positive recommendation was made only if a specific intervention was effective for an outcome.” 95 Interventions such as stroke unit care. body structure. standard deviation and sample size in each group are known. TENS was defined as a form of electrical stimulation that triggers nervous endings to inhibit the message of pain. walking distance. fixed-ef- . or rate) is the ratio of people with an event in a group to the total in the group. and return to work. A WMD is “a method of meta-analysis used to combine measures on continuous scales (such as weight). “data with a potentially infinite number of possible values along a continuum. According to Cochrane. activities and participation.and low-intensity levels. Acceptable comparisons were placebo.Clinical Practice Guidelines 7 stimulation of a specific muscle or nerve such as thumb flexors and extensors to help trigger nervous fibers and achieve motor recovery. We tested data heterogeneity across the results of different included studies. Positional feedback stimulation training was defined as auditory and visual feedback during training to achieve a target position of the joint. discharge disposition. no treatment. balance status. global physician assessment. sensory status. or general availability of equipment and resources required to carry out the interventions under investigation.e. as measured by a validated scale. The a priori outcomes were classified according to two WHO concepts: (1) Body function: pain reduction. Statistical analysis The outcomes were selected and based upon the World Health Organization’s96 (WHO’s) new pro- The data were analyzed using Review Manager Software. Post-stroke rehabilitation interventions related to acupuncture were identified as any treatment using needles to stimulate specific anatomical point with the hands or with electrical stimulation. enhanced upper extremity treatment. Outcomes posal of the International Classification of Functioning. Ultrasound was identified as an electrophysical modality using an ultrasonic wave to treat a specific area. TENS is identified as being given at high. Study selection was not restricted by the cost.” 98 were analyzed using the weighted mean differences (WMDs) between the intervention and control groups at the end of the study. length of stay. and intensive outpatient physiotherapy rehabilitation were included as part of intensity and organization of post-stroke rehabilitation. patient adherence. spasticity/muscle tone. where the mean. (2) Activities and participation: walking speed. Psychological outcomes such as depression were excluded (Table 1). Studies designed with a comparison of two interventions instead of treatment versus control were included as long as both interventions respected the inclusion criteria. patient satisfaction. ROM. muscle strength. The risk (proportion. motor function/motor recovery. 80–82 clinical improvement for all interventions studied by the Ottawa Panel was defined as 15% improvement. relative to a control. or D) of evidence. participants in a meta-analysis study) are the ones of interest and thus constitute the entire population of units. the gait speed of the group receiving the aerobic training is not statistically different from that of the control. Random-effects models include both within-study sampling error (variance) and between-study variation in the assessment of the uncertainty (confidence interval) of meta-analysis results. four special cases of calculation appeared where new formulas were needed to calculate the RD in the change from baseline. where the number of participants in the study is equal to or higher than 100. clinically important benefit (>15%).80 However. the stronger grade was kept. C. clinically important benefit (>15%) was necessary for a grade A recommendation. The new formulas used to calculate the relative difference in change from baseline for each of the four aforementioned scenarios are given in Appendix 2.cochrane. Evidence from one or more RCTs of a statistically significant.g.. was necessary for a grade D– recommendation (Table 2).org).g. A grade C recommendation was given to those interventions where an appropriate outcome was measured in a study that met the inclusion criteria. For dichotomous data. For example. The first case occurred when the baseline values were not available for an outcome. C+. The second scenario involved an outcome that was measured as a change from baseline. the confidence interval contains a zero and the difference between the two groups is not statistically significant. To determine clinical improvement. Absolute benefit was calculated as the improvement in the treatment group minus the improvement in the control group. illustrates the WMD between the two groups. when they are compared for a specific outcome of interest. if the evidence was from observational studies or CCTs.8 TOPICS IN STROKE REHABILITATION/SPRING 2006 fect models were used. The recommendations were graded by their level (I for RCTs. All figures were created using Cochrane Collaboration methodology (www. The horizontal line represents the standard deviation of the WMD. in the fourth case. A fixed-effect model is a statistical model that stipulates that the units under analysis (e. Evidence of clinical importance (>15%) but not statistical significance earned a grade C+ recommendation. no measurement scales exist for strength). during this meta-analysis. Such random-effects models were used when heterogeneity was significant. The third case encountered was also where the outcome was measured as a change from baseline but both the baseline values and the measurement scales were either not available or were nonexistent (e. maintaining the original units of measurement. II for nonrandomized studies) and strength (A. Evidence from one or more RCTs of a statistically significant benefit favoring the control group (<0%: favors controls) resulted in a grade D recommendation. Fixed-effect models were used to generalize data across the included studies. the absolute benefit and relative difference in the change from baseline were calculated. Finally. If two or more studies had different grades for the same outcome for the same time period. the relative percentage of improvement was calculated as the difference in the percentage of improvement between the intervention and control groups. Outcomes not supported in .. A grade B recommendation was given for a statistically significant. The relative difference (RD) was calculated as the absolute benefit divided by the baseline mean (weighted for the intervention and control groups). B. in TE-Figure 1A that illustrates the comparison between aerobic training and a control group where gait speed at end of treatment is the outcome measure. Evidence from one or more RCTs of a clinically important benefit (≤ −15% for controls) that was statistically significant. where the scale of measurement was known but baseline values were absent. If the standard deviation line touches the central vertical line of the graph. but no clinically important difference and no statistical significance were shown. A grade of D+ was given for evidence of clinical importance (≤ −15% for controls) without statistical significance. based upon the following assumption: the mean of scale + 1 = mean of original scale + 1 and SD of scale + 1= SD of original scale. a sum of 1 was added to all the values in the formula of clinical relevance. The square in TE-Figure 1A. Based on previous Philadelphia and Ottawa Panels’ consensus. where the baseline mean was given as 0. Scales demonstrated to be valid and sensitive to change were required to support a positive recommendation (A or B). 148 articles on therapeutic exercises for post-stroke rehabilitation were initially identified. Thirty studies were included and 45 were excluded for different reasons. The initial search found 368 studies for electrotherapy. Reviewing the guidelines The guidelines were sent to the external experts for review. From the 23 potentially relevant articles concerning sensory interventions at the end of 2004. therapeutic ultrasound. From these. The other 23 trials were excluded from the final selection for various reasons (Gait-Table 73). only one of these was included (Appendix 3K) and the remaining three were excluded (USTable 157). In the end. and. In electrical stimulation. Initially. 50 of these were considered potentially relevant based upon the selection criteria. of these. Eleven of them ended up being included (Appendix 3I) and 26 were excluded (ESTable 135). 151 articles were considered potentially relevant and. After the last search in December 2004. From these. For balance training. From the selected articles. the positive recommendations were also sent to practitioners for feedback. finally. 16 articles were considered after the last search. 19 were included (Appendix 3C) and 45 were excluded for different reasons (BFB-Table 57). Results of literature search The initial literature search in 2002 identified 1. balance training. By the end of 2004. CIMT included 5 articles (Appendix 3G). Intensity and organization of rehabilitation initially had 272 potential articles. 56 trials were considered for therapeutic exercises. By the end of December 2004. TENS had 11 potentially relevant trials. However. 9 were included (Appendix 3F) and 14 were excluded (SI-Table 107). From these. . Nineteen of these articles relating to gait training met the selection criteria and were included (Appendix 3D). whether they felt that the literature search on the different intervention of rehabilitation was relevant and complete.533 potential articles on post-stroke rehabilitation interventions. TENS. Acupuncture was found to have 19 potential articles. From the last search of 2004. Twenty-two trials were considered relevant in the treatment of shoulder subluxation. task-oriented training. To judge the clinical usefulness of the guidelines. Fifty-six were finally included with respect to the inclusion criteria (Appendix 3M) and 102 were excluded for different reasons (IR-Table 167). 11 met the inclusion criteria and were kept (Appendix 3E) and 4 were excluded (BT-Table 96). acupuncture. After many updated literature searches that ended in December 2004. In task-oriented training. Eight were included (Appendix 3H) and the other 13 were excluded for various reasons (SH-Table 123). and sensory intervention. we created the following five subcategories of therapeutic exercise: therapeutic exercises. Their questions and comments were carefully addressed to improve the clarity of the final guidelines. whether the practitioners agreed with the recommendation. Seven were included (Appendix 3L) and 11 were excluded (AC-Table 160). while 13 trials were excluded (CIMT-Table 117) from the various updated searches leading up to December 2004 (N = 17 potential articles). 66 were considered potentially relevant. 131 articles were identified for biofeedback. 75 trials were considered potentially relevant. Four articles were considered potentially relevant for therapeutic ultrasound. 29 trials met the inclusion criteria and were then included (Appendix 3A) and 27 trials were excluded for different reasons (TE-Table 3). Practitioners were asked four questions for each guideline: whether the recommendation was clear.Clinical Practice Guidelines 9 the scientific literature by an existing validation study but that provided useful information in the studies were insufficient to warrant a grade A or B recommendation. and whether the results of the trials in the guidelines were interpreted according to the practitioners’ understanding of the data. Also. Electrotherapy was then separated into more specific interventions: electrical stimulation. 71 articles met the selection criteria and were included. From these. 17 were included (Appendix 3B) and 22 were excluded (TOT-Table 37). From these. 156 were considered as potentially relevant. 39 articles were considered as potentially relevant. 41 articles were considered potentially relevant. Six finally met the inclusion criteria and were included (Appendix 3J) and six were excluded (TENS-Table 148). 433 potential ar- ticles on gait training for post-stroke rehabilitation were initially identified. CIMT. 8 weeks (no benefit demonstrated). and balance standing at end of treatment. ROM of the wrist and ankle at end of treatment. and quality of life (NHP–loss of energy) at end of treatment. balance. 1 year. and for functional status (Frenchay Activities Index [FAI]: global. functional status (Barthel Index) at follow-up. grade D for ROM of the wrist and ankle at end of treatment. Patients with subacute and chronic stroke. 3 months. Patients with postacute stroke. 10 weeks (clinically important benefit demonstrated). walking outside) at end of treatment.10 TOPICS IN STROKE REHABILITATION/SPRING 2006 Results Clinical practice guidelines for therapeutic exercises Aerobic training versus control. Bobath approach training versus control. social outings. grade C for balance sitting at end of treatment. 3 months. 2 weeks. 6 months (no benefit demonstrated but favoring control). motor function (SMES: upper extremity) at end of treatment. PNF versus Bobath approach training. grade C for mobility at end of treatment. 3 months. 12 weeks (clinically important benefit favoring control dem- . 8 weeks (clinically important benefit demonstrated). ROM of the wrist at end of treatment. 3 months (clinically important benefit favoring control demonstrated without statistical significance). 2 and 12 weeks (clinically important benefit demonstrated without statistical significance). level I (RCT): Grade A for physical fitness (highest test stage completed of the stress test and maximal workload) and mobility (stair climbing) at end of treatment. motor function (SMES: lower extremity and trunk. 4. and follow-up. quality of life (Nottingham Health Profile [NHP]– global) at follow-up. decrease of resting heart rate and decrease of resting systolic and diastolic blood pressure). 2. level I (RCT): Grade C for mobility at end of treatment. and 6 weeks. 6 weeks (clinically important benefit favoring control demonstrated without statistical significance). and 6 weeks. grade D+ for ROM of the ankle at end of treatment. 10 weeks. grade C for cardiopulmonary function (maximal heart rate. 4. 1 year and 4 years. grade D+ for balance sitting at follow-up. level I (RCT): Grade A for cardiopulmonary function (expiration per minute [VE]). 4 years (no benefit demonstrated). Aerobic individualized program training versus control. 1 year and 4 years. level I (RCT): Grade C for functional status and upper extremity muscle strength at end of treatment. VO2 max. 6 weeks (no benefit demonstrated). grade C+ for gait speed at end of treatment. 1 year. Patients with subacute stroke. and gait. and follow-up. and functional status at end of treatment. and functional status (walking) at end of treatment. level I (RCT): Grade C+ for balance standing at follow-up. Patients with subacute stroke. VCO2 max) and motor function at end of treatment. grade D for balance sitting at follow-up. level I (RCT): Grade C+ motor function (Sodring Motor Evaluation Scale [SMES]: upper extremity) at follow-up. grade D+ for pain relief (NHP–pain) at end of treatment. grade C+ for mobility (walking distance) at end of treatment. 6 months (no benefit demonstrated). Bobath approach versus standard customary muscle training. grade C for cardiovascular function (maximal heart rate. 4. 2. and follow-up. (no benefit demonstrated but favoring control). 4 weeks (no benefit demonstrated but favoring control). gait speed. grade D for functional status (FAI: light housework activities) at end of treatment. 4 weeks (no benefit demonstrated). 4 years. 6 weeks. 10 weeks (clinically important benefit demonstrated without statistical significance). Patients with acute and subacute stroke. and 6 weeks. 6 weeks (no benefit demonstrated). 6 weeks (no benefit demonstrated but favoring control). grade D for mobility at end of treatment. muscle power. 3 months (clinically important benefit demonstrated without statistical significance). 8 weeks (clinically important benefit demonstrated without statistical significance). functional status (Barthel Index) at end of treatment. and Motor Assessment Scale) at end of treatment. 2. Proprioceptive neuromuscular facilitation (PNF) for upper extremity versus standard customary muscle training. grade C+ for peak torque for knee flexors at end of treatment. 1 month (clinically important benefit demonstrated). 6. upper extremity isometric torque at follow-up. level I (RCT): Grade C+ for functional status at end of treatment. 1 month (clinically important benefit demonstrated without statistical significance). motor function upper extremity. motor function upper extremity. 16 weeks (clinically important benefit demonstrated). 4 weeks. Functional task training for upper extremity versus strength training. 4 weeks. grade C functional status (FIM self-care and FIM mobility) at end of treatment. level I (RCT): Grade A for functional status at end of treatment.5 to 8 months (clinically important benefit favoring control demonstrated without statistical significance). 4 weeks and 8 weeks. and follow-up. and follow-up. and follow-up. level I (RCT): Grade C for motor recovery at end of treatment. Progressive resistance versus no resistance training. Patients with subacute stroke. 6.5 to 8 months (clinically important benefit demonstrated without statistical significance). 4 weeks (no benefit demonstrated). Inc. 16 weeks (no benefit demonstrated). functional status *FIM is a trademark of Uniform Data System for Medical Rehabilitation. 6. and follow-up. 4 weeks and 8 weeks. Patients with postacute stroke. and followup. 4 weeks. a division of UB Foundation Activities. level I (RCT): Grade A for cardiopulmonary function and peak torque for shoulder flexors at end of treatment.5 to 8 months.5 to 8 months. 1 month (no benefit demonstrated but favoring control). 6. grade D for gait endurance at end of treatment. Patients with chronic stroke. Progressive resistance training versus active training for the lower extremity. Patients with post-acute stroke.5 to 8 months (no benefit demonstrated but favoring control). grade D+ for lateral pinch at end of treatment. Active training for the lower extremity versus control (no exercise). and grip strength at end of treatment. 6. Patients with subacute stroke.Clinical Practice Guidelines 11 onstrated without statistical significance). level I (RCT): Grade D for functional status at end of treatment. grade C for peak torque for shoulder extensors and peak torque for knee extensors at end of treatment. isometric torque at end of treatment. and follow-up. pain relief. level I (RCT): Grade A for upper extremity isometric torque at end of treatment. 4 weeks. 4 weeks. grade C+ for motor function upper extremity and functional status (FTHUE) at end of treatment. Patients with post-acute stroke.5 to 8 months. Strength training versus control.5 to 8 months. functional status (FIM mobility). 6 months (no benefit demonstrated). grip strength.5 to 8 months. (Functional Test of the Hemiparetic Upper Extremity [FTHUE]) at end of treatment.5 to 8 months. palmar pinch at end of treatment. Aerobic and strength versus aerobic training. Progressive resistance training for the lower extremity versus control. functional status (FIM self-care and FIM mobility). grip strength and lateral pinch at follow-up. sensory function upper extremity. Patients with subacute stroke. and lateral pinch at end of treatment. pain relief. ROM upper extremity. Patients with subacute stroke. and palmar pinch at followup. 6. and followup. 4 weeks (clinically important benefit demonstrated without statistical significance). grade C for sensory function upper extremity at end of treatment. 6. and grade C+ favoring strength training for grip strength and palmar pinch at end of treatment. 4 weeks (no benefit demonstrated). . 4 weeks. 4 weeks. pain relief. 4 weeks. 4 weeks (clinically important benefit demonstrated). isometric torque. grade D for ROM upper extremity at end of treatment. 6. 16 weeks (clinically important benefit demonstrated without statistical significance). functional status (FIM selfcare) at end of treatment. 6. level I (RCT): Grade C+ favoring functional task training for functional status (FIM* self-care and FIM mobility). 6 months (no benefit demonstrated but favoring control). 4 weeks. functional status (FTHUE) at follow-up. at end of treatment. Patients with subacute and post-acute stroke. 5 weeks (no benefit demonstrated but favoring control). Patients with subacute and post-acute stroke. Patients with subacute stroke. Resisted extension training for the hand versus control. grade C+ for ROM at end of treatment. 8–10 weeks (no benefit demonstrated but favoring control). level I (RCT): Grade D for pain relief at end of treatment. 12 weeks (no benefit demonstrated). functional status (Instrumental ADL and Barthel ADL Index). level I (RCT): Grade C+ for ROM at end of treatment. Passive ROM training for shoulder versus skateboard. level I (RCT): Grade D for mobility at end of treatment. torque (change in knee isometric extensors). level I (RCT): Grade A for motor function (change in tapping) at end of treatment. gait endurance. level I (RCT): Grade A for change in gait speed. Ballistic extension training for the hand versus control. grade D for motor function (change in grasp/release) at end of treatment. and cardiopulmonary function at end of treatment. grade C+ for motor function (change in Fugl-Meyer lower extremity). grade D for motor function (change in grasp/release) at end of treatment. level I (RCT): Grade A for motor function (change in tapping) and ROM at end of treatment. level I (RCT): Grade C for pain relief at end of treatment. level I (RCT): Grade C+ for motor function (change in tapping) at end of treatment. gait endurance. Ballistic extension versus resisted grasp training for the hand. grade D for motor function (change in grasp/release) at end of treatment. 2 weeks (no benefit demonstrated). grade C for motor function (change in Fugl-Meyer upper extremity and lower extremity). 2 weeks (clinically important benefit demonstrated). Patients with subacute stroke. Patients with subacute and postacute stroke. 2 weeks (no benefit demonstrated). 2 weeks (clinically important benefit demonstrated). Resisted extension versus ballistic extension training for the hand. level I (RCT): Grade C+ for pain relief at end of treatment. . 8–10 weeks (clinically important benefit demonstrated without statistical significance). and functional status (physical function index). 2 weeks (clinically important benefit demonstrated). Patients with post-acute stroke. 12 weeks (clinically important benefit demonstrated without statistical significance). Grade C+ for ROM at end of treatment. 8–10 weeks (no benefit demonstrated). Patients with subacute and post-acute stroke. 12 weeks. 2 weeks (clinically important benefit demonstrated). grade C+ for ROM at end of treatment. 2 weeks (clinically important benefit demonstrated without statistical significance). Patients with post-acute stroke. Patients with subacute and post-acute stroke. 2 weeks (no benefit demonstrated). 2 weeks (no benefit demonstrated). change in gait speed. 2 weeks (clinically important benefit demonstrated without statistical significance). grade C motor function at end of treatment. Resisted extension versus resisted grasp training for the hand. balance (Berg balance and change in Berg balance). 2 weeks (no benefit demonstrated but favoring control). endurance.12 TOPICS IN STROKE REHABILITATION/SPRING 2006 Kinetron training for lower extremity versus control (no Kinetron). 2 weeks (no benefit demonstrated but favoring control). Patients with subacute stroke. grade D for torque (change in ankle isometric dorsiflexors) (no benefit demonstrated but favoring control). level I (RCT). grade C for motor function (change in grasp/release) at end of treatment. grade C for ROM at end of treatment. 2 weeks (no benefit demonstrated). level I (RCT): Grade A for motor function (change in tapping) at end of treatment. 2 weeks (clinically important benefit without statistical significance). grade C for motor function (change in tapping) at end of treatment. grade D+ for balance (functional reach) at end of treatment. Patients with subacute and post-acute stroke. 12 weeks (clinically important benefit favoring control demonstrated without statistical significance). Skateboard versus overhead pulley training for the shoulder. strength (change in grip strength) at end of treatment. Home-based exercise training versus control. 2 weeks (clinically important benefit demonstrated without statistical significance). grade C for motor function (change in grasp/release) and ROM at end of treatment. 2 weeks (no benefit demonstrated but favoring control). Resisted grasp training for the hand versus control. Overhead pulley versus control (passive ROM training for shoulder). grade D for motor function (change in Fugl-Meyer for shoulder. 6 weeks (no benefit demonstrated).Clinical Practice Guidelines 13 Robot-aided training versus no robot-aided training. Patients with chronic stroke. 6 weeks (clinically important benefit demonstrated without statistical significance). bal- . level I (RCT): Grade A for hip and knee extensors strength (affected side) at end of treatment. elbow. 1 month (clinically important benefit demonstrated without statistical significance). Robot-aided progressive resistance training versus robot-aided active-assisted training. 2 months. level I (RCT): Grade C+ for step reaction time at follow-up. 6 weeks. abductors. grade C for ROM (shoulder flexion) at end of treatment. grade C for motor function (change in Fugl-Meyer for shoulder. 8 weeks (no benefit demonstrated but favoring control). 6 months. 1 month. forward lateral. 8 weeks (no benefit demonstrated). level I (RCT): Grade C for decrease of spasticity. 6 weeks. motor function (change in Fugl-Meyer for wrist and hand and change in MSS for wrist and hand) at end of treatment. level I (RCT): Grade C+ for decrease of spasticity at end of treatment. Patients with chronic stroke. 2 months (clinically important benefit demonstrated). grade C+ for change in motor power for shoulder and elbow at follow-up. grade C+ for cardiopulmonary function (VO2 max) at end of treatment. Patients with chronic stroke. 3 years (no benefit demonstrated). Agility exercise versus stretching/weightshifting exercise. adductors. 6 weeks. 8 weeks. 2 months. grade C for hip and knee extensors strength (unaffected side) at end of treatment. grade D for balance at end of treatment. level I (RCT): Grade C+ for ROM (elbow extension) at end of treatment. 8 weeks (clinically important benefit demonstrated without statistical significance). 3 years. and flexors strength [%]) and functional reach (change in forward medial. and motor function (change in MSS for shoulder and elbow) at end of treatment. Music-making training versus control. motor function. Patients with post-acute stroke. 3 years (no benefit demonstrated but favoring control). 6 weeks. and coordination) at followup. (no benefit demonstrated). mobility. and strength at end of treatment. 2 months. 8 weeks (clinically important benefit demonstrated). motor function (Fugl-Meyer for shoulder. motor function (change in Fugl-Meyer hand and wrist) at end of treatment. and motor power for shoulder and elbow at end of treatment. 6 weeks (clinically important benefit demonstrated). forward. and coordination) at end of treatment. 5 weeks. and follow-up. 6 weeks (clinically important benefit demonstrated without statistical significance). and follow-up. motor function (Fugl-Meyer scale for upper extremity). 5 weeks (clinically important benefit demonstrated). grade C for balance. level I (RCT): Grade A for strength (change in elbow extensors. Water-based training versus control. and gait speed at end of treatment. Robot-assisted versus neurodevelopmental (NDT) training. elbow. change in motor power upper extremity at end of treatment. level I (RCT) and level II (CCT): Grade A for motor power for shoulder and elbow at end of treatment. muscle power at end of treatment. 5 weeks. 5 weeks. 3 years. functional status (FIM for upper extremity) at end of treatment. 6 months. and lateral reach extent) at end of treatment. and follow-up. grade B for motor function (MSS for upper extremity) at end of treatment. shoulder internal rotators. motor function (MSS for wrist and hand) at end of treatment. grade C for motor function (Fugl-Meyer upper extremity and MSS for shoulder and elbow and wrist and hand). 1 month. 10 weeks (clinically important benefit demonstrated without statistical significance). Patients with chronic stroke. 5 weeks and 6 weeks. and coordination and Motor Status Score [MSS] for shoulder and elbow) at end of treatment. Progressive-resistive robotic training versus sensorimotor training. elbow. 8 weeks. Patients with subacute-chronic stroke. motor function (change in Fugl-Meyer shoulder and elbow) at end of treatment. and follow-up. grade C+ for strength (change in shoulder external rotators and extensors strength [%]) at end of treatment. motor function (MSS for wrist and hand) at end of treatment. 10 weeks (no benefit demonstrated). 6 weeks (no benefit demonstrated). grade C for functional status (change in Barthel Index and change in FIM) at follow-up. motor power for upper extremity at end of treatment. 6 months. 1 week. 99–127 Seven subcategories of exercise therapies were administered: 1) aerobic exercises: cycle ergometer for the lower extremities (n = 185) 100.110. 10 weeks (no benefit demonstrated). level I (RCT): Grade C+ for change in strength at end of treatment. while in Langhammer’s studies. and progressive walking program/exercise on a bicycle ergometer (n = 112). n = 77).123 and for the upper body (n = 40). level I (RCT): Grade A for level of independence in performing tasks at end of treatment. step reaction time at end of treatment. ballistic extension and resisted grasp for the hand (n = 20)121. Patients with acute stroke.110. Patients with chronic stroke. These outcomes were also statistically significant (TE-Figure 1A. No benefit was demonstrated for cardiopulmonary function as measured (maximal . and 41% RD.100 as well as water-based aerobic training (n = 12)101.14 TOPICS IN STROKE REHABILITATION/SPRING 2006 ance confidence. 6) functional training (n = 106)114. 6 weeks (clinically important benefit demonstrated without statistical significance).116.111 resisted extension of fingers. In Duncan et al. TE-Figure 1A.122. grade D for level-walking and stair-walking (no benefit demonstrated but favoring control). balance training. upper extremity functional use.113 (TE-Appendix 3A).104 The length of each exercise session ranged from 20 minutes to 2 hours per day. and quality of life at end of treatment.109. respectively). 2 weeks. In total. Maximal isokinetic strengthening versus control. 4) exercises for the upper extremity: gross and fine movement exercises and muscle strengthening (n = 92).128–137 healthy subjects were used in three studies.123 resulted in clinically important benefits for cardiopulmonary function (expiration per minute [VE]).145 The remaining studies were excluded for various other reasons146–158 (TE-Table 3).107 and passive ROM (n = 20)110.103 patients were instructed to continue exercising independently for an additional 4 weeks. Mental imagery versus standard functional training. Summary of trials Twenty-eight RCTs and one CCT were included that evaluated the efficacy of different kinds of therapeutic exercises in comparison to either another type of exercise therapy or to a placebo (N = 1. 6 weeks (no benefit demonstrated). 3) exercises for the lower extremity: progressive resistance exercises (n = 230). 1 month. and 3 weeks (clinically important benefit demonstrated).116.126 active exercises with a skateboard and overhead pulley and passive ROM exercises for the shoulder (n = 28). 31 studies were excluded for the following reasons: there was no control group in 10 of the studies.118 active exercises (also for the trunk.125.115 the Bobath approach (n = 40).141.127. and the treatment programs’ durations ranged from 2 sessions per week to daily for 2 weeks to 6 months or until discharge. patients continued treatment as outpatients112. and follow-up.127 robot-aided therapy with goal-directed movements (n = 97).’s study.103. 2) therapies based on theories in neurology: proprioceptive neuromuscular facilitation (PNF. 101. Clinically important benefits were demonstrated without statistical significance for gait speed at the end of 10 weeks of treatment (33% RD. Patients with chronic stroke.102.105.120. strengthening resistive exercises using PNF patterns for upper and lower extremities or theraband exercises.143.119.121.107. grade C for quality of life and at end of treatment. 7) mixture of exercise therapies: ROM and flexibility exercises for the upper and lower extremities and trunk. n = 173). and functional status (walking measured through the Adjusted Activity Score [AAS]) at the end of 10 weeks of treatment (18%.142 two studies were not specific to stroke patients.144 and another study lacked an intervention. Table 4A).138–140 two studies had insufficient statistical data.119 and approaches based on neurophysiological and developmental theories (n = 47)106.121. muscle power according to the maximal workload. 5) balance exercises (n = 88)117.318). Table 4A). 10 weeks. Efficacy Aerobic training for patients in the subacute and chronic phases of stroke recovery versus a control group (3 RCTs. 35%.99. n = 145)108. Table 5) at the end of 8 weeks of treatment. n = 40). No other outcomes were measured. TE-Figure 2. There was no benefit demonstrated. and 6 weeks of treatments. For PNF versus the Bobath approach in subacute stroke patients (one RCT. and 6 weeks of treatment (TEFigure 3. Table 6A). Table 4B). Table 5). No other outcomes were measured. 36%. respectively. Clinically important benefits without statistical significance were demonstrated for mobility (walking distance) at the end of 8 weeks of treatment (28% RD. A clinically important benefit was found without statistical significance favoring the control therapy for pain relief (NHP–pain) at the end of 3 months of treatment (TE-Figure 5. 4. social outings. n = 212). Results favored the control group for mobility number (number of patients independent in walking) at the end of 2. Table 4C).115 no benefit was found for functional status (Barthel Index) and upper extremity muscle strength (manual muscle test) at the end of 6 weeks of treatment (TE-Figure 3.and 4-year follow-up. motor function (SMES lower extremity and trunk. gait speed. No other outcomes were measured. Table 8).109 statistically significant and clinically important benefits were found for physical fitness (highest test stage completed of the stress test and maximal workload) and mobility (stair climbing) at the end of 8 weeks of treatment (33%. n = 90). n = 131). and functional status (FIM. TE-Figure 2. 4.112. and 6 weeks of treatment and ROM of the wrist and ankle the at end of 6 weeks of treatment (TEFigure 4.119 a clinically important benefit without statistical significance was found for standing balance at the 2 and 12 week follow-up (22%–35% RD).102. Table 6B) and for ROM of the wrist number (number of patients with limited ROM) at the end of 6 weeks of treatment (TE-Figure 3. motor function (SMES upper extremity) at the end of 3 months of treatment and at the 1-year follow-up. Table 8).102. decrease of resting heart rate. VCO2 max) and motor function (Fugl-Meyer index) at the end of 10 weeks of treatment (TE-Figure 1A. quality of life (NHP–global) at the 1-year and 4-year follow-ups (26% and 22% RD. Table 4A) and for functional status (FAI total. No benefits were demonstrated for mobility (number of patients independent in walking) at the end of 2. walking outside) at 6 months (TE-Figure 1B. No other outcomes were measured. Table 6B). but results favored the control therapy for ROM of the wrist and ankle at the end of 6 weeks of treatment and functional status (Barthel Index) at the end of 3 months of treatment and at the 1-year follow-up (TE-Figure 5. and 130% RD. decrease of resting systolic and diastolic blood pressure). TE-Figure 5. No benefit was demonstrated for cardiovascular function (maximal heart rate. Table 6B).Clinical Practice Guidelines 15 heart rate. VO2 max. and functional status (Barthel Index) at 4 years follow-up (TE-Figure 5. TE-Figure 3. A clinically important benefit without statistical significance that favored control was demonstrated for sitting balance at the 12-week . TE-Figure 2. 4. and quality of life (NHP– loss of energy) at the end of 3 months of treatment (23% RD. Table 8). No benefit was demonstrated for sitting balance at end of 4 weeks of treatment. and Motor Assessment Scale) at the end of 3 months of treatment and at the 1. A clinically important benefit without statistical significance was found that favored control for ROM of the ankle (number of patients with limited ROM. For Bobath approach training in subacute stroke patients versus control (one RCT. Table 5). For PNF versus standard customary muscle training of the upper extremity in post-acute stroke patients (two RCTs. For the Bobath approach versus standard customary muscle training in acute and subacute stroke patients (three RCTs. Table 7). Table 8). respectively). balance and gait.113 clinically important benefits without statistical significance were found for motor function (SMES upper extremity) at the 4-year follow-up (16% RD). Results favored the control group for functional status during light housework activities at the end of 6 months of treatment (TE-Figure 1B. For individualized aerobic program training versus control in patients during the subacute phase of stroke (one RCT. Results favored the control group for sitting balance at the 2-week followup and standing balance at the end of 4 weeks of treatment. 102 no benefits were found for mobility (number of patients independent in walking) at the end of 2. n = 173). No other outcomes were measured. to 8-month followup. No benefit was demonstrated for sensory function of the upper extremity at the end of 4 weeks of treatment and at the 6. For progressive resistance training of the lower extremity in post-acute stroke patients versus control (one RCT. TEFigure 9. and grip strength (36% RD) and lateral pinch (30% RD) at the 6.118 no benefit was shown for motor recovery (Chedoke-McMaster Stroke Assessment [CMSA]: walking and gross motor function index section) at the end 4 weeks and 8 weeks of treatment and at the 6-month follow-up. grip strength (317% RD).16 TOPICS IN STROKE REHABILITATION/SPRING 2006 follow-up (TE-Figure 6. Table 9). Table 15) at the end of 4 weeks of treatment. No other outcomes were measured.107 a clinically important benefit with statistical significance was found for functional status (number of patients improved in more than two activities of daily living [ADL] items.127 clinically important benefits were found with statistical significance for upper extremity isometric torque (34% RD.5. and palmar pinch (119% RD) at the 6. n = 60).5.5. palmar pinch at the end of 4 weeks of treatment and at the 6. n = 77). No benefit was demonstrated. 34% RD) at end of treatment. but results favored control for gait endurance (2-minute walking test) at the end of 4 and 8 weeks of treatment and at the 6-month follow-up (TE-Figure 10. For functional task training of the upper extremity versus strength training in subacute stroke patients (one RCT.to 8-month follow-up (49%–54% RD). and pain relief and grip strength at the end of 4 weeks of treatment (TE-Figure 12. Table 10). No other outcomes were measured. 107 no benefit was demonstrated. but results favored control for functional status (number of patients improved in more than two ADL items) without statistical significance at end of 1 month of treatment (TEFigure 8.107 clinically important benefits without statistical significance were found for functional status (number of patients improved in more than two ADL items) at the end of 1 month of treatment (26% RD. For active training of the lower extremity in post-acute stroke patients versus control (no exercise) (one RCT. No other outcomes were measured.to 8month follow-up and lateral pinch at the end of 4 weeks of treatment at the 9-month follow-up (39% and 47% RD. functional status (FIM mobility). n = 77). A clinically important benefit was demonstrated without statistical significance for motor function of the upper extremity (42% RD) and functional status. respectively).to 8-month follow-up and functional status (FTHUE) at the 6. Table 15). n = 60). Table 15). Clinically important benefits favoring control without statistical significance were demonstrated for lateral pinch at the end of 4 weeks of treatment. Table 14). upper extremity sensory and motor function. For strength training in subacute stroke patients versus control (one RCT. n = 77).127 clinically important benefits without statistical significance were shown favoring functional task training for functional status (FIM self-care and FIM mobility. 24% and 17% RD. 1 month (TE-Figure 7. pain relief. n = 133). A clinically important benefit without statistical significance was demonstrated favoring strength training for grip strength (30% RD) and palmar pinch (19% RD) at the end of 4 weeks of treatment (TE-Figure 11. No other outcomes were measured.5to 8-month follow-up (TE-Figure 12. Table 14). No other outcomes were measured. Table 15). upper extremity isometric torque (62% RD).5. For progressive resistance in subacute stroke patients versus no resistance training (one RCT.5. and functional status (FTHUE) at the end of 4 weeks of treatment and at the 6. Table 11). respectively) (TE-Figure 11. Table 12). functional status (FIM self-care and FIM mobility). No benefit was demonstrated for upper extremity ROM. measured by the FTHUE (17% RD) at the end of 4 weeks of treatment.to 8-month follow-up and isometric torque at the end of 4 weeks of treatment (TE-Figure 11. The results favored control for upper extremity ROM at the end of 4 weeks of treatment and at the 6. For progressive resistance training versus active training of the lower extremity in postacute stroke patients (one RCT.5to 8-month follow-up (TE-Figure 12.5.to 8-month follow-up . TE-Figure 12. Table 14). Table 13). and upper extremity isometric torque at the 6. No other outcomes were measured. Table 18). Table 18). Table 21). For skateboard use versus overhead pulley training of the affected shoulder in subacute stroke patients (one RCT. change in gait speed (94% RD). and strength (change in grip strength. n = 28).111 no benefit was found but results favored control for pain relief (number of patients without pain) at the end of 8–10 weeks of treatment (TEFigure 17. No benefit was demonstrated for motor function (change in grasp/release and change in status-tapping. No other outcomes were measured. Table 18). Table 20). Table 22). Table 18). For passive ROM training of the affected shoulder versus skateboard use in subacute stroke patients (one RCT. 18% RD) and peak torque of shoulder flexors (47% RD) at the end of 16 weeks of treatment.121 a clinically important benefit without statistical significance was found for ROM change in finger ROM at the end of 2 weeks of treatment (42% RD). No benefit was demonstrated for peak torque of shoulder extensors and peak torque of knee extensors at the end of 16 weeks of treatment (TEFigure 13. torque (change in knee isometric extensors. balance (Berg balance and change in Berg balance). n = 20).104 clinically important benefits with statistical significance were shown for change in gait speed (48% RD). feet. For Kinetron training of the lower extremity in stroke patients during the post-acute phase of recovery versus control (no Kinetron. endurance (change in duration of bicycle exercises. but results favored control for mobility (Functional Ambulation Profile [FAP] test) at the end of 5 weeks of treatment (TE-Figure 14. 17% RD) at the end of 12 weeks of treatment (TE-Figure 15. For home-based exercise training in postacute stroke patients versus control (two RCTs.Clinical Practice Guidelines 17 (TE-Figure 12. No other outcomes were measured. A clinically important benefit without statistical significance was shown favoring control for balance (functional reach) at the end of 12 weeks of treatment (TE-Figure 15. Table 16). 164% RD).103. n = 20). A clinically important benefit was demonstrated without statistical significance for peak torque of knee flexors (16% RD) at the end of 16 weeks of treatment. Table 19). Table 18). No other outcomes were measured. 16. and cardiopulmonary function (change in peak VO2. gait endurance (change in 6minute walk test.111 no benefit was shown for pain relief (number of patients without pain) at the end of 8–10 weeks of treatment (TEFigure 18. No benefit was demonstrated for motor function (change in Fugl-Meyer upper extremity and lower extremity). For resisted extension versus ballistic extension training of the hand in subacute and postacute stroke patients (one RCT. 61% RD). n = 20). feet. gait endurance (change in 6-minute walk test. TE-Figure 19. but results favored control for torque (change in ankle isometric dorsiflexors) at the end of 12 weeks of treatment (TE-Figure 15.100 clinically important benefits with statistical significance were shown for cardiopulmonary function (VO2 max. For resisted extension exercises versus resisted grasp training of the hand in subacute and post-acute stroke patients (one RCT. n = 40).111 a clinically important benefit without statistical significance was found for pain relief (number of patients without shoulder pain) at the end of 8–10 weeks of treatment (50% RD. A clinically important benefit was demonstrated without statistical significance for motor function (change in Fugl-Meyer lower extremity. Table 15). No other outcomes were measured. 20% RD). TE-Figure 16. No other outcomes were measured. Comparing the use of an overhead pulley versus control (passive ROM training for shoulder) for subacute stroke patients (one RCT. No other outcomes were measured. No other outcomes were measured. 15% RD). 185% RD) at the end of 12 weeks of treatment (TE-Figure 15. n = 28). or functional status (In- strumental ADL and Barthel ADL Index) at the end of 12 weeks of treatment (TE-Figure 15. n = 28).7% RD). n = 112). 59% RD).121 a clinically important benefit with statistical significance was found for motor function (change in . one RCT. functional status (physical function index. Table 17). No other outcomes were measured.106 no benefit was found. No benefit was demonstrated. For combined aerobic and strength versus aerobic training alone in chronic stroke patients (one RCT. and motor function (change in MSS for shoulder and elbow) at the end of 6 weeks of treatment and at 3 years followup (32. Table 28A). and coordination) at the end of 6 weeks of treatment. but results favored control for motor function (change in tapping and change in grasp/release) and ROM (change in finger ROM) at the end of 2 weeks of treatment (TEFigure 24.99. and no benefit was demonstrated but results favored control for motor function (change in grasp/ release) at the end of 2 weeks of treatment (TEFigure 23. n = 88). change in motor power upper extremity at the end of 6 weeks treatment (15% RD). n = 20). For resisted extension training of the hand in subacute and post-acute stroke patients versus control (one RCT. and motor power for upper extremity at the end of 6 weeks of treatment (37% RD.125. No benefit was demonstrated for ROM (change in finger ROM) at the end of 2 weeks of treatment. respectively. No benefit was demonstrated. Table 27). No benefit was demonstrated for motor function (change in grasp/release) and ROM (change in finger ROM) at the end of 2 weeks of treatment (TE-Figure 22. 121 a clinically important benefit without statistical significance was found for ROM (change in finger ROM) at the end of 2 weeks of treatment (84% RD). No other outcomes were measured. and motor function (change in FuglMeyer for wrist and hand and change in MSS for wrist and hand) at the end of 6 weeks of treatment and at 3 years follow-up (TE-Figure . A clinically important benefit was demonstrated without statistical significance for ROM (change in finger ROM) at the end of 2 weeks of treatment (50% RD). For resisted grasp training of the hand in subacute and post-acute stroke patients versus control (one RCT. TE-Figure 25A.121 a clinically important benefit with statistical significance was found for motor function (change in tapping) at the end of 2 weeks of treatment (108% RD). Clinically important benefits were demonstrated without statistical significance for change in motor power for shoulder and elbow at 3 years follow-up (20% RD). functional status (FIM for upper extremity) at the end of 5 weeks and 6 weeks of treatment. respectively). n = 20). No other outcomes were measured.121 a clinically important benefit with statistical significance was shown for motor function (change in tapping) and ROM (change in finger ROM) at the end of 2 weeks of treatment (118% and 122% RD.121 a clinically important benefit without statistical significance was shown for motor function (change in tapping) and ROM (change in finger ROM) at the end of 2 weeks of treatment (112% and 97% RD. No other outcomes were measured. For robot-aided training in subacute-chronic stroke patients versus no robot-aided training (two RCTs and one CCT. Table 24).18 TOPICS IN STROKE REHABILITATION/SPRING 2006 tapping) at the end of 2 weeks of treatment (115% RD). Table 23). No other outcomes were measured. Table 25). For ballistic extension versus resisted grasp training of the hand in subacute and post-acute stroke patients (one RCT. elbow. motor function (Fugl-Meyer scale for upper extremity. No other outcomes were measured. n = 20). 26% RD) at the end of 6 weeks of treatment.126 clinically important benefits with statistical significance were shown for motor power for shoulder and elbow at the end of 5 weeks of treatment (124% RD). n = 20). No benefit was demonstrated. A clinically important benefit was demonstrated without statistical significance for ROM (change in finger ROM) at the end of 2 weeks of treatment (91%). Table 28 A&B). No benefit was demonstrated for motor function (change in Fugl-Meyer for shoulder. For ballistic extension training of the hand in subacute and post-acute stroke patients versus control (one RCT. Table 28A). respectively). respectively). A clinically important benefit with statistical significance was demonstrated for motor function (MSS for upper extremity) at the end of 6 weeks of treatment (64% RD.5% and 30. but results favored control for motor function (change in grasp/release) at the end of 2 weeks of treatment (TE-Figure 21. Table 26). TE-Figure 25A&B. motor function (Fugl-Meyer for shoulder and elbow and MSS for shoulder and elbow) at the end of 5 weeks of treatment (18% and 43% RD. motor function (MSS for wrist and hand) at the end of 5 weeks of treatment (40% RD).5% RD. TEFigure 20. TE-Figure 25A. No benefit was demonstrated for motor function (change in tapping) at the end of 2 weeks of treatment. No benefit was demonstrated for motor function (change in grasp/release. flexors and extensors strength [%]) and functional reach (change in forward medial. and coordination. forward. n = 27).117 clinically important benefits without statistical significance were shown for step reaction time at the 1-month follow-up (24% RD). increase in motor function (Fugl-Meyer scale. A clinically important benefit was demonstrated without statistical significance for strength (change in shoulder external rotators and extensors strength [%]) at the end of 2 months of treatment (47% and 198% RD. TE-Figure 26A&B. 270%. and flexors strength [%]) and functional reach (change in forward medial. respectively. No benefit was demonstrated for hip and knee strength (unaffected side) at the end of 8 weeks of treatment. for motor function (change in Fugl-Meyer shoulder and elbow) at the end of 1 month and 2 months of treatment and at 6 months follow-up. elbow. and gait speed at end of 8 weeks of treatment (16% RD). n = 20). For agility exercise versus stretching/weightshifting exercise in chronic stroke patients (one RCT. 99%. No other outcomes were measured. and motor power for the shoulder and elbow (Medical Research Council [MRC] motor power score) at the end of 6 weeks of treatment (TE-Figure 28.120 clinically important benefits without statistical significance were demonstrated for ROM (elbow extension) at the end of 10 weeks of treatment (20% RD). No other outcomes were measured. forward lateral. No benefit was demonstrated. Table 29A). No benefit was demonstrated for balance (Berg scale). abductors. internal rotators. for strength (change in elbow flexors and extensors. Table 29A&B). For robot-assisted versus neurodevelopmental (NDT) training in chronic stroke patients (one RCT. No benefit was demonstrated for functional status (change in Barthel Index) and motor function (change in FIM) at 6 months follow-up. but results favored control for motor function (change in Fugl-Meyer for shoulder. For water-based training in chronic stroke patients versus control (one RCT.122 there was no benefit shown for decrease in spasticity (measured by the Modified Ashworth scale). n = 48). n = 20). For robot-aided progressive resistance training versus robot-aided active-assisted training in chronic stroke patients (one RCT. measured by the Modified Ashworth scale (20% RD) at the end of 6 weeks of treatment. Table 29A&B). No other outcomes were measured. Table 32). Clinically important benefits were demonstrated without statistical significance for cardiopulmonary function (VO2 max) at the end of 8 weeks of treatment (20% RD). adductors. 229%. for motor function (change in FuglMeyer hand and wrist) at the end of 1 month of treatment. For music-making training in post-acute stroke patients versus control (RCT. adductors. MSS shoulder/elbow and hand/wrist). n = 18). Table 28A). and shoulder external rotators. Table 31). Table 28A&B). balance confidence (activities-specific Balance Confidence Scale). 107%. abductors. No other outcomes were measured. 134%. For progressive-resistive robotic training ver- sus sensorimotor training in chronic stroke patients (one RCT. mobility (Timed Up & Go). No other outcomes were measured. 160%.101 clinically important benefits with statistical significance were found for hip and knee extensors strength (affected side) at the end of 8 weeks of treatment (15% RD). shoulder internal rotators.Clinical Practice Guidelines 19 25A&B. and 612% RD. and lateral reach extent) at the end of 2 months of treatment (270%. No other outcomes were measured. No benefit was demonstrated for motor function (Fugl-Meyer upper extremity and MSS for shoulder/elbow and wrist/hand). Table 30). forward lateral. and lateral reach extent) at the end of 2 months of treatment (TE-Figure 26A&B. Table 33). and no benefit was demonstrated but results favored control for balance (Berg scale) at the end of 8 weeks of treatment (TE-Figure 30. TE-Figure 25A. forward. 116 a clinically important benefit with statistical significance was found for strength (change in elbow extensors. muscle power (maximal workload) at the end of 8 weeks of treatment (22% RD). TEFigure 26A. n = 12).105 clinically important benefits without statistical significance were shown for decrease in spasticity. No benefit was demonstrated for ROM (shoulder flexion) at the end of 10 weeks of treatment (TE-Figure 29. and quality of life (NHP) at the end of 10 weeks of treatment and at the 1-month follow-up . 175%. respectively. and improved strength (measured with manual muscle testing and peak force generated) at the end of 6 weeks of treatment (TE-Figure 27. and poor evidence exists to support strengthening in the rehabilitation of acute and subacute stroke patients (grade D for ROM of wrist and ankle. and level I evidence (two RCTs) for balance training in patients with acute to chronic stroke. 114 clinically important benefits with statistical significance were demonstrated for the level of independence at the end of 1 week. St. and grade D+ for pain relief ). quality of life. No benefit was demonstrated for quality of life (SF-36) at the end of 6 weeks of treatment. and level I evidence (four RCTs) for balance training as an intervention in stroke rehabilitation (Appendix 4). Where there were more than four RCTs and the results of only one was conflicting. Both the Heart and Stroke Foundation of Ontario71 and St. n = 46). Table 34). Joseph’s Health Care London73 found level I evidence (one RCT) for aggressive range of motion therapy using overhead pulleys for the shoulder (Appendix 4). Last. conflicting evidence refers to a disagreement between the findings of at least two RCTs. The Ottawa Panel found level I evidence (one RCT) for the Bobath approach training. respectively. No other outcomes were measured. Clinical recommendations compared with other guidelines The Ottawa Panel found level I evidence (three RCTs) for strengthening exercises and level I evidence (one RCT) for a strengthening and aerobic exercise program in patients post stroke. grade C+ for peak torque of knee flexors). The Ottawa Panel also found level I evidence (one RCT) for sensorimotor rehabilitation. level I evidence (two RCTs with conflicting evidence*) for sensory-motor training with robotic devices. No benefit was demonstrated. Joseph’s Health Care London. but results favored control for level walking (self-selected and maximal gait speed) and stair walking (self-reported and maximal stair climbing speed. and 3 weeks of treatment (19%. The strength of the evidence has also been graded by the Department of Veterans Affairs/Department of Defense US Army (VA/DoD).20 TOPICS IN STROKE REHABILITATION/SPRING 2006 and for step reaction time at the end of 10 weeks of treatment (TE-Figure 31. functional status. These recommendations are in accordance with previous guidelines by the VA/DoD. Appendix 4). Table 35). Strength of published evidence compared with other guidelines (five RCTs) and level II (one CCT) evidence for robot-aided training for the upper extremity. Appendix 4). 33%. For maximal isokinetic strengthening of chronic stroke patients versus control (one RCT. In comparison. and 36% RD. Table 36). No other outcomes were measured. level I The Ottawa Panel concluded that good evidence exists to recommend that chronic stroke patients participate in regular strengthening and aerobic exercise programs (grade A for cardiopulmonary function and peak torque for shoulder flexors. For mental imagery therapy versus standard functional training in acute stroke patients (one RCT. unless the study with conflicting results was of higher quality. TE-Figure 32. . n = 20). TE-Figure 33. while the Heart and Stroke Foundation of Ontario71 found level I and II evidence (RCTs and cohort trials. the Ottawa Panel found level I evidence (one RCT) for overhead pulley exercises for the shoulder of patients with subacute stroke. Joseph’s Health Care London73 found level II evidence (at least one nonexperimental study) for the restorative (Bobath) approach.75 which found level III evidence (a working group consensus) for strengthening exercises in stroke patients during the acute phase of recovery and level II evidence (well-designed cohort and case-control analytic studies) for a strengthening and aerobic exercise program in stroke rehabilitation (Appendix 4).75 The Ottawa Panel can neither corroborate or refute the findings of the Heart and Stroke Foun*According to the St. No other outcomes were measured. For this intervention.110 a clinically important benefit without statistical significance was found for change in strength (composite score of paretic side) at end of 6 weeks of treatment (112% RD). the strength of evidence found by the VA/DoD75 was also level I evidence (a properly done RCT). level I evidence (nine RCTs) for strength training. level I evidence (two RCTs) for strength training. the conclusion was based on the results of the majority of the studies. 2 weeks. subacute. not to control. func- tion and strength of the shoulder and elbow) of subacute and chronic stroke patients. All other interventions and outcomes evaluated by the Ottawa Panel could not be compared to other such previously existing clinical practice guidelines. Patients with post-acute stroke. Similarly. and chronic post-stroke patients. 2 weeks (no benefit demonstrated). grade C+ for hand movement time (forward) at end of treatment. 3 weeks (no benefit demonstrated). grade D for functional status. the evidence found by St. 2 weeks (clinically important benefit demonstrated). 3 weeks (no benefits demonstrated but favoring control). level I (RCT): Grade A for hand movement time (ipsilateral and across). Appendix 4). the Panel also found fair evidence to recommend the Bobath approach (grade C+ for motor function of the upper extremity and for quality of life) for acute and subacute patients (Appendix 4). as it resulted in increasing the number of patients who were institutionalized (Appendix 4). St. This is in line with the guidelines of the VA/DoD. although progressive-resistive robotic training produced a clinically important improvement in spasticity relative to sensorimotor training (grade C+. limited evidence was found by St. and joint velocity (maximal flexion velocity to target and to mouth) at end of treatment. Joseph’s Health Care London73 found strong evidence that strength training improves gait and sensory motor training and improves functional and motor outcomes for the shoulder and elbow but not for the wrist and hand. However.Clinical Practice Guidelines 21 dation of Ontario. Repetitive elbow joint movement training versus control. level I (RCT): Grade A for ROM in forearm supination at end of treatment. Patients with chronic stroke. 1 day (clinically important benefit demonstrated). The Panel also found good evidence for robot-assisted training for the upper extremity (grade A for motor power. Last. Clinical practice guidelines for task-oriented training Seated reaching task training versus control. grade C for reaching distance and peak vertical reaction force (ipsilateral) at end of treatment. motor function (Fugl-Meyer) at end of treatment. The Ottawa Panel. motor function (Frenchay Arm Test). Joseph’s for the use of the restorative approach (Bobath). peak vertical ground reaction force (forward and across) at end of treatment. Between the two interventions. based upon poor evidence (grades C+ and D for pain relief). because they were deemed not applicable (Appendix 4). Fair evidence was found by the Panel to support the use of balance training techniques such as the Bobath approach (grade C+ for balance standing) and agility exercise training (grade C+ for step reaction time) as interventions for acute. Adapted game training versus control. Functional upper extremity training versus . which indicate that there is good evidence that sensorimotor training for the upper limb should be included as an intervention for post-stroke rehabilitation. They found that balance training also improves outcomes. Patients with subacute stroke. does not recommend the inclusion of overhead pulley exercises as an intervention for the shoulder of subacute stroke patients. Joseph’s Health Care London73 and the Heart and Stroke Foundation of Ontario71 is against the use of overhead pulley (Appendix 4). Joseph’s guidelines also indicated that there is limited evidence that the Bobath approach improves the quality of gait.71 The Ottawa Panel could only assess the effectiveness of sensorimotor training in comparison to a program of progressive-resistive robotic training. The Ottawa Panel found good evidence to recommend a home-based exercise program that includes strength training to improve the gait of post-acute stroke patients (grades A and C+ for gait speed and endurance). St. Similarly. 2 weeks (clinically important benefit demonstrated without statistical significance). in contrast to the Ottawa Panel. there were no significant differences for motor function or motor power.75 which also do not support overhead pulley exercises. level II (CCT): Grade C for joint velocity (maximal extension velocity to target and to mouth). Trunk rotation feedback training versus control. Patients with subacute stroke. Patients with acute and subacute stroke. grade C for balance sitting at follow-up. 18. grade D for functional status (FIM self-care) and lateral pinch at end of treatment. and follow-up. Patients with subacute stroke. upper extremity ROM at end of treatment. Task-specific reach training versus standard rehabilitation. level I (RCT): Grade C+ for balance sitting at follow-up. Traditional functional retraining (TFR) approach versus NDT training. mobility. 1 month. 8 months (clinically important benefit demonstrated without statistical significance). and follow-up. functional status (FIM mobility) and motor function upper extremity at follow-up. and follow-up. palmar pinch at end of treatment. and 32 weeks. functional status (Frenchay Activities Index) at follow-up. pain relief and upper extremity sensory function at end of treatment. 6 and 32 weeks (clinically important benefit demonstrated without statistical significance). 6 months and 1 year. bathing. 4 weeks (no benefit demonstrated). quality of life (Sickness Impact Profile) at end of treatment. grade D+ for grip strength at end of treatment. 4 weeks. and 32 weeks (no benefit demonstrated). 8 months. 1 month (clinically important benefit demonstrated . 2 months (no benefit demonstrated). 18 weeks. 4 weeks. grade C for balance standing at end of treatment. grade C for functional status (FIM mobility) at end of treatment. 4 weeks. 8 months. Patients with subacute stroke. grade D for mobility at end of treatment. level I (RCT): Grade A for functional status and unilateral neglect at end of treatment. 18 and 32 weeks. and balance standing at follow-up. 6 months and 1 year (clinically important benefit demonstrated). and isometric torque at end of treatment. and follow-up. 4 weeks (clinically important benefit favoring control demonstrated without statistical significance). 20 weeks (no benefit demonstrated but favoring control). and follow-up. maximum gait speed at end of treatment. grade C+ favoring Bobath approach training for balance sitting at end of treatment. 8 months. 4 weeks. 6 weeks. grade C for functional status at end of treatment. 12 weeks. Trunk control training versus control.22 TOPICS IN STROKE REHABILITATION/SPRING 2006 control. maximum gait speed at follow-up. 6. 2 months (clinically important benefit demonstrated without statistical significance). supine-to-prone. and follow-up. 1 month. 12 and 20 weeks. level I (RCT): Grade A for quality of life (NHP) at end of treatment. 12 weeks (clinically important benefit demonstrated). 8 months (no benefit demonstrated but favoring control). 12 and 20 weeks. 8 months (no benefit demonstrated). grade C for quality of life (NHP) at follow-up. supine-to-sit. 2 and 12 weeks (clinically important benefit demonstrated without statistical significance). level I (RCT): Grade A (favoring TFR) for gross manual dexterity at follow-up. and follow-up. 2 weeks (clinically important benefit favoring control demonstrated without statistical significance). 6. 6 and 32 weeks. level I (RCT): Grade C+ for balance sitting at follow-up. 6 and 32 weeks. 4 weeks. dressing. and follow-up. and unilateral neglect at end of treatment. 12 weeks. 4 weeks. and follow-up. 1 month. Patients with subacute stroke. and feeding) at end of treatment. Patients with subacute stroke. level I (RCT): Grade C+ for postural status. grooming. 4 weeks. 4 weeks (clinically important benefit demonstrated without statistical significance). and follow-up. and quality of life (NHP) at follow-up. 18. 1 month (clinically important benefit demonstrated). and balance standing at end of treatment. functional status (FIM self-care and FTHUE) and isometric torque at follow-up. 18 weeks. grade C+ for comfortable gait speed at end of treatment. comfortable gait speed at follow-up. level I (RCT): Grade C+ for motor function upper extremity. 1 month. and follow-up. unsupported standing. stride length at follow-up. 6 months and 1 year. and functional status (time for independence: prone-to-supine. grade C+ (favoring TFR) for gait speed at end of treatment. 4 weeks. 2 and 12 weeks (no benefit demonstrated). 12 weeks. 2 weeks. and follow-up. ambulation without device. Task-specific reach training versus Bobath approach training. grade D+ for balance sitting at end of treatment. and mobility at end of treatment. Functional task training for upper extremity versus control. and follow-up. functional status (FTHUE). grip strength and lateral pinch at follow-up. 12 weeks. Patients with acute. Leisure task versus functional task (ADL selfcare) training. Patients with acute. Functional approach versus transfer approach training. and follow-up. 6 weeks (no benefit demonstrated but favoring control). 6 weeks (clinically important benefit favoring control demonstrated without statistical significance). subacute. 1 month. level I (RCT): Grade C+ for change in shoulder strength. Leisure task training versus control. grade C for functional status (time for independence: unsupported sitting) and stride length at end of treatment. subacute. grade C for resource cost perception and functional status (Barthel Index) at end of treatment. 1 year (no benefit demonstrated but favoring control). Weight garments training versus control. and post-acute stroke. games and sports]) at 6-months follow-up (no benefit demonstrated but favoring control). grade C for change in Fugl-Meyer at end of treatment. Patients with chronic stroke. grade D+ for step length symmetry and double support time symmetry at end of treatment. 6 months (no benefit demonstrated). Wolf Motor Arm Test (time). grade C for gait speed and cadence at end of treatment. Patients with chronic stroke. and mobility outside]) and leisure activities (number of patients improved on Nottingham Leisure Questionnaire Scale [shopping. and post-acute stroke. and postacute stroke. 6 months and 1 year (no benefit demonstrated but favoring control). and post-acute stroke. Patients with acute. subacute. and functional status at follow-up. Functional task (ADL self-care) training versus control. Bilateral arm training versus NDT approach. 6 weeks (no benefit demonstrated). level I (RCT): Grade C for functional status (Nottingham Extended Activities of Daily Living [EADL]) at follow-up. and hobbies]) at 6-months follow-up (no benefit demonstrated). grade D for functional status (London Handicap Scale) and leisure activities at follow-up. Task-specific training versus control. level I (RCT): Grade C for leisure activities at follow-up. gardening. cooking. level I (RCT): Grade A favoring functional approach for functional status (Edmans ADL index) and gross motor function at end of treatment. 3 months (no benefit demonstrated but favoring control). level I (RCT): Grade C for functional status (number patients improved on Barthel Index [dressing and bathing] and number patients improved on EADL Scale [cleaning. fine motor coordination. Patients with subacute stroke. grade D for balance at end of treatment. 6 weeks (clinically important benefit demonstrated without statistical significance). 6 weeks (clinically important benefit favoring control demonstrated without statistical significance). 6 months and 1 year. entertainment. Functional training (dressing practice) versus control. 6 weeks (no benefit demonstrated). level I (RCT): Grade C+ for motor function (Fugl-Meyer subscale: upper extremity and lower extremity control]) and balance (Berg Scale) at end of treat- . grade D for functional status (Rivermead ADL selfcare) at end of treatment. grade D for functional status at follow-up. 3 months (no benefit demonstrated). 6 weeks (clinically important benefit demonstrated without statistical significance). functional status (FIM). and finger dexterity at end of treatment. level I (RCT): Grade C for leisure activities and functional status at follow-up.Clinical Practice Guidelines 23 without statistical significance). level I (RCT): Grade C+ for single support time symmetry and support base width symmetry at end of treatment. 6 months and 1 year (no benefit demonstrated). Patients with chronic stroke. Functional (ADL) training versus leisure activities. Patients with acute. Patients with post-acute stroke. 6 weeks (clinically important benefit demonstrated). and selfreported use of paretic arm at end of treatment. subacute. 1 month. 6 months and 1 year (no benefit demonstrated). 6 weeks (no benefit demonstrated). level I (RCT): Grade C for functional status (Nottingham stroke dressing) at end of treatment. grade D+ for change in Wolf Motor Arm Test (weight) and elbow strength at end of treatment. 6 months and 1 year (no benefit demonstrated). grade D for functional status (number patients improved on Barthel Index [bed to chair transfers] and number of patients improved on EADL Scale [mobility on uneven ground]) and leisure activities (number of patients improved on Nottingham Leisure Questionnaire Scale [cooking. 20 weeks) and at 6-week follow-up (40%. but no clinical benefit was found at the 18-week follow-up (TOTFigure 37. 6 weeks (clinically important benefit demonstrated without statistical significance). 40%. grade C for balance (Fugl-Meyer subscale: balance) and gait speed at end of treatment. respectively). The task-oriented training exercises examined were specific to each trial and included reaching and balance tasks. and 22% RD. 189. n = 20). The adapted dice game was designed to challenge the patient’s ability to perform functional forearm supination. statistically significant and clinically important benefits were shown for hand movement time (ipsilateral and across) and peak vertical ground reaction force (forward and across) at the end of 2 weeks of intervention (one RCT. Six of these studies lacked a control group. 6 weeks (clinical benefits favoring control). and other functional tasks (Appendix 3B) In total. A clinically important effect without statistical significance was shown for the same outcome measure at the 6-week and 32-week follow-ups (18% and 22% RD. Outcomes for comfortable gait speed revealed clinically important benefits without statistical significance at the end of treatment (12 weeks. 159 RDs were −32%. and −5%. duration of follow-up. trunk control and trunk rotation training. A statistically significant and clinically important benefit with regard to degree of forearm supination was found at the end of the 1-day intervention (15% RD. finding statistically significant and clinically important benefits for quality of life (NHP) at the end of 12 weeks of treatment (−32% RD). No long-term follow-up was performed. yielded no clinically beneficial results at any time point. TOT-Figure 35. motor function (Frenchay Arm Test).184–188 and two studies did not report any outcomes of interest. RDs were −1%. the Sickness Impact Profile. Table 41). grade D for functional status (Barthel Index) at end of treatment. respectively). and 54%. Summary of trials Sixteen RCTs (n = 963) and 1 CCT (n = 27) evaluating task-oriented training in stroke were included. no clinical benefit was found for maximal joint extension velocity (to target and to mouth) or motor function (Fugl-Meyer Scale) at the end of 3 weeks of treatment. leisure activities. forward. Clinically important benefits without statistical significance were shown for hand movement time in the forward direction (−35% RD). ADLs.127.165 examined the effect of functional extremity training versus control in subacute stroke. Clinically important effects without statistical significance were shown for . time of stroke onset. 6 weeks (no benefit demonstrated). upper extremity training. −31%. 22 studies were excluded (TOT-Table 37). The RD of −31% for the Frenchay Arm Test suggested a clinically relevant advantage for the control intervention. 191–195 Efficacy In comparing seated reaching task training to control in chronic stroke patients. Results favored control for maximal joint flexion velocity (to target and to mouth). Another quality of life measure.180–183 five studies did not examine an appropriate study population. respectively. −9%. Kwakkel et al.159–173 The size and methodological quality of the trials varied widely as did the treatment schedules. Specifically. 42%. and materials required (Appendix 3B). No other outcome measures were assessed. Table 39). Table 40).174– 179 four studies provided insufficient statistical data. −42%. but no benefit at the 18-week and 32week follow-ups. No clinical benefit was demonstrated for maximum reaching distance (ipsilateral.164. 119.24 TOPICS IN STROKE REHABILITATION/SPRING 2006 ment. The only included CCT (n = 27)161 showed no statistically significant or clinically important outcomes for repetitive elbow joint movement training compared to control in subacute stroke (TOT-Figure 36. and functional status (Barthel Index). One RCT (n = 26)168 investigated the effect of adapted game training versus control in postacute stroke patients with pronator spasticity. Table 38). Patients with subacute stroke. respectively.190 The remaining studies were excluded for reasons detailed in TOT-Table 37. across) and peak vertical ground reaction force (ipsilateral) (see TOT-Figure 34. upright equilibrium. A comparison of traditional functional retraining versus NDT training in subacute stroke patients demonstrated a statistically and clinically . Clinically important effects without statistical significance were found for postural status (trunk control. however. 396%. 20 weeks) and at the 6-week and 32-week follow-ups (30%. 29%. 38%. no statistically significant differences were found comparing functional task training of the upper extremity with control for any of the outcomes measured (one RCT. Table 44). −41%. with end of treatment scores paired with follow-up scores for each outcome measure. for grip strength and lateral pinch at the 8month follow-up. With respect to mobility (number of patients using walking aids). −33%. −40%. In patients with acute and subacute stroke. There was no benefit for sitting balance at 2 weeks follow-up or for standing balance at any time point. no benefit was found at any time point and a clinically unimportant trend favoring control was seen at the end of 20 weeks of treatment. A clinically relevant effect favoring Bobath approach training was observed for sitting balance at the end of the 4-week treatment in contrast to at follow-up (20% RD).119 Clinically important effects without statistical significance favoring task-related reach were only observed for sitting balance at 12 weeks follow-up (−52% RD. 22%. −39%. one RCT (n = 20)160 showed no statistically significant differences (TOT-Figure 41. RDs were 31%. Table 43). 63%. and unilateral neglect (Bell Test) at the end of treatment (4 weeks) and at 2 months follow-up. 36%. 80%. Still. with end of treatment and follow-up values paired for each outcome measure. −50%. n = 40). and 202% RD. No clinical benefit was demonstrated for functional status (FTHUE) and isometric torque at 8 months follow-up or for pain relief and upper extremity sensory function at the end of treatment and at 8 months follow-up. motor function of the upper extremity and FIM mobility at 8 months follow-up. RDs for functional status (FIM) and unilateral neglect (Schekenberg Test. TOT-Figure 39. −49%. respectively). were observed for functional status (FTHUE) and isometric torque and motor function at the end of the 4-week treatment. Albert Test. Bell Test) were 20%. sitting equilibrium).173 trunk rotation feedback training in subacute stroke patients with severe unilateral neglect syndrome produced both clinically and statistically significant benefits compared to control in all outcomes measured at the end of treatment and at 1-month follow-up (TOTFigure 42. respectively. Table 42). 65%. For trunk control training using the Bon Saint Come device compared to standard rehabilitation control in subacute stroke patients. mobility (functional ambulation classification). Clinical benefits were not seen in two other outcomes: FIM mobility at the end of treatment and FIM self-care at 8 months follow-up. 45%. 25%. n = 60) (TOT-Figure 38. No benefit was demonstrated for functional status (FAI) at the 6-week and 32-week follow-ups. Clinically relevant effects favoring control were demonstrated for sitting balance at the end of treatment and at the 2-week follow-up (20% and 18% RD. and 22% RD. Table 45). clinically important benefits favoring task-specific reach training were shown for standing balance at the 2-week and 12-week follow-ups and for sitting balance at the 12-week follow-up. and upper extremity ROM both at the end of treatment and at follow-up. 35%. Grip strength measurement at the end of treatment revealed a clinically relevant benefit favoring control (−17% RD). Table 46). 110%. There was no benefit for standing balance at the end of treatment. 20%. 244%. The same RCT119 compared task-specific reach training to standard rehabilitation and. respectively. In one RCT (n = 22). No benefits were shown for functional status (FIM) at the end of treatment or at 2 months follow-up. and for palmar pinch at the end of the 4-week treatment and at the 8-month followup (28%. no statistically significant differences were found (one RCT. and −50%. respectively). again.Clinical Practice Guidelines 25 maximum gait speed at the end of treatment (12 weeks. found no statistically significant differences between groups (TOT-Figure 40. For task-specific reach training versus Bobath approach training in subacute stroke patients. but not at the 18-week follow-up. respectively).127 Clinically important benefits without statistical significance. 100%. Outcomes favoring control were shown for FIM self-care and lateral pinch at the end of treatment. and −24%. 56%. some of the results favored control but were without statistical significance or clinical importance (TOT-Figures 46&47. mobility outside). 144%. −39%. Table 53). no benefits were demonstrated for leisure task training versus control or for functional task training (ADL self-care) versus control for any of the reported outcomes.169 investigated the effects of leisure task training. and double support time symmetry.170 No statistically significant differences were found. dressing. −19%. of which the latter two outcomes were clinically relevant (-26% and 20% RD. supineprone. Table 52). entertainment. and time for independence in performing ADLs (prone-to-supine. functional task training (ADL selfcare). and post-acute stroke patients (TOT-Figure 48. subacute. and number of patients improved on the Nottingham Leisure Questionnaire (cooking. see Appendix 3B for treatment description). and no occupational therapy on three outcome measures in acute. There was no benefit of leisure task training compared to functional task training (ADL self-care) with regard to the results of the Nottingham Leisure Questionnaire. ambulation without a device) at the end of treatment or for fine motor coordination and finger dexterity and functional status (FIM) at any time point. Clinically important benefits without statistical significance were observed for gait speed at the end of 1 month of treatment and at the 6-month and 12-month follow-ups. No long-term follow-up was done. stride length at the 6-month and 12month follow-ups. TOT-Figure 50. Table 49). bathing. −36%. respectively. n = 79)162 produced statistically and clinically significant benefits compared to transfer approach training with regard to functional status (Edmans ADL index) and gross motor function (Rivermead Motor Assessment) at the end of 6 weeks of treatment (24% and 200% RD. The effect of weight garment training compared to control on balance and gait in chronic stroke patients was assessed by one RCT (n = 24). TOT-Figure 49. −47%. grooming. and post-acute stroke patients in one RCT (n = 466). and time for independence (unsupported sitting. No clinical benefit was observed for one measure of functional status (Nottingham stroke dressing) at the end of the 3-month intervention. games. A statistically insignificant and clinically unimportant trend favoring control was shown for number of patients improved on the EADL scale (mobility on uneven ground). number of patients improved on the Barthel Index (bed to chair transfers). −26%. One RCT (n = 30)172 evaluating functional training (dressing practice) in chronic stroke patients showed no statistically significant differences compared to control (TOT-Figure 44. A clinically important benefit without statistical significance was shown for single support time symmetry and support base width symmetry at the end of 6 weeks of treatment (−25% and −35% RD. The remaining outcomes did not show statistical significance. Parker et al. Table 48). n = 27)163 (TOTFigure 43. −48%. cooking. and −84% RD. Logan et al. No benefit was observed for the Rivermead Perceptual . A clinically relevant advantage favoring control was demonstrated for another functional status measure (Rivermead ADL self-care) at the end of treatment (−27% RD). respectively). Trends favoring control were demonstrated for balance (Berg Scale). and feeding) at the end of treatment (16%. gardening. −43%. one RCT. bathing. No benefits were shown for stride length. respectively. ambulation without device. Table 54). 125%.26 TOPICS IN STROKE REHABILITATION/SPRING 2006 significant benefit for gross manual dexterity at the 6-month and 12-month follow. and the London Handicap Scale at 6 months and 12 months followup (TOT-Figure 45. 28%. step length symmetry. respectively). For these same comparisons. Functional approach training in post-acute stroke patients (one RCT. number of patients improved on the Barthel Index (dressing. respectively. gross manual dexterity. Furthermore. or number of patients improved on the Nottingham Leisure Questionnaire (shopping. bathing). −84%. Table 47. sport) at 6 months follow-up. subacute. No benefit was shown for gait speed or cadence at the end of treatment.166 compared functional task training (ADL) to leisure task training in acute. dressing. supine-to-sit. No benefit was shown for number of patients improved on the EADL scale (cleaning. unsupported standing. the Nottingham EADL. hobbies) at 6 months follow-up. Tables 50&51).ups (97% and 94% RD. and self-reported use of paretic arm at the end of 6 weeks of treatment (59%. 25%. respectively. respectively).167 Clinically important benefits without statistical significance were demonstrated for change in shoulder strength. or resource cost (length of stay). or less beneficial (grade C+) than bilateral arm training depending on the specific outcome measure (Appendix 4). trunk rotation training. TOT-Figure 52. Indeed. No benefit was found for balance (FuglMeyer subscale: balance) and gait speed. C+) for the following interventions: seated reaching task training. No statistically significant differences were demonstrated between task-specific training in subacute stroke patients and control for any outcome measures at the end of treatment (one RCT.70 the Stroke Prevention and Educational Awareness Diffusion Collaboration. Appendix 4) The Ottawa Panel guidelines are in agreement with existing clinical practice guidelines. . The Ottawa Panel guidelines are also in concordance with St. A statistically insignificant and clinically unimportant trend was seen favoring control for functional status (Barthel Index). n = 21). TOTFigure 51. weight garment training. and task-specific training. the Barthel Index measure of functional status. no different (grade C). the neurodevelopmental approach was shown to be either more beneficial (grade D+). Strength of the published evidence compared with other guidelines Clinical recommendations compared with other guidelines The Ottawa Panel found level I (RCTs) and level II (CCT) evidence evaluating various types of taskoriented training in post-stroke rehabilitation. Notably. n = 27). Table 56). Table 55). functional upper extremity training. The VA/DoD75 stated that there is insufficient evidence to recommend for or against NDT compared to other approaches for motor retraining post stroke. The Ottawa Panel found good evidence to recommend considering task-oriented training as an approach to stroke rehabilitation. functional approach training. while the Ottawa Panel found some evidence (grade C+) that NDT is inferior to traditional functional retraining.73 which concluded that the benefit of leisure therapy post-stroke is uncertain. the Scottish Intercollegiate Guidelines Network74 supported the use of task-specific training to improve task performance. While the findings were not consistent for all outcome measures. Joseph’s Health Care London. respectively. The evidence for recommending dressing practice and repetitive elbow movement training was found to be poor (grade D.75 the Scottish Intercollegiate Guidelines Network. No long-term follow-up was carried out. Similarly.74 the Heart and Stroke Foundation of Ontario. the Wolf Motor Arm Test (time). AHCPR.171 Clinically important effects without statistical significance were shown for motor function (Fugl-Meyer subscale: upper extremity and lower extremity control) and balance (Berg Scale) (43%. traditional functional retraining. functional task training for the upper extremity.76 and the Heart and Stroke Foundation of Ontario77 all encouraged functional task training for stroke patients with functional deficits in their affected limbs. adapted game training (forearm supination task for stroke patients with pronator spasticity).71 St. trunk control training.73 and the Stroke Prevention and Educational Awareness Diffusion Collaboration76 were also based on level I evidence (RCTs). there is sufficient support (grade A. Similarly. No long-term follow-up was done. bilateral arm training. the recommendations of the VA/DoD. and 16% RD. and 16% RD. −100%. The AHCPR70 found level II evidence (non-RCTs) to support its recommendations regarding task-oriented training (Appendix 4). No benefit was found for change in motor function (Fugl-Meyer). Furthermore. task-specific reach training. No long-term follow-up was done. changes in elbow strength and the Wolf Motor Arm Test (weight) favored control to a clinically relevant degree (−123% and −50% RD. Joseph’s Health Care London.Clinical Practice Guidelines 27 Assessment battery. It is unclear whether to include or exclude leisure task training as a rehabilitation strategy based on the available evidence (grade C). No statistically significant outcomes were found for bilateral arm task training in chronic stroke patients versus a neurodevelopmental approach (one RCT. EMG-BFB training for the wrist versus control. 2 months. stride width at follow-up. 5 weeks (clinically important benefit demonstrated without statistical significance). 4 weeks. 3 months (clinically important benefit demonstrated without statistical significance). improvement in lower extremity support asymmetry at follow-up. Patients with chronic stroke. level I (RCT): Grade C+ for pain relief at end of treatment. 4 weeks. 6 weeks. grade C for active shoulder ROM at end of treatment. level I (RCT): Grade C+ for motor function at end of treatment. 3 months. mobility at end of treatment. and followup. 5 weeks (no benefit demonstrated). step length at end of treatment. Patients with acutechronic stroke. Patients with subacute and post-acute stroke. and motor function at follow-up. EMG-BFB training for the lower extremity versus placebo. gait quality at end of treatment. 3 and 9 months (clinically important benefit demonstrated). Patients with chronic stroke. and follow-up. and followup. 3 months. and follow-up. and ankle strength at end of treatment. 6 weeks. 4 weeks. stride width at end of treatment. grade C+ for motor function (time to abduct shoulder to 90º) at end of treatment. 2 months. level II (CCT): Grade B for grip strength at follow-up. 6 weeks and 2 months. 4 weeks. ankle ROM (change in active ROM) at end of treatment. 9 months (clinically important benefit favoring control demonstrated without statistical significance). grade D+ for physical abilities at follow-up. 4 weeks (clinically important benefit favoring control demonstrated without statistical significance). functional status at end of treatment. quality of life at end of treatment. ankle angle (ankle angle at heel strike) at end of treatment. (clinically important benefit demonstrated). grade D+ for grip strength at follow-up. grade D for physical abilities at end of treatment. decrease of spasticity at end of treatment. 3 months. grade C+ for knee ROM (decrease of hyperextension) at end of treatment. 4 weeks (clinically important benefit demonstrated). level II (CCT): Grade A for motor function (time to make a circle with tip of olecranon) at end of treatment. 3 months. grade C for ankle ROM (active ankle ROM) at end of treatment. level II (CCT): Grade B for ankle . level I (RCT) and level II (CCT): Grade A for change in timed ambulation on carpeted surface at end of treatment. 4 and 6 weeks. ankle angle at end of treatment. gait cycle time at end of treatment. and at follow-up. 2 months. 4 weeks. 9 months (clinically important benefit favoring control demonstrated without statistical significance). change in timed ambulation on smooth surface and improvement in ankle angle at heel strike at end of treatment. grade C+ for grip strength at end of treatment. 4 weeks. 2 months (no benefit demonstrated). EMG-BFB relaxation training for the shoulder versus control. step length at end of treatment. 2 weeks (no benefit demonstrated). 3 months. 6 weeks. 2 weeks (clinically important benefit demonstrated without statistical significance).28 TOPICS IN STROKE REHABILITATION/SPRING 2006 Clinical practice guidelines for biofeedback EMG-BFB training versus control. 2 months. grade D for knee angle at end of treatment. 2 months. global neurological status at end of treatment. EMG-BFB training for the upper extremity versus control. EMG-BFB training for the lower extremity versus control. 6 months (clinically important benefit demonstrated). 4 weeks (clinically important benefit demonstrated without statistical significance). 6 weeks. 4 weeks and 2 months. and motor function at end of treatment. 9 months. grade B for ankle ROM (change in active ankle dorsiflexion) and knee ROM (change in active knee flexion) at end of treatment. gait speed at end of treatment. 4 weeks. ankle strength at follow-up. 2 months (no benefit demonstrated but favoring control). Patients with postacute stroke. ankle angle (improvement in ankle angle at toe-off at end of treatment. 6 months. grade D+ for improvement in lower extremity support asymmetry at end of treatment. 3 months. 6 weeks. 2 months. grade C for upper extremity motor function at follow-up. 6 weeks. 2 days (no benefit demonstrated). Patients with subacute and post-acute stroke. 6 weeks. level I (RCT): Grade C+ for stride length at end of treatment. 3 months (clinically important benefit demonstrated without statistical significance). 4 weeks (clinically important benefit demonstrated without statistical significance). 8 weeks (clinically important benefit demonstrated without statistical significance). 6 weeks. 6 weeks. level II (CCT): Grade C+ for active knee ROM at end of treatment. 6 weeks (clinically important benefit demonstrated without statistical significance). 8 weeks (no benefit demonstrated). 8 weeks. grade C for step length and stride width at end of treatment. grade C for motor recovery at end of treatment. grade D+ for active ankle ROM and mobility at end of treatment. gait quality and ankle ROM at followup. 6 weeks. grade C+ for gait quality and ankle ROM at end of treatment. grade D for active elbow ROM at end of treatment.Clinical Practice Guidelines 29 strength at end of treatment. 6 weeks (no benefit demonstrated). 8 weeks. and gait speed at end of treatment. grade C for decrease of unilateral neglect (line bisection task) at end of treatment. 3 weeks (no benefit demonstrated but favoring control). EMG-BFB training for the shoulder versus placebo. 6 weeks (no benefit demonstrated). and follow-up. 3 months (clinically important benefit favoring control demonstrated without statistical significance). . 3 weeks (clinically important benefit demonstrated without statistical significance). gait speed at follow-up. 6 weeks (no benefit demonstrated). Video feedback training versus control. level II (CCT): Grade B for decrease of unilateral neglect (baking tray task) at end of treatment. grade D for decrease of unilateral neglect (line cancellation task) at end of treatment. grade C for motor function and mobility (Timed Up & Go) at end of treatment. and gait endurance (2-minute walking test) at follow-up. Patients with chronic stroke. and dexterity at follow-up. Patients with chronic stroke. level I (RCT): Grade C+ for gait speed at end of treatment. 6 weeks. 8 weeks. Patients with chronic stroke. 2 days (clinically important benefit demonstrated). Force-feedback training for upper extremity versus control. Patients with post-acute stroke. 6 weeks (clinically important benefit demonstrated without statistical significance). 6 weeks (clinically important benefit demonstrated without statistical significance). 3 months. 2 days (no benefit demonstrated but favoring control). grade D+ for wrist ROM at end of treatment. level I (RCT): Grade C+ for functional status at end of treatment. Audio and visual feedback training with general relaxation versus control. Patients with chronic stroke. and followup. Patients with subacute stroke. Patients with subacute-chronic stroke. and active ankle ROM at end of treatment. 4 weeks. BFB training versus FES. Patients with chronic stroke. and gait endurance at end of treatment. 6 weeks (no benefit demonstrated but favoring control). 12 weeks. grade D for coordination at end of treatment. and follow-up. level I (RCT): Grade C for motor function at end of treatment. level I (RCT): Grade C+ for passive elbow ROM at end of treatment. EMG-BFB training for hand versus placebo. 3 months (no benefit demonstrated). level I (RCT): Grade A for ankle ROM at end of treatment. Patients with chronic stroke. 12 weeks. Rhythmic positional BFB training versus control. grade C for ankle and knee angle and gait cycle time at end of treatment. and follow-up. 4 weeks. 3 months (no benefit demonstrated). and follow-up. and followup. EMG-BFB training for the elbow versus placebo. and follow-up. and for dexterity at end of treatment. level I (RCT): Grade C+ for upper extremity motor function at end of treatment. 4 weeks (no benefit demonstrated). 6 weeks. 6 weeks (clinically important benefit demonstrated). 8 weeks. Force-feedback training for lower extremity versus control. 196–210 The following treatments were evaluated: EMG-BFB training (n = 42)197. In total. For EMG-BFB training for the wrist of patients with chronic stroke versus control (one CCT. No benefit was demonstrated. 6 months (65% RD. 42 studies were excluded for the following reasons: there were insufficient statistical data in nine studies.221–224 there was no control group for four other studies. No benefit was demonstrated for active shoulder ROM (flexion and abduction) at end of treatment.51. 3 and 9 months (31%– 44% RD). n = 31). n = 205).47.198 clinically important benefits without statistical significance were found for motor function (Upper Extremity Function Test) at end of treatment. but results favored the control treatment for physical abilities (Finger Oscillation Test) at end of treatment.197. 3 months.50.51.198. A clinically important benefit favoring control for grip strength was demonstrated without statistical significance at follow-up.51 Treatments were given 2 to 5 times per week for 20 to 60 minutes per session. EMG-BFB training for the upper extremity (n = 31).204 clinically important benefits with statistical significance were shown for grip strength at follow-up. Table 60).178.50. 5 weeks.202 elbow (n = 16).199. healthy subjects were used. For EMG-BFB training for the lower extremity for patients with acute-chronic stroke versus control (four RCTs and five CCTs. 6 months (912% RD).209 a clinically important benefit . EMG-BFB-Figure 56. For EMG-BFB training for the upper extremity of patients with chronic stroke versus control (one CCT. n = 42). 9 months. and motor function (Fugl-Meyer) at end of treatment.212–220 the patient served as his own control in four studies.210 a clinically important benefit with statistical significance was demonstrated for motor function (time to make a circle with tip of olecranon) at end of treatment. EMG-BFB relaxation training for the shoulder (n = 20)208.209 versus control or placebo.225–227 while in another four studies there were fewer than five subjects per group. video feedback training (n = 14)207. and motor function at followup. A clinically important benefit was demonstrated without statistical significance for grip strength at end of treatment. n = 20). No other outcomes were measured.46.211 wrist (n = 18). 9 months (EMG-BFBFigure 54. No other outcomes were measured.208 clinically important benefit without statistical significance were observed for pain relief (McGill Pain Questionnaire) at end of treatment.204 and hand (n = 27)196. A clinically important benefit without statistical significance was demonstrated for motor function (time to abduct shoulder to 90º) at end of treatment. For EMG-BFB relaxation training for the shoulder for patients with subacute and postacute stroke versus control (one RCT. Table 61).237 while two studies were not clinical trials45.16.206. and BFB training versus FES (n = 36). audio and visual feedback training with general relaxation (n = 31)210. for a total duration of treatment of 2 days to 6 months. force-feedback training for the upper and lower extremities (n = 25)200 versus a control treatment. 9 months (EMG-BFB-Figure 53. Table 58). No other outcomes were measured.231–233 while no outcomes of interest were reported in three of the other studies.234–236 Three studies were meta-analyses. n = 18).239 Finally. 2 weeks (18% RD). rhythmic positional BFB training (n = 37)205.52.206. sometimes with follow-up at 2 weeks to 12 months (EMG-BFB-Appendix 3C). Table 59). A clinically important benefit favoring control was demonstrated without statistical significance for physical abilities at follow-up. 3 months (39% RD). 5 weeks (61% RD).51.238 and one study lacked standard deviations.210 for the shoulder (n = 40). eight other studies were excluded for various other reasons240–247 (EMG-BFB-Table 57).203. Efficacy For EMG-BFB training for patients with postacute stroke versus control (two RCTs. No other outcomes were measured.228–230 In three of the studies.199.203. and EMG-BFB training for the lower extremity (n = 68)16. 2 weeks (EMG-BFB-Figure 55. 3 months (25% RD).50. and follow-up.30 TOPICS IN STROKE REHABILITATION/SPRING 2006 Summary of trials Twelve RCTs and seven CCTs were found that evaluated the efficacy of various BFB techniques in the rehabilitation of acute to chronic post-stroke patients (n = 444). A clinically important benefit favoring control was demonstrated without statistical significance for improvement in lower extremity support asymmetry (single lower extremity support) at end of treatment. and follow-up. and follow-up. 2 months (EMG-BFB-Figures 57A-H. 3 weeks (24% RD). 6 weeks. step length at end of treatment. and follow-up. and global neurological status (Adams Scale) at end of treatment. and ankle ROM (change in active ankle dorsiflexion) and knee ROM (change in active flexion) at end of treatment. decrease in spasticity (Ashworth Scale) at end of treatment. 6 weeks (18% and 36% RD. stride width at end of treatment. ankle angle (at swing phase) at end of treatment. respectively). n = 16). and change in timed ambulation on smooth surface and improvement in ankle angle at heel strike at end of treatment. respectively). and for ankle angle (improvement in ankle angle at toeoff) at end of treatment. gait quality (Basmajian Scale) at end of treatment. 4 weeks (650% RD). A clinically important benefit was demonstrated without statistical significance for gait quality (number of patients improved) and ankle ROM (number of patients improved in dorsiflexion) at end of treatment. 6 weeks (64% and 27% RD. 2 months. 4 weeks (752% and 960% RD. 6 weeks. Table 63). 4 weeks (25% and 47% RD. No benefit was demonstrated for step length and stride width at end of treatment. No benefit was demonstrated. 6 weeks (20% RD). and gait quality (number of patients improved) and ankle ROM (number of patients improved in dorsiflexion) at follow-up. one RCT (n = 40)202 showed clinically important benefits without statistical significance for upper extremity motor function (Action Research Arm Test and Brunnström-Fugl-Meyer Test) at end of treatment. 3 months. 6 weeks (45% and 45% RD. respectively). A clinically important benefit was observed without statistical significance for knee ROM (decrease of hyperextension) at end of treatment. 2 months. No benefit was demonstrated for ankle ROM (active ankle ROM) at end of treatment. 3 weeks (EMGBFB-Figure 60. 4 weeks. and follow-up. gait speed at end of treatment. Table 64). 4 weeks. No other outcomes were measured. gait cycle time at end of treatment. mobility (number of patients improved in assistive devices necessary) at end of treatment. 4 and 6 weeks. 4 weeks and 2 months. 4 weeks. and follow-up. and functional status (Barthel Index) at end of treatment. No other outcomes were measured. For EMG-BFB training of the elbow for patients with chronic stroke versus placebo (one RCT. and active ankle ROM at end of treatment. respectively). n = 35). No other outcomes were measured. respectively). but results favored control for active elbow ROM (extension) at end of treatment. For EMG-BFB training of the lower extremity in patients with subacute-chronic stroke versus placebo (two CCTs. and follow-up. respectively). 6 weeks. 4 weeks. 4 weeks. quality of life (Canadian Neurological Scale) at end of treatment. Tables 62A-I). 3 months (113% and 225% RD.Clinical Practice Guidelines 31 with statistical significance was demonstrated for change in timed ambulation on carpeted surface at end of treatment. one RCT . For EMG-BFB training of the shoulder for patients with subacute and post-acute stroke versus placebo. No benefit was demonstrated for upper extremity motor function (Action Research Arm Test and Brunnström-Fugl-Meyer Test) at follow-up. ankle ROM (change in active ROM) at end of treatment. 2 months. 4 weeks. 4 weeks (29%–49% RD). 3 months. 2 months (34% RD). 3 months (50% RD). 3 months (EMGBFB-Figure 58. 2 months. step length at end of treatment. 6 weeks. Table 65).211 clinically important benefits without statistical significance were observed for passive elbow ROM (extension) at end of treatment.201 clinically important benefits with statistical significance were shown for ankle strength (number of patients improved in dorsiflexors strength) at end of treatment. No other outcomes were measured. improvement in lower extremity support asymmetry (single lower extremity support) at follow-up. 6 weeks (45% and 64% RD). 2 months. For EMG-BFB training of the hand in patients with post-acute stroke versus placebo.50. No benefit was demonstrated but results favored control for knee angle (at swing phase) at end of treatment. ankle angle (ankle angle at heel strike) at end of treatment. 2 months. 6 weeks (EMG-BFB-Figure 59. and follow-up. 6 weeks and 2 months. 6 weeks. one RCT (n = 25)200 demonstrated clinically important benefits without statistical significance for gait speed at end of treatment. respectively. 8 weeks. 6 weeks (EMG-BFB-Figure 66. For audio and visual feedback training with general relaxation for patients with chronic stroke versus control. Strength of published evidence compared with other guidelines The Ottawa Panel found level I (12 RCTs) and level II evidence (7 CCTs) concerning the use of BFB in post-stroke rehabilitation. No benefit was demonstrated for motor function (Fugl-Meyer lower extremity). 8 weeks (15% RD). 22 RCTs. n = 37). 2 days (EMG-BFB-Figure 64. and gait endurance (2-minute walking test) at follow-up. 8 weeks. 6 weeks (EMGBFB-Figure 65.207 clinically important benefits with statistical significance were found for decrease in unilateral neglect (baking tray task) at end of treatment. it also demonstrated a clinically important benefit without statistical significance favoring control for active ankle ROM (change in active dorsiflexion) and mobility (number of patients improved in assistive devices necessary) at end of treatment. No other outcomes were measured. and 2 CCTs) for the use of BFB in post-stroke rehabilitation (Appendix 4). 8 weeks. No benefit was demonstrated. n = 36). gait speed at follow-up.200 no benefit was shown for motor function (Fugl-Meyer upper extremity and Test Évaluant la Performance des Membres supérieurs des Personnes âgées [TEMPA]) at end of treatment. Table 66). and gait endurance at end of treatment. Table 72). but results favored control for coordination (finger-to-nose) at end of treatment. Table 67). 12 weeks (28% RD). EMG-BFB-Figure 62.51 clinically important benefits without statistical significance were observed for stride length at end of treatment. Tables 68A&B). 4 weeks (21% RD). one CCT (n = 31)210 showed a clinically important benefit without statistical significance for active knee ROM (change in active flexion) at end of treatment. 6 weeks. No other outcomes were measured. 3 months (62% and 71% RD. (one RCT. For force-feedback training for the upper extremity for patients with chronic stroke versus control.205 a clinically important benefit with statistical significance was shown for ankle ROM at end of treatment. No other outcomes were measured. For force-feedback training for the lower extremity for patients with chronic stroke versus control. while the Royal College of Physicians72 found both level I and II evidence (4 meta-analyses. 3 months (EMG-BFB-Figure 63. 6 weeks. No benefit was demonstrated. the VA/DoD75 found level I evidence (3 RCTs). 6 weeks (22% RD). 2 days. mobility (Timed Up & Go) at end of treatment. No benefit was demonstrated for ankle and knee angle (at swing phase) and gait cycle time at end of treatment. No benefit was demonstrated for motor recovery (Brunnstrom’s stages of recovery) at end of treatment. 4 weeks (EMG-BFBFigure 61. 12 weeks. 6 weeks (24% RD). However. n = 25). Table 70). and followup. No other outcomes were measured. No other outcomes were measured.32 TOPICS IN STROKE REHABILITATION/SPRING 2006 (n = 27)196 illustrated clinically important benefits without statistical significance for functional status (scale for judging the performance of drinking from a glass) at end of treatment. In comparison. and dexterity at end of treatment. 6 weeks. 3 months (2955% RD). and follow-up. and follow-up. and follow-up. Table 69). No benefit was demonstrated for unilateral neglect (line bisection task) at end of treatment. Table 71). 6 weeks (EMG-BFB-Figure 67. and dexterity (box and blocks) at follow-up. but results favored control for decrease in unilateral neglect (line cancellation task) at end of treatment. For FES versus BFB for patients with chronic stroke (one RCT. The Ottawa Panel found level I (one RCT) for EMG-BFB relaxation training for the shoulder and . No other outcomes were measured. For rhythmic positional BFB training for patients with chronic stroke versus control (one RCT. For video feedback training for patients with subacute stroke versus control (one CCT. and gait speed at end of treatment. 8 weeks. A clinically important benefit favoring control was demonstrated without statistical significance for wrist ROM (active wrist extension) at end of treatment. 8 weeks. 4 weeks. No other outcomes were measured. 2 days (44% RD). n = 14). The Panel also found level II evidence (two CCTs) for EMG-BFB training of the lower extremity and level I and II evidence (four RCTs and five CCTs) for EMG-BFB training for the lower extremity.71 the Ottawa Panel also found control therapies beneficial (grade D+ for physical abilities. EMG-BFB training for the elbow (grade C+ for passive ROM) for patients with chronic stroke. Joseph’s Health Care London73 guidelines that there is strong evidence that BFB training improves gait and standing post stroke. the Panel disagrees with the Royal College of Physicians that BFB systems should be routinely excluded as an intervention for post-stroke rehabilitation (Appendix 4). three CCTs. The Ottawa Panel found level I evidence (two RCTs) for EMG-BFB training. The Panel found level II evidence (one CCT) for both EMG-BFB training of the wrist and the upper extremity (one CCT). grade C+ for grip strength) for patients with chronic stroke. force-feedback training for the lower extremity (grade C+ for gait speed and gait endurance) for patients with chronic . The Scottish Intercollegiate Guidelines Network74 evidence was only based on four meta-analyses for EMG-BFB for outcomes of function and movement (Appendix 4). The Panel also found level II evidence for both audio and visual feedback training with general relaxation (one CCT) and video feedback training (one CCT). The Ottawa Panel found the following treatments beneficial: EMG-BFB training (grade C+ for motor function) for patients with post-acute stroke. unlike the Heart and Stroke Foundation. EMG-BFB training for the wrist (grade B for grip strength and motor function. The Ottawa Panel found the following treatments beneficial: rhythmic positional BFB training (grade A for ankle ROM and gait speed) for patients with chronic stroke. and grip strength. Appendix 4). and EMG-BFB training for the upper extremity (grade A and C+ for motor function) for patients with chronic stroke (Appendix 4). However. The Heart and Stroke Foundation of Ontario71 also found level I and II evidence (one case series. wrist ROM. Clinical recommendations compared with other guidelines The Ottawa Panel agrees with the VA/DoD75 that found insufficient evidence concerning the routine use of BFB as an intervention for patients undergoing post-stroke rehabilitation. In comparison. However. and one RCT) for motor impairment and functional motor recovery outcomes (Appendix 4). motor function.Clinical Practice Guidelines 33 level I evidence (one RCT) for EMG-BFB training for the elbow for patients in post-stroke rehabilitation. The Ottawa Panel found level I (one RCT) for rhythmic positional BFB training. audio and visual feedback training with general relaxation (grade C+ for active knee ROM) for patients with chronic stroke. BFB training versus FES (grade C+ for stride length) for patients with chronic stroke. and force-feedback training for the lower extremity (one RCT). The Ottawa Panel agrees with the St. EMG-BFB training for the shoulder (grade C+ for upper extremity motor function) for patients with subacute and post-acute stroke. EMGBFB training for the hand (grade C+ for functional status) for patients with post-acute stroke. The Ottawa Panel agrees with the Heart and Stroke Foundation of Ontario71 that EMG-BFB should be included as an intervention for poststroke patients who have a high level of motor return. The Ottawa Panel found the following therapies beneficial: EMG-BFB relaxation training for the shoulder (grade C+ for pain relief) in patients with subacute and post-acute stroke. forcefeedback training for the upper extremity (grade C for motor function and dexterity) for patients with chronic stroke. Joseph’s Health Care London73 found level I evidence (nine RCTs) for gait and standing outcomes (Appendix 4). and video feedback training (grade B for decrease of unilateral neglect) for patients with subacute stroke (Appendix 4). Level I evidence (one RCT) was also found for EMG-BFB training of the hand and force-feedback training of the upper extremity (one RCT). St. as well as for EMGBFB training of the shoulder (one RCT). The Ottawa Panel agrees with the Scottish Intercollegiate Guidelines Network74 that there is fair evidence that EMG-BFB should not be used routinely in the rehabilitation of function and move- ment in patients undergoing stroke rehabilitation. BFB training versus FES (one RCT). and follow-up. level I (RCT): Grade C+ for gait endurance and length of stay at end of treatment. Treadmill training and BWS versus aggressive bracing-assisted walking. change in timed ambulation and improvement in ankle ROM at heel strike. 3 months. Patients with post-acute and chronic stroke. walking distance and step length (nonaffected side) at end of treatment. 3 months (no benefit demonstrated). Treadmill training versus standard customary exercises. level II (CCT): Grade B for mobility at end of treatment. 2 and 4 weeks (clinically important benefit demonstrated without statistical significance). mobility. and mobility at end of treatment. 2 weeks (no benefit demonstrated). grade C+ for stride length at end of treatment. level I (RCT): Grade C+ for fastest comfortable gait speed. and EMG-BFB training for the lower extremity (grade A for change in timed ambulation. and quality of life at end of treatment. 4 weeks (clinically important benefit . 3 weeks (clinically important benefit demonstrated). 3 weeks (clinically important benefit demonstrated without statistical significance). and ankle angle at toe-off during gait) for patients with acute-chronic stroke was also found to be beneficial (Appendix 4). Patients with chronic stroke. level I (RCT): Grade A for fastest comfortable gait speed and stride length at end of treatment. Electrogoniometric feedback training versus control. 4 weeks. Patients with subacute stroke. 4 weeks. 2 and 4 weeks (clinically important benefit demonstrated). grade D for gait cadence at end of treatment 4 weeks. 4 weeks (clinically important benefit demonstrated without statistical significance). Patients with chronic stroke. and grade B and C+ for gait quality and ankle ROM. grade C+ for gait speed and stride length at end of treatment. grade B for ankle strength. 2 weeks (clinically important benefit demonstrated). Treadmill training combined with overground ambulation versus control. gait cycle time. Patients with subacute stroke. and gait speed and gait cadence at end of treatment. and gait cadence at end of treatment. gait speed. 3 months. 4 weeks (no benefit demonstrated but favoring control). High-speed treadmill training versus standard gait training. and follow-up. 4 weeks. 3 months (clinically important benefit demonstrated). grade C for stride length at end of treatment. 4 weeks. A control therapy (grade D+ for improvement in lower extremity support asymmetry. Patients with chronic stroke. 2 and 4 weeks. 4 months (no benefit demonstrated). and gait cadence at end of treatment. 2 weeks (clinically important benefit demonstrated without statistical significance). Clinical practice guidelines for gait training Treadmill training and body-weight support (BWS) combined with physiotherapy versus treadmill training alone. All other interventions and outcomes evaluated by the Ottawa Panel were not compared because the other previously existing clinical practice guidelines examined did not apply (Appendix 4). level I (RCT): Grade C+ for gait speed at end of treatment. and follow-up. percent body weight support (%BWS) and upper extremity support at end of treatment. level I (RCT): Grade A for step length (affected side) at end of treatment. 3 weeks (clinically important benefit demonstrated without statistical significance). 2 weeks (no benefit demonstrated). and follow-up. grade C+ for knee ROM. level I (RCT): Grade C+ for change in gait speed and maximum knee ROM (decrease of hyperextension) at end of treatment. gait cadence. and follow-up. 2 and 4 weeks (no benefit demonstrated). level I (RCT): Grade A for fastest comfortable gait speed at end of treatment. and ankle strength). 4 weeks. Low-speed treadmill training versus standard gait training. grade C for gait speed. 3 months. quality of life and walking distance at follow-up. grade C+ for gait speed at end of treatment.34 TOPICS IN STROKE REHABILITATION/SPRING 2006 stroke. Patients with chronic stroke. grade C for step width at end of treatment. 4 weeks (clinically important benefit demonstrated without statistical significance). High-speed treadmill training versus lowspeed treadmill training. 4 weeks. grade C for gait speed at follow-up. grade C for gait speed at end of treatment. level I (RCT): Grade A for gait speed and stride length at end of treatment. and 3 weeks (clinically important benefit favoring control without statistical significance). 3 weeks (clinically important benefit demonstrated). Patients with post-acute stroke. and for spasticity at end of treatment. 6 weeks. 1 week. PCI without FES (orthosis off). 6 weeks (no benefit demon- strated but favoring control). 2. grade C+ for gait cadence and gait speed at end of treatment. grade C for gait cadence at end of treatment. 4 and 12 weeks (no benefit demonstrated but favoring control). and follow-up. and 3 weeks. FES of the ankle dorsiflexors versus control for gait training. 4 weeks (clinically important benefit demonstrated without statistical significance). 4 weeks (no benefit demonstrated). level I (RCT): Grade A for stride length at end of treatment. 3 weeks (clinically important benefit demonstrated without statistical significance). decrease of spasticity (area beneath curve) at end of treatment. level I (RCT): Grade A for gait cycle time at end of treatment. Patients with chronic stroke. level 1 (RCT): Grade C for step length at end of treatment. 6 weeks (clinically important benefit demonstrated). grade D for motor function at end of treatment. 3 weeks (clinically important benefit demonstrated without statistical significance). 5 weeks (clinically important benefit demonstrated without statistical significance). grade C+ for gait cycle time at end of treatment. 6 weeks (clinically important benefit demonstrated). Patients with post-acute stroke. PCI with FES (orthosis on) at end of treatment. FES of the ankle dorsiflexors versus control for gait training. 2. grade D+ for walking ability at end of treatment. and follow-up. grade C+ for gait symmetry at end of treatment. grade D for ankle angle at end of treatment. 6 weeks (no benefit demonstrated). 5 weeks. Patients with post-acute stroke. FES versus placebo for gait training. 1. 4 weeks (no benefit demonstrated). Patients with post-acute stroke. Patients with chronic stroke. and gait symmetry at end of treatment. and follow-up. level I (RCT): Grade A for physiological cost index (PCI) with FES (orthosis on) and decrease of spasticity (area beneath curve) at end of treatment. level I (RCT): Grade A for maximum isometric voluntary contraction of ankle dorsiflexors at end of treatment. Step length BFB training versus control for gait training. grade C for motor function at end of treatment. level I (RCT): Grade A for maximum isometric voluntary contraction of ankle dorsiflexors at end of treatment. and 3 . 6 weeks (clinically important benefit demonstrated without statistical significance). 2 and 3 weeks (clinically important benefit demonstrated). 6 weeks (no benefit demonstrated). and follow-up. grade C+ for maximum isometric voluntary contraction of ankle dorsiflexors at end of treatment. gait speed without FES at end of treatment. 5 weeks. grade D for stride length and ankle and knee angle at end of treatment. and for spasticity at end of treatment. grade C for gait speed with FES (orthosis on). 4 and 12 weeks. Patients with post-acute stroke. FES versus standard rehabilitation for gait training. 3 weeks (clinically important benefit demonstrated). and decrease of spasticity (relaxation index) at end of treatment. 4 weeks. 4 weeks (no benefit demonstrated but favoring control). grade C for stride length and knee angle at end of treatment. BFB followed by FES versus control for gait training.Clinical Practice Guidelines 35 demonstrated without statistical significance). grade C+ for maximum isometric voluntary contraction of ankle dorsiflexors at end of treatment. Patients with chronic stroke. FES of the ankle dorsiflexors and/or gastrocnemius versus control for gait training. 12 weeks (clinically important benefit demonstrated). 2. grade C for gait cadence and heel-on–toe-off distance at end of treatment. 3 weeks (no benefit demonstrated). 6 weeks. Patients with post-acute stroke. Rhythmic auditory facilitation training versus control for gait training. Musical motor feedback training versus control for gait training. level I (RCT): Grade C+ for gait speed. 1 and 2 weeks. level I (RCT): Grade C+ for functional status and level of walking independence at end of treatment. grade C for walking ability at follow-up. 5 weeks (no benefit demonstrated). 4 weeks (clinically important benefit demonstrated without statistical significance). 4 weeks. stride length. 3 weeks (no benefit demonstrated). 1. and follow-up. 1. 12 weeks. grade D+ for spasticity at end of treatment. 12 and 20 weeks. 2–3 weeks (clinically important benefit demonstrated). 6 weeks. and follow-up. for spasticity at end of treatment.248–264 Eleven trials examined the use of treadmill training in patients post stroke. grade C+ for cardiovascular endurance at end of treatment. and quality of life at follow-up. while six trials utilized a control . and energy expenditure at end of treatment. and 52 weeks. grade C for mobility at end of treatment.252–255. and for walking ability at end of treatment. 1 week (clinically important benefit favoring control without statistical significance). 3 months (clinically important benefit demonstrated without statistical significance). Summary of trials Twenty-two trials were included for comparison with a total of 923 patients. 3 months. 10 weeks. comfortable gait speed and maximum gait speed at end of treatment. 2 and 3 weeks (clinically important benefit favoring control). 2–3 weeks.51.263 Of these.165 while four trials evaluated individual interventions including electrogoniometric feedback. Patients with acute and post-acute stroke. gait distance at end of treatment. 1 week (no benefit demonstrated). Placebo FES versus control for gait training. quality of life at end of treatment. and follow-up.252. 6 weeks. 10 weeks. and follow-up. and follow-up.257.249. 6 weeks. balance at end of treatment. oxygen consumption at end of treatment. Patients with subacute stroke. and follow-up. motor function at end of treatment.263 step length BFB. 18 and 32 weeks. 2–3 weeks. grade C for maximum isometric voluntary contraction of ankle dorsiflexors at end of treatment. and for walking ability at end of treatment. 32 weeks (no benefit demonstrated). functional status and cognitive status at end of treatment. 2 weeks. 5 weeks (no benefit demonstrated). and follow-up. Patients with post-acute stroke. 6. 10 months (no benefit demonstrated but favoring control). grade D for functional status and quality of life at follow-up. 5 weeks (clinically important benefit demonstrated without statistical significance). Functional lower extremity training versus control. 6 weeks. 5 weeks.262. 12 and 20 weeks. 2 and 3 weeks.262. 6 and 18 weeks.165. and follow-up. and follow-up.251. 1 week (clinically important benefit favoring control without statistical significance).264 Two trials examined functional lower extremity training. level I (RCT): Grade A for walking ability at end of treatment.51. 3 months.248. and 10 weeks. and follow-up. 12 weeks. 1 and 2 weeks.for walking ability at end of treatment. grade C+ for maximum isometric voluntary contraction of ankle dorsiflexors at end of treatment.256. and 32 weeks (no benefit demonstrated but favoring control).164.260. 2.206. Patients with post-acute stroke.36 TOPICS IN STROKE REHABILITATION/SPRING 2006 weeks. 3 weeks. 10 months. 26. 5 weeks (clinically important benefit demonstrated without statistical significance).250. gait endurance at end of treatment. 32 weeks (clinically important benefit demonstrated without statistical significance). grade C for mobility at end of treatment.16. grade D.206 and musical motor feedback. grade D for motor function at follow-up. 3. 5 weeks.164. 6 weeks (clinically important benefit demonstrated). and functional status at follow-up. grade C for walking ability at followup. 38.16 rhythmic auditory facilitation. grade D+ for walking ability at end of treatment. 3 weeks (clinically important benefit demonstrated).249. and decrease in gait energy cost at end of treatment.263 Five randomized controlled trials studied the effect of FES.253. Treadmill training and BWS versus control. 2–3 weeks (clinically important benefit favoring control demonstrated without statistical significance). 2–3 weeks. 2 and 3 weeks (no benefit demonstrated).259 Sixteen trials compared the intervention of interest with an active intervention. grade D+ for FIM locomotion at end of treatment. motor recovery at end of treatment. functional status at follow-up. motor recovery at follow-up. 10 months. and follow-up. level I (RCT): Grade A for quality of life at end of treatment. level I (RCT): Grade A for gait speed at end of treatment 2–3 weeks and follow-up. six trials examined the use of treadmill training and BWS. 18. grade C+ for comfortable gait speed and maximum gait speed at follow-up. 2 weeks. respectively. 2 weeks (44% and 15% RD. respectively)262. 3 months (108% RD)262. In addition. 4 weeks (72% RD). 2–3 weeks (98% RD)253. When comparing low-speed treadmill training . these results were not statistically significant. No other outcomes were measured. gait distance at end of treatment. No other outcomes were measured. while no benefit was demonstrated for gait speed at follow-up. and oxygen consumption at end of treatment. 10 months. 6 weeks (22% RD)249. inappropriate control group. 2 and 3 weeks. 3 months (97% and 114% RD. 2–3 weeks (35% RD). motor recovery as measured using STREAM at end of treatment. and follow-up. as measured with the FIM at end of treatment and gait speed at follow-up. fastest comfortable gait speed at end of treatment. For high-speed treadmill training versus lowspeed treadmill training in chronic stroke patients. and 10 weeks. In addition. 10 months. No benefit was demonstrated for gait speed at end of treatment. Table 74).265–283 Reasons for exclusion included insufficient statistical data. Table 77). Total treatment length varied between 2 weeks and 20 weeks. gait energy expenditure at end of treatment. 6 weeks (34% RD). No other outcomes were measured. Efficacy For treadmill training and BWS versus control. When comparing treadmill training and BWS to aggressive brace-assisted walking. or inappropriate study design. Gait-Figure 71. 3 weeks (63 and 26% RD. Twenty-seven trials were excluded (Gait-Table 73). 6 weeks. 10 weeks. However. Table 77) and clinically important benefits without statistical significance for gait speed and stride length at end of treatment. no outcomes of interest. 3. gait speed. Gait-Figure 70. clinically important benefits were demonstrated for high-speed treadmill training for stride length at end of treatment. gait endurance at end of treatment. balance at end of treatment (28% RD)262. No other outcomes were measured. 2–3 weeks (95% RD) 253. clinically important benefits were demonstrated for gait speed at end of treatment. Other outcomes were measured but no meaningful statistical data could be extracted. one RCT (n = 28)263 found a clinically important benefit for gait speed at end of treatment. % BWS (Gait-Table 79). For treadmill training and BWS combined with physiotherapy versus treadmill training alone. and cognitive status (FIM cognitive scale) at follow-up. 2 and 4 weeks (18%–34% RD).Clinical Practice Guidelines 37 group. However. this result was not statistically significant. 2 weeks (31% RD. balance (Berg). 2–3 weeks (35% RD)252 (Gait-Figure 68. and follow-up. 10 months. and follow-up. respectively) 249. 3 weeks (24% RD. functional status (FIM motor scale) at end of treatment. Gait-Figure 69. and gait cadence at end of treatment. and found a clinically important benefit with statistical significance for mobility at end of treatment (39% RD. 2. but results favored the control group for motor function (FuglMeyer scale). Gait-Figure 72. Table 78). No clinical benefit was demonstrated. or motor function (Fugl-Meyer scale). Table 76). clinically important benefits were demonstrated for high-speed training by Pohl258 (n = 60) for fastest comfortable gait speed at end of treatment. 3 months (18% and 21% RD. One CCT255 (n = 25) compared treadmill training to standard customary exercise. motor recovery and balance at follow-up. one RCT (n = 55)254 demonstrated clinically important benefits for the outcomes of gait endurance and length of stay at end of treatment. 2 weeks (18% RD).253 and follow-up. and gait cadence at end of treatment. and gait speed at end of treatment. 10 weeks. respectively. and individual treatment sessions ranged between 20 minutes and 3 hours (Gait-Appendix 3D). Sullivan (n = 24) found no difference between the two comparison groups for gait speed. 2–3 weeks (18% RD)252. Clinically important benefits without statistical significance were demonstrated for cardiovascular endurance at end of treatment. and cognitive status (FIM cognitive scale) at end of treatment. Gait-Figure 71. balance. No clinical benefits were found for mobility (Functional Ambulation Category Scale) at end of treatment. or upper extremity support at end of treatment. 10 months. a clinically important benefit favoring the control group was found for locomotion. 4 weeks (18% RD). energy expenditure at end of treatment. Table 75). respectively) and follow-up (15% and 59% RD. and follow-up.51 clinically important benefits were established for the PCI (orthosis on) and spasticity at end of treatment. FES of the ankle dorsiflexors in subacute stroke patients (one RCT. While no benefit was demonstrated for motor function at end of treatment or follow-up. and for gait cadence at end of treatment. Table 84) when compared to a control group. For high-speed treadmill training versus standard gait training (one RCT. 4 weeks (98% RD)251 (Gait-Figure 79. respectively. and 24% RD. No benefit was found for step width at end of treatment or follow-up or for quality of life (Sickness Impact Profile) and walking distance at follow-up. 4 or 12 weeks. 12 weeks (114% and 24% RD. No benefits were demonstrated for stride length at end of treatment. Gait-Figure 78. 4 weeks (112% and 71% RD. respectively. but results favoring the control group were found for gait cadence at end of treatment and follow-up and for quality of life at end of treatment. results favored the control group. No other outcomes were measured. . No benefit was established for stride length or ankle or knee angle at end of treatment. No other outcomes were measured. 2 and 4 weeks. or fastest comfortable gait speed and gait cadence at end of treatment. n = 38)256 produced clinically important benefits without statistical significance for functional status (Barthel Index) and level of walking independence (Massachusetts General Hospital Functional Ambulation Classification) at end of treatment (15% and 59% RD. for stride length (47% RD). gait cadence. n = 60). For BFB followed by FES (one RCT. there was no statistical significance.251 (n = 36). Gait-Figure 74. 2 and 4 weeks (25% and 38% RD) (Gait-Figure 73. Clinically important benefits were also established for gait cycle time at end of treatment. 4 weeks (38%. However. Gait-Figure 77. 6 weeks (25% RD)51 and for the PCI (orthosis on) at end of treatment. FES of the ankle dorsiflexors in post-acute stroke patients (one RCT. Clinically important benefits without statistical significance were demonstrated for comfortable gait speed and stride length at end of treatment. No other outcomes were measured.248 clinically important benefits were demonstrated for step length on the affected side at end of treatment and follow-up (15%–20% RD) and step length on the nonaffected side at end of treatment. gait cadence (32% RD).258 clinically important benefits were demonstrated for fastest comfortable gait speed and stride length at end of treatment. respectively). Gait-Figure 75. Gait-Figure 79. Gait-Figure 73. 6 weeks. n = 36).258 clinically important benefits were demonstrated for fastest comfortable gait speed. Table 82). For FES of the ankle dorsiflexors and/or gastrocnemius in chronic stroke patients versus control (n = 32 ). or spasticity at end of treatment. Table 86). When comparing electrogoniometric feedback training to a control group for gait training. 6 weeks (19% RD.38 TOPICS IN STROKE REHABILITATION/SPRING 2006 to standard gait training (one RCT. Gait-Figure 75. Table 85). No other outcomes were measured. n = 60). Clinically important benefits were also demonstrated for gait speed at end of treatment and follow-up (17% RD) and walking distance and step length on the nonaffected side at end of treatment (26% and 17% RD. However. However. 3 months. one RCT (n = 26)16 demonstrated clinically important benefits for change in gait speed and reduction of knee hyperextension at end of treatment. results for gait cadence and gait speed were not statistically significant. respectively. GaitFigure 76. However.51 a clinically important benefit was shown for gait cycle time at end of treatment. 3 weeks. 2 weeks (54% and 23% RD. there was no statistical significance. No other outcomes were measured. No other outcomes were measured. 4 weeks (155% and 25% RD. 4 and 12 weeks. No benefit was established for gait speed (orthosis on). n = 20)250 demonstrated clinically important benefits at end of treatment. 2 weeks. n = 27). results favored the control group. Table 86). Table 80). Table 83). Table 82). and mobility at end of treatment. No other outcomes were measured. respectively. these results were not statistically significant. or for gait speed without FES at end of treatment. No benefit was demonstrated for motor function at end of treatment. respectively. respectively. PCI (orthosis off). and gait speed (92% RD. Table 81). 4 weeks (17% RD. For treadmill training combined with overground ambulation versus control (one RCT. However. 19%. 4 weeks (35% and 124% RD. No benefits were demonstrated. respectively). Table 80). 6 and 18 weeks . and follow-up. No benefit was found for gait cadence at end of treatment. 491%. respectively. Gait-Figure 85. Table 91). two RCTs (n = 89. Clinically important benefits were also established for the maximum isometric voluntary contraction of the ankle dorsiflexors at the end of treatment. spasticity at end of treatment. and 3 weeks. n = 20)261 demonstrated clinically important benefits at end of treatment for gait speed (40% RD) and stride length (37% RD. Gait-Figure 85. No benefit was found for maximum isometric voluntary contraction of the ankle dorsiflexors at end of treatment. 2 and 3 weeks. n = 101)164. Table 93). Clinically important benefits without statistical significance were also established for maximum isometric voluntary contraction of the ankle dorsiflexors at the end of treatment.Clinical Practice Guidelines 39 Gait-Figure 80. respectively. and 238% RD. Gait-Figure 81. Table 92). stride length. A clinically important benefit without statistical significance was established for gait symmetry (19% RD. 4 weeks (GaitFigure 82. respectively. The results at 2 and 3 weeks were also statistically significant. 5 weeks (33% RD. or 3 weeks. No benefits were demonstrated for stride length or knee or ankle angle at end of treatment. and for spasticity at end of treatment 1. 5 weeks (123%. Table 89). 5 weeks (22%. 133%. Gait-Figure 85. 389%. When comparing FES in subacute stroke patients to standard rehabilitation (one RCT. 5 weeks (207%. Table 92). No benefit was demonstrated for gait cadence or heel-to–toe-off distance. 2. For FES compared to a placebo (one RCT. Gait-Figure 84. Table 90). 1. or for walking ability at end of treatment. 2 weeks. Gait-Figure 84. Clinically important benefits without statistical significance were found for the maximum isometric voluntary contraction of the ankle dorsiflexors at end of treatment. and 58% RD. respectively. 2. and follow-up. n = 14)206 demonstrated no benefit for step length at end of treatment. For functional lower extremity training versus control. 1 and 2 weeks. Table 92). respectively. 1. 2 and 3 weeks (214% and 228% RD. and follow-up. 3 weeks (20%. respectively. 2. and 157% RD. GaitFigure 86. 1 week. they were not statistically significant. 6 weeks. A clinically important benefit favoring the control group without statistical significance was established for spasticity at end of treatment. and for walking ability at end of treatment. 17%. 3 weeks (65% RD.165 showed clinically important benefits for functional status (Sickness Impact Profile) at end of treatment. Table 91). Table 93). n = 38). Rhythmic auditory facilitation training (one RCT. No benefit was demonstrated for walk- ing ability at end of treatment.259 clinically important benefits without statistical significance were established for gait speed. For musical motor feedback training versus control (one RCT. and 374% RD. 1 week. 5 weeks (47%. 527% and 567% RD. but the results favored the control group. Placebo FES (one RCT. n = 23). Table 88) when compared to a control. 1 week. n = 41)264 produced a clinically important benefit for walking ability at end of treatment. respectively. Gait-Figure 81. the results favored the control group for the outcome on ankle angle. and 3 weeks. and at follow-up. respectively. However. 5 weeks (32% and 23% RD. and 31% RD. 319%. and walking ability (Timed Up & Go) at follow-up. 5 weeks (70% and 186% RD. 1. Table 93) when compared to a control group. Gait-Figure 86. Gait-Figure 83. and gait symmetry at end of treatment. 3 weeks (218% RD. 3 weeks. No other outcomes were measured. No other outcomes were measured. and for spasticity at end of treatment. Clinically important benefits favoring the control group were found for walking ability at end of treatment. 2 and 3 weeks and follow-up.264 a clinically important benefit was demonstrated for the maximum isometric voluntary contraction of the ankle dorsiflexors at end of treatment. 5 weeks (279%. Gait-Figure 85. No other outcomes were measured.256 clinically important benefits were found for the maximum isometric voluntary contraction of the ankle dorsiflexors at the end of treatment. 1 and 2 weeks. Table 91). 240%. No other outcomes were measured. 80%. Gait-Figure 86. 12 weeks. Table 90). respectively. and follow-up. Table 88). Table 92). Gait-Figure 84. No other outcomes were measured. Table 87) when compared to a control group. and follow-up. Gait-Figure 83. and at follow-up. However. n = 41). No other outcomes were measured. Step length BFB training in stroke patients (one RCT. The panel also reported level I (RCT) evidence for the use of FES of the ankle dorsiflexors and/or gastrocnemius to increase the maximum isometric According to the Ottawa Panel. There was equally level I (RCT) evidence to support the use of treadmill training and overground ambulation to increase step length on the affected side. Where there were more than four RCTs and the results of only one was conflicting. and the PCI and to decrease spasticity. 32 weeks. 38. stride length. Gait-Figure 87. 12 and 20 weeks. gait distance. Joseph’s Health Care London. 6 weeks (19% RD. Gait-Figure 87. Table 94). balance. Gait-Figure 87. quality of life (NHP) at end of treatment. and functional status at followup. . 18 and 32 weeks (19%–23% and 18%–25% RD. conflicting evidence refers to a disagreement between the findings of at least two RCTs. the conclusion was based on the results of the majority of the studies. gait endurance. Table 94). Strength of published evidence compared to other guidelines voluntary contraction of the ankle dorsiflexors. motor recovery. Table 94). The strength of the evidence has also been graded by St. but results favoring the control group were found for functional status and quality of life at follow-up. This is in line with the Royal College of Physicians72 and Department of Veterans Affairs75 recommendations that treadmill training with partial BWS should be included as an adjunct to conventional therapy for patients undergoing stroke rehabilitation. Joseph’s Health Care London. and oxygen consumption. and follow-up. Gait-Figure 87. Joseph’s Health Care London. *According to the St. The strength of the evidence has also been graded by the Department of Veterans Affairs75 and St. respectively.73 which reported level I evidence (9 RCTs) for the use of BFB training for gait (Appendix 4). Gait-Figure 87. However. 20%. Joseph’s Health Care London. grade C+ for cardiovascular endurance. Table 94).73 The Department of Veterans Affairs reported level I (RCT) evidence for the use of multichannel FES in severe hemiplegic patients and level II evidence (cohort/case control studies) for the use of FES for gait training following stroke. Level I evidence was also found for the use of placebo FES to improve walking ability in subacute patients post stroke. or follow-up. while St. Joseph’s Health Care London. gait energy cost. The strength of the evidence has also been graded by St. Clinical recommendations compared with other guidelines The Ottawa Panel found level I (RCT) evidence for the use of treadmill training and BWS to increase gait speed and gait distance and to improve balance. Table 94) and quality of life (Sickness Impact Profile) at follow-up. motor recovery. 12 weeks (20% RD. 32 weeks (15% RD. Clinically important benefits without statistical significance were demonstrated for comfortable gait speed and maximum gait speed at follow-up. Last.40 TOPICS IN STROKE REHABILITATION/SPRING 2006 (27%. and 32 weeks. there is good evidence that treadmill training with BWS (grade A for gait speed. No benefit was demonstrated for mobility (number of patients using walking aids.73 which reported level 1 (RCT) evidence for the use of treadmill training (Appendix 4). respectively. unless the study with conflicting results was of higher quality. Level I (RCT) evidence was also found for the use of high-speed treadmill training. and oxygen consumption. and 22% RD. 6 weeks (36%–64% and 41%–66% RD. The strength of the evidence has also been graded by the Department of Veterans Affairs. Joseph’s Health Care London.72 and St. and comfortable gait speed and maximum gait speed at end of treatment. and motor recovery) should be included as an intervention for stroke patients. Gait-Figure 87.73 which found conflicting evidence* on the use of BWS and treadmill training (Appendix 4). Gait-Table 95) at end of treatment.73 which also reported level I (RCT) evidence respectively for the use of partial BWS and treadmill training. this recommendation is contrary to the recommendations by St.75 the Royal College of Physicians. 18. and 52 weeks. functional status (FAI) at follow-up. 26. 12 and 20 weeks. Joseph’s Health Care London73 reported level I evidence for the use of FES in gait training (Appendix 4). the Panel found good evidence to support the use of BFB followed by FES to increase gait cycle time and rhythmic auditory facilitation to increase gait speed and stride length. respectively. Table 94). 6. No benefit was demonstrated. Patients with subacute and post-acute stroke. 33 months (no benefit demonstrated). strength (dynamic knee flexors strength in eccentric movement). 33 months (clinically important benefit demonstrated). and strength (dynamic knee extensors strength in eccentric movement) at end of treatment. Joseph’s Health Care London.73 which found conflicting evidence* on the use of treadmill training (Appendix 4). physical performance. and spasticity.8 seconds. 10 days (clinically important benefit demonstrated). Patients with subacute stroke. gait speed. level I (RCT) and level II (CCT): Grade A for motor function (Rivermead Motor Function Scale: global and gross motor function) at end of treatment. ***Directional control is defined as the ratio of the actual distance traveled by the center of gravity from the center to end point excursion compared with the shortest distance between those two points (a straight line). Joseph’s Health Care London73 that reported strong evidence to include FES for patients un- dergoing stroke rehabilitation. level of walking independence. rate of rise in force during sit-to-stand (% of body weight/second). the Ottawa Panel is in agreement with the recommendations by St. 4 weeks. 4 weeks. time down and strength (dynamic knee extensors strength in concentric movement) at follow-up. 8 weeks.Clinical Practice Guidelines 41 The Ottawa Panel also found good evidence (grade A for fastest comfortable gait speed. This is in line with the recommendations made by St. dynamic balance (end point excursion* [right and backward]. strength (dynamic knee flexors in concentric movement). PCI. Base of support training with extrinsic auditory feedback versus control. The Ottawa Panel found good evidence (grade A for gait speed and stride length. gait cadence. 6 weeks (clinically important benefit demonstrated without statistical significance). grade C+ for gait symmetry) to support the use of rhythmic auditory stimulation as an intervention following stroke (Appendix 4). 6 months (clini- *End point excursion refers to the distance traveled by the center of gravity on the primary attempt to reach a target moving in a different direction in 0. and body weight distribution on affected lower extremity in rising and sitting at follow-up. and directional control*** [forward-backward]) at follow-up. Clinical practice guidelines for balance training Balance training (sit-to-stand) with force platform and auditory feedback versus control (no feedback). body weight distribution. and gait cycle time) in gait training for stroke patients. Joseph’s Health Care London. grade C+ for functional status. 6 weeks. gait cadence. it is in partial agreement with the conflicting guidelines made by the Department of Veterans Affairs73 that recommended FES for gait training following stroke but also found insufficient evidence to recommend multi-channel FES for severe hemiplegic patients with gait impairment (Appendix 4). **Axis velocity is the average speed of the subject’s center of gravity movement in the specified direction. body weight distribution on affected lower extremity in rising and sitting. and activities of daily living at end of treatment. 6 weeks. 6 weeks. and follow-up. and step length on the affected side) to include treadmill training without BWS as an intervention for stroke patients. stride length. level I (RCT): Grade A for step width at end of treatment. The Ottawa Panel also reported that there is good evidence to support the use of FES (grade A for maximum isometric voluntary contraction. and motor function in sit to stand at end of treatment. Again.73 which reported strong evidence for the use of rhythmic auditory stimulation in patients post stroke. In addition. grade D for time down. Balance training with visual feedback versus control. this recommendation conflicts with that of St. grade C for time up. 33 months. level I (RCT): Grade A for time up at follow-up. axis velocity** [right-left]. and follow-up. functional status at end of treatment. . 33 months (clinically important benefit favoring control demonstrated). grade C+ for strength (dynamic knee extensors strength in concentric movement) at end of treatment. Finally. timed task (duration of sit-to-stand). and followup. level I (RCT): Grade A for standing balance at end of treatment. and sway vision/sway surface). eyes closed/sway surface. grade C+ for sitting balance and standing balance at follow-up. static balance (maximal stability eye open and eye closed). 3 weeks (clinically important benefit demonstrated without statistical significance). grade D+ for sitting balance at follow-up. and standing balance at follow-up. and timed task (duration of stand-to-sit) at follow-up. 1 month. motor function (Rivermead Motor Function Scale: lower extremity and trunk) at end of treatment. and follow-up. eyes open/sway surface) at follow-up. 3 and 4 weeks. eyes closed/sway surface. and balance (Berg Scale) at end of treatment. functional mobility at end of treatment. and standing balance at end of treatment. Patients with subacute stroke. 4 weeks and 6 weeks. 6 months. 1 month. 4 weeks. balance (Berg Scale) at end of treatment. 3 weeks (clinically important benefit demonstrated). grade D+ for balance (postural sway eyes closed) at end of treatment. grade C for static balance (center of gravity alignment: eyes closed. 4 weeks. Platform training versus control. and gait cycle duration) at end of treatment. 12 weeks (clinically important benefit demonstrated without statistical significance).42 TOPICS IN STROKE REHABILITATION/SPRING 2006 cally important benefit demonstrated). 8 weeks (clinically important benefit favoring control demonstrated without statistical significance). Balance training with visual feedback versus Bobath approach training. 4 weeks (no benefit demonstrated). Patients with subacute stroke. eyes open/sway surface. static balance (ankle strategy eyes open/ sway surface) at follow-up. 8 weeks. 12 weeks (clinically important benefit demonstrated without statistical significance). and sway vision/sway surface). 4 and 6 weeks. 12 weeks. Patients with subacute stroke. mobility (stride length. motor function (Rivermead Motor Function Scale: global and lower extremity and trunk) at follow-up. Patients with subacute and post-acute stroke. Patients with subacute stroke. level I (RCT): Grade A for standing balance at end of treatment. static balance (ankle strategy eyes open. Balance training with visual feedback versus control. **Axis velocity is the average speed of the subject’s center of gravity movement in the specified direction. and follow-up. 1 month (no benefit demonstrated but favoring control). ***Directional control is defined as the ratio of the actual distance traveled by the center of gravity from the center to end point excursion compared with the shortest distance between those two points (a straight line). 6 months (no benefit demonstrated). 6 months. 6 months. functional mobility and balance (postural sway eyes opened) at follow-up. grade C for sitting balance at end of treatment. 4 weeks. and follow-up. and standing balance at follow-up. 2 weeks (clinically important benefit demonstrated). 2 weeks (clinically important benefit favoring control demonstrated without statistical significance). level I (RCT): Grade A for standing balance at follow-up. grade C for weight distribution at end of treatment. 3 weeks. gait speed at end of treatment. 3 weeks (no benefit demonstrated). 3 weeks. balance (postural sway eyes open) at end of treatment. 6 months. and follow-up. cadence. sway vision. grade C+ for sitting balance at end of treatment. dynamic balance (end point excursion* left and forward) at follow-up. 4 weeks. . level I (RCT): Grade A for standing balance at end of treatment. and sway vision/sway surface) at follow-up. 4 weeks. 2 weeks. 2 weeks (clinically important benefit demonstrated). *End point excursion refers to the distance traveled by the center of gravity on the primary attempt to reach a target moving in a different direction in 0. grade C+ for sitting balance at end of treatment. 4 weeks (no benefit demonstrated). 12 weeks. gait speed and balance (standing symmetry) at follow-up. grade C for sitting balance at follow-up. Balance training with visual feedback versus task-specific training. 1 month. motor function (Rivermead Motor Function Scale: gross motor function) at follow-up. 12 weeks (clinically important benefit demonstrated without statistical significance). eyes closed. 4 weeks. 2 weeks (no benefit demonstrated). dynamic balance-axis velocity** (forwardbackward) and dynamic balance-directional control*** (right-left). sway vision. and follow-up. eyes closed/sway surface. 2 weeks (clinically important benefit demonstrated).8 seconds. grade C for sitting balance at follow-up. grade C+ for static balance (center of gravity alignment: eyes open. grade D for static balance (maximal stability sway vision. functional mobility and gait speed at end of treatment. balance (standing symmetry) at end of treatment 3 weeks. 6 weeks. 284–293 The individual training methods varied. Clinic a l l y i m portant benefits without statistical sign i f i c a n c e were demonstrated for static balance (center of gravity alignment: eyes open.294 the treatment period was not standardized and varied between and within the treatment and control groups (BT-Table 96).294–296 In two cases. strength (dynamic knee flexors strength in eccentric movement). Statistically and clinically significant benefits favoring control were found for time down (22% RD) and motor function in sit to stand (−100% RD) at the end of treatment. timed task (duration of sit-to-stand) and body weight distribution and rate of rise in force during sit-to-stand (% of body weight/second) at 6 months follow-up (−24%. Table 99). Treatment schedules ranged from a single 30minute session per day for 2 weeks to three 15minute sessions per day for 5 days a week and over 6 weeks.284 No follow-up was done.291. but most of them employed supplementary visual or auditory feedback to guide postural balance. 29%. n = 30. −21%. insufficient statistical data were provided. n = 16. eyes closed/sway surface. Clinically important benefits without statistical significance were demonstrated for strength (dynamic knee extensors strength in concentric movement) at the end of 6 weeks of treatment (15% RD). respectively.Clinical Practice Guidelines 43 Summary of trials Ten RCTs (n = 306) and 1 CCT (n = 42) evaluating balance training in the inpatient or outpatient setting were included. BT-Figure 89. and 29% RD. A statistically insignificant and clinically unimportant trend favoring control was shown for strength (dynamic knee flexors in concentric movement) at the end of treatment and body weight distribution on affected lower extremity in rising and sitting at the 33 month follow-up. and sway vi- In comparing balance training (sit-to-stand) with force platform and auditory feedback to a control training group without BFB in subacute and post-acute stroke patients. Six RCTs (n = 196) and 1 CCT (n = 42) examined balance training with visual feedback relative to a control intervention without feedback for stroke patients in the subacute and post-acute phases of recovery.292 In general. dynamic balance (end point excursion [right and backward]). No benefit was observed for time up. sway vision.291–293 Statistically significant and clinically important benefits were shown for motor function (Rivermead Motor Function Scale: global and gross motor function) at the end of 4 weeks of treatment (40% and 42% RD. Efficacy down and strength (dynamic knee extensors strength in concentric movement) at 33 months follow-up and strength (dynamic knee extensors strength in eccentric movement) at end of treatment and follow-up. Table 99). Table 100).287The RD between experimental and control groups was 90%. body weight distribution on affected lower extremity in rising and sitting. three potentially relevant studies were excluded. BT-Figure 92. Table 100).285–289.290 In the third study. Recruited patients were in the subacute or post-acute phase of stroke (Appendix 3E). and directional control [forward-backward]) at 6 months follow-up (55%. and 88% RD. In most of the trials. respectively. BT-Figure 91. statistically significant and clinically important benefits were shown for time to rise to a standing position (time up) at 33 months follow-up (one RCT. the control interventions consisted of standard balance training without BFB or customary care (Appendix 3E). one RCT. For base of support training with extrinsic auditory feedback for subacute stroke patients compared to control. BT-Figure 92. BT-Figure 90. Benefits were also not seen for time . Table 98). functional status (Nottingham 10-point ADL scale) at the end of 4 weeks of treatment and at 8 weeks follow-up (43% and 21% RD. statistically significant and clinically important benefits were shown for step width at the end of the 10 day treatment (41% RD. physical performance (Fugl-Meyer). axis velocity [right-left]. BT-Figure 88.119. Altogether. and activities of daily living (Barthel ADL Index) at the end of 6 weeks of treatment. respectively.289. patients were positioned on force-transducing platforms such that they could monitor their relative weight distribution and center of gravity during the training exercises. Table 97).285–289. 24%. respectively.119. and motor function (Rivermead Motor Function Scale: global and lower extremity and trunk) at 8 weeks follow-up (−31% RD. and −40% RD. Clinically important benefits without statistical significance were demonstrated for sitting balance at the end of the 4-week treatment and at the 12-week follow-up (−27% and −30% RD. sway vision. and sway vision/sway surface) and static balance (ankle strategy eyes open/sway surface) at 6 months followup. BT-Figure 93. −15%. For balance training with visual feedback compared to Bobath approach training for subacute stroke patients (one RCT. gait speed at the end of treatment at 4 weeks and 6 weeks. Table 100). balance (standing symmetry) at the end of 3 weeks of treatment. There were clinically important benefits without statistical significance for sitting balance and standing balance at the 12-week follow-up (−52% and −99% RD. Clinically important benefits favoring control but without statistical significance were demonstrated for balance (postural sway with eyes closed) at the end of 3 weeks treatment and 1 month follow-up (−74% and −90% RD. and static balance (maximal stability eyes open and eyes closed). dynamic balance (axis velocity [forward-backward]. eyes closed/sway surface. motor function (Rivermead Motor Function: lower extremity and trunk) at the end of 4 weeks of treatment (37% RD. respectively. respectively. Table 99). BT-Figure 92. respectively) and standing balance at the 12-week follow-up (−31% RD). n = 40). functional mobility (Timed Up & Go) and balance (postural sway eyes opened) at 1 month follow-up and balance (Berg Scale) at the end of 6 weeks treatment and 1 month follow-up. There were clinically important benefits without statistical significance in sitting balance at the end of 4 weeks of treatment and at the 12-week follow-up (−21% and −104% RD. Table 99). eyes closed. No benefit was demonstrated for sitting balance at end of the 4 weeks of treatment. BT-Figure 92. BT-Figure 94. For balance training with visual feedback compared to control in subacute stroke patients. No benefit was demonstrated for static balance (center of gravity alignment: eyes closed. Table 100). functional mo- bility (Timed Up & Go) and gait speed at the end of 3 weeks treatment (RD: 55% and −48% RD. and gait cycle duration) at the end of 4 weeks treatment. No benefit was shown for sitting balance at the 2-week follow-up and standing balance at the end of treatment. respectively. dynamic balance (end point excursion [left and forward]) at 6 months follow-up (21% and 24% RD. eyes closed/sway surface. one RCT. static balance (ankle strategy eyes open. one RCT. Table 104). mobility (stride length.44 TOPICS IN STROKE REHABILITATION/SPRING 2006 sion/sway surface) at 6 months follow-up (−18%. respectively.119 statistically significant and clinically important improvements in standing balance were seen at the end of 4 weeks of treatment and at the 2-week follow-up (−34% and −36% RD. Similar benefits occurred for standing balance at the 12-week follow-up (−32% RD). Statistically insignificant and clinically unimportant trends favoring control were found for static balance (maximal stability sway vision. respectively. BT-Figure 91. Table 102). and balance (postural sway with eyes open) at the end of 3 weeks of treatment (17% RD. −15%. Table 103). Table 105). eyes open/sway surface. cadence. motor function (Rivermead Motor Function Scale: gross motor function) at 8 weeks followup. BTFigure 91. BT-Figure 93. n = 40)119 (BT-Figure 95. Statistically insignificant but clinically important benefits favoring control were . functional mobility (Timed Up & Go) at the end of treatment at 4 and 6 weeks. Table 100). directional control [right-left]). No benefit was demonstrated for sitting balance at the 2-week follow-up. Table 101). balance (Berg Scale) at the end of treatment at 3 and 4 weeks. statistically significant and clinically important benefits were found for standing balance at the 2-week follow-up (-30% RD. and timed task (duration of stand-tosit) at the end of 6 months follow-up. respectively). statistically significant and clinically important improvements in standing balance were shown at the end of the 4-week treatment and at the 2-week follow-up (−19% and −81% RD. BT-Figure 92. respectively). respectively. For balance training with visual feedback compared to task-specific training in subacute stroke patients. eyes open/sway surface) at 6 months follow-up. Table 100). and gait speed and balance (standing symmetry) at 1 month follow-up (BT-Figure 93. n = 40)119 (BT-Figure 96. sway vision/sway surface). 73 which found strong evidence that balance training post stroke improves outcomes. functional status at the end of 4 weeks of treatment and 8 weeks of follow-up. Patients with subacute and post-acute stroke. platform training (grade A for standing balance at the end of 6 weeks of treatment). and grade D for visual attention (Behavioral Inattention Test – conventional subtests) at end of treatment. These recommendations are in agreement with those of St. dynamic balance (end point excursion [right and backward]. change in sense of elbow . 4 weeks (no benefits demonstrated but favoring control). one RCT. The clinical practice guidelines formulated by St. motor function (Rivermead Motor Function Scale: global and gross motor function) at the end of 4 weeks of treatment. Patients with subacute stroke. rate of rise in force during sit-tostand (% of body weight/second). and directional control [forward-backward]) at 6 months follow-up. No follow-up was done. Patients with chronic post-stroke. Joseph’s Health Care London73 were based on level I (RCT) evidence. grade C+ for strength [dynamic knee extensors strength in concentric movement] at the end of 6 weeks of treatment). timed task (duration of sit-to-stand). Specifically. Sensory function training for the hand versus control. No benefit was seen for weight distribution (number of patients improved on weight distribution) at the end of the 3week treatment. dynamic balance-end point excursion (left) and (forward) at 6 months follow-up. and balance (postural sway eyes open) at the end of 3 weeks of treatment (Appendix 4). Other preexisting guidelines could not be compared to those of the Ottawa Panel. sway vision. Joseph’s Health Care London. level I (RCT): Grade C for proportion of eye movements and visual attention (Behavioral Inattention Test – behavioral subtests) at end of treatment. eyes closed/sway surface. balance training (sit-to-stand) with force platform and auditory feedback (grade A for time up at 33 months follow-up. 4 weeks (no benefit demonstrated). 4 weeks (no benefit demonstrated).Clinical Practice Guidelines 45 found for sitting balance at the 2-week follow-up (24% RD). Passive vestibular stimulation versus control. Clinical recommendations compared with other guidelines The Ottawa Panel found good evidence to recommend balance training as a rehabilitation intervention for subacute and post-acute stroke patients. n = 24)290 (BT-Figure 97. 2 weeks (clinically important benefit demonstrated without statistical significance). because they did not apply (Appendix 4). motor function (Rivermead Motor Function: lower extremity and trunk) at the end of 4 weeks of treatment. level II (CCT): Grade A for sensory function (change in location of touch. and sway vision/ sway surface) at 6 months follow-up. axis velocity [right-left]. level I (RCT): Grade C for motor function at end of treatment. represented by a change in the maximum movement amplitude of the platform (RD: 66% RD. Strength of the published evidence compared with other guidelines The Ottawa Panel found level I (RCTs) and level II (CCT) evidence evaluating balance training in poststroke rehabilitation. Tape-recorded imagery versus control. Table 106). although nonRCTs were also considered (Appendix 4). and balance training with visual feedback (grade A for standing balance at the end of 4 weeks of treatment and 2 weeks of follow-up). grade C+ for sitting balance and static balance (center of gravity alignment: eyes open. level II (CCT): Grade C+ for mobility at end of treatment. A comparison of platform training to control revealed statistically and clinically significant benefits with respect to standing balance. good evidence was found for base of support training with extrinsic auditory feedback (grade A for step width at the end of 10 days treatment). body weight distribution. Clinical practice guidelines for sensory interventions Feedback of eye movement versus control. change in twopoint discrimination. 297–305 The sensory interventions tested in the trials included passive vestibular training to improve functional ambulation. Patients with subacute stroke.175. and visual attention processing at end of treatment. retraining of hand sensory function.309 two studies assigned fewer than five patients per group.314 and in two studies the subjects served as their own controls. mental practice of upper extremity exercises using taped visual imagery.311 one study did not measure any outcomes of interest.306. and grade D for functional status (Barthel Index) at end of treatment. A clinically unimpor- . level I (RCT): Grade A for reaction time at end of treatment 5–10 weeks (clinically important benefit demonstrated). seven RCTs (n = 318) and two CCTs (n = 59) examining the efficacy of sensory interventions post stroke were included. selective attention/visual scanning.46 TOPICS IN STROKE REHABILITATION/SPRING 2006 position. rectangular area eyes open and eyes closed at end of treatment. Three of these studies lacked a control group. 4 weeks and 8 weeks (no benefit demonstrated). grade C for Brunnstrom-Fugl-Meyer log at end of treatment. 14 studies were excluded (SI-Table 107). Sensory motor integrative intervention using the affected upper extremity versus functional intervention using compensation techniques. Altogether. Visual attention training versus visuoperception training. 5–10 weeks (no benefit demonstrated). repetitive sensory-motor training (rocking chair stimulation). and change in stereognosis) at end of treatment. 2 weeks (no benefit demonstrated). perceptual learning exercises to improve standing balance. visual conceptual/ visuomotor tracking (Trail Making Test A and Trail Making Test B).318 Efficacy One RCT (n = 18)297 evaluated the effect of eye movement feedback versus control in subacute. No benefit was demonstrated for proportion of eye movements to the left/right or visual attention (behavioral subtests of Behaviour Inattention Test) at the end of 4 weeks of treatment (SI-Table 108. Perceptual learning exercise versus control. Figure 98). visual scanning/visual attention (Single Letter Cancellation Test and Double Letter Cancellation Test). Patients with post-acute stroke. 17 weeks and 43 weeks (clinically important benefit demonstrated). right-hemispheric stroke patients with left-sided visual neglect. Patients with chronic post-stroke. Brunnstrom-Fugl-Meyer log at follow-up 17 weeks. over an 8week period. Treatment schedules ranged from 5 to 10 sessions per week lasting 40 minutes each. 43 weeks and 5 years. post-acute. Rocking chair stimulation versus control. 6 weeks (clinically important benefit demonstrated). 43 weeks (no benefit demonstrated). and grade C for visual perception skills. right/ left directional orientation. 2 weeks (clinically important benefit demonstrated without statistical significance). Patients with post-acute stroke. number of patients improved more than 10% on Brunnstrom-FuglMeyer log at follow-up.316 Other reasons for exclusion are detailed in SI-Table 107.308. grade D+ for Barthel Index at follow-up. Patients were recruited in the subacute. visual attention retraining to assist driving performance. 4 weeks and 8 weeks (no benefits demonstrated but favoring control).315.312 one study examined a mixed population of patients with stroke and head injury.317.307 two studies provided insufficient statistical data. level I (RCT): Grade C for functional ability-meal preparation at end of treatment. Summary of trials In total. level I (RCT): Grade C+ for total locus length eyes open and enveloped area eyes open at end of treatment. and follow-up. Patients with subacute stroke. and sensorymotor integrative treatment (Appendix 3F). and grade C for total locus length eyes closed. or chronic phases of stroke (Appendix 3F). level I (RCT): Grade A for Brunnstrom-FuglMeyer and Action Research Arm Test at follow-up. enveloped area eyes closed. 3 weeks and 6 weeks.313 one study was a caseseries. auditory feedback to reduce visual neglect.310. 43 weeks and 5 years (clinically important benefits favoring control demonstrated without statistical significance). respectively). on the other hand. n = 39. elbow position sense (change in elbow flexion).299 Patients were asked to rock the chair back and forth using their heels and affected arm. One RCT (n = 26)303 evaluated the effect of a perceptual learning exercise in which blindfolded patients were asked to estimate the hardness of various sponges placed underneath the soles of their feet. selective atten- . Figures 104&105). SI-Table 110. respectively.298. rocking chair stimulation demonstrated statistically significant and clinically important benefits for motor function (Brunnstrom-Fugl-Meyer and Action Research Arm Test) at 43 weeks followup and 5 years follow-up (317%.301 Statistically significant but clinically unimportant benefits favoring control were shown for functional status (Barthel Index) at 4 and 8 weeks. and stereognosis at the end of 6 weeks of treatment (one CCT. 171%. skills felt to be important for driving (one RCT. Visual attention retraining exercises were developed using the Useful Field of View (UFoV) software program to target visual processing speed. Figure 100). a sensory-motor integrative approach showed no benefit compared to a functional approach for functional ability (meal preparation) at the end of 4 and 8 weeks (one RCT. No benefit was found for total locus length eyes closed. Figure 103).305 In subacute stroke. motor function (Brunnstrom-Fugl-Meyer log) at 17 weeks follow-up (17% RD). (SI-Tables 114&115. 187%. SI-Table 112. Figure 106). and selective attention. and rectangular area eyes open and eyes closed at the end of 2 weeks. respectively). In patients with subacute stroke. and motor function (number of patients improved more than 10% on Brunnstrom-Fugl-Meyer) at 17 weeks follow-up and 43 weeks follow-up (31% and 33% RD. The control group. n = 90. divided attention.98 Patients in the experimental group listened to tape-recorded visual imagery of their affected arm being used in various tasks. Retraining of hand sensory function in chronic stroke patients demonstrated statistically significant and clinically important improvements in localization of touch. ≥15%. No benefit was demonstrated for motor function (Brunnstrom-Fugl-Meyer log) after 3 weeks and 6 weeks of treatment or at 43 weeks follow-up. In to included articles. respectively) (SI-Table 111. 125%. visual scanning/visual attention (Single Letter Cancellation Test and Double Letter Cancellation Test). n = 20)300 (SITable 109. After 2 weeks of treatment. envel- oped area eyes closed. SI-Table 113. visual attention retraining provided statistically significant and clinically important benefits in reaction time at the end of treatment (20 sessions or 5–10 weeks). n = 86. The use of taped visual imagery in chronic stroke patients with right arm hemiparesis produced no benefit in motor function (% improvement in Fugl-Meyer Score) at the end of 4 weeks (one RCT. and 209% RD. SI-Table 116. No other outcome measures were assessed. No benefits were found for visual perception skills (MotorFree Visual Perception Test). The RD for this outcome was −54%. visual conceptual/visuomotor tracking (Trail Making Test A and Trail Making Test B). subacute stroke patients were seated in a rocking chair with the affected arm placed in a position contrary to the typical pattern of spasticity and supported by an inflatable long-arm splint (n = 100.Clinical Practice Guidelines 47 tant and statistically insignificant trend favoring control was observed for the conventional subtests of the Behavioral Inattention Test. based on the same study sample. respectively). and ≥15% RD. computerized visual perception retraining). n = 16. subacute and postacute stroke patients who were subjected to passive vestibular stimulation showed clinically important improvements without statistical significance in mobility as measured by the functional ambulation profile (one CCT. 285%. two-point discrimination. Figure 99). right/left directional orientation (Road Map Test). there were clinically important benefits without statistical significance for total locus length eyes open and enveloped area eyes open at the end of the 2-week treatment (−20% and −18% RD. Clinically important benefits favoring control but without statistical significance were shown for functional status (Barthel Index) at 43 weeks follow-up and 5 years follow-up (−22% and −22% RD. The RD was 52%. Figure 102). Figure 101).302 Compared to a control intervention (traditional. Compared to control. listened to a tape of introductory information about stroke that required attention and participation. bathing. 2 weeks (no benefit . There is also poor evidence to include eye movement feedback in subacute stroke patients with unilateral visual neglect. there is poor evidence to suggest an advantage of a sensory-motor integrative approach to a functional approach in improving functional status (Appendix 4). subacute and post-acute stroke). Joseph’s Health Care of London73 found that there is conflicting evidence as to whether external sensory interventions such as eye movement feedback are beneficial in the treatment of visual neglect. post-acute stroke) (Appendix 4). Finally. the evidence is poor to either include or exclude this rehabilitative strategy in patients who have entered the chronic phase of stroke. and perceptual learning exercises (grade C+ for total locus length eyes open and enveloped area eyes open at the end of 2 weeks of treatment. passive vestibular training (grade C+ for functional ambulation at the end of 2 weeks of treatment. grade C+ for motor function (ARA-grasp. 2 weeks (clinically important benefit demonstrated). Joseph’s Health Care London73 related to sensory interventions were based on level I (RCT) evidence. 2 weeks (clinically important benefit demonstrated without statistical significance). which is consistent with the Ottawa Panel’s guidelines regarding sensory function training of the hand. visual attention retraining (grade A for reaction time at the end of 20 treatment sessions. Brunnstrom-Fugl-Meyer log at 17 weeks follow-up. The value of taped visual imagery in promoting upper extremity motor function is uncertain. subacute stroke). St. and grooming.73 St. and visual attention processing (Charron Test). Joseph’s Health Care of London. including sensory function training of the hand (grade A for change in location of touch. chronic stroke). eating. The recommendations formulated by St. Strength of the published evidence compared with other guidelines The Ottawa Panel found level I (RCTs) and level II (CCT) evidence evaluating sensory interventions in post-stroke rehabilitation. level I (RCT): Grade A for motor function (Action Research Arm [ARA]-pinch and ARA-total) at end of treatment. The quality of the evidence for sensory interventions has not been evaluated by other preexisting guidelines (Appendix 4). Furthermore. and Barthel Index) at end of treatment. Clinical recommendations compared with other guidelines The Ottawa Panel found good evidence to recommend some types of sensory-based interventions for stroke rehabilitation. gross motor and grip) at end of treatment. lower extremity dressing ability. change in two-point discrimination. the Ottawa Panel’s recommendation on visual attention retraining is consistent with St. and change in stereognosis at the end of 6 weeks of treatment. rocking chair stimulation (grade A for Brunnstrom-Fugl-Meyer and Action Research Arm Test at 43 weeks and 5 years follow-up. Joseph’s Health Care of London’s73 assessment that there is strong evidence that visual scanning techniques improve visual neglect and produce associated improvements in function. Similarly. and number of patients improved more than 10% on Brunnstrom-FuglMeyer log at 17 weeks and 43 weeks follow-up. grade C for functional status (FIM upper extremity [UE] dressing ability.48 TOPICS IN STROKE REHABILITATION/SPRING 2006 tion (Bell Test). The Ottawa Panel also found poor evidence to recommend eye movement feedback for reducing visual neglect in affected stroke patients (Appendix 4). Joseph’s Health Care of London73 found strong evidence that perceptual training interventions improve perceptual functioning. Clinical practice guidelines for constraint-induced movement therapy Constraint-induced movement therapy (CIMT) versus standard customary occupational therapy. change in sense of elbow position. post-acute stroke). The recommendations of the Ottawa Panel are in agreement with the recommendations outlined by St. and Barthel Index) at end of treatment. CIMT versus control.Clinical Practice Guidelines 49 demonstrated). Motor Activity . and quality of life at end of treatment. there were fewer than five subjects per group. grade C for change in arm impairment and change in hand impairment at end of treatment. Patients with subacute stroke. 3 weeks.327.319 clinically important benefits were shown for motor function (ARApinch and ARA-total) at end of treatment. No benefit was found for CIMT versus bimanual training based on NDT for chronic stroke patients who could perform some active wrist and finger extension (one RCT. CIMT-Appendix 3G). personal care. Table 118) Clinically important benefits without statistical significance were demonstrated for motor function (ARA-grasp. 2 weeks (CIMT-Figure 107. occupation). 3) CIMT given for 6 hours per day versus CIMT given for 3 hours per day (n = 15)321.319–323 The treatment types given were as follows: 1) CIMT versus standard occupational therapy (n = 20)319. n = 20). level I (RCT): Grade A for change in functional status at end of treatment. Patients with chronic stroke who can perform some active finger and wrist extension prior to CIMT. motor function. and grip) with respective RDs of 62%. 2) CIMT versus bimanual training based upon NDT (n = 62)322.320 while the hemiplegic arm was used to perform functional tasks or ADLs (CIMT-Appendix 3G).328 Two other studies lacked sufficient numerical data. CIMT for 6 hours per day versus CIMT for 3 hours per day. RAP. CIMT consisted of the upper unaffected extremity being constrained either with an arm sling and a hand splint321–323 or padded mittens or mittens without thumbs. 10 days (clinically important benefit demonstrated). while for two other studies. level I (RCT): Grade C+ for dexterity at end of treatment. 45%. bathing. 10 days (no benefit demonstrated). Chronic stroke patients who can perform some active finger and wrist extension prior to CIMT. For three studies.23. who can perform some active finger and wrist extension prior to CIMT.330–334 (CIMT-Table 117). 2 weeks (86% and 33% RD. no benefit was demonstrated for functional status (FIM-eating. respectively). and 5) CIMT versus standard physical therapy (n = 23320. lower and upper extremity dressing ability. CIMT versus bimanual training based upon NDT. Treatment duration ranged from 1 to 6 hours per day. 2 weeks. In total. and follow-up at 6 weeks and 1 year (no benefit demonstrated).329 and the rest were excluded for various other reasons21. Patients with chronic stroke who can perform some active finger and wrist extension prior to CIMT. No other outcomes were measured. These outcomes were also statistically significant. However. 2 months (clinically important benefit demonstrated without statistical significance). over an 8-day to 2week period (CIMT-Appendix 3G). and 35%. 2 months (no benefit demonstrated). 2 months (no benefit demonstrated. gross motor. Table 118). CIMT versus standard physical therapy. level I (RCT): Grade C+ for functional status at end of treatment. the patient served as his or her own control324–326. (CIMT-Figure 107. 13 studies were excluded for the following reasons. but favoring control). level I (RCT): Grade C for functional status. grade D for change in postural control impairment at end of treatment. grade C for motor function at end of treatment. 4) CIMT versus control (n = 16)323. and frequency ranged from 5 to 7 days a week.319. For CIMT compared to standard customary occupational therapy for subacute stroke patients who could perform some active wrist and finger extension (one RCT. Patients with acute stroke. Summary of trials Efficacy Five RCTs involving CIMT for stroke patients were included (n = 136). n = 62)322 with respect to the following outcomes: functional status (Rehabilitation Active Profile [RAP]. grooming. and follow-up at 1 month (clinically important benefit demonstrated without statistical significance). Joseph’s Health Care London73 also found level I evidence (two or more RCTs) for the use of CIMT in stroke patients. be included as an intervention for patients undergoing stroke rehabilitation (Appendix 4). Strength of published evidence compared with other guidelines The Ottawa Panel found level I evidence (five RCTs)319–323 for the use of CIMT in the treatment of subacute. Table 121).323 a clinically important benefit was demonstrated for change in functional status (change in MAL-ADL assessment) at end of treatment. results favored control for change in postural control impairment (CMII score) at end of treatment. These Ottawa Panel recommendations are in agreement with the guidelines set out by the VA/ DoD75 that CIMT should be considered as a treatment for a select group of patients with 20º of wrist extension and 10º of finger extension who have no sensory and cognitive deficits. The strength of the evidence has not been measured by other previous guidelines (Appendix 4). Both the VA/DoD75 and St. n = 23)320 with respect to arm and hand dexterity (Action Research Arm Test [ARAT] score) at end of treatment. n = 16). In comparing CIMT for chronic stroke patients with some active wrist and finger extension to control (one RCT. but no benefit was demonstrated. gross motor. Appendix 4).50 TOPICS IN STROKE REHABILITATION/SPRING 2006 Log (MAL: amount of use and quality of movement in ADL). acute. 2 months (CIMT-Figure 111. 6 weeks and 1 year. No other outcomes were measured. and grip]). 1 month (26% and 15%–28% RD. respectively).321 a clinically important benefit was found for functional status (MAL: amount of use and quality of movement in ADL) at end of treatment. . No other outcomes were measured (CIMT-Figure 108A-C. Table 120). No benefit was demonstrated for motor function (change in Wolf Function Test) at end of treatment. as they did not apply to the recommendations of the Ottawa Panel. No other outcomes were measured. However. 10 days. No benefit was demonstrated for change in arm and hand impairment (Chedoke-McMaster Impairment Inventory [CMII] score) at end of treatment. 10 days (22% RD). and follow-up. Joseph’s Health Care London73 also recommended that constraint-induced therapies. According to the VA/DoD. The Panel also found good evidence to recommend that CIMT be considered as an intervention for the treatment of chronic stroke patients with some active finger and wrist extension prior to CIMT (grade A for change in functional status. and follow-up. St. and chronic stroke patients. Table 122). No other outcomes were measured (CIMT-Figure 109. Clinical recommendations compared with other guidelines The Ottawa Panel found good evidence to recommend the consideration of the inclusion of CIMT in the treatment of subacute stroke patients with some active finger and wrist extension prior to CIMT (grade A for motor function [ARA pinch and total] and grade C+ for motor function [ARAgrasp. 2 months. 3 weeks. n = 15). This outcome was also statistically significant (CIMT-Figure 110. 2 months (40% RD)(CIMT-Figure 111. Table 119). 2 weeks.75 the only demonstrated benefit to date occurs in individuals who receive between 6 and 8 hours of daily training for at least 2 weeks. Table 122). For CIMT for 6 hours per day versus CIMT for 3 hours per day for chronic stroke patients with some active wrist and finger extension (one RCT. as opposed to traditional therapies. motor function (ARA-test score and Fugl-Meyer). Other preexisting guidelines could not be compared. Clinically important benefits without statistical significance were found for CIMT versus standard physical therapy for acute stroke patients (one RCT. and quality of life (MAL-problem score) at end of treatment. 1 day. FES of the supraspinatus versus no treatment. motor function (UE function). where the v = vertical component of the glenohumeral alignment is determined by measuring the vertical distance between the acromial point and the central point of the humeral head in millimeters. level I (RCT): Grade C+ for ROM (active abduction [ABD]) at end of treatment. 6 weeks (no benefit demonstrated). and 24 months (clinically important benefit demonstrated). Support methods – Henderson shoulder ring versus no support. 6 weeks (clinically important benefit demonstrated without statistical significance). Patients with post-acute stroke. but favoring control). and follow-up. 6 weeks. 8 weeks (clinically important benefit demonstrated without statistical significance). level I (RCT): Grade C for decrease in shoulder subluxation at end of treatment. Patients with post-acute stroke. Patients with subacute stroke. 4 weeks. 6. 6 weeks. FES of the supraspinatus versus FES of the *v-value is calculated by using a radiological technique. grade B for pain relief at end of treatment 3. 12. Support methods – Bobath versus Henderson. level I (RCT): Grade C+ for shoulder lateral ROM (SLROM). 8 weeks. level I (RCT): Grade C+ for pain relief at end of treatment. . motor function. level II (CCT): Grade B for decrease in shoulder subluxation at end of treatment. 12. 8 weeks (no benefit demonstrated). 6. **The degree of subluxation was determined on the x-ray by measuring the shortest perpendicular distance (in mm) between tangents drawn through the inferior border of the acromion and the most superior aspect of the head of the humerus of the affected upper extremity. and decrease in shoulder subluxation**(mm) at end of treatment. and follow-up. and motor function (% of patients with recovery of motor function) and decrease in shoulder subluxation (% of decreased shoulder subluxation) at end of treatment. grade C for decrease in shoulder subluxation at end of treatment. 1 day (clinically important benefit demonstrated). 4 weeks.Clinical Practice Guidelines 51 Clinical practice guidelines for shoulder subluxation FES versus control. 6 weeks (no benefit demonstrated). FES versus control. and follow-up. level II (CCT): Grade B for decrease in shoulder subluxation at end of treatment. 4 weeks. grade C for ROM (passive external rotation) and pain relief at end of treatment. level II (CCT): Grade C for decrease in shoulder subluxation at end of treatment. 6 weeks. Patients with post-acute stroke. Patients with chronic stroke. 1 day (clinically important benefit demonstrated). 6 weeks. 12 and 18 weeks (no benefit demonstrated). Patients with acute stroke. level I (CCT): Grade C+ for muscle force and decrease in shoulder subluxation at end of treatment. Patients with subacute stroke. Patients with subacute stroke. Support methods – Bobath shoulder roll versus no support. and follow-up. and 24 months. 6 weeks (clinically important benefit demonstrated without statistical significance). 2 months (clinically important benefit demonstrated without statistical significance).” middle deltoid. decrease in shoulder subluxation (vvalue* difference). level I (RCT) and level II (CCT): Grade A for SLROM. 8 weeks (no benefit demonstrated. and improvement of muscle tone on affected upper extremity (UE) at end of treatment. grade C for SLROM and decrease in shoulder subluxation at follow-up. level I (CCT): Grade C+ for muscle force at end of treatment. Patients with chronic stroke. level II (CCT): Grade C+ for muscle force and decrease in shoulder subluxation at end of treatment. and muscle bulk at end of treatment. 6 weeks (clinically important benefit demonstrated without statistical significance). Patients with chronic stroke. 12 and 18 weeks (clinically important benefit demonstrated). grade D for motor function at follow-up. Strapping versus no strapping. Shoulder positioning versus no treatment. and decrease in shoulder subluxation at end of treatment. and pain relief at end of treatment. Patients with chronic stroke. FES of the middle deltoid of chronic versus no treatment. FES versus control. The method was generally accepted and used for finding all “decrease in shoulder subluxation. Efficacy treatment and at 8 weeks follow-up (126% and 189% RD.335 where prolonged positioning of the affected shoulder was used. no benefit was demonstrated for SLROM and decrease in shoulder subluxation at 8 weeks follow-up or for muscle bulk (upper arm circumference) at the end of 4 weeks of treatment and at 8 weeks follow-up.336.52 TOPICS IN STROKE REHABILITATION/SPRING 2006 Summary of trials Five RCTs (n = 224)335–339 and three CCTs (n = 163)340–342 involving various treatments for shoulder subluxation in post-stroke patients were included. 15%. n = 40)335 for SLROM (the pain free range of lateral rotation). However. and 1000% RD. from 5 to 7 days a week.350.336 clinically important benefits with statistical significance were seen for SLROM (isometric difference in SLROM between affected and unaffected side). 13 studies were excluded for the following reasons. with an on/off period of 15 seconds each and a ramp up/down of 2 to 3 seconds (n = 235) compared to control. **The degree of subluxation was determined on the x-ray by measuring the shortest perpendicular distance (in mm) between tangents drawn through the inferior border of the acromion and the most superior aspect of the head of the humerus of the affected upper extremity. and decrease in shoulder subluxation (subluxation scale) at the end of 4 weeks of treatment (17%. Positions were held for 20 minutes and treatment sessions took place 5 days a week over a 6-week period (SH-Appendix 3H). 24 hours a day. 64%–81% 160%–186%.347–349 Another two were excluded because not enough data were available. over a 4-week to 24-month period (SH-Appendix 3H). Clinically important benefits without statistical significance were found for FES in acute stroke patients versus control (one RCT.25-cm-thick piece of polyethylene foam warmed in an oven compared to no treatment for 1 day (n = 26)342 (SH-Appendix 3H). Table 125). Treatment sessions lasted between 5 and 60 minutes and were given 2 to 4 times a day. motor function (motor grading scale). and 82%–200% (SH-Figure 113. In total. where the v = vertical component of the glenohumeral alignment is determined by measuring the vertical distance between the acromial point and the central point of the humeral head in millimeters. Table 124). The method was generally accepted and used for finding all “decrease in shoulder subluxation. 2) The use of support methods that consisted of the Bobath shoulder roll made of a 1-cm strip of foam rubber padding and the Henderson shoulder ring made of a 1. but results favored control for motor function (motor grading scale) at 8 weeks follow-up. 7 days a week.338–341 where pulse frequency ranged from 1 to 45 Hz. n = 120340. respectively) (SH-Figure 112. decrease in shoulder subluxation (v-value difference*) and improvement of muscle tone on the affected UE (Tone scale) at the end of 6 weeks of treatment and at 6 weeks follow-up with respective RDs of 95%–100%.” . (Verbal Pain Rating Scale) at the end of 4 weeks of *v-value is calculated by using a radiological technique. for 6 weeks (n = 98). n = 26). Clinically important benefits with statistical significance were also found for decrease in shoulder subluxation** (mm) at the end of 12 weeks and 18 weeks of treatment (63%–73% RD. For FES treatment of the subluxed shoulder in subacute stroke patients versus control (one RCT. 12. n = 16)339 (SH-Figure 113. motor function (% of patients with recovery of motor function). and pulse duration ranged from 300– 350 µs. 12. 6. and 24 months of treatment [≥ 15% RD]). The following were the categories of treatment for shoulder subluxation. motor function (UE function).337 4) Shoulder positioning compared to no treatment (n = 28).351 The remaining studies were not included for various reasons352–355 (SH-Table 123). as well as pain relief. 1) FES was applied to either the supraspinatus or middle deltoid. Four studies lacked a control group. 3) The use of strapping with two main supporting tapes compared to no treatment. No benefit was demonstrated. and 24 months of treatment (≥ 15% and 30%– 60% RD) were also shown to have clinically important benefits with statistical significance (one CCT. respectively). No other outcomes were measured. 6. Table 125). Pain relief (% of patients with no pain at the end of 3.343–346 and three studies did not include an intervention. one RCT. Table 125). (SH-Figure 113. No other outcomes were measured. and decrease in shoulder subluxation (% of decreased shoulder subluxation) at the end of 3. For FES applied to the supraspinatus muscle of the same group of chronic stroke patients versus no treatment (one CCT. Table 134). there is level II evidence (one CCT)342 for the use of support methods such as Bobath and Henderson. 45%. Joseph’s Health Care London73 also found level II (CCT) evidence for support methods (Appendix 4). Clinically important benefits of using a Bobath shoulder roll versus no support (one CCT. Relative differences were 26%. The Ottawa Panel found level I (RCT) evidence for both prolonged shoulder positioning335 and strapping. St. n = 98).341 clinically important benefits without statistical significance were demonstrated for muscle force (maximum ABD force) and decrease in shoulder subluxation (with and without stress) at the end of 6 weeks of treatment. No benefit was found for Bobath shoulder roll versus Henderson shoulder ring use with respect to decreasing shoulder subluxation among post-acute stroke patients at the end of 1 day of treatment (one CCT. n = 11)341 for muscle force (maximum ABD force) and decrease in shoulder subluxation (with and without stress) at the end of 6 weeks of treatment. SH-Figure 115.338. Clinically important benefits without statistical significance were observed for shoulder positioning of subacute stroke patients versus no treatment (one RCT. For strapping of the subluxed shoulder of subacute stroke patients versus no strapping (one RCT.337 St. No benefits were demonstrated for ROM (passive external rotation) and pain relief (pain on dressing) at the end of 6 weeks of treatment. and 24%. . No other outcomes were measured. n = 28)335 with respect to ROM (active ABD) at the end of 6 weeks of treatment (111% RD) (Figure 122. SH-Figure 121. No other outcomes were measured. Table 133). n = 16). According to the Ottawa Panel. no benefit was demonstrated for decreasing shoulder subluxation (with and without stress) at the end of 6 weeks of treatment. However. No other outcomes were measured. Table 128). Joseph’s Health Care London73 also found level I (two or more RCTs) evidence for the use of FES for the shoulder (Appendix 4).339 no benefit was demonstrated for decrease in shoulder subluxation at the end of 12 weeks and 18 weeks of treatment. St. n = 12)341 for muscle force (maximum ABD force) at the end of 6 weeks of treatment (31% RD. This outcome was also statistically significant (SH-Figure 120. respectively (SH-Figure 117. Joseph’s Health Care London73 also found level I (RCT) evidence for both of these interventions. No other outcomes were measured. Table 126). Clinically important benefits without statistical significance were observed for FES of the supraspinatus muscle versus FES of the middle deltoid muscle in chronic stroke patients (one CCT. clinically important benefits without statistical significance were found for FES applied to the middle deltoid muscle of chronic stroke patients versus no treatment (one CCT. n = 26)342 were observed in decreasing shoulder subluxation among post-acute stroke pa- tients at the end of the 1 day treatment (25% RD). No other outcomes were measured (SH-Figure 114. No other outcomes were measured.337 clinically important benefits without statistical significance were found for pain relief (pain on dressing) at the end of 6 weeks of treatment and at 2 months follow-up (172%– 235% RD. and 29%. Relative differences were 47%. n = 26342. Table 132). No other outcomes were measured. This outcome was also statistically significant (SHFigure 119. Table 129). n = 12). respectively (SH-Figure 116. No other outcomes were measured. 41%. Table 127). No other outcomes were measured.341 for the use of FES in reducing shoulder subluxation. Table 131). Similarly.339 and level II evidence (two CCTs)340.Clinical Practice Guidelines 53 For FES treatment of the subluxed shoulder in chronic stroke patients versus control (one RCT. Strength of published evidence compared with other guidelines The Ottawa Panel found both level I (three RCTs) 336. Table 130). SH-Figure 118. The clinically important benefits of using a Henderson shoulder ring versus no support (one CCT. n = 26)342 were found for decreasing shoulder subluxation in post-acute stroke patients at the end of 1 day of treatment (28% RD). Clinical recommendations compared with other guidelines According to the Ottawa Panel. Patients with postacute stroke. the Ottawa Panel recommends that the Bobath shoulder roll and the Henderson shoulder ring be considered as an intervention for the reduction of shoulder subluxation (grade B for decrease in shoulder subluxation). 2 and 4 weeks. active ABD. passive external rotation. level I (RCT): Grade C+ for ROM (selective knee extension: extension of the knee without any help of the synergistic muscles) at end of treatment. 2.73 which found that there is limited evidence that shoulder slings influence clinical outcomes (Appendix 4). and increase in muscle tone. as the Ottawa Panel also found poor evidence (grade C for decrease in shoulder subluxation) to support either the inclusion or exclusion of shoulder slings as an intervention for post-acute stroke patients. Joseph’s Health Care London that proper positioning of the hemiplegic shoulder does indeed help prevent subluxation (Appendix 4). level I (RCT): Grade A for torque and ROM at end of treatment. 2. grade C was given for ROM (selective extension) at end of treatment. and pain relief). This is in partial agreement with the finding of St. Joseph’s Health Care London73 that prolonged positioning does not result in significant reductions in pain or improve upper limb function or range of motion. Patients with subacute and postacute stroke. grade D+ for ROM (selective extension) at end of treatment.73 which concluded that shoulder strapping does not result in significant reductions in pain or improve upper limb function or ROM (Appendix 4). 3. Clinical practice guidelines for electrical stimulation FES of quadriceps and rectus femoris combined with positional feedback stimulation training versus control for the knee. Joseph‘s Health Care London guidelines73 (Appendix 4). there is good evidence that FES should be included as an intervention for the reduction of shoulder subluxation in subacute stroke patients (grade A for SLROM. Neuromuscular electrical stimulation of the . However. and 4 weeks. Joseph’s Health Care London. Joseph’s Health Care London. and grade C for ROM. This is in partial agreement with St. Finally. Based upon fair evidence. 3. it is also in partial agreement with the Heart and Stroke Foundation of Ontario71 and St. consensus opinion refers to the agreement of a group of experts on an appropriate course of treatment in the absence of evidence. and knee extension torque and ROM (synergistic ROM extension: extension of the knee with possible help of synergistic muscles) at end of treatment. motor function. The Ottawa Panel found fair evidence to support the use of shoulder strapping for patients with subacute stroke (grade C+ for pain relief). and grade B for pain relief and motor function). It is regarded as the lowest form of evidence and can be considered as no evidence at all. and 4 weeks (clinically important benefit demonstrated without statistical significance). the Ottawa Panel found fair evidence regarding the use of positioning of the shoulder as an intervention for patients with post-acute stroke (grade C+ for ROM. 1. 1 week (no benefit demonstrated).54 TOPICS IN STROKE REHABILITATION/SPRING 2006 The strength of the evidence has not been graded by other preexisting guidelines (Appendix 4). Positional feedback stimulation training of wrist extensors versus control. *According to St. decrease in shoulder subluxation. Joseph’s Health Care London. 3 weeks (clinically important benefit favoring control demonstrated without statistical significance). This recommendation concurs with the Heart and Stroke Foundation of Ontario71 and the St. The Ottawa Panel is however in agreement with the consensus opinion* of St. Other preexisting guidelines concerning shoulder subluxation did not apply to those of the Ottawa Panel. Patients with chronic stroke. level I (RCT): Grade A for active ROM at end of treatment. grade C+ for active ROM at end of treatment. 3 weeks (no benefit demonstrated). grade D+ for motor function (feeding. motor function (ARAT-grip. 8 weeks. 10. 24 weeks (clinically important benefit demonstrated without statistical significance). gross movement. and follow-up. 6 weeks (no benefit demonstrated but favoring control). and gross movement) at follow-up. and motor function (turning pages. functional status. functional status at end of treatment. decrease of spasticity at end of treatment. 6 weeks. torque (moment of extension at 0º) at end of treatment. 6 weeks. and follow-up. grade C for decrease in spasticity at end of treatment. grade D was given for ROM (maximum passive extension of the wrist) at follow-up. pinch. 8 weeks. grade C+ for ROM (resting wrist angle) at follow-up. functional status at follow-up. 3 and 6 weeks. 24 weeks. 24 weeks. 8 weeks. 6 weeks. and follow-up. grade C+ for active wrist ROM and functional status at end of treatment. grade D+ was given for grip strength at follow-up. 23 weeks (clinically impor- . and functional status (% of maximum score for higher and lower functioning group) at follow-up. 24 weeks (no benefit demonstrated). 8 weeks. decrease of visuospatial neglect at end of treatment. but demonstrated without statistical significance). level I (RCT): Grade A for stride length at end of treatment. 3. FES of the finger thumb extensors and flexors for the hand versus control. 3 weeks. grade D for gait cycle time at end of treatment. and 23 weeks. and follow-up. 24 weeks (clinically important benefit favoring control demonstrated without statistical significance). 6 weeks. small objects. 24 weeks. 8 weeks.Clinical Practice Guidelines 55 wrist and finger extensors versus control. 8 weeks. pinch. level I (RCT): Grade A for grip strength (grip in kilograms) at end of treatment. 3 weeks (no benefit demonstrated but favoring control). decrease in spasticity for higher functioning group at follow-up. level I (RCT): Grade A for functional status (average successful trials for higher and lower functioning groups) at end of treatment. 6 weeks. Patients with chronic stroke. grade C was given for torque (moment of extension at 30o). grade C for dexterity at end of treatment. level I (RCT): Grade A for active ankle ROM at end of treatment. coordination for lower functioning group at follow-up. Patients with chronic stroke. 3. 3 weeks. 24 weeks. 8 weeks. 6 weeks (clinically important benefit demonstrated). EMG-triggered electrical muscle stimulation training versus control. 5 weeks (clinically important benefit demonstrated without statistical significance). FES of anterior tibialis and gastrocnemius combined with EMG-BFB versus FES of anterior tibialis and gastrocnemius for gait training. shoulder muscle tone at end of treatment. and follow-up. and total score) at end of treatment. and 23 weeks. 5 weeks (no benefit demonstrated). ROM (maximum passive extension of the wrist and resting wrist angle). motor function (ARAT-grasp) at end of treatment. 3 weeks (clinically important benefit favoring control. FES of the posterior deltoid and supraspinatus for the shoulder versus control. decrease in shoulder subluxation at end of treatment. 24 weeks. and motor function (ARAT total) at end of treatment. 8 weeks. level I (RCT): Grade C+ for strength. and follow-up. and stacking) at end of treatment. NMES of chronic stroke patients for the hand versus placebo. heavy cans) at end of treatment. 24 weeks. 6 weeks (clinically important benefit demonstrated). 8 weeks. ROM (maximum active extension) at end of treatment. and follow-up. grade D for motor function (light cans. and follow-up. and follow-up. Patients with subacute stroke. motor function (ARAT-grip. 10. 3 weeks (clinically important benefit demonstrated without statistical significance). tracking accuracy) at end of treatment. 24 weeks. and motor function (ARAT total) at follow-up. 8 weeks (clinically important benefit demonstrated). 24 weeks (no benefit demonstrated but favoring control). 6 weeks (clinically important benefit demonstrated without statistical significance). and follow-up. 23 weeks. 24 weeks. torque (moment of extension at 15º) at end of treatment. 5 weeks (clinically important benefit demonstrated). grade C for ankle and knee angle at end of treatment. and difference in active ROM between affected and nonaffected shoulder at end of treatment. Patients with subacute and post-acute stroke. 2 weeks (no benefit demonstrated but favoring control). 6 weeks. Blocked practice combined with NMES of the extensor communis digitorium/extensor carpiulnaris/triceps brachii/anterior and middle deltoid versus passive/active ROM. (no benefit demonstrated). and 23 weeks (no benefit demonstrated). 2 weeks (clinically important benefit demonstrated without statistical significance). grade C for bilateral pre-motor reaction time and unilateral pre-motor reaction time at end of treatment. Patients with chronic stroke. 3 weeks.360 as well as the finger and/or thumb flexors and extensors for the hand versus control (n = 28). 2 weeks (no benefit demonstrated but favoring control). knee flexors. 6 weeks (clinically important benefit demonstrated). 6 weeks (no benefit demonstrated). level I (RCT): Grade A for decrease in spasticity at end of treatment.361 8) blocked practice was combined with neuromuscular stimulation of extensor communis digitorium/extensor carpi ulnaris/triceps brachii/anterior and middle deltoid . level I: Grade A for motor reaction time (time starting directly after pre-motor time and ended with movement initiation at bilateral peak force) favoring random practice at end of treatment. Summary of trials Eleven RCTs involving FES of stroke patients compared to placebo or no treatment as control (n = 385) were included. and manual dexterity.357 3) NMES of the wrist and finger extensors was compared to control (n = 60). level I (RCT): Grade C+ for unilateral pre-motor reaction time and bilateral motor reaction time at end of treatment.356–365 The types of FES treatment given were as follows. 51 Transcutaneous electrical stimulation of the arm.363 4) NMES for the hand was compared to placebo (n = 16). and follow-up. grip muscle force. 1) Electrical stimulation of the quadriceps and rectus femoris was combined with positional feedback stimulation training (PFST) for the knee and compared to control (n = 40).51. 2 weeks. grade C+ for coordination for lower functioning group at end of treatment. Patients with chronic stroke. Blocked practice combined with NMES of the extensor communis digitorium/extensor carpi ulnaris/triceps brachii/anterior and middle deltoid versus random practice combined with NMES of extensor communis digitorium/extensor carpi ulnaris/triceps brachii/anterior and middle deltoid. 2 weeks (clinically important benefit demonstrated). 6 weeks. grade C for bilateral pre-motor reaction time at end of treatment.362 5) FES was ap- plied to the posterior deltoid and supraspinatus for the shoulder versus control (n = 89). and follow-up. grade C for decrease in spasticity at follow-up.356. and ankle extensors triggered by EMG was compared to control (n = 28). 10. Patients with chronic stroke. 2 weeks (no benefit demonstrated). grade D for unilateral motor reaction time at end of treatment. 2 weeks (clinically important benefit demonstrated without statistical significance). Random practice combined with NMES of the extensor communis digitorium/extensor carpi ulnaris/triceps brachii/anterior and middle deltoid versus passive/active ROM. motor impairment. 3. Patients with chronic stroke. 2 weeks (clinically important benefit demonstrated without statistical significance). 3 weeks. grade C for decrease in spasticity for lower functioning group at end of treatment. grade C for premotor bilateral reaction time and unilateral motor reaction time at end of treatment.365 2) PFST of the wrist extensors was compared to control (n = 30).363 6) FES of the anterior tibialis and gastrocnemius was also combined with EMG-BFB for gait training and compared to FES of the anterior tibialis and gastrocnemius (n = 16).56 TOPICS IN STROKE REHABILITATION/SPRING 2006 tant benefit demonstrated). Electrical stimulation of extensors versus alternating electrical stimulation of flexors and extensors. and wrist mobility at end of treatment. forearm. Patients with subacute and post-acute stroke. level I (RCT): Grade C+ for bilateral motor reaction time at end of treatment. grade C+ for pre-motor reaction time (time from stimulus onset until the EMG activity of the muscles reaches 30% of unilateral peak reaction) favoring blocked practice at end of treatment. Clinical Practice Guidelines 57 and compared to random practice combined with NMES of extensor communis digitorium/extensor carpi ulnaris/triceps brachii/anterior and middle deltoid (n = 28).358 Blocked practice combined with NMES was also compared to active and passive ROM (n = 20), as was random practice combined with NMES (n = 20).358 9) Electrical stimulation of extensors was compared to alternating electrical stimulation of flexors and extensors (n = 28)359 (ES-Appendix 3I). During treatment, the frequency of electrical stimulation ranged from 36 to 80 Hz, with a pulse duration varying from 0.3 to 200 ms. Intensity varied from 20 mA to 60 mA. Treatment sessions lasted from 20 to 60 minutes, with the number of sessions ranging from 8 to 112, over a 3- to 8-week period (ES-Appendix 3I). Twenty-six trials were excluded for the following reasons. Ten trials were excluded because they lacked a control group.366–375 Another eight trials were excluded because there were fewer than five subjects per group.376–383 Two studies were eliminated because they were literature reviews.59,60 The remaining studies were excluded for other reasons384–389 (ES-Table 135). Efficacy For FES of the quadriceps and rectus femoris combined with positional feedback stimulation training for the knee of post-acute stroke patients versus control (one RCT, n = 40),365 a clinically important benefit without statistical significance was shown for ROM (selective knee extension) at end of treatment, 2 and 4 weeks (18%–41% RD), knee torque (extension) and ROM (synergistic extension) at end of treatment, 1, 2, 3, and 4 weeks, with relative differences (RDs) of 96%–199% and 21%–31% respectively. No benefit was demonstrated for ROM (selective extension) at end of treatment, 1 week. A clinically important benefit without statistical significance favoring control was found for ROM (selective extension) at end of treatment, 3 weeks. No other outcomes were measured (ES-Figure 123, Table 136). Clinically important benefits were found for PFST of the wrist extensors of subacute and post-acute stroke patients versus control (one RCT, n = 30)357 with respect to change in torque (change in 30º torque flexion and change in 30º torque extension) and ROM (change in selective ROM, change in synergistic ROM) at end of treatment, 2, 3, and 4 weeks. RDs were 96%–143%, 87.5%–137%, 124%–150%, and 107%–133%, respectively. These outcomes were also statistically significant (ES-Figure 124A&B, Table 137A&B). No other outcomes were measured. For neuromuscular stimulation of the wrist and finger extensors in subacute stroke patients versus control (one RCT, n = 60),364 clinically important benefits were demonstrated for grip strength (grip in kilograms) at end of treatment, 8 weeks (102% RD); motor function (ARAT total) at the end of 8 weeks of treatment (272% RD); and torque (moment of extension at 15º) at end of treatment, 8 weeks, and follow-up, 24 weeks (1179%–1878% RD, respectively). These outcomes were also statistically significant (ES-Figure 125A, Table 138A). Clinically important benefits without statistical significance were found for ROM (resting angle) at 24 weeks follow-up (58% RD); and torque (moment of extension at 0º) at the end of 8 weeks of treatment and at the 2-week follow-up with respective RDs of 222% and 284%. Clinically important benefits were also found for ROM (maximum active extension of the wrist) at end of treatment, 8 weeks, and follow-up, 24 weeks, where RD ranged from 17%–22%; motor function (ARAT-grasp) at end of treatment, 8 weeks, and follow-up, 24 weeks (400%–200% RD); motor function (ARAT-grip-pinch-gross movement-total score) at end of treatment, 8 weeks ( 15% RD for all); motor function (ARAT total) at follow-up, 24 weeks (160% RD); and functional status measured by the Barthel Index at follow-up, 24 weeks (RD 40%) (ES-Figure 125A,C,D, Table 138A,C,D). No benefit was demonstrated for ROM (maximum passive extension and resting wrist angle) and functional status (Barthel Index) at the end of 8 weeks of treatment, torque (moment of extension at 30º) at the end of 8 weeks of treatment and at 24 weeks follow-up, motor function (ARAT-grip, pinch, gross movement) at 24 weeks follow-up, decrease of visuospatial neglect (Stars Cancellation Test) at the end of 8 weeks of treatment and at 24 weeks 58 TOPICS IN STROKE REHABILITATION/SPRING 2006 follow-up, and decrease of spasticity at the end of 8 weeks of treatment and at 24 weeks follow-up (ES-Figure 125B&D, Table 138B&D). There was no clinical benefit, but results favored control for ROM (maximum passive extension of the wrist) at 24 weeks follow-up (ES-Figure 125C, Table 138C). Clinically important benefits without statistical significance favoring control were shown for grip strength at 24 weeks follow-up (ES-Figure 125E, Table 138E). No other outcomes were measured. For FES of the anterior tibialis and gastrocnemius combined with EMG-BFB versus FES of the anterior tibialis and gastrocnemius of chronic stroke patients for gait training (one RCT, n = 16),51 clinically important benefits were demonstrated for stride length at end of treatment, 6 weeks (17% RD). This outcome was also statistically significant (ES-Figure 126, Table 139). No clinically important benefit was demonstrated for ankle and knee angle (swing phase) at end of treatment, 6 weeks. However, results favored control without clinical benefit for gait cycle time at end of treatment, 6 weeks. No other outcomes were measured. Clinically important benefits with statistical significance were found for EMG-triggered electrical muscle stimulation training of the upper arm, forearm, knee flexors, and ankle extensors of patients with subacute stroke versus control (one RCT, n = 28)361 for active ankle ROM (dorsiflexion) at end of treatment, 5 weeks (61% RD) (ES-Figure 127, Table 140). Clinically important benefits without statistical significance were demonstrated for active wrist ROM (extension) and functional status (Barthel Index) at end of treatment. 5 weeks (62% and 23% RD, respectively; ES-Figure 127, Table 140). No benefits were demonstrated for decrease of spasticity (upper and lower extremities) at end of treatment, 5 weeks. No other outcomes were measured. Clinically important benefits were found for FES of the posterior deltoid and supraspinatus of subacute and post-acute stroke patients for the shoulder versus a control of standard physiotherapy (two RCTs, n = 89)356,360 with respect to the following outcomes: active ROM at end of treatment, 6 weeks (667% RD); difference in active ROM between affected and nonaffected shoulder at the end of 6 weeks of treatment and at the 6week follow-up (67% and 73% RD, respectively); and decrease in shoulder subluxation at the end of 6 weeks of treatment (44% RD). These outcomes were also statistically significant (ES-Figure 128A&B, Table 141A&B). Clinically important benefits without statistical significance were demonstrated for active ROM at end of treatment, 3 weeks, and follow-up, 6 weeks, with respective RDs of 93% and 480%; difference in active ROM between affected and nonaffected shoulder at follow-up, 6 weeks (73% RD); and shoulder muscle tone measured by the Ashworth Scale at end of treatment, 3 and 6 weeks, and follow-up, 6 weeks (162%–200% RD; ES-Figure 128A&B, Table 141A&B). No other outcomes were measured. Clinically important benefits without statistical significance were found for NMES of chronic stroke patients for the hand versus placebo (one RCT, n = 16)362 with respect to the following outcomes: strength at end of treatment, 3 weeks (23% RD); functional status measured by the MAL indicating the amount of use and quality of movement at end of treatment, 3 weeks (34% and 28% RD, respectively); and motor function measured by the Jebsen Taylor Hand Test involving page turning, small objects, and stacking at end of treatment, 3 weeks. RDs were 19%, 20%, and 76%, respectively (ES-Figure 129A&B, Table 142). No benefit was demonstrated for dexterity (box/block) at end of treatment, 3 weeks. However, clinically important benefits without statistical significance were demonstrated for control with respect to motor function (feeding, tracking, and accuracy) at end of treatment, 3 weeks. Similarly, for motor function measured through the Jebsen Taylor Hand Test involving heavy and light cans at the end of the 3-week treatment, results favored control though no clinical benefit was demonstrated. No other outcomes were measured. For FES of the finger and thumb extensors and flexors of subacute and post-acute stroke patients versus functional tasks without FES for the hand (one RCT, n = 14),363 clinically important benefits were found for the following outcomes: functional status for higher and lower functioning groups at end of treatment, 3 weeks, and follow- Clinical Practice Guidelines 59 up, 3, 10, and 23 weeks, measured through the average number of successful trials in the Upper Extremity Function Test (RDs were 155%–273% and ≥ 15% RD, respectively); coordination for the higher and lower functioning groups measured through the drawing test at end of treatment, 3 weeks, and follow-up, 3, 10, and 23 weeks (ESFigure 130A&B, Table 143). RDs were 32%– 38% for the higher group and 63%–73% for the latter group (ES-Figure 130A&B, Table 143). Clinically important benefits were also found for the decrease in spasticity of the higher functioning group measured by the Ashworth Scale at follow-up, 23 weeks (32% RD); and functional status for higher and lower functioning group measured by the percentage maximum score on the MAL at follow-up, 23 weeks (209%–237% and ≥ 15% RD, respectively; ES-Figure 130A&B, Table 143). Clinically important benefits without statistical significance were demonstrated for decrease in spasticity for lower functioning group (Ashworth Scale) at follow-up, 23 weeks. No other outcomes were measured (ESFigure 130A&B, Table 143). For blocked practice combined with NMES of the extensor communis digitorium/extensor carpi ulnaris/triceps brachii/anterior and middle deltoid versus random practice combined with NMES of extensor communis digitorium/extensor carpi ulnaris/triceps brachii/ anterior and middle deltoid of chronic stroke patients (one RCT, n = 28),358 clinical benefits favoring random practice were demonstrated for bilateral motor reaction time at end of treatment, 2 weeks (16% RD). This outcome was also statistically significant (ES-Figure 131, Table 144). A clinically important benefit without statistical significance favoring blocked practice was demonstrated for unilateral pre-motor reaction time at end of treatment, 2 weeks (ES-Figure 131, Table 144). No other outcomes were measured. Clinically important benefits without statistical significance were found for blocked practice combined with NMES of the extensor communis digitorium/extensor carpi ulnaris/triceps brachii/anterior and middle deltoid of chronic stroke patients versus passive/active ROM (one RCT, n = 20),358 with respect to unilateral and bilateral pre-motor reaction time at end of treatment, 2 weeks (15% and 16% RD, respectively; ES-Figure 132, Table 145). No benefit was demonstrated for unilateral pre-motor reaction time at end of treatment, 2 weeks. However, results also favored control for unilateral motor reaction time at end of treatment, 2 weeks, although no benefit was demonstrated. No other outcomes were demonstrated. For random practice combined with NMES of the extensor communis digitorium/extensor carpi ulnaris/triceps brachii/anterior and middle deltoid of chronic stroke patients versus passive/active ROM (one RCT, n = 20),358 clinically important benefits without statistical significance were found for bilateral motor reaction time at end of treatment, 2 weeks (34% RD) (ES-Figure 133, Table 146). No benefits were demonstrated for bilateral and unilateral pre-motor reaction time at end of treatment, 2 weeks. No other outcomes were measured. For the electrical stimulation of extensors versus alternating electrical stimulation of flexors and extensors of chronic stroke patients (one RCT, n = 28),359 clinically important benefits were found for decrease in spasticity measured by the Ashworth Scale at end of treatment, 6 weeks (100% RD). This outcome was also statistically significant (ES-Figure 134A&B, Table 147). No benefit was demonstrated for decrease in spasticity at follow-up, 6 weeks; manual dexterity (ARAT); grip muscle force (hand ratio); motor impairment (Motricity Index); and wrist mobility (active ROM) at end of treatment, 6 weeks, and follow-up, 6 weeks. No other outcomes were measured. Strength of published evidence compared with other guidelines The Ottawa Panel found level I (one RCT) evidence for the use of FES for gait training.51 The strength of the evidence was also found to be level I (RCT) by both St. Joseph‘s Health Care London,73 whose findings for FES for gait training were based upon the results of two or more RCTs, and the Royal College of Physicians.72 However, the VA/ DoD75 found level II (one CCT) evidence for the use of FES in gait training and level I (one RCT) 60 TOPICS IN STROKE REHABILITATION/SPRING 2006 evidence for the use of multiple channel FES for gait impairment75 (Appendix 4). The Ottawa Panel also found level I (two RCTs)356,360 evidence for FES for the shoulder. The VA/DoD,75 the Heart and Stroke Panel on the Management of the Hemiplegic Arm and Hand,71 and St. Joseph’s Health Care London73 also found level I (RCT) evidence for FES used for shoulder subluxation (Appendix 4). Although the Ottawa Panel found level I (RCT) evidence for FES for the knee and hand, positional feedback stimulation training of the wrist and finger extensors, NMES for the hand, and EMG-BFB triggered electrical muscle stimulation, the strength of the evidence of these interventions has not been graded by other guidelines (Appendix 4). Clinical recommendations compared with other guidelines According to the Ottawa Panel, there is good evidence to recommend that FES of the ankle dorsiflexors be considered as an intervention for gait training in chronic stroke patients (grade A for stride length). This recommendation is in agreement with the clinical practice guidelines of both the VA/DoD75 and St. Joseph’s Health Care London73 that also recommend the use of FES for gait training. However, the Panel disagrees with the finding of the VA/DoD that there is insufficient evidence* as to whether multi-channel FES should or should not be included as an intervention for *According to VA/DoD, a grading of insufficient evidence (I) indicates that one cannot determine from the evidence the net benefit of the intervention, either for or against, and therefore clinicians must use their judgment in either including or excluding it in the treatment of the patient. severe hemiplegic patients with gait impairment (Appendix 4). With respect to the use of FES in the treatment of the shoulder, the Ottawa Panel is in agreement with the VA/DoD,75 the Heart and Stroke Panel on the Management of the Hemiplegic Arm and Hand71 and St. Joseph’s Health Care London73 that FES be included as an intervention for the treatment of the shoulder in subacute and post-acute stroke patients (grade A for active ROM, decrease in shoulder subluxation, and grade C+ for active ROM, difference in active ROM between affected and nonaffected shoulder and shoulder muscle tone; Appendix 4). According to the Ottawa Panel, there is good evidence to recommend the use of FES applied to the finger and thumb flexors and extensors as an intervention for the hands of subacute and postacute stroke patients (grade A for functional status, decrease in spasticity, and coordination for the higher and/or lower functioning groups). Based upon good evidence, the Ottawa Panel also recommends the consideration of the inclusion of EMGtriggered electrical muscle stimulation of the upper arm, forearm, knee flexors, and ankle extensors (grade A for active ankle ROM, and grade C+ for active wrist ROM and functional status). These guidelines are in line with the recommendation made by the Heart and Stroke Foundation of Ontario71 that EMG-BFB and electrical stimulation of the wrist and the forearm be included as an interventions to reduce motor impairment and improve functional motor recovery (Appendix 4). Finally, the Ottawa Panel disagrees with the Royal College of Physicians72 that FES should not be routinely considered as an intervention for stroke patients. Other preexisting guidelines concerning electrical stimulation do not apply to those of the Ottawa Panel (Appendix 4). Clinical Practice Guidelines 61 Clinical practice guidelines for transcutaneous electrical nerve stimulation (TENS) Low-intensity TENS applied to lower extremity versus placebo, level I (RCT): Grade A for decrease in spasticity for lower extremity at end of treatment, 2 and 3 weeks (clinically important benefit demonstrated); grade C+ for dorsiflexor strength at end of treatment, 3 weeks (clinically important benefit demonstrated, without statistical significance). Patients with chronic stroke. Low-intensity TENS applied to the elbow and ankle versus placebo, level I (RCT): Grade A for functional status at end of treatment, 8 weeks (clinically important benefit demonstrated). Patients with post-acute stroke. Low-intensity TENS applied to the shoulder versus placebo, level I (RCT): Grade C for passive shoulder ROM at end of treatment, 4 weeks, and at follow-up, 4 weeks (no benefit demonstrated). Patients with post-acute stroke. Low-intensity TENS applied to the upper extremity versus control, level I (RCT): Grade C for motor function (Fugl-Meyer) and functional status at end of treatment, 3 months, and followup, 3 years, as well as motor function (change in Fugl-Meyer) and decrease in spasticity (elbow flexors) at end of treatment, 3 months (no benefit was demonstrated); grade D+ for decrease in spasticity (wrist flexors) at follow-up, 3 years (clinically important benefit favoring control, demonstrated without statistical significance); grade D for decrease in spasticity (wrist flexors) at end of treatment, 3 months. Patients with chronic stroke. High-intensity TENS applied to the shoulder versus placebo, level 1 (RCT): Grade A for passive shoulder ROM at end of treatment, 4 weeks, and follow-up, 4 weeks (clinically important benefit demonstrated). Patients with post-acute stroke. High-intensity TENS versus low-intensity TENS applied to the shoulder, level I (RCT): Grade A for passive shoulder ROM (extension, abduction, external rotation) at end of treatment, 4 weeks, and follow-up, 4 weeks, and passive shoulder ROM (flexion) at follow up, 4 weeks (clinically important benefit demonstrated); grade C for passive shoulder ROM (flexion) at end of treatment, 4 weeks (no benefit demonstrated). Patients with post-acute stroke. Low-intensity TENS applied to the hand versus placebo, level II (CCT): Grade B for sensation at end of treatment, 3 weeks (clinically important benefit demonstrated); grade C for motor function and gait speed at end of treatment, 3 weeks (no benefit demonstrated). Patients with chronic stroke. Low-intensity TENS applied to the foot versus placebo, level II (CCT): Grade B for sensation at end of treatment, 3 weeks (clinically important benefit demonstrated); grade C for motor function and gait speed at end of treatment, 3 weeks (no benefit demonstrated). Patients with chronic stroke. Summary of trials Five RCTs68,69,390–392 and one CCT (n = 264),393 involving TENS with either a placebo or no treatment as control, were included. Three types of TENS were prescribed: 1) low-intensity TENS (1.7–50 Hz, 125–200 µs) applied to the upper and lower extremity, elbow, ankle, hand, and foot versus placebo or control (n = 244)68,69,390–393; 2) highintensity TENS (100 Hz) applied to the shoulder versus placebo (n = 40)68; 3) high-intensity TENS versus low-intensity TENS applied to the shoulder (n = 40).68 Therapeutic applications of TENS ranged from 20 and 60 minutes and the number of sessions ranged from 9 to 60, over a 3- to 12-week period (TENS-Appendix 3J). Five trials were excluded for the following reasons. One trial was excluded due to a lack of a control group.394 Another study was excluded because no intervention was used.395 One trial was excluded because more than 20% of participants were recurrent stroke victims, 396 while another had fewer than five subjects in the control group.397 Finally, one trial was excluded because healthy subjects were used in the control group398 (TENS-Table 148). No other outcomes were measured. However. For high-intensity TENS applied to the shoulder of post-acute stroke patients versus placebo (one RCT. 37%–42%. at end of treatment. 2 and 3 weeks (15%–21% RD). The RD for this outcome was 37% (TENS-Figure 141. and external rotation) at end of treatment. 3 years. n = 17).62 TOPICS IN STROKE REHABILITATION/SPRING 2006 Efficacy For low-intensity TENS applied to the lower extremity versus placebo (one RCT. 8 weeks (91% RD). or gait speed (10 m walking time) at end of treatment. No other outcomes were measured. 4 weeks. n = 49)69. 4 weeks. No other outcomes were measured. and 30%–34%.390 a clinically important benefit was demonstrated for the decrease in spasticity of the lower extremity at end of treatment.68 clinically important benefits were found for passive shoulder ROM (flexion. However. However. High-intensity TENS versus low-intensity TENS applied to the shoulder of post-acute stroke patients (one RCT. measured through the Modified Motor Assessment Scale. No clinical benefit was demonstrated for decrease in spasticity of wrist flexors at the end of treatment. Table 154). A clinically important and statistically significant benefit was shown for sensation at end of treatment.391 demonstrated no clinical benefit for motor function. Table 152). abduction. there was no statistical significance. No other outcomes were measured. no benefit was demonstrated for motor function. Table 156). measured by the MAS. However. and follow-up. For low-intensity TENS applied to the elbow and lower extremity versus placebo (one RCT. Low-intensity TENS applied to the upper extremity of chronic stroke patients versus control (two RCTs. abduction.Figure 139. n = 60). and gait speed (10 m walking time) at end of treatment. 3 weeks. 3 weeks (28% RD). This outcome was statistically significant (TENS-Figure 136. For low-intensity TENS versus placebo applied to the foot of chronic stroke patients (one CCT. 3 months. RDs were 22%–27%. No other outcomes were measured. n = 40)68 for passive shoulder ROM (flexion. No other outcomes were measured. and 24%–30%. Equally. respectively. and follow-up. 3 weeks (19% RD) (TENS-Figure 135. 25%–29%. Table 154). Table 153). 3 months. when low-intensity TENS versus placebo (one CCT.393 a clinically important benefit was found for sensation at end of treatment. external rotation) at end of treatment. . Table 149). no clinical benefit was demonstrated for passive shoulder ROM (flexion) at end of treatment. 4 weeks (TENS-Figure 137. n = 27). 3 years (TENS-Figure 138. A clinically important benefit with statistical significance (20% RD) was also shown for passive shoulder ROM (flexion) at follow-up. and follow-up. 4 weeks. Clinically important benefits were demonstrated for dorsiflexor muscle force at end of treatment. abduction.392 clinically important benefits were shown for the functional status of post-acute stroke patients. and functional status measured by the Barthel Index at end of treatment. and follow-up. n = 51)393 was applied to the hands of chronic stroke patients. 3 weeks. measured by the Fugl-Meyer scale. Table 150). n = 40). extension. This outcome was also statistically significant (TENS-Figure 142. Table 151). no benefit was demonstrated for either the motor function. n = 40)68 demonstrated clinically important benefits for passive shoulder ROM (extension. Table 152). 4 weeks (TENS-Figure 140. Table 155). extension. These outcomes were also statistically significant (TENS.Figure 140. 3 weeks. No other outcomes were measured. clinically important benefits favoring control without statistical significance were demonstrated for decrease of spasticity in the wrist flexors at follow-up. there was no clinical benefit for motor function (change in FuglMeyer) and decrease in spasticity of the elbow flexors at end of treatment. 3 months (TENSFigure 138. Table 149). No clinical benefit was found for low-intensity TENS applied to the shoulder versus placebo (one RCT. No other outcomes were measured. RDs were 16%–24%. These outcomes were also statistically significant (TENS. 4 weeks. respectively. at end of treatment. measured by the Barthel Index. However. and this outcome was statistically significant for chronic stoke patients (TENS-Figure 135. 4 weeks. external rotation) of post-acute stroke patients. 4 weeks. The Ottawa Panel found good evidence to recommend the use of high-intensity TENS applied to the shoulder (grade A for passive shoulder ROM) as an intervention for stroke patients. unless the study with conflicting results was of higher quality. There was also level I evidence (one RCT)68 for the use of high-intensity TENS. and grade C+ for dorsiflexor muscle force) and elbow and wrist (grade A for functional status) should be included as an intervention for stroke patients. if nonsteroidal anti-inflammatory analgesia has no significant effect (Appendix 4). However. The strength of the evidence has not been reported by other guidelines (Appendix 4).69. Where there were more than four RCTs and the results of only one was conflicting. the Ottawa Panel disagrees with the recommendation of the Royal College of Physicians72 that TENS should not be used as a routine intervention for improving muscle control for patients undergoing stroke rehabilitation in the context of ongoing trials. the conclusion was based on the results of the majority of the studies. Other preexisting guidelines concerning TENS did not apply to those of the Ottawa Panel. The strength of the evidence has also been graded by the Royal College of Physicians. spasticity. Based upon fair evidence. Joseph’s Health Care London73 also found level I evidence for TENS. Clinical recommendations compared with other guidelines According to the Ottawa Panel.390–392 and level II evidence (one CCT)393 for the use of low-intensity TENS in the treatment of stroke patients. *According to the St. Finally. the Panel also recommends that low-intensity TENS for the hand and foot be specifically considered as an intervention for sensation (grade B). Joseph’s Health Care London73 finding that there is conflicting evidence* that TENS improves a variety of outcomes. there is good evidence that low-intensity TENS applied to the lower extremity (grade A for decrease in spasticity. and ADL (Appendix 4). Joseph’s Health Care London. St.and lowintensity TENS. .Clinical Practice Guidelines 63 Strength of published evidence compared with other guidelines The Ottawa Panel found level I evidence (five RCTs)68.72 which also reported level I evidence (RCTs) for high. the Ottawa Panel agrees with the St. This is in line with the Royal College of Physicians72 recommendation that high-intensity TENS should be included as an intervention for patients undergoing stroke rehabilitation. including motor recovery. conflicting evidence refers to a disagreement between the findings of at least two RCTs. abduction in external rotation) at end of treatment. grade D+ for ROM (external rotation) at end of treatment. Three trials were excluded for the following reasons.401 A third trial was excluded because it included patients with periarthritis post trauma. 4 weeks. and sclerosis402 (US-Table 157). grade D for ROM [flexion. grade C for ROM (abduction in internal rotation and abduction in external rotation) at end of treatment. Summary of trials One RCT that compared therapeutic ultrasound to both a placebo and a control was included (n = 33). . the Based on the evidence of this trial. level I (RCT): Grade D for ROM (flexion. Strength of the published evidence compared with other guidelines The Ottawa Panel found level I evidence (one RCT) for the effects of ultrasound on post-stroke patients. abduction in internal rotation. Table 158). fractures. n = 20). Efficacy results favored control with respect to ROM (flexion and abduction in internal and external rotation). US-Figure 144. 399 At the end of 4 weeks of treatment. there was a clinically important trend without statistical significance favoring ROM (external rotation) at the end of treatment (93% RD. Table 159). Joseph’s Health Care London72 also based their findings on level I evidence (a single RCT). The strength of evidence for ultrasound has not been evaluated by other guidelines (Appendix 4). the Ottawa Panel is in partial agreement with the St. Patients with chronic stroke. Other preexisting recommendations regarding ultrasound did not apply to those of the Ottawa Panel (Appendix 4). Patients with chronic stroke. No other outcomes were measured. US-Figure 143. level I (RCT): Grade C+ for ROM (flexion and external rotation) at end of treatment. but results favored control). The control group (n = 10) received only the concurrent treatment (US-Appendix 3K). while the placebo group (n = 10) received ultrasound with the energy turned off prior to exercises.64 TOPICS IN STROKE REHABILITATION/SPRING 2006 Clinical practice guidelines for therapeutic ultrasound Ultrasound versus placebo applied to the shoulder.399 The treatment group received therapeutic ultrasound to the paravertebral and shoulder joint areas for 5 minutes prior to exercise (n = 10). and sessions took place 7 days a week for 4 weeks (US-Appendix 3K). and grade D+ for ROM [external rotation]).399 a clinically important benefit without statistical significance was demonstrated for ROM (flexion and external rotation) at the end of the 4week treatment (20% and 57% RD. One provided insufficient statistical data. abduction in external rotation]. where a clinically important benefit was demonstrated without statistical significance. abduction in internal rotation. One treatment was given per session. although these results were without statistical significance or clinical importance. 4 weeks (no benefit was demonstrated).400 whereas another combined the results for both groups. Joseph’s Health Care London73 finding that adding ultrasound therapy to ROM exercises does not change outcomes. 4 weeks (clinically important benefit favoring control demonstrated without statistical significance). respectively. Notably. St. (grade C+ for ROM [flexion and external rotation]. n = 23). grade C for ROM [abduction in internal rotation and abduction in external rotation]. 4 weeks (no benefit was demonstrated. No benefits were shown for therapeutic ultrasound applied to the shoulder versus control in chronic stroke patients (one RCT. No benefit was demonstrated for ROM (abduction in internal and external rotation) at the end of treatment. No other outcomes were measured. Clinical recommendations compared with other guidelines For ultrasound applied to the shoulder of chronic stroke patients versus placebo (one RCT. Ultrasound versus control applied to the shoulder. pain relief at end of treatment. grade C for quality of life (number of patients without loss of energy) at end of treatment. 10 months. level I (RCT): Grade A for motor function at end of treatment. for motor function (NHP–physical movement) at follow-up.403–409 The outcomes assessed in the various studies included functional status. Patients with chronic stroke. 1 month and 3 months. 10 and 15 days (clinically important benefit demonstrated). 12 months. level 1 (RCT): Grade C for functional status at end of treatment. for functional status (Sunnaas Scale) at follow-up. 6 weeks. 3 months and 10 months (no benefit demonstrated). Surface acupuncture with electrical stimulation versus no acupuncture. Except for one study. change in Barthel Index. and for quality of life (number of patients without loss of energy) at follow-up. level I (RCT): Grade A for walking mobility at end of treatment. 10 months (no benefit demonstrated but favoring control). Patients with subacute stroke. grade C for motor function of upper and lower extremity and functional status at end of treatment. 1 day (no benefit demonstrated). Needle acupuncture with manual and electrical stimulation versus placebo acupuncture. 10 months. 6 weeks (no benefit demonstrated). level I (RCT): Grade A for decrease of spasticity at end of treatment. 12 months. motor function. walking mobility. grade C+ for motor function (NHP–physical movement. Needle acupuncture with electrical stimulation on paretic side versus placebo. level I (RCT): Grade C for ankle spasticity at end of treatment 4 weeks (no benefit demonstrated). balance. and for motor function at end of treatment. 2 weeks (clinically important benefit demonstrated). level I (RCT): Grade C+ for ROM at end of treatment. lower thresholds were used in other studies (AC-Appendix 3L). for walking mobility and for balance at end of treatment. grade C+ for decrease of spasticity at end of treatment. Patients with postacute stroke. ROM. and MAS) at end of treatment. Patients with acute stroke. 3 months. While stimulation settings were adjusted to induce visible muscle contractions in some studies. 3 months (clinically important benefit demonstrated without statistical significance). level of energy. 6 weeks. Patients with acute and subacute stroke. 5 days (clinically important benefit demonstrated without statistical significance).Clinical Practice Guidelines 65 Clinical practice guidelines for acupuncture Needle acupuncture without stimulation versus placebo. for motor function (NHP–physical movement) at follow-up. Summary of trials Seven RCTs (n = 417) were included that investigated the effects of acupuncture compared to either no acupuncture or a placebo control following stroke. There was substantial variation in acupuncture technique. grade D for functional status (change in neurological scale. Needle acupuncture with electrical stimulation on paretic side versus needle acupuncture without stimulation. and for functional status (Sunnaas Scale) at end of treatment. 1 month (clinically important benefit demonstrated without statistical significance). 12 months (clinically important benefit demonstrated). There was little consistency in the choice of stimulation frequency from one study to the next (range. Needle acupuncture with manual and electrical stimulation versus no acupuncture. and follow-up. 1 month. Three RCTs404–406 reported manual stimulation of inserted needles. Patients with post-acute stroke. relief of spasticity.403 experimental and control groups received standard rehabilitative care concurrently. 6 weeks. 1–50 Hz). and follow-up. grade C for decrease of spasticity at end of treatment. and relief of pain (AC-Appendix 3L). electrical stimulation was used in seven RCTs404–409 and was typically applied to selected points on the paretic side. In addition. change in Sunnaas Scale) at end of treatment. 2 weeks (no benefit demonstrated). Three trials used sham or placebo . Table 162). and change in Sunnaas Scale) at the end of 3 months of treatment or at 10 months follow-up (AC-Figure 147. 112%. No benefits were demonstrated for functional status (change in Neurological Scale. 29%.404. AC-Figure 148. Table 163). Table 164). n = 78. Needle acupuncture with electrical and manual stimulation was compared to no acupuncture in acute and subacute stroke patients (three RCTs. 36%. n = 41406. No other outcomes were measured. n = 104). as well as for pain relief (number of patients with no pain) at the end of 6 weeks of treatment and at 12 months follow-up (−35%.406 Clinically and statistically nonsignificant changes in functional status (change in neurological scale.408 The RD at the end of 1 month of treatment was 40% (AC-Figure 146. one contained fewer than five subjects in the control group.408 The duration of most individual acupuncture sessions was 30 minutes. n = 16). In another study. walking mobility. Patients in the acute phase of stroke who were unable to walk without support or perform ADLs without assistance were randomized to receive needle acupuncture with manual and electrical stimulation or placebo acupuncture (one RCT. the reasons for which are listed in AC-Table 160. In one of the RCTs. one did not involve acupuncture. benefits for ROM (number of patients that improved more than 10% on ROM tests) compared to placebo acupuncture in patients with post-acute. and MAS) at the end of 6 weeks of treatment and at 12 months follow-up. two were case series. Other outcomes were not assessed. the number of sessions allocated to each patient varied between 8 and 24 sessions (ACAppendix 3L). Table 161). and 40% RD. Efficacy In one RCT (n = 25). Overall. −44%. and quality of life (number of patients with no loss of energy) at 12 months follow-up (one RCT. At the end of 4 weeks of treatment. but statistically nonsignificant. left hemispheric stroke (one RCT. 410–421 Two studies were reviews.403 needle acupuncture without manual or electrical stimulation was compared to placebo acupuncture in chronic stroke patients with spastic equinovarus deformity of the leg (AC-Figure 145. one was written in a foreign language.66 TOPICS IN STROKE REHABILITATION/SPRING 2006 acupuncture as the control intervention. balance.404 In the experimental group. Twelve articles were excluded. needles inserted on the nonparetic side were stimulated manually and needles introduced on the paretic side were stimulated electrically at low frequency (2 Hz).405 but no improvement of quality of life (number of patients with no loss of energy) or functional status (Sunnaas Scale) at the end of 6 weeks of treatment. The control group received placebo acupuncture. 20%. respectively). n = 223404–406. 35%.403. and 35% RD. and functional status (Barthel Index) at the end of 3 months of treatment (one RCT. one lacked a control group. one was a duplicate of an already included study. and walking mobility at the end of 1 month of treatment and for balance. 112%. change in Barthel Index. 34%. respectively).405 Important clinical benefits that did not achieve statistical significance were found for motor function (NHP–physical movement. statistically significant and clinically important benefits were shown for motor function (NHP–physical movement). Needle acupuncture with low frequency (1-2 Hz) electrical stimulation produced clinically important. no benefits were observed for ankle spasticity (modified Ashworth Scale). functional status (Sunnaas Scale). change in Barthel Index. there were clinically meaningful effects on motor function at the end of 3 months of treatment (25% RD). 406 Additionally. similarly positive effects were shown for motor function. in which four shortened needles were placed superficially just under the skin – one at each limb – and left without further stimulation (AC-Appendix 3L). and 30% RD. −4%. and in two studies more than 20% of the study sample was represented by patients with recurrent stroke. respectively). and the frequency of sessions ranged from 2 to 5 per week and the total treatment interval ranged from 4 to 10 weeks. change in Sunnaas Scale) favoring control were seen at the end of 3 months of treatment and at 10 months follow-up.404 . 409 where acupuncture points located on the affected extremities of subacute stroke patients were stimulated electrically via surface electrodes instead of through percutaneous needles. Statistically significant and clinically meaningful decreases in spasticity (modified Ashworth Scale) were observed at the end of 10 and 15 days of treatment (−27% and − 27% RD. respectively. Table 165). With regard to motor function. The evidence from three RCTs that assessed functional status was also inconsistent. The evidence for the effects of acupuncture on spasticity.Clinical Practice Guidelines 67 A unique technique was used in one RCT (n = 118). No benefits were found for functional status (FIM) or for motor function (Brunnstrom) of the upper and lower extremity. No benefits were seen in terms of degree of spasticity at the end of 1 day of treatment. AC-Figure 150. motor function. The Ottawa Panel recommends that there is good scientific evidence to consider including acupuncture as an adjunct to standard stroke rehabilitation to improve walking mobility (grade A for walking mobility). The RD was 47%. another study revealed statistically significant and clinically important benefits of electroacupuncture on elbow spasticity compared to standard acupuncture in post-acute stroke. The Royal College of Physicians72 concluded that the evidence was insufficient to make definitive statements about the role of acupuncture. However. the Ottawa Panel wishes to emphasize that the available evidence is not conflicting with respect to all stroke outcomes. statistically significant and clinically important benefits were shown for walking mobility at the end of 2 weeks of treatment (AC-Figure 149. with two RCTs suggesting no effect and the other RCT suggesting statistically significant and clinically important benefits (Appendix 4). Joseph’s Health Care London73 were based on level I (RCT) evidence as well (Appendix 4). The additional benefit of electroacupuncture in post-acute stroke patients with elbow spasticity was investigated in one RCT (n = 35). Joseph’s Health Care London. No other outcomes were assessed. but needle acupuncture with manual and electrical stimulation showed positive results. One study reported no benefit of needle acupuncture without stimulation for ankle spasticity in chronic stroke patients with spastic equinovarus deformity (grade C). The intensity of stimulation was sufficient to achieve muscle contraction and the frequency was adjusted to 20–25 Hz.73 which found that “there is conflicting evidence that acupuncture is effective for improving stroke outcomes. but without statistical significance (−15% RD). . Compared to no acupuncture. Strength of the published evidence compared with other guidelines Clinical recommendations compared with other guidelines The Ottawa Panel found level I (RCTs) evidence evaluating acupuncture in stroke patients. Table 166). surface acupuncture with electrical stimulation was not effective.407 where needle acupuncture with electrical stimulation of selected points on the paretic side was compared to needle acupuncture without electrical stimulation. Clinically important decreases in spasticity also occurred after 5 days of treatment. and functional status are conflicting. and balance (grade A for balance).” However. The Ottawa Panel recommendations are generally consistent with the recommendations of St. ROM (grade A for number of patients improved on ROM tests). They expressed a cautious statement based on consensus opinion that “acupuncture should only be used as an intervention for patients undergoing post-stroke rehabilitation in the context of ongoing trials” (Appendix 4). The clinical practice guidelines developed by the Royal College of Physicians72 and St. 68 TOPICS IN STROKE REHABILITATION/SPRING 2006 Clinical practice guidelines for intensity and organization of rehabilitation Stroke unit versus general ward, level I (RCT) and level II (CCT): Grade A for length of stay at end of treatment, 2 weeks, and follow-up, 3 years (clinically important benefit demonstrated); grade B for mobility (number of patients able to walk long distances independently) at end of treatment, 6 weeks (clinically important benefit demonstrated); grade C+ for functional status (number of patients with mild-moderate impairment) at follow-up, 1 year (clinically important benefit demonstrated without statistical significance); grade C for functional status (number of patients deteriorated in ADL score) at end of treatment, 3 months, and follow-up, 6 months, functional status (number of patients independent in ADL) at end of treatment, 6 weeks, length of stay (in days) at end of treatment, 6 weeks and 3 months, mobility (number of patients independent in walking mobility) at end of treatment, 16 weeks, mobility (number of patients independent in walking [Barthel Index], number of patients independent in indoor and outdoor walking [Rivermead ADL Scale–self-care], number of patients independent in walking outside and climbing stairs [Rivermead ADL Scale–household]) at end of treatment, 3 and 6 months, motor function (number of patients independent in upper extremity and lower extremity function) at end of treatment, 16 weeks, efficiency at end of treatment, 2 weeks, postural status (number of patients sitting and standing) at follow-up, 6 weeks, functional status (ADL score) at end of treatment, 3 months, and follow-up, 9 months, and resource cost (total cost per patient in thousands of dollars) at follow-up, 1 year (no benefit demonstrated); grade D for mobility (number of patients able to walk short distances with or without aids) at end of treatment, 6 weeks, functional status (number of functional patients) at follow-up, 1 year, and resource cost (number of physician visits per patient) at follow-up, 1 year (no benefit demonstrated but favoring control); grade D+ for functional status (ADL score) at end of treatment, 1 week (clinically important benefit favoring control demonstrated without statistical significance). Patients with acute, subacute, postacute, and chronic stroke. Stroke unit versus home care, level I (RCT): Grade A for functional status (number of patients independent with Barthel) at follow-up, 9 months (clinically important benefit demonstrated); grade C for functional status (number of patients independent with Modified Rankin score) at end of treatment, 3 months, and follow-up, 9 months, and functional status (number of patients independent with Barthel) at end of treatment, 3 months (no benefit demonstrated). Patients with acute stroke. Stroke unit (large artery stroke) versus general ward (large artery stroke), level I (RCT): Grade A for functional status at follow-up, 1 year, and quality of life at follow-up, 3 months (clinically important benefit demonstrated); grade C for functional status at follow-up, 3 months, and quality of life at follow-up, 3 months (no benefit demonstrated); grade D for length of stay at follow-up, 3 months (no benefit demonstrated but favoring control); grade D- for efficiency at follow-up, 3 months (clinically important benefit favoring control demonstrated with statistical significance). Patients with acute stroke. Stroke unit (small artery stroke) versus general ward (small artery stroke), level I (RCT): Grade A for quality of life at follow-up, 3 months (clinically important benefit demonstrated); grade C for quality of life at follow-up, 1 year (no benefit demonstrated); grade D for functional status at follow-up, 3 months, and 1 year (no benefit demonstrated but favoring control); grade D- for length of stay and efficiency at follow-up, 3 months (clinically important benefit favoring control demonstrated with statistical significance). Patients with acute stroke. Intensive outpatient physiotherapy rehabilitation program versus control group, level I (RCT): Grade C+ for quality of life at end of treatment, 3 months (clinically important benefit demonstrated without statistical significance); grade C for functional status at end of treatment, 3 months (no benefit demonstrated); grade D for functional status at follow-up, 6 months (no benefit demonstrated but favoring control). Patients with chronic stroke. Six days/week versus seven days/week treatment, level I (RCT): Grade C+ for mobility at end of treatment, 3 weeks (clinically important benefit Clinical Practice Guidelines 69 demonstrated without statistical significance); grade C for functional status and length of stay at end of treatment, 3 weeks (no benefit demonstrated). Patients with post-acute stroke. Enhanced occupational therapy versus standard customary occupational therapy, level I (RCT): Grade A for functional status (number of patients improved in ADL) at end of treatment, 8 weeks and 6 months, life habit/leisure (overall leisure score) at end of treatment, 3 and 6 months, life habit/leisure (total leisure score) at end of treatment, 6 months, mobility (Nottingham EADL score for mobility) at end of treatment, 3 and 6 months, functional status (Nottingham EADL score) at end of treatment, 8 weeks, 3 months, and 6 months (clinically important benefit demonstrated); grade C+ for quality of life (number of patients living independently) and functional status (FIM for upper extremity and lower extremity dressing) at end of treatment, 3 weeks, and functional status (EADL total score) at follow-up, 3 months (clinically important benefit demonstrated without statistical significance); grade C for life habit/leisure (total leisure score) and mobility (NHP score for mobility) at end of treatment, 6 months, functional status (Barthel Index score) at follow-up, 3 months (no benefit demonstrated); grade D for mobility (NHP score for mobility) at end of treatment, 3 months (no benefit demonstrated but favoring control); grade D+ for pain relief at end of treatment, 3 months and 6 months, and quality of life (General Health Questionnaire) at follow-up, 3 months (clinically important benefit favoring control demonstrated without statistical significance). Patients with subacute stroke. Enhanced occupational therapy versus no therapy, level I (RCT): Grade A for mobility (NHP score for mobility and Nottingham EADL for mobility) at end of treatment, 3 months and 6 months, life habit/leisure (overall leisure score and total leisure activity) at end of treatment, 3 and 6 months, functional status (number of patients improved in ADL) at follow-up, 6 months (clinically important benefit demonstrated); grade C+ for activity involvement (Katz Adjustment Index: number of patients satisfied with their walking) at follow-up, 13 weeks, activity involvement (number of patients satisfied with their work in the yard) at end of treatment, 5 weeks, and functional status (EADL) at follow-up, 1 year (clinically important benefit demonstrated without statistical significance); grade C for functional status (Barthel ADL Index) at follow-up, 6 months and 1 year, functional status (EADL) at follow-up, 6 months, activity involvement (number of patients satisfied with their work in and around the house and number of patients satisfied with their walking) at end of treatment, 5 weeks, and activity involvement (number of patients satisfied with their work in the yard) at follow-up, 13 weeks (no benefit demonstrated); grade D for activity involvement (number of patient satisfied with their work in and around house) at follow-up, 13 weeks (no benefit demonstrated but favoring control); grade D+ for pain relief at end of treatment, 3 and 6 months (clinically important benefit favoring control demonstrated without statistical significance). Patients with subacute stroke. Standard customary occupational therapy versus no therapy, level I (RCT): Grade A for functional status (EADL score) at follow-up, 1 month (clinically important benefit demonstrated); grade C+ for mobility (NHP for mobility) at end of treatment, 3 and 6 months, for pain relief at end of treatment, 3 months (clinically important benefit demonstrated without statistical significance); grade C for life habit/leisure (overall leisure score and total leisure activity score) at end of treatment, 3 and 6 months, for functional status (Barthel Index score) at follow-up, 1 month, pain relief at end of treatment, 6 months (no benefit demonstrated); grade D for quality of life at follow-up, 1 month (no benefit demonstrated but favoring control); grade D+ for functional status (EADL score for mobility) at end of treatment, 3 months and 6 months (clinically important benefit favoring control demonstrated without statistical significance). Patients with subacute stroke. Enhanced physiotherapy (60-minute treatment of physiotherapy) versus standard customary physiotherapy care (30 minutes), level I (RCT): Grade C for quality of life at end of treatment, 6 weeks (no benefit demonstrated); grade D for quality of life at end of treatment, 6 months (no benefit demonstrated but favoring control). Patients with chronic stroke. 70 TOPICS IN STROKE REHABILITATION/SPRING 2006 Enhanced physiotherapy versus standard customary physiotherapy treatment, level I (RCT): Grade A for motor function (ARAT) at follow-up, 21 weeks (clinically important benefit demonstrated); grade C+ for functional status (Barthel Index) at follow-up, 3 and 16 weeks (clinically important benefit demonstrated without statistical significance); grade C for functional status (Barthel Index) at end of treatment, 5 weeks, and follow-up, 21 weeks, functional status (EADL score) at followup, 16 weeks and 21 weeks, motor function (Rivermead Motor Assessment–upper extremity) at end of treatment, 5 weeks, and follow-up, 21 weeks, motor function (Ten-Hole Peg Test) at end of treatment, 5 weeks, and follow-up, 16 weeks, and motor function (ARAT) at end of treatment, 5 weeks (no benefit demonstrated); grade D for functional status (EADL score) at end of treatment, 5 weeks (no benefit demonstrated but favoring control); grade D+ for motor function (Rivermead Motor Assessment–gross function) at follow-up, 3 weeks, and grip strength (maximum grip) at followup, 16 weeks (clinically important benefit favoring control demonstrated without statistical significance); grade D- for motor function (Rivermead Motor Assessment-upper extremity) at follow-up, 3 weeks and 16 weeks, motor function (ARAT) at follow-up, 16 weeks, motor function (Rivermead Motor Assessment–gross function) at end of treatment, 5 weeks, and follow-up, 16 weeks, and grip strength (maximum grip) at end of treatment, 5 weeks, and follow-up, 3 weeks (clinically important benefit favoring control demonstrated with statistical significance). Patients with subacute stroke. Enhanced assistant physiotherapist versus standard customary physiotherapy treatment, level I (RCT): Grade A for motor function (Rivermead Motor Assessment-upper extremity) at follow-up, 21 weeks, motor function (ARAT) at end of treatment, 5 weeks, and follow-up, 21 weeks (clinically important benefit demonstrated); grade C+ for functional status (Barthel Index) at follow-up, 3 and 16 weeks, functional status (EADL) at end of treatment, 5 weeks, and followup, 21 weeks, motor function (ARAT) at followup, 16 weeks (clinically important benefit demonstrated without statistical significance); grade C for functional status (Barthel Index) at end of treat- ment, 5 weeks, functional status (EADL score) at follow-up, 16 weeks, motor function (Rivermead Motor Assessment-upper extremity) at end of treatment, 5 weeks, and follow-up, 16 weeks, motor function (Rivermead Motor Assessment–gross function) at follow-up, 3 and 16 weeks, motor function (Ten-Hole Peg Test) at end of treatment, 5 weeks, and follow-up, 16 weeks (no benefit demonstrated); grade D for functional status (Barthel Index) at follow-up, 21 weeks (no benefit demonstrated but favoring control); grade D+ for motor function (Rivermead Motor Assessment-upper extremity) at follow-up, 3 weeks, and grip strength (maximum grip) at end of treatment, 5 weeks, and follow-up, 16 weeks (clinically important benefits favoring control demonstrated without statistical significance); grade D- for motor function (Rivermead Motor Assessment–gross function) at end of treatment, 5 weeks, and grip strength (maximum grip) at follow-up, 3 weeks (clinically important benefit favoring control demonstrated with statistical significance). Patients with subacute stroke. Enhanced physiotherapy versus enhanced assistant physiotherapist treatment, level I (RCT): Grade A for motor function (Rivermead Motor Assessment–gross function) at end of treatment, 5 weeks, grip strength (maximum grip) at follow-up, 3 weeks, and motor function (ARAT) at follow-up, 21 weeks (clinically important benefit demonstrated); grade A favoring enhanced assistant physiotherapist for functional status (Barthel Index) at end of treatment, 5 weeks, motor function (Rivermead Motor Assessment–upper extremity) at follow-up, 16 weeks and 21 weeks, functional status (EADL score) at follow-up, 21 weeks, motor function (ARAT) at end of treatment, 5 weeks, and follow-up, 16 weeks (clinically important benefit demonstrated); grade C+ for motor function (Rivermead Motor Assessment–gross function) at follow-up, 16 weeks (clinically important benefit demonstrated without statistical significance); grade C+ favoring enhanced assistant physiotherapist for functional status (Barthel Index) at follow-up, 3 and 16 weeks, functional status (EADL) at end of treatment, 5 weeks, motor function (Rivermead Motor Assessment–upper extremity) at follow-up, 3 weeks, grip strength at end of Clinical Practice Guidelines 71 treatment, 5 weeks, and follow-up, 16 weeks (clinically important benefit demonstrated without statistical significance); grade C for functional status (Barthel Index) at follow-up, 21 weeks, functional status (EADL score) at follow-up, 16 weeks, motor function (Rivermead Motor assessment–upper extremity) at end of treatment, 5 weeks, and motor function (Ten-Hole Peg Test) at end of treatment, 5 weeks, and follow-up, 16 weeks (no benefit demonstrated). Patients with subacute stroke. Enhanced upper-extremity treatment versus interdisciplinary treatment, level I (RCT): Grade A for motor function (Frenchay Arm Test) and functional status (Barthel Index) at follow-up, 18 weeks (clinically important benefit demonstrated); grade C for motor function (Upper Limb Motricity Index and Frenchay Arm Test) at follow-up, 6 weeks, functional status (Nottingham EADL) at follow-up, 18 weeks, and functional status (Barthel Index) at follow-up, 6 weeks (no benefit demonstrated); grade D for motor function (Upper Limb Motricity Index) at follow-up, 18 weeks, functional status (Nottingham EADL) at followup, 6 weeks (no benefit demonstrated but favoring control); grade D+ for motor function (ARAT) at follow-up, 6 and 18 weeks (clinically important benefit favoring control demonstrated without statistical significance). Patients with subacute stroke. Enhanced therapy (severe stroke) versus standard customary care (severe stroke), level I (RCT): Grade D for mobility at end of treatment, 6 months (no benefit demonstrated). Patients with acute stroke. Enhanced therapy (mild stroke) versus standard customary care (mild stroke), level I (RCT): Grade D for mobility at end of treatment, 6 months (no benefit demonstrated). Patients with acute stroke. Home therapy (physiotherapy) versus standard customary care without home visits, level I (RCT): Grade C+ for functional status (Instrumental Activities of Daily Living [IADL]–domestic activities) at follow-up, 6 months (clinically important benefit demonstrated without statistical significance); grade C for discharge disposition, functional status, mobility, and life habits/leisure at follow-up, 6 months (no benefit demonstrated). Patients with chronic stroke. Home-based physiotherapy at high-intensity versus low-intensity physiotherapy control, level I (RCT): Grade A for motor function (STroke REhabilitation Assessment of Movement [STREAM] lower extremity) at follow-up, 11 weeks (clinically important benefit demonstrated); grade C+ functional status and motor function (STREAM–upper extremity) at followup, 11 weeks (clinically important benefit demonstrated without statistical significance); grade C for mobility at follow-up, 11 weeks, functional status and motor function (STREAM–upper extremity) at follow-up, 22 weeks (no benefit demonstrated); grade D for mobility at follow-up, 22 weeks (no benefit demonstrated but favoring control); grade D+ for motor function (STREAM–lower extremity) at follow-up, 22 weeks (clinically important benefit favoring control demonstrated without statistical significance). Patients with chronic stroke. Home-based rehabilitation versus hospitalbased rehabilitation, levels I and II (RCT, CCT): Grade C for resource cost at follow-up, 1 year, and mobility and functional status at end of treatment, 3 months (no benefit demonstrated). Patients with post-acute and chronic stroke. Rehabilitation versus no rehabilitation group, level II (CCT): Grade D for motor function at end of treatment, 6 months (no benefit demonstrated but favoring control); grade D+ for functional status at end of treatment, 6 months (clinically important benefit favoring control demonstrated without statistical significance). Patients with subacute stroke. Home therapy (physician) versus standard customary care without home visits, level I (RCT): Grade A for decrease in hospital readmissions and functional status (FAI) at follow-up, 6 months (clinically important benefit demonstrated); grade C for functional status (Functional Quality of Movement Scale [FQM]) motor performance, Barthel Index, EADL–personal daily care, IADL–domestic activities), mobility and life habits/ leisure at follow-up, 6 months (no benefit demonstrated); grade D for functional status (FQM quality of movement) at follow-up, 6 months (no benefit demonstrated but favoring control). Patients with chronic stroke. 72 TOPICS IN STROKE REHABILITATION/SPRING 2006 Home therapy (physician) versus home therapy (physiotherapy), level I (RCT): Grade C+ favoring home therapy (physiotherapy) for functional status (IADL–domestic activities) at follow-up, 6 months (clinically important benefit demonstrated without statistical significance); grade C for decrease in hospital readmission, functional status (FAI, FQM motor performance, FQM quality of movement, Barthel Index, and EADL–personal daily care), mobility and life habits/leisure at follow-up, 6 months (no benefit demonstrated). Patients with chronic stroke. Extended stroke unit service with early supported discharge versus ordinary stroke unit service, level I (RCT): Grade A for functional status (number of patients with Rankin score less than 2) at follow-up, 6 months (clinically important benefits demonstrated); grade C+ for physical mobility at follow-up, 3 weeks and 1 year (clinically important benefits demonstrated without statistical significance); grade C for functional status (number of patients with Barthel Index score higher than 95) at follow-up, 3 weeks, 6 months, and 1 year, for discharge status and preventing mortality at follow-up, 1 year, for energy level and pain at follow-up, 3 weeks, 6 months, and 1 year, for global health status at follow-up, 1 year, and functional status (number of patients with Rankin score less than 2) at follow-up, 3 weeks and 1 year (no benefit demonstrated); grade D for global health status at follow-up, 3 weeks and 6 months (no benefit demonstrated but favoring control); grade D+ for physical mobility at follow-up, 6 months (clinically important benefits demonstrated without statistical significance favoring control). Patients with acute stroke. Early physiotherapy intervention versus control group, level I (RCT): Grade C+ for functional status (Modified Barthel Index) and motor function (Fugl-Meyer score for lower extremity) at end of treatment, 1 month, and follow-up, 5 months, and motor function (Fugl-Meyer score for upper extremity) at end of treatment, 1 month (clinically important benefits demonstrated without statistical significance); grade D for motor function (Fugl-Meyer score for upper extremity) at followup, 5 months (no benefit demonstrated but favoring control). Patients with acute stroke. Home-based exercise training versus control, level I (RCT): Grade A for change in gait speed, gait endurance, torque (change in knee isometric extensors), endurance, and cardiopulmonary function at end of treatment, 12 weeks; grade C+ for motor function (change in Fugl-Meyer lower extremity), change in gait speed, gait endurance, functional status (Physical Function Index), and strength (change in grip strength) at end of treatment, 12 weeks (clinically important benefit demonstrated without statistical significance); grade C for motor function (change in Fugl-Meyer upper extremity and lower extremity), balance (Berg balance and change in Berg balance), functional status (IADL and Barthel ADL Index) at end of treatment, 12 weeks (no benefit demonstrated); grade D+ for balance (Functional reach) at end of treatment, 12 weeks (clinically important benefit favoring control demonstrated without statistical significance); grade D for torque (change in ankle isometric dorsiflexors; no benefit demonstrated but favoring control). Patients with post-acute stroke. Outpatient versus home exercise group, level I (RCT): Grade C+ favoring home exercise group for gait speed at end of treatment, 6 months, and follow-up, 3 months (clinically important benefit demonstrated without statistical significance); grade C for single support time at end of treatment, 6 months, and follow-up, 3 months (no benefit demonstrated). Patients with chronic stroke. Outpatient versus control, level I (RCT): Grade D for gait speed at follow-up, 3 months (no benefit demonstrated but favoring control); grade D+ for gait speed at end of treatment, 6 months, and single support time at end of treatment, 6 months, and follow-up, 3 months (clinically important benefit demonstrated without statistical significance). Patients with chronic stroke. Outpatient therapy versus home therapy, level I (RCT): Grade C for grip strength on affected side and motor assessment, functional status, and gait speed at end of treatment, 6 weeks and 3 months (no benefit demonstrated). Patients with subacute stroke. Home physiotherapy versus day-hospital group, level I (RCT): Grade A for resource cost at end of treatment, 8 weeks (clinically important benefit demonstrated). Patients with subacute stroke. level I (RCT): Grade A for resource cost at followup. and pain relief) at end of treatment. 1 month (no benefit demonstrated but favoring control). 3 months (clinically important benefit demonstrated). functional status (Barthel Index) and pain relief at end of treatment. 9 weeks (no benefit demonstrated). level I (RCT): Grade A for length of stay at end of treatment. grade D for motor function and functional status (Nottingham ADL) at end of treatment. quality of life at follow-up. 9 months (clinically important benefit favoring control demonstrated without statistical significance). 6 weeks (no benefit demonstrated). 1 and 3 months. level I (RCT): Grade C for mobility and functional status at follow-up. 3 months. Patients with chronic stroke. and follow-up. Patients with subacute stroke. level I (RCT): Grade A for length of stay and quality of life (Dartmouth Coop Global Health Status–total) at end of treat- ment. Early supported discharge with home rehabilitation versus standard customary rehabilitation. 3 months (no benefit demonstrated). 3 months (no benefit demonstrated). 6 months (no benefits demonstrated but favoring control). pain relief and functional status (Barthel Index) at end of treatment. grade D for single support time at end of treatment. and length of stay at follow-up. Early care versus standard customary care in stroke unit. Patients with acute stroke. 3 months (no benefit demonstrated). 3 months (clinically important benefit demonstrated). and quality of life (Dartmouth Coop Global Health Status–physical fitness. number of patients with no problems with usual activities) and pain relief at end of treatment. Patients with subacute stroke. 6 months. Patients with acute stroke. 6 months. 6 months. 6 months (no benefit demonstrated). Home therapy versus control group. grade D for functional status (Nottingham EADL score) at end of treatment. and functional status (Nottingham EADL) at follow-up. Integrated care pathway versus standard customary multidisciplinary team care. 3 months. Early supported discharge versus standard customary rehabilitation. grade D+ for functional status (Nottingham ADL) at follow-up. and pain relief at end of treatment. 1 and 3 months. Patients with acute and post-acute stroke. 6 months. 3 months. Full-time integrated treatment (FIT) versus standard customary rehabilitation. level I (RCT): Grade C for functional status (number of patients with no problems with self-care. Combined outpatients and home exercise versus control group. level I (RCT): Grade C for gait speed at end of treatment. functional status (number of patients with some problems with usual activities). 9 months. Patients with chronic stroke. 3 months. grade D+ for functional status (number of patients with some problems with washing and dressing) at end of treatment. and follow-up. grade C for motor function and mobility at end of treatment. 3 months (no benefit demonstrated but favoring control). level II (CCT): Grade C for motor function at end of treatment.Clinical Practice Guidelines 73 Home-exercise versus control group. and follow-up. 9 months. Home intervention (rehabilitation and nursing services) versus standard customary care. level II (CCT): Grade C for functional status at end of . 6 weeks (clinically important benefit demonstrated). grade D for single support time at end of treatment. Patients with acute stroke. 1 year (no benefit demonstrated). daily activities. grade C for motor function and functional status (Rivermead ADL score) at follow-up. 6 months (clinically important benefit favoring control demonstrated without statistical significance). grade C for quality of life at follow-up. level I (RCT): Grade C for gait speed at end of treatment. Nursing early activation program versus no therapy. level I (RCT): Grade A for functional status (Older Americans Resource Scale for Instrumental ADL) at end of treatment. 3 months (no benefit demonstrated but favoring control). 6 months. gait speed and functional status (Barthel ADL Index) at end of treatment. 3 months (no benefit demonstrated but favoring control). and follow-up. and follow-up. 3 months (no benefit demonstrated). grade D for mobility. and follow-up. 3 months (no benefit demonstrated). 3 months (clinically important benefit demonstrated). 6 months. quality of life at end of treatment. Patients with acute stroke. grade C for mobility and functional status at end of treatment. 28) outpatient therapy versus home therapy (n = 100) 428. 20) rehabilitation versus no rehabilitation group (n = 43)442. 36) home intervention (rehabilitation and nursing services) versus standard customary care (n = 114)469. 21) home therapy (physician) versus standard customary care without home visits (n = 310)423.424.433.433.104. and follow-up.441. 26) outpatient versus home exercise group (n = 20)472.104. 18) home-based at high-intensity versus low-intensity physiotherapy control (n = 19)451. 12) enhanced assistant physiotherapist versus standard customary physiotherapy treatment (n = 564)453. 19) home-based rehabilitation versus hospital-based rehabilitation (n = 205)425.457. n = 137)468.452.439. 11) enhanced physiotherapy versus standard customary physiotherapy treatment (n = 564)453. 37) nursing early activation program versus no therapy (n = 59)443.441. n = 137)468. 1 month (no benefit demonstrated but favoring control).432. Critical path method versus standard customary care method.446. Patients with acute stroke. 34) early supported discharge with home rehabilitation versus standard customary rehabilitation (n = 196)427. 22) home therapy (physician) versus home therapy (physiotherapy) (n = 310)423. 33) early care versus standard customary care in stroke unit (n = 30)444. grade D for functional status (FIM raw score) and length of stay at end of treatment.457. 17) home therapy (physiotherapy) versus standard customary care without home visits (n = 310)423.424. 4 weeks (no benefit demonstrated). level I (RCT): Grade D for neurological status and functional status at follow-up. Structured nursing intervention versus conventional rehabilitation. 6 months (no benefit demonstrated but favoring control). 4) stroke unit (small artery stroke) versus general ward (small artery stroke) (n = 267)434.454 .432. 25) home-based exercise training versus control (n = 112)103.279. 15) enhanced therapy (severe stroke) versus standard customary care (severe stroke. 4 weeks and 6 weeks. 24) early physiotherapy intervention versus control group (n = 128)436. Patients with acute stroke. 31) home therapy versus control group (n = 22)470.463–465 . 10) enhanced physiotherapy (60-minute treatment of physiotherapy) versus standard customary physiotherapy care (30 minutes.437–439.461. Summary of trials Forty-eight RCTs and eight CCTs were found that evaluated the efficacy of varying intensities and organizations of rehabilitation for acute to chronic stroke patients (n = 8. 38) integrated . 3 months. 16) enhanced therapy (mild stroke) versus standard customary care (mild stroke.432. 3 months (no benefit demonstrated). and length of stay at end of treatment.455. 9) standard customary occupational therapy versus no therapy (n = 378)431. 13) enhanced physiotherapy versus enhanced assistant physiotherapist treatment (n = 564)453.471.447.n = 114)458.146)431. 8) enhanced occupational therapy versus no therapy (n = 481)430.932).445. 30) home-based exercise versus control group (n = 20)472. 6) 6 days/week versus 7 days/week treatment (n = 113)462. Patients with acute stroke. level I (RCT): Grade C for functional status (FIM and IADL) and selfperception of health at end of treatment.448– 450. Patients with acute stroke. 27) outpatient versus control (n = 20)472. 1 month (no benefit demonstrated). 5) intensive outpatient physiotherapy rehabilitation program versus control group (n = 54)279. 2) stroke unit versus home care (n = 447)449. 23) extended stroke unit service with early supported discharge versus an ordinary stroke unit service (n = 702)426.422–474 The following treatments were evaluated: 1) stroke unit versus general ward (n = 3.103.457. 35) early supported discharge versus standard customary rehabilitation (n = 323)460. level I (RCT): Grade C for functional status (FIM motor subscale) at end of treatment.424. 7) enhanced occupational therapy versus standard customary occupational therapy (n = 492) 410. 29) home physiotherapy versus day-hospital group (n = 95)474. 3) stroke unit (large artery stroke) versus general ward (large artery stroke) (n = 267)434. Home hospitalization versus standard stroke care (inpatient). 14) enhanced upper extremity treatment versus interdisciplinary treatment (n = 626)459. 32) combined outpatients and home exercise versus control group (n = 20)472.74 TOPICS IN STROKE REHABILITATION/SPRING 2006 treatment. 6 weeks and 3 months. 9 months. 6 weeks (18% RD). number of patients with medical complications) at end of treatment.475–490 For 14 other studies. functional status (number of patients independent in ADL) at end of treatment. For stroke unit rehabilitation for patients with acute stroke versus home care (one RCT. and resource cost (total cost per patient in thousands of dollars) at follow-up. 40) critical path method versus standard customary care method (n = 121)435. post-acute.449 clinically important benefits with statistical significance were observed for functional status (number of patients with Barthel score between 15 and 20) at follow-up.524–569 Efficacy For stroke unit rehabilitation for patients with acute. one RCT. No benefit was demonstrated for functional status (number of patients deteriorated in ADL score) at end of treatment. 1 week. 3 months. No benefit was demonstrated for functional status (number of patients with Modified Rankin score from 0 to 3) at end of treatment. 6 weeks. and quality of life . subacute. respectively). but results favored the control treatment for mobility (number of patients able to walk short distances with or without aids) at end of treatment. and chronic stroke versus general ward rehabilitation (eight RCTs and three CCTs. mobil- ity (number of patients independent in walking [Barthel Index]. mobility (number of patients independent in walking mobility) at end of treatment. No benefit was demonstrated.146). 429. 9 months. No other outcomes were measured (IR-Figures 151A-F. and functional status (number of patients with Barthel score between 15 and 20) at end of treatment. 6 weeks. Among these. functional status (number of functional patients) at follow-up. n = 267). 3 years (19% and 46% RD. with follow-up at 2 weeks up to 3 years (Appendix 3M).434 clinically important benefits with statistical significance were seen for functional status (number of patients with Barthel score 15–20) at follow-up.25. A clinically important benefit with statistical significance was demonstrated for mobility (number of patients able to walk long distances independently) at end of treatment. and follow-up. 16 weeks. n = 3. resulting in the exclusion of 19 more studies.452. and follow-up. there were 96 studies excluded. For stroke unit (large artery stroke) rehabilitation for patients with acute stroke versus general ward (large artery stroke.448– 450.491–505 Another major reason for exclusion was the participation of subjects with either multiple conditions or multiple strokes. motor function (number of patients independent in upper extremity and lower extremity function) at end of treatment. 1 year. Table 169). A clinically important benefit favoring control was demonstrated without statistical significance for functional status (ADL score) at end of treatment.463–465 clinically important benefits with statistical significance were shown for length of stay (days) at end of treatment. 39) fulltime integrated treatment (FIT) versus standard customary rehabilitation (n = 106)466. Tables 168A-J). No other outcomes were measured (IR-Figure 152. and climbing stairs [Rivermead EADL household]) at end of treatment.Clinical Practice Guidelines 75 care pathway versus standard customary multidisciplinary team care (n = 152)467.438. 41) structured nursing intervention versus conventional rehabilitation (n = 155) 456. walking outside. there was more than a 20% subject drop-out rate. In total.431. efficiency (number of patient in-hospital fatalities. number of patients independent upon discharge. and resource cost (number of physician visits per patient) at follow-up. 6 months.460 for a total duration of treatment of 1 week to 6 months. 2 weeks. 6 weeks. 1 year (22% RD). 3 and 6 months.506–523 The remaining studies were excluded for various other reasons outlined in IRTable 167. functional status (ADL score) at end of treatment. A clinically important benefit without statistical significance was demonstrated for functional status (number of patients with mild-moderate impairment) at follow-up. number of patients independent in indoor and outdoor walking [Rivermead EADL– self-care]. postural status (number of patients sitting and standing) at follow-up. 3 months. 3 months. 2 weeks.437. 9 months (15% RD). 1 year (16% RD). 16 weeks. and follow-up. and follow-up. 1 year. 3 months. and 42) home hospitalization versus standard stroke care (inpatient) (n = 120)422 session or even all day in one study. 1 year. and length of stay (days) at end of treatment. 17 were excluded due to insufficient statistical data. n = 447). No other outcomes were measured (IR-Figure 156. 3 months (28% RD).433. No other outcomes were measured (IR-Figures 157A-D. 3 months and 1 year. and 28% RD.441. For enhanced occupational therapy for patients with subacute stroke versus no therapy (five RCTs.76 TOPICS IN STROKE REHABILITATION/SPRING 2006 (Euroqol score) at follow-up. 8 weeks. 3 months (15% RD). For intensive outpatient physiotherapy rehabilitation for patients with chronic stroke versus control group (one RCT. but the results favored the control therapy for mobility (NHP score for mobility) at end of treatment. Tables 170A&B). No benefit was demonstrated. functional status (FIM for upper extremity and lower extremity dressing. n = 481). 3 months.440. No benefit was demonstrated for life habit/leisure (total leisure score) and mobility (Nottingham EADL for mobility) at end of treatment. and functional status (Nottingham EADL score) at end of treatment. respectively) at end of treatment. and quality of life (Euroqol score) at follow-up. life habit/leisure (overall leisure score) at end of treatment. No other outcomes were measured (IR-Figure 154. one RCT. 3 months. respectively). 41% and 50% RD. 3 months. No benefit was demonstrated for quality of life (Euroqol score) at follow-up. Clinically important benefits without statistical significance were demonstrated for quality of life (number of patients living independently) at end of treatment. No benefit was demonstrated. 6 months (23% RD). 3 months (22% RD). Table 172). mobility (Nottingham EADL score for mobility) at end of treatment. No other outcomes were measured (IR-Figure 155. 6 months.431. 3 weeks (19% RD). No benefit was demonstrated for functional status (FIM) at end of treatment. 3 months.434 clinically important benefits with statistical significance were shown for quality of life (Euroqol score) at follow-up. or functional status (Barthel Index score) at follow-up. n = 267). 3 months. 3 weeks (28%). n = 492). 6 months.432. 3 and 6 months. No other outcomes were measured (IR-Figure 153.431.447 clinically important benefits with statistical significance were demonstrated for mobility (NHP for mobility and . Tables 174A-D). 1 year. 3 months. life habit/leisure (total leisure activity score) at end of treatment. hours) at follow-up. Table 173). For 6 days/week of rehabilitation for patients with post-acute stroke versus 7 days/week treatment. one RCT (n = 113)462 showed clinically important benefits without statistical significance for mobility (ambulation section of Functional Recovery Scale) at end of treatment. 3 and 6 months (15%– 24%). No benefit was demonstrated for functional status (number of patients with Barthel score 15–20) at follow-up.430. Clinically important benefits favoring the control therapy were demonstrated without statistical significance for pain relief (NHP score for pain) at end of treatment. A clinically important benefit favoring control was demonstrated with statistical significance for efficiency (duration of physiotherapy visit.279 clinically important benefits without statistical significance were observed for quality of life (Sickness Index Profile) at end of treatment. 3 months. but results favored the control therapy for functional status (Sickness Index Profile) at follow-up. Tables 171A&B). and quality of life (General Health Questionnaire) at follow-up. For enhanced occupational therapy for patients with subacute stroke versus standard customary occupational therapy (five RCTs. but there was favor for the control rehabilitation for length of stay (in days) at followup. A clinically important benefit favoring control was demonstrated with statistical significance for length of stay (in days) and efficiency (duration of physiotherapy visit. and 6 months (16%. 3 and 6 months (56%–58%). No benefit was demonstrated. 3 months. 3 months (28% RD). 3 months.441. 3 months. hours) at followup.n = 54).454 clinically important benefits with statistical significance were demonstrated for functional status (number of patients improved in ADL) at end of treatment. 91%. 3 weeks (28% RD). and functional status (EADL total score) at follow-up. 8 weeks and 6 months (23%–18% RD). No benefit was demonstrated. No benefit was demonstrated for functional status (dressing section of Functional Recovery Scale) and length of stay (days). For stroke unit (small artery stroke) rehabilitation for patients with acute stroke versus general ward (small artery stroke. but the control therapy was favored for functional status (number of patients with Barthel score 15–20) at follow-up. Clinically important benefits favoring control were demonstrated without statistical significance for pain relief (NHP for pain) at end of treatment. Clinically important benefits favoring control were demonstrated with statistical significance for mo- . and grip strength (maximum grip) at follow-up. and functional status (number of patients improved in ADL) at follow-up. 3 and 6 months (32%–38% RD). 3 and 6 months. No benefit was demonstrated for life habit/leisure (overall leisure score and total leisure activity) at end of treatment. for functional status (Barthel Index score) at followup. A clinically important benefit favoring control was demonstrated without statistical significance for motor function (Rivermead Motor Assessment– gross function) at follow-up. good evidence (one RCT. No benefit was demonstrated.433. functional status (EADL) at follow-up. 16 weeks. 1 year (40% RD). Tables 175A-D). 1 month. For enhanced physiotherapy (60 minutes of physiotherapy) for patients with chronic stroke versus standard customary physiotherapy (30 minutes of physiotherapy) care group. n = 114)458 showed no benefit for quality of life (profiles of recovery) at end of treatment. and follow-up. 5 weeks. but results favored the control therapy for quality of life (profiles of recovery) at end of treatment. and activity involvement (number of patients satisfied with their work in the yard) at follow-up. and functional status (EADL) at follow-up. For standard customary occupational therapy for patients with subacute stroke versus no therapy. 5 weeks (15% RD). respectively). 13 weeks. 5 weeks. No benefit was demonstrated. 3 weeks. For enhanced physiotherapy for patients with subacute stroke versus standard customary physiotherapy (two RCTs. and for pain relief (NHP) at end of treatment. A clinically important benefit was demonstrated without statistical significance for functional status (Barthel Index) at follow-up. 13 weeks.471 showed clinically important benefits with statistical significance for functional status (EADL score) at followup. 16 weeks and 21 weeks. 3 and 6 months (24%–30% and 20%–30% respectively). 6 months. but results favored the control therapy for functional status (EADL score) at end of treatment. 6 months (19% RD). Clinically important benefits were demonstrated without statistical significance for activity involvement (Katz Adjustment Index: number of patients satisfied with their walking) at follow-up. 16 weeks. functional status (EADL score) at follow-up.457 clinically important benefits with statistical significance were demonstrated for motor function (ARAT) at follow-up. 21 weeks (18% RD). Table 177). and follow-up. and pain relief at end of treatment. 6 months and 1 year. 5 weeks. No benefits were demonstrated for functional status (Barthel Index) at end of treatment. 6 weeks. motor function (Rivermead Motor Assessment–upper extremity) at end of treatment. 1 month. 3 months and 6 months. 21 weeks. No other outcomes were measured (IRFigure 160. three RCTs (n = 378)431.Clinical Practice Guidelines 77 EADL for mobility) at end of treatment. 3 months (34% RD). 3 and 16 weeks (15% RD). activity involvement (number of patients satisfied with their work in the yard) at end of treatment. 5 weeks. but results favored the control for activity involvement (number of patient satisfied with their work in and around house) at follow-up. Clinically important benefits were demonstrated without statistical significance for mobility (NHP for mobility) at end of treatment. and followup. No other outcomes were measured (IR-Figures 158A&B. and motor function (ARAT) at end of treatment. 5 weeks. 5 weeks. No benefit was demonstrated. 13 weeks (20% RD). 1 month (48% RD). No benefit was demonstrated. 3 months and 6 months (49%–62% and 39%–40% RD. 21 weeks. 6 months.452. motor function (Ten-Hole Peg Test) at end of treatment. n = 564). No benefit was demonstrated for functional status (Barthel ADL Index) at follow-up. 6 months. No other outcomes were measured (IRFigures 159A&B. activity involvement (number of patients satisfied with their work in and around the house and number of patients satisfied with their walking) at end of treatment. life habit/leisure (overall leisure score and total leisure activity) at end of treatment. Tables 176A&B). 3 and 6 months. A clinically important benefit favoring control was demonstrated without statistical significance for functional status (EADL score for mobility) at end of treatment. but there was favor for the control therapy for quality of life (General Health Questionnaire) at follow-up. A clinically important benefit favoring the control therapy was demonstrated with statistical significance for motor function (Rivermead Motor Assessment–gross function) at end of treatment. and grip strength (maximum grip) at follow-up. For enhanced upper-limb treatment for patients with subacute stroke versus interdisciplinary treatment. No benefit was demonstrated. 21 weeks (20% RD). 16 weeks. For enhanced assistant physiotherapy for patients with subacute stroke versus standard customary physiotherapy treatment. No benefit was demonstrated for functional status (Barthel Index) at follow-up. 16 weeks. 3 and 16 weeks (15% RD). 21 weeks (33% RD). and motor function (ARAT) at follow-up. 16 weeks. two RCTs (n = 564)452. and motor function (ARAT) at end of treatment. 5 weeks (18% and 43% RD. and motor function (Ten-Hole Peg Test) at end of treatment. respectively). respectively). 5 weeks. and 21 weeks (200% and 20% RD. motor function (Rivermead Motor Assessment–UE) at follow-up. and grip strength (maximum grip) at end of treatment. n = 564). 5 weeks. and follow-up. 5 weeks. functional status (EADL score) at follow-up. 3 weeks and 16 weeks. 16 weeks (≥15% RD). 3 weeks. Table 179). respectively). 5 weeks (100% RD). 3 weeks. motor function (ARAT) at follow-up. Clinically important benefits favoring control were demonstrated without statistical significance for motor function (Rivermead Motor Assessment– upper extremity) at follow-up. 21 weeks (34% and 28% RD. 5 weeks. For enhanced physiotherapy for patients with subacute stroke versus enhanced assistant physiotherapist treatment (two RCTs. motor function (Rivermead Motor Assessment– upper extremity) at end of treatment. 5 weeks. 21 weeks (27% RD). and grip strength (maximum grip) at end of treatment. and follow-up. No other outcomes were measured (IRFigures 161A&B. but results favored the control therapy for functional status (Barthel Index) at follow-up. 21 weeks. grip strength (maximum grip) at follow-up. motor function (Rivermead Motor Assessment–gross function) at follow-up. A clinically important benefit was demonstrated without statistical significance for motor function (Rivermead Motor Assessment–gross function) at follow-up. and follow-up.452. and motor function (Ten-Hole Peg Test) at end of treatment. respectively). motor function (Rivermead Motor Assessment– gross function) at end of treatment. and grip strength at end of treatment. 5 weeks. 5 weeks. No other outcomes were measured (IRFigures 163A&B. 5 weeks. No benefit was demonstrated for functional status (Barthel Index) at end of treatment. Table 180). and follow-up. 3 weeks (100%). 16 weeks. 16 weeks (≥15% RD). 16 weeks (250% RD). No other outcomes were measured (IR-Figures 162A&B. motor function (Rivermead Motor Assessment-upper extremity) at end of treatment. motor function (Rivermead Motor Assessment–upper extremity) at follow-up. 3 weeks (≥15% RD). 5 weeks. functional status (EADL) at end of treatment.457 showed clinically important benefits with statistical significance for motor function (Rivermead Motor Assessment–upper extremity) at follow-up. and follow-up. Table 178). 5 weeks. 16 weeks. 3 and 16 weeks. and follow-up. and follow-up. 3 weeks. functional status (EADL score) at follow-up. and motor function (ARAT) at end of treatment. Clinically important benefits with statistical significance favoring enhanced assistant physiotherapist were found for functional status (Barthel Index) at end of treatment. and follow-up. and follow-up. respectively). 21 weeks. 5 weeks. 5 weeks.457 clinically important benefits with statistical significance were shown for motor function (Rivermead Motor Assessment–gross function) at end of treatment. 5 weeks (19% RD). one RCT (n = 626)459 showed a clinically important benefit with statistical signifi- . 16 weeks. 16 weeks. 16 weeks. A clinically important benefit was demonstrated without statistical significance favoring enhanced assistant physiotherapist for functional status (Barthel Index) at follow-up. functional status (EADL score) at follow-up. 21 weeks (17% and 33% RD. and follow-up. 16 weeks (19% and ≥15% RD. functional status (EADL) at end of treatment. 5 weeks. A clinically important benefit was demonstrated without statistical significance for functional status (Barthel Index) at follow-up. 3 and 16 weeks (≥15% RD). and motor function (ARAT) at followup.78 TOPICS IN STROKE REHABILITATION/SPRING 2006 tor function (Rivermead Motor Assessment–upper extremity) at follow-up. 16 weeks. 11 weeks. and life habits/leisure (IADL–leisure/social activities) at followup. 6 months. and functional status (Barthel Index) at follow-up. Barthel Index. mobility (number of patients able to walk 10 m without an aid).451 clinically important benefits with statistical significance were shown for motor function (STREAM– lower extremity) at follow-up. 18 weeks. No other outcomes were measured (IRFigure 166. No other outcomes were measured (IR-Figure 169. 11 weeks (25% RD). FAI. 22 weeks. 11 weeks (17% and 21% RD.Clinical Practice Guidelines 79 cance for motor function (Frenchay Arm Test) and functional status (Barthel Index) at follow-up. No other outcomes were measured (IR-Figure 170. No other outcomes measured (IR-Figure 164. 6 months. 6 weeks. No other outcomes were measured (IRFigure 165. 18 weeks. No benefit was demonstrated for motor function (Upper Limb Motricity Index and Frenchay Arm Test) at follow-up. For rehabilitation for patients with subacute stroke versus no rehabilitation group. No other outcomes were measured (IR-Figures 167A&B. No other outcomes were measured (IR-Figure 168. 22 weeks. EADL–personal daily care). For high-intensity home-based physiotherapy for patients with chronic stroke versus lowintensity physiotherapy (one RCT. A clinically important benefit favoring control was demonstrated without statistical significance for motor function (STREAM–lower extremity) at follow-up. Table 185). 22 weeks. n = 19). 1 year. one CCT (n = 43)442 showed no benefit but the results favored the control rehabilitation for motor function (Brunnstrom Upper Extremity Scale. No benefit was demonstrated for mobility (STREAM–basic mobility) at follow-up.468 no benefit was shown but results favored the control therapy for mobility (number of patients independent in walking) at end of treatment. For enhanced therapy (mild stroke) for patients with acute stroke versus standard customary care (mild stroke. No benefit was demonstrated. 6 and 18 weeks. No benefit was demonstrated but results favored the control therapy for mobility (STREAM–basic mobility) at follow-up. For home-based rehabilitation for patients with post-acute and chronic stroke versus hospital-based rehabilitation (one RCT and one CCT. 6 months. 3 months. 6 months. and functional status (Barthel Index) and motor function (STREAM–upper extremity) at follow-up. Table 183). 6 months. For home visit (physiotherapy) for patients with chronic stroke versus standard customary care without home visit groups (two RCTs. but results favored the control treatment for motor function (Upper Limb Motricity Index) at followup. 6 weeks.423. mobility (EADL–mobility). A clinically important benefit favoring control was demonstrated without statistical significance for functional status (Barthel ADL Index) at end of treatment. respectively).425. Table 182). one RCT (n = 137)468 showed no benefit but the results favored the control therapy for mobility (number of patients independent in walking) at end of treatment. Table 181). n = 137). n = 205). n = 310). Brunnstrom Lower Extremity Scale. 6 weeks. Tables 184A&B). Clinically important benefits were demonstrated without statistical significance for functional status (Barthel Index) and motor function (STREAM–upper extremity) at follow-up. For enhanced therapy (severe stroke) for patients with acute stroke versus standard customary care (severe stroke). 6 months. FQM quality of movement. For home therapy (physician) for patients . one RCT. Tables 186A&B). Upper Extremity Functional Test) at end of treatment. and functional status (Nottingham EADL) at follow-up. functional status (Nottingham EADL) at follow-up.424 a clinically important benefit without statistical significance was observed for functional status (IADL–domestic activities) at follow-up. Clinically important benefits favoring the control treatment were also demonstrated without statistical significance for motor function (ARAT) at follow-up. functional status (number of patients independent in Barthel ADL Index and number of patients independent in IADL) at end of treatment. 18 weeks.445 no clinically important difference was shown for resource cost (total cost) at follow-up. Table 187). No benefit was demonstrated for discharge disposition (number of readmissions into hospital because of stroke-related condition) and functional status (FQM motor performance. respectively) and motor function (Fugl-Meyer for upper extremity) at end of treatment. FQM quality of movement. gait endurance (change in 6-minute walk test. FQM motor performance. 6 months.104 clinically important benefits with statistical significance were observed for change in gait speed (48% RD). 6 months. n = 128).423. 164% RD). but results favored the control treatment for global health status score (NHP) at follow-up. endurance (change in duration of bicycle exercies. A clinically important benefit without statistical significance was demonstrated for physical mobility (NHP) at follow-up. No benefit was demonstrated for decrease in hospital readmission (number of readmissions into hospital because of stroke-related condition) and functional status (FAI. global health status score (NHP) at follow-up. n = 310). and 1 year. gait endurance (change in 6minute walk test.436 a clinically important benefit without statistical significance was demonstrated for functional status (Modified Barthel Index) and motor function (Fugl-Meyer score for lower extremity) at end of treatment. energy level and pain (NHP) at follow-up. For early physiotherapy intervention for patients with acute stroke versus control group (one RCT. A clinically important benefit without statistical significance favoring control was demonstrated for physical mobility (NHP) at follow-up. n = 112). 5 months. 6 months. 6 months (23% RD). preventing mortality (number patients deceased) at follow-up. feet. and 1 year. feet. mobility (EADL– mobility). 6 months. For home-based exercise program training for patients with post-acute stroke versus control (two RCTs. but results favored the control group for motor function (Fugl-Meyer score for upper extremity) at followup. No benefit was demonstrated for functional status (number of patients with Barthel Index score higher than 95) at follow-up. Tables 188A&B). 1 year. For extended stroke unit service with early discharge for patients with acute stroke versus ordinary stroke unit service (three RCTs.424 a clinically important benefit without statistical significance was shown favoring home physiotherapy (physiotherapy) of home visit (physician) for functional status (IADL–domestic activities) at follow-up. No other outcomes were measured (IR-Figures 173A-C. Table 191). 1 month (18% RD).439. 5 months (27%–39% and 21%–15% RD. 3 weeks. EADL–personal daily care. but results favored the control therapy for functional status (FQM quality of movement) at follow-up. 6 months. For home therapy given by physician to patients with chronic stroke versus home therapy given by a physiotherapist (one RCT. and follow-up. n = 702). functional status . respectively). 61% RD). and cardiopulmonary function (change in peak VO2. 6 months. No other outcomes were measured (IR-Figures 172A&B. A clinically important benefit was demonstrated without statistical significance for motor function (change in FuglMeyer lower extremity.80 TOPICS IN STROKE REHABILITATION/SPRING 2006 with chronic stroke versus standard customary care without home visits (two RCTs. 59% RD).423. and functional status (number of patients with Rankin score less than 2) at follow-up. No clinically important benefit was demonstrated. No benefit was demonstrated for functional status (FQM motor performance. discharge status (number of patients discharged at home). No benefit was demonstrated. 12 weeks. 3 weeks and 1 year (30% and 23% RD). 15% RD). Tables 190A&B). and life habits/leisure (IADL–leisure/social activities) at follow-up. 17% RD).424 clinically important benefits with statistical significance were shown for decrease in hospital readmissions (number of readmissions into hospital because of stroke-related condition) and functional status (FAI) at follow-up. No other outcomes were measured (IR-Figures 171A&B. 6 months (18% and 20% RD. and life habits/leisure (IADL–leisure/social activities) at follow-up.103. No other outcomes were measured (IR-Figure 174. 3 weeks and 1 year. 3 weeks and 6 months. Barthel Index. 185% RD) at end of treatment. Barthel Index. 1 year. and EADL– personal daily care).426. 3 weeks. 6 months (18% RD). change in gait speed (94% RD).446 a clinically important benefit with statistical significance was demonstrated for functional status (number of patients with Rankin score less than 2) at follow-up. No benefit was demonstrated. torque (change in knee isometric extensors. n = 310). 1 month. mobility (EADL–mobility). Tables 189A&B). IADL–domestic activities). Table 198). For outpatient therapy for patients with chronic stroke versus control group. balance (Berg balance and change in Berg balance). another RCT (n = 20)472 showed no benefit for gait speed at end of treatment. No benefit was demonstrated. 12 weeks. For home exercise for patients with chronic stroke versus control. 6 months. 20% RD). Table 194). Table 192).Clinical Practice Guidelines 81 (physical function index. Table 199). and functional status (Barthel Index) and pain relief at end of treatment. No ben- . 6 months. Table 197). 3 months. No other outcomes were measured (IR-Figure 176. 6 weeks and 3 months. Table 195). No other outcomes were measured (IR-Figure 177. 17% RD) at end of treatment. For outpatient therapy for patients with subacute stroke versus home therapy. 3 months (24% RD). 12 weeks. and follow-up. but results favored the control for torque (change in ankle isometric dorsiflexors) at end of treatment. 1 month and 3 months. 6 months. A clinically important benefit favoring the control was demonstrated without statistical significance for balance (functional reach) at end of treatment. gait speed (10 m walking speed). Table 193). No benefit was demonstrated. No other outcomes were measured (IR-Figure 181. 6 months. For home therapy for patients with subacute stroke versus control group. 8 weeks. quality of life at follow-up. 6 months. 3 months. mobility (Timed Up & Go) at end of treatment.444 a clinically important benefit with statistical significance was shown for length of stay (days). 12 weeks.n = 20). No benefit was demonstrated for single support time at end of treatment. No other outcomes were measured (IR-Figures 175A-C. n = 100)428 that showed no benefits for grip strength on affected side and motor assessment. For day-hospital for patients with subacute stroke versus home physiotherapy group. For outpatient therapy for patients with chronic stroke versus home-exercise group (one RCT.472 clinically important benefits without statistical significance favoring home exercise group were observed for gait speed at end of treatment. respectively) and length of stay at follow-up.455 showed a clinically important benefit with statistical significance for functional status (Older Americans Resource Scale for Instrumental ADL) at end of treatment. 6 months. and follow-up. No benefit was demonstrated for motor function (change in Fugl-Meyer upper extremity and lower extremity). For early care for patients with acute stroke versus standard customary care in stroke unit (one RCT. 6 weeks. 3 months (16%– 24% RD). or functional status (Barthel Index) at end of treatment. Table 196). 3 months. and single support time at end of treatment. one RCT (n = 95)474 showed a clinically important benefit with statistical significance for resource cost (total cost in pounds) at end of treatment. No other outcomes were measured (IR-Figure 182. and follow-up. one RCT (n = 20)472 showed no benefit but favored the control group for gait speed at follow-up. 6 months. 6 months. but results favored the control group for single support time at end of treatment. 12 weeks. (one RCT. 3 months. n = 20)470 no benefit was illustrated for gait speed. and follow-up. and follow-up. and strength (change in grip strength. and follow-up. but results favored the control for single support time at end of treatment. No other outcomes were measured (IRFigure 179. 3 months. 1 and 3 months (16% and 15% RD. one CCT (n = 22)470 demonstrated no benefit for motor function (Peg Test Time) at end of treatment. Table 200). For early supported discharge with home rehabilitation for patients with acute stroke versus standard customary rehabilitation. For combined outpatient and home exercise for patients with chronic stroke versus control group. n = 30). 3 months. one RCT (n = 196)427. No other outcomes were measured (IR-Figure 178. No benefit was demonstrated. No other outcomes were measured (IR-Figure 180. Clinically important benefits favoring control were demonstrated without statistical significance for gait speed at end of treatment. 3 months. No benefit was demonstrated for motor function (STREAM). good evidence was found (one RCT. No other outcomes were measured (IR-Figure 183. 9 weeks. No benefit was demonstrated for functional status (ADL score) and mobility (ambulatory ability) at end of treatment. functional status (IADL and Barthel ADL Index) at end of treatment. and pain relief at end of treatment. 3 months. respectively) and functional status (Nottingham EADL) at follow-up. n = 323). and follow-up. 3 months. Table 207). 3 months. For full-time integrated treatment for patients with acute stroke versus standard customary rehabilitation. but results favored the control rehabilitation for functional status (Nottigham EADL score) at end of treatment. and pain relief and functional status (Barthel ADL Index) at end of treatment. 1 month.461 a clinically important benefit with statistical significance was observed for length of stay and quality of life (Dartmouth Coop Global Health Status– total) at end of treatment. No other outcomes were measured (IR-Figure 186. No . functional status (number of patients with some problems with usual activities). one RCT (n = 114)469 showed a clinically important benefit with statistical significance for resource cost (total cost) at follow-up. No benefit was demonstrated for quality of life (SF-36) at follow-up. 6 months. and for length of stay at end of treatment. 1 month. No other outcomes were measured (IR-Figures 185A-C. but results favored the control rehabilitation for motor function and functional status (Nottingham ADL score) at end of treatment. 3 months. No benefit was demonstrated. 3 months. one RCT (n = 152)467 showed no benefit for functional status (number of patients with no problems with selfcare. No benefit was demonstrated. 9 months. A clinically important benefit favoring the control treatment was demonstrated without statistical significance for functional status (number of patients with some problems with washing and dressing) at end of treatment. Table 203). quality of life at end of treatment. Table 205). No other outcomes measured (IR-Figure 188.459. n = 155)456 showed no benefit for functional status (FIM and IADL) and self-perception of health care at end of treatment. and pain relief) at end of treatment.82 TOPICS IN STROKE REHABILITATION/SPRING 2006 efit was demonstrated. For integrated care pathway for patients with acute stroke versus standard customary multidisciplinary team care. A clinically important benefit favoring control was demonstrated without statistical significance for functional status (Nottingham ADL score) at follow-up. 3 months (40%–49% and 40% RD. 3 months. the evidence (one RCT. Tables 204A&B). 6 months. No other outcomes were measured (IR-Figure 189. 3 months (35% RD). 4 weeks. daily activities. but results favored the control treatment for mobility (number of patients with some problems walking and with no problems walking). 3 months (35% RD). For structured nursing intervention for patients with acute stroke versus conventional rehabilitation. 9 months. and quality of life (Dartmoyth Coop Global Health Status–physical fitness. Table 206). For home intervention (rehabilitation and nursing services) for patients with subacute stroke versus standard customary care. No other outcomes were measured (IRFigures 184A-D. No other outcomes were measured (IRFigure 190. 6 months. Tables 201A-C). one CCT (n = 106)466 showed no benefit for functional status (FIM motor subscale and total) at end of treatment. one RCT (n = 121)435 showed no benefits for functional status (FIM motor subscale) at end of treatment. number of patients with no problems with usual activities) and pain relief at end of treatment. For the critical path method for patients with acute stroke versus the standard customary care method. but there was favor for the control method for functional status (FIM total raw score) and length of stay (days) at end of treatment. 1 year. one RCT (n = 59)443 showed no benefits for mobility (number of patients independent in walking) and functional status (number of patients independent in household work and ADL Index score) at follow-up. 3 months. 1 month. No other outcomes were measured (IR-Figure 187. 4 weeks and 6 weeks. 6 months. 3 months. No benefit was demonstrated for motor function (Motricity Index) and functional status (Rivermead ADL score) at follow-up. and follow-up. For early supported discharge for patients with acute and post-acute stroke versus routine rehabilitation (two RCTs. Tables 202A&B). No benefit was demonstrated. 9 months. For nursing early activation program for patients with acute stroke versus no therapy. and follow-up. gait speed (5 m timed walk) and functional status (Barthel ADL Index) at end of treatment. Table 209). occupational therapy (13 RCTs).Clinical Practice Guidelines 83 other outcomes were measured (IR-Figure 191. This is in line with the VA/DoD75 that found good evidence that early rehabilitation therapy should be provided as soon as the patient’s medical status is stable (Appendix 4). the Ottawa Panel found that stroke unit care versus care in a general ward was better for functional status outcomes (grades A and C+) for patients with acute to chronic stroke (Appendix 4). The Scottish Intercollegiate Guidelines Network74 equally found level I evidence for the treatment of acute stroke patients in a multidisciplinary unit and level III evidence for occupational therapy treatment. functional status. functional outcomes from rehabilitation. and quality of life. rehabilitation in specialized stroke units. The Ottawa Panel also found level I and level II evidence for conventional or standard customary rehabilitation (15 RCTs and 3 CCTs). Strength of published evidence compared with other guidelines Clinical recommendations compared with other guidelines The Ottawa Panel found level I evidence (2 RTCs) for multidisciplinary team care. but results demonstrated a favor for the control treatment for neurological status (Neurological Impairment Score) and functional status (Functional Impairment Score) at follow-up. This is in line with the Royal College of Physicians. As articulated by the St. This is in line with the Scottish Intercollegiate Guidelines Network74 that found good evidence that stroke patients in the acute phase should be treated in a multidisciplinary stroke unit (Appendix 4). The Panel found good evidence supporting treatment in a stroke unit (grade A for length of stay. 6 months. The European Stroke Initiative78 found evidence for the referral to a home management program. and grade C+ for functional status) and poor evidence supporting treatment in a general ward (grade D+ for functional status) for patients with acute to chronic stroke. stroke unit and general ward care (15 RCTs. and enhanced therapy (24 RCTs) in post-stroke rehabilitation. The Ottawa Panel supports early care (grade A for length of stay) and early physiotherapy intervention (grade C+ for functional status and motor function for the lower and upper extremities) for patients with acute stroke. Similarly. and additional home-based therapy and level II evidence for early admission to rehabilitation. St. early care (3 RCTs). Last. Table 208). functional status. In comparison. Joseph’s Health Care London73 also found level I evidence for the intensity of therapy. physiotherapy (9 RCTs). However. grade B for mobility. The Ottawa Panel found poor evidence for the use of care pathways in rehabilitation such as an integrated care pathway (grade C for functional status and pain relief. one RCT (n = 120)422 showed no benefit. and home therapy (18 RCTs. the VA/DoD75 also found level I evidence for early rehabilitation and inpatient versus outpatient stroke rehabilitation. and pain relief) and full-time inte- . early supported discharge (6 RCTs). Joseph’s Health Care London73 found fair evidence that an early admission to post-stroke rehabilitation should be considered for medically stable stroke patients (Appendix 4). outpatient therapy (6 RCTs). The Royal College of Physicians72 found level I evidence concerning the expertise of specialists in a stroke unit and expertise of care in home services.72 which found good evidence that acute care for patients undergoing post-stroke rehabilitation in a hospital should be delivered in a ward or stroke unit with specialists with expertise in stroke management. 3 CCTs). care pathways (2 RCTs. For home hospitalization for patients with acute stroke versus standard stroke care (inpatient). care pathways in rehabilitation. and grade D for mobility. Joseph’s Health Care London 73 guidelines. 2 CCTs). St. the type of evidence (RCT or CCT) was not reported. No other outcomes were measured (IR-Figure 192. The Ottawa Panel found evidence in favor for an interdisciplinary treatment approach (grade D+ for arm motor function) for patients with subacute stroke and in favor for a standard customary multidisciplinary team care (grade D+ for functional status) for patients with acute stroke. 1 CCT). Similarly. Joseph’s Health Care London. and grade C+ for functional status). enhanced physiotherapy (grade A for motor function. evidence-based practice in the area of stroke rehabilitation has been gaining popularity. The Ottawa Panel conducted a systematic review of the literature. and grade C+ for quality of life and functional status) for patients with subacute stroke. mobility. or C+. For enhanced therapies. Based on this systematic review.84 TOPICS IN STROKE REHABILITATION/SPRING 2006 grated treatment (FIT) (grade C for functional status and length of stay) and for a critical path method (grade C for functional status) for patients with acute stroke. Similarly.73 which found good evidence that additional home-based therapy does not improve the overall functional outcome scores for patients undergoing post-stroke rehabilitation (Appendix 4). there is also support for home-based rehabilitation (grade C for resource cost. All other interventions and outcomes evaluated by the Ottawa Panel were not compared. while the European Stroke Initiative78 found poor evidence as to whether care services that are able to provide adequate and flexible support within 24 hours for stroke patients should be considered for a home management program (Appendix 4). grades A and C) for patients with chronic stroke. Joseph’s Health Care London73 found good evidence that care pathways do not improve post-stroke rehabilitation outcomes and do not reduce hospital costs or decrease the length of hospital stays for patients undergoing post-stroke rehabilitation (Appendix 4).72 which found that there is good evidence that stroke patients should only be managed at home. life habit/ leisure. The Ottawa Panel also agrees with the VA/ DoD75 that there is insufficient evidence as to whether inpatient stroke rehabilitation care demonstrates superiority in outcomes. because they did not apply to other preexisting clinical guidelines (Appendix 4). St. The Ottawa Panel found some support for home therapy (physiotherapy or exercise training. B. and for early supported discharge with home rehabilitation (grades A and C) for the outcome of functional status for patients with acute stroke. and functional status) versus hospital-based rehabilitation for patients with post-acute and chronic stroke and for home physiotherapy (grade A for resource cost) versus day-hospital for patients with subacute stroke (Appendix 4). This is in line with the Royal College of Physicians. Joseph’s Health Care London73 found good evidence that a faster recovery and an earlier discharge from the hospital can result from intense therapies delivered in short periods of time within the post-stroke rehabilitation process (Appendix 4). grades C+ and C) and home-based rehabilitation (grade C) for patients with post-acute and chronic stroke. and mobility. Discussion For the past 5 years. resulting in 147 positive recommendations with grades of A. This is in partial agreement with St. which revealed a number of physical interventions in post-stroke rehabilitation whose clinical effectiveness was supported by one or more comparative controlled studies (CCSs). for home therapy (provided by a physician. if the services delivered at home are part of a stroke service provided by specialists. The Panel found that stroke unit rehabilitation was preferred (grade A and C for functional status) over home rehabilitation and standard inpatient stroke care was preferred (grade D for neurological status and functional status) instead of home hospitalization for patients with acute stroke. the Panel found evi- dence in favor of extended stroke unit service with early supported discharge (grade A for functional status. when compared to outpatient stroke rehabilitation. Other interventions in stroke rehabilitation require further evidence to prove their effectiveness . St. Otherwise. and enhanced occupational therapy (grade A for functional status. The Ottawa Panel found good evidence to recommend early supported discharge with home rehabilitation (grade A for functional status) for patients with acute stroke. these patients should be admitted to the hospital for initial care and assessment (Appendix 4). and grade C+ for physical mobility) for patients with acute stroke. EBCPGs were developed. However. The Panel found good evidence that treatment in a stroke unit was preferred over home care (grade A for functional status) for patients with acute stroke. However.70. org). uottawa. The evidence for the Ottawa Panel’s EBCPGs was based on systematic reviews and meta-analyses that were conducted according to Cochrane Collaborations methods. several guidelines used a more descriptive approach to obtain consensus recommendations. and 6 (editorial independence). Exact scores and a decision aid tool are available on the University of Ottawa School of Rehabilitation Sciences’ Web page (www. The Ottawa Panel also faced other limitations with regard to the development of these guidelines. 2 (stakeholder involvement). treatment schedules.71 These differences could potentially explain some of the variation in guideline recommendations. the categorization of studies according to the type of interven- . Weighing the evidence in such situations inevitably involves value judgments and is subject to interpretation.570 However. On dimensions 1 (purpose). as the Ottawa Panel also came up with 272 negative recommendations with grades of C (n = 148). Due to the absence of a clear consensus with regard to the relative importance of specific. other guidelines either did not recommend the intervention or found the evidence to be insufficient to make a recommendation. For example.ca/rehabguidelines). outcome measures. several practitioners sat on the Ottawa Panel and participated in feedback surveys regarding the relevance of these guidelines in their daily practice.72–76 while others. there is relative consistency (Appendix 4). like the Ottawa Panel. The clinical studies that met the Ottawa Panel’s selection criteria rarely exceeded 3 out of 5 on the Jadad scale. when the Ottawa Panel assigned a grade of C+ for shoulder strapping and therapeutic ultrasound. the Ottawa Panel guidelines were evaluated according to the Appraisal of Guidelines Research and Evaluation (AGREE) criteria84 (www. These methodological issues limit the reliability of the reported outcomes and the overall quality of the evidence. considered a positive recommendation by the Panel. in general.health. heterogeneity with respect to interventions. resulting in the following scores. used a more quantitative approach. the strength of clinical practice guidelines depends upon the quality of the primary studies found in the literature. It is important to point out that the Ottawa Panel EBCPGs are not without limitations. quantitative pooling of data through metaanalysis was not appropriate in most cases. D (n = 79). Inadequate reporting of side effects and risks in the primary trials lowered the rigor of the development score. the Ottawa Panel does not recommend the inclusion of these interventions for the management of stroke survivors for specific outcomes The strength of the Ottawa Panel’s post-stroke guidelines lies in the rigorous methodology used to develop them. Second. the findings were sometimes inconsistent from one study or outcome measure to the next. First of all. and methods of applying and monitoring the guidelines. potential organizational barriers. Equally. Finally. all guidelines developers face these same issues with regard to methodological considerations. A systematic method of grading the evidence designed by an earlier expert panel (Philadelphia Panel)90 was used. and D.(n = 4). To establish both the clarity and practicality of the guidelines. 4 (clarity). some disagreements exist. statistical signifcance. study populations. the guidelines received excellent scores. in which the direction. Moreover. it is often difficult to achieve adequate blinding with physical treatments that produce cutaneous sensation. In identifying cost implications. Lower scores were obtained on dimensions 3 (rigor of development) and 5 (applicability). which reduced the comparability of individual trials. CCT) were taken into account. and clinical importance of the reported outcomes and the overall study design (RCT vs. the EBCPGs’ applicability was rated as low. Articles in the scientific literature were only considered if they were written in English or French due to the additional time and resources required for translation. In comparing the Ottawa Panel guidelines with other existing guidelines on post-stroke rehabilitation.agreecollaboration.94 and the sample sizes were generally small. individual study findings were not weighted according to the type of outcome assessed or measurement scale used. validated outcome measures. As a result. Of additional note. and comparators was frequently encountered. Consequently.Clinical Practice Guidelines 85 with regard to specific outcomes. For example. it is fair to say that. D+ (n = 41). The Ottawa Panel agrees with other clinical guidelines70–76 in not fully recommending the use of the Bobath approach/NDT at large. However. music-making training. and 3) home-based exercise for improving balance. strengthening. there is strong evidence suggesting that aerobic training. resisted and ballistic finger resisted extension training. functional training (either combined or alone. that cost and resource availability are important factors in the individual clinician’s descion-making process. developed a standardized methodology to estimate the variance of data (Appendix 2). this criterion remains somewhat arbitrary and may not be applicable to all rehabilitation interventions or outcome measures. we recommend that the same approach be excluded in the management of short-term pain and sitting balance among stroke survivors who are in the acute and subacute phases of recovery. The Ottawa Panel’s recommendations are consistent with recent systematic reviews on therapeutic exercise. and mental imagery should be included as interventions in post-stroke rehabilitation. strength training (either combined with aerobic exercise or alone). In the calculations of clinical relevance. such as for improving motor function and quality of life over the long term.14 Meek et al. However. In another review.17. water-based training. however.571 conducted a systematic review of three studies that were included by the Ottawa Panel and found similar results. Interventions that showed clinically important benefits without statistical significance for validated outcomes (grade C+) were interpreted as worthy of consideration in the rehabilitation of stroke patients and were given positive recommendations. difficulties also arose when the variance of data was not directly provided in the published articles. the Ottawa Panel does not recommend the following: 1) PNF for increasing ankle ROM in post-acute stroke.86 TOPICS IN STROKE REHABILITATION/SPRING 2006 tion examined was not always straightforward. This was the best conservative approximation that could be used to produce the Ottawa Panel recommendations.8 progressive strengthening exercise. because patients need greater supervision to ensure their safety.).478. and maximal isokinetic strengthening depending on the specific characteristics of individual stroke patients. which may further account for any differences in recommendations made by other guideline development groups. 2) the use of overhead pulley in the subacute phase of stroke. the Ottawa Panel did not formally assess the cost-effectiveness of the various interventions studied.13.W.A. The Ottawa Panel is generally in concordance with other existing reviews on the efficacy of post-stroke general therapeutic exercise. This decision was inherently subjective and could contribute to potential variation in the Ottawa Panel’s recommendations with other published clinical practice guidelines. agility exercise training. The Ottawa Panel also recommends progressive resistance muscle training. especially in presence of spasticity.573 and robot-aided training. van der Lee572 did not find enough evidence to determine which form of therapeutic exercises produces the best outcomes in post-stroke rehabilitation.19 Post-stroke aerobic exercise. The Ottawa Panel recommends the use of the Bobath approach/NDT for at least some outcomes. the Ottawa Methods Group. functional task training. Finally. . working closely with a senior biostatistician (G.7. It is recognized. robot-aided training. Most of the existing EBCPGs on stroke rehabilitation did not consider clinical significance in synthesizing the evidence. see Task-Oriented section). NDT has tended to integrate more functional components in their approach to treat stroke patient. As a result. the Ottawa Panel considered a 15% improvement relative to control as clinically important. With regard to the calculation of treatment benefit. robot-aided training.573 aerobic training. because in some cases a particular study could be applied to several categories. water-based training.18. Over time. especially if the shoulder is subluxed (see Shoulder Management section). but these elements do not seem to translate into functional outcomes as reflected by validated outcomes measures used in stroke rehabilitation. However. Therapeutic exercises According to the Ottawa Panel. A decision was made as to which category of intervention a particular study best belonged in order to avoid duplication.13. active shoulder ROM using a skateboard. Furthermore. and task-specific training. Potempa et al.12 suggested that task-oriented training is of particular value when applied intensively and early after stroke onset. weight garment training. Mulder and Hochstenbach587 stated that variable but structured stimulation. task-specific reach training. it is beneficial to continue functional task training even years after stroke onset. enables patients to adapt their learned skills to the changing environment of everyday life. frequency. but in all of the muscle groups necessary to function as well. functional task training for the upper extremity.332. not all clinical settings have access to costly equipment such as Kinetron and robot-aided devices. such as varying the context or the characteristics of the movements being practiced. trunk rotation training.580. More details are urgently needed on which type of TE treatment may achieve the most optimal health outcomes under the safest conditions in this heterogeneous population.579. The advantage of resistive training in comparison to passive exercise is that active participation better promotes central nervous system activity and neural reorganization. and feedback are all components of motor learning and may indicate that practice of a specific movement with concentration is more important in regaining motor control than recruitment of motor units.584 Repetitive functional or task-specific training affects the adaptive reorganization of the central nervous system. Muscle strengthening in the context of functional.74. Exercises practiced at different specific speeds using a Kinetron may contribute to improve muscle contraction and may reflect what happens in a functional context.200 and promote muscle strength and endurance. In their review.71. traditional functional retraining.586 This type of training appears to make a difference. leading to improved functional recovery. practice.76 The Ottawa Panel guidelines are also in concordance with recent systematic reviews. trunk control training. which is limited in hemiparesis. and content according to different patient characteristics. also found that aerobic exercise after stroke improves tolerance to ADLs by increasing the maximal rate of oxygen consumption and lowering heart rate and systolic blood pressure.8. The Ottawa Panel guidelines are in agreement with existing clinical practice guidelines.555 Task-oriented training The Ottawa Panel strongly recommends the consideration of task-oriented training as a therapeutic strategy in stroke rehabilitation.156 Aerobic training plays an important role in the reduction of cardiovascular risk factors and in maximizing the patient’s physical endurance to fully participate in community life. Interestingly.13. Therefore. duration. instead of limiting rehabilitation to the few months following stroke. which consistently made favorable recommendations for task-specific training. as the brain remains plastic throughout life. The following interventions are supported by the available evidence: seated reaching task training.585.478. Also. van Peppen et al.12. dosage. functional approach training.582 However. The taskoriented approach aims to rehabilitate stroke patients by engaging them in functional tasks that are more meaningful to everyday life and for which there may be greater motivation to perform. The key to a successful program is to understand the patient’s needs and develop functional objectives. Attention.124 Subjects were given immediate feedback. The Ottawa Panel agrees with previous reviews that more research is needed to establish the optimal exercise intensity. regardless of when it has been administered. patients may not be able to reproduce these sophisticated exercises in the home setting.583 which drew similar conclusions about task-oriented training. task-oriented training improves strength not only in paretic muscles. This could explain why the ballistic and resisted extension demonstrated greater benefits in finger tapping.574–578 and progressive resistance muscle training all improve motor unit recruitment.581 Resisted and ballistic extension for the hand were all favored compared to resisted grasp and control for improvements in finger tapping. bilateral arm training.580 It is based on the overload principle that states that a threshold of stress must be exceeded for muscle adaptation to occur.70.Clinical Practice Guidelines 87 mental imagery. improvement of motor control after stroke can occur with meaningful rehabilita- .263. functional upper extremity training. 72. and maintenance of physical activity and is necessary for individuals with chronic diseases to obtain long-term beneficial effects from therapeutic exercise. Joseph’s Health Care London73 that there is strong evidence that BFB training improves gait and standing post-stroke. and LE rhythmic positional BFB training (chronic stroke) and LE audio and visual feedback training with general relaxation (chronic stroke). The Ottawa Panel also agrees with St. the Ottawa Panel disagrees with several other guidelines.590 This may account for the Ottawa Panel finding that rhythmic auditory facilitation (using a metronome or special music tapes) was effective at improving gait speed. part of physical rehabilitation for the stroke patient.588 For example. adherence. The use of the term routine may be a further source of disagreement. The Ottawa Panel agrees with the Heart and Stroke Foundation of Ontario guidelines. EMG-BFB constitutes a relevant. has a positive impact on the patients’ motivation and enjoyment.589 Biofeedback The Ottawa Panel recommends the use of several forms of EMG-BFB training for the upper (UE) and lower (LE) extremities at all stages of stroke recovery.579.155. albeit small.75 These discrepancies could be partially attributed to the fact that only the Ottawa Panel and the Heart and Stroke Foundation of Ontario71 based their recom- mendations on a quantitative analysis of relevant trials.74. general facilitation EMG-BFB training for the UE (subacute and chronic stroke) and the LE (acute to chronic stroke). The available evidence provides strong support for video feedback training for unilateral neglect reduction (subacute stroke). resulting in important clinical gains. However. which state that BFB systems should not be routinely included as an intervention for stroke survivors undergoing rehabilitation. helping them to execute more controlled movements using the appropriate groups of muscle in the correct sequence.579. Perhaps for these reasons. For instance.71 which found that EMG-BFB should be included as an intervention for post-stroke patients who have a high level of motor return.590 According to Moreland and Thomson. There is also sufficient evidence for the value of LE force-feedback training in chronic stroke and UE EMG-BFB relaxation training in subacute and post-acute stroke. At present. The majority of previous post-stoke rehabilitation guidelines based their recommendations on descriptive conclusions provided by the authors of the included studies. clinicians frequently use “verbal cues” to guide postural/alignment corrections and facilitate the equalization of weight distribution. 45–49.584 Motivation is a very important element involved in the adoption. they are not widely available in clinical and community-based settings and are not convenient to transport. and swing symmetry. stride length. There is strong evidence in favor of treadmill training (subacute stroke). Still.292 Gait training The Ottawa Panel recommends the use of several types of gait training methods during the postacute to chronic stages of stroke recovery. busy clinicians use other forms of immediate feedback in their daily practice. A provocative hypothesis that deserves further exploration is that constant external feedback may not encourage subjects to develop their own intrinsic feedback mechanisms and therefore limits their learning. previous guidelines have not supported the “routine” use of sophisticated and costly EMG equipment. EMG-BFB was found to provide subjects with useful information about their muscle activity.46 It has been suggested that feedback.88 TOPICS IN STROKE REHABILITATION/SPRING 2006 tion consisting of functional tasks important to the daily life of the patient. which might explain why they showed less functional improvement.472 Standardized exercises may be less appealing to the patient compared to more functional activities. stroke patients seemed more concerned with walking quickly than with maintaining a symmetrical gait pattern. treadmill training combined with . particularly provided through music.579. While BFB systems are recognized as being effective. because gait speed is a more meaningful and practical outcome (for example when crossing a street). high-speed treadmill (chronic stroke). The Ottawa Panel’s guidelines are consistent with previous systematic reviews examining the efficacy of EMG-BFB. Of note. First. comfortable gait speed. The Ottawa Panel‘s recommendations are in agreement with the Royal College of Physicians72 and the VA/DoD75 that treadmill training with partial BWS should be included as an adjunct to conventional therapy for patients undergoing stroke rehabilitation. Recovery of functional walking depends in part on the strength of the lower extremities. patients with gait impairment. this recommendation is contrary to the recommendations of St. FES of the ankle dorsiflexors (post-acute or chronic stroke). treadmill training and BWS in acute and post-acute stroke. it is not surprising that an intensive leg muscle performance training program results in improvements in gait speed. The quantitative analysis used by the Ottawa Panel has the important advantage of being more precise and being able to resolve conflicting evidence. The Ottawa Panel also agrees with the VA/DoD75 that recommended FES for gait training following stroke but disagrees with their finding that there is insufficient evidence to recommend for or against the use of multi-channel FES for severe hemiplegic *According to the St. rhythmic auditory facilitation training (post-acute stroke). and treadmill training and BWS for FIM locomotion in acute and post-acute stroke.12. Moseley29 only presented statistically significant results. However. The primary outcome used in their review was independence with walking. the Ottawa Panel does not recommend the following: FES of the ankle dorsiflexors for walking abilities outcome in postacute stroke.. some of the studies included in their review did not meet our selection criteria for reasons such as insufficient sample size or inappropriate study population (e. walking speed. the partial disagreement with the Ottawa Panel recommendations may be related to the fact that previous poststoke rehabilitation guidelines formulated consensus recommendations based on the descriptive conclusions provided by the included studies. the walking speed must be . whereas our review considered clinical significance as well. when they compared treadmill training and BWS to other treatment. Intensive lower extremity training produced clinically important increases in walking speed and statistically significant improvements in walking ability. Finally. Moseley29 chose to make different comparisons than the Ottawa Panel by pooling studies together in a different way. unless the study with conflicting results was of higher quality. The Ottawa Panel’s guidelines are generally consistent with the conclusions of previous reviews on the efficacy of treadmill training combined with BWS. electrogoniometric feedback training in post-acute stroke.73 which found conflicting evidence* on the use of BWS combined with treadmill training and treadmill alone.33.580 During a gait training program. This may be explained in part by the greater balance required at faster speeds of walking. placebo FES in post-acute stroke for reduction of spasticity. conflicting evidence refers to a disagreement between the findings of at least two RCTs. and musical motor feedback training in post-acute stroke. they combined studies that used different comparators such as general physiotherapy at two different intensities and bracing. and maximal gait speed. The Ottawa Panel agrees with St.g. while our primary outcome was gait speed. High-speed treadmill training was favored over low-speed training for improving gait cadence. patients with multiple infarcts).28–33 However. lowspeed treadmill training in chronic stroke. Again. Joseph’s Health Care London. lowspeed treadmill training was favored for decreasing the percentage of BWS required. Furthermore. Where there were more than four RCTs and the results of only one was conflicting. BFB followed by FES (chronic stroke). and stride length. FES of the ankle dorsiflexors in post-acute stroke. Joseph’s Health Care London. The available evidence also provides sufficient support for BWS in post-acute and chronic stroke.33. Gait training on a treadmill has consistent positive results according to the literature. However. Joseph’s Health Care London73 that there is strong evidence to use FES as well as rhythmic auditory stimulation in patients undergoing stroke rehabilitation. FES of the ankle dorsiflexors and/ or gastrocnemius (chronic stroke).591 Therefore.Clinical Practice Guidelines 89 overground ambulation (chronic stroke). the conclusion was based on the results of the majority of the studies. and functional lower extremity training (subacute stroke). walking on different surfaces. using a treadmill or cycling.591.591 Hesse and Werner found that treadmill training with BWS versus standard and usual customary care in chronic nonambulatory hemiparetic patients restores gait and increases gait velocity. which occurs with other assistive walking devices.249.33.249 Richards et al.33 The BWS provided should be progressively decreased with training to challenge the patient’s posture by improving activation of weight-bearing muscles. as needed. up and down ramps.592 Plasticity of the central nervous system and subsequent improvement of gait is positively influenced by training in stroke rehabilitation. In addition. In the clinical setting.249 However.249 BWS is better than walking on a treadmill without BWS or walking within parallel bars.591 BWS with treadmill training resulted in greater functional benefits.590 in their meta-analysis.590.33 BWS with treadmill walking minimizes compensations. by forcing the use of the paretic lower extremity.30 Practice is necessary for learning.249. sophisticated and costly .579.30. than overground ambulation. improves gait post-stroke. proper outcome measures are used. resulting in a more symmetrical gait pattern. Although a specific treatment may appear to be ineffective in one type of patient.249 Exercises such as walking and strengthening in the weight-bearing position help prevent muscle shortening and stiffness.33. reduce dependence on walking aids.592 The location and amount of activity in the brain depends on the characteristics (force.592 Training must be specific. because it reduces compensations made by the upper extremities and non-paretic lower extremities. suggesting that improvements in gait are best achieved with direct gait training so that the sensory stimuli are the same as those produced during walking.. complexity) of the motor task.90 TOPICS IN STROKE REHABILITATION/SPRING 2006 raised to a level that adequately challenges the patient in order to promote the activation of weight-bearing muscles. and walking endurance in people with neurological conditions and produced more benefits than conventional or gait training in full weight bearing. and formation of new circuits through sprouting in both damaged and unaffected areas of the brain. Future investigations on the effects of the phase of recovery. increases the cardiovascular and energy demands of walking.590 BWS provided through a harness is therefore very helpful at reducing the unnecessary physical effort required from therapists.590 It is theorized that the recovery of functional walking ability after stroke greatly depends upon the adaptive reorganization of cortical and subcortical structures. and anxiety to practice many repetitions of the full gait cycle without compensatory movements. Barbeau et al.33. speed of walking.33 suggested that treadmill training with partial BWS. similar results cannot be assumed for other types of patients.33.30. major muscle weakness.249 Endurance training is essential for helping stroke patients achieve a functional walking ability and perform ADLs. Treadmill training with BWS or no BWS was also more effective on outcomes of interest than gait training over-ground. lower limb motor recovery. poor trunk stabilization.. balance. Researchers must ensure that when trials are conducted. increase walking speed.591 Gait training facilitates trunk posture and hip extension by providing sensory inputs of loading249.33 A major disadvantage of over-ground ambulation and treadmill training is the amount of physical effort required by the physiotherapists to obtain a satisfactory walking pattern. found that BWS with treadmill walking increased gait. such as increased walking speed. and treatment duration would also be useful.579 Recovery of walking continues up to 2 years after stroke.33 BWS with treadmill training can help stroke patients with poor coordination.30.592 Motor tasks increase the activity of neurons leading to increased tissue blood flow to the motor cortex. decrease energy cost. plasticity of synapses.33 Gait training should take place under varying conditions so that different sensory inputs can be engaged (e.33. to promote weight bearing and appropriate muscle activity. amplitude. with obstacles. intensity of treatment.579 and activates gait pattern generators in the spine and brain. They state that partial BWS with treadmill training after stroke is considered a task-oriented repetitive approach.591 Prac- tice of the whole task or gait cycle is very important to improve coordination. the patient’s body weight should not be supported more than 30%.g. stairs).30 Gait training in stroke patients is a difficult topic to research for clinical and methodological reasons.249 Studies have found that endurance training. and improve cardiovascular fitness. rate. However. or chronic phases of . and visual attention training in post-acute stroke. exceptions related to two specific long-term outcomes. there are no other systematic reviews published on sensory interventions for post-stroke rehabilitation. There are.73 which reported strong evidence that perceptual training interventions improve perceptual functioning. Similarly.597 and other associated complications. subacute. Joseph’s Health Care London73 that overall there is strong evidence that balance training post-stroke improves outcomes. The available evidence provides strong support for sensory function training of the hand in chronic stroke. stroke is considered to be one of greatest risk factors for falls in older adults. this review did not include recent trials. Indeed. Joseph’s Health Care of London’s73 assessment that there is strong evidence to indicate that visual scanning techniques improve visual neglect and produce associated functional improvements.594 Because of the fear of falling.595 Consequently. cognitive. the balance scores of people who have falls or restricted their activity after falls tend to be reduced. base of support training with extrinsic auditory feedback in subacute stroke. grade A recommendations were found for all the following post-stroke balance interventions: balance training (sit-to-stand) with force platform and auditory feedback in subacute and post-acute stroke. and platform training in subacute stroke. balance training with visual feedback in subacute stroke. For instance. the Ottawa Panel’s recommendation on visual attention retraining is consistent with St. It is well-recognized that stroke survivors may have sensori-motor. however. To our knowledge. Constraint-induced movement therapy According to the Ottawa Panel. there is sufficient evidence to recommend the use of CIMT during the acute. rocking chair stimulation in subacute stroke. which The Ottawa Panel recommends the use of several types of sensory training during the subacute to chronic stages of stroke recovery.593 Indeed. balance training with visual feedback in subacute and post-acute stroke. Balance training may partly explain the different conclusions. There is also sufficient support for passive vestibular stimulation in the subacute and post-acute stages of stroke and perceptual learning exercises in the post-acute stage of stroke.Clinical Practice Guidelines 91 equipment such as a BWS system and treadmill may not be appropriate for every stroke patient. The Ottawa Panel does not recommend balance training with visual feedback in subacute and post-acute stroke to improve postural sway with eyes closed or balance training with visual feedback to improve sitting balance in subacute stroke. the Ottawa Panel recommendations differ from the conclusions of another systematic review that suggested that there is insufficient evidence that any one physiotherapy treatment approach is more effective than another in promoting the recovery of postural control36. 23% to 73% of community-dwelling older adults in the chronic phase of stroke have been reported to fall over a period of 4–6 months. Joseph’s Health Care of London’s guidelines. and another person must operate the control panel. The Ottawa Panel’s recommendations are in agreement with St.598 Sensory interventions The Ottawa Panel strongly recommends balance training as a rehabilitation intervention for subacute and post-acute stroke patients. it involves two or three rehabilitation staff to train a stroke patient with a BWS system and treadmill: one physiotherapist has to facilitate the proper trunk alignment and weight transfer to maximize the quality of the gait pattern. one physiotherapist needs to assist the leg swing. The Ottawa Panel’s recommendation regarding sensory function training of the hand is consistent with St. The results of a systematic review of balance training35 that force platform feedback (visual or auditory) improved stance symmetry but not sway in standing are in concordance with our recommendations. The BWS system combined with treadmill training requires significant financial and human resources. and perceptual impairments that affect their mobility and balance.596. balance training is a key element in post-stroke gait rehabilitation591 and is essential in preventing falls46. 600 Passive ROM exercises performed on the shoulder of the stroke survivor by a qualified rehabilitation practitioner are favored over overhead pulley and skate- *According to St. www. The Ottawa Panel’s recommendation of FES in the management of shoulder subluxation is consistent with the guidelines of the Heart and Stroke Foundation of Ontario71 and St. disagrees with St. Joseph’s Health Care London is that proper positioning of the hemiplegic shoulder does indeed help prevent subluxation. upper limb function. Furthermore. rather than abduction alone. Joseph’s Health Care London. The results of a large. Rather. and functional status in stroke patients capable of some active finger and wrist extension. The overhead pulley exercises are not recommended by the Ottawa Panel and others. there are some discrepancies between the conclusions of the Ottawa Panel and those of Price and Pandyan54 related to the use of FES in the management of post-stroke shoulder pain. Price and Pandyan stated that the evidence from RCTs does not confirm whether FES should be included or excluded in the management of post-stroke shoulder pain. Joseph’s Health Care London73 that shoulder strap- ping and prolonged positioning do not result in significant improvements in pain.73. These differences are attributed to the following factors: their systematic review is not upto-date. However. which lead to grade B recommendations. ongoing. It is regarded as the lowest form of evidence and can be considered as no evidence at all. which allowed for the pooling of data from RCTs using different scales for the same outcome. Joseph’s Health Care London73 that found limited evidence that shoulder slings influence clinical outcomes.75 including St. our review also included CCTs. The Ottawa Panel. Joseph’s Health Care. A recent review599 was conducted on the efficacy of FES in the management of shoulder pain and subluxation. .org) is expected to provide stronger evidence regarding this promising intervention. there is sufficient evidence to recommend the use of FES during the acute and chronic phases of stroke as well as shoulder strapping during the subacute phase of stroke.74. and the Ottawa Panel recommendations fully agree with the results of this review. CIMT was derived directly from basic research on monkeys with somatosensory deafferentation.585 that recommended the use of this innovative rehabilitation intervention. and VA/ DoD.excite.23. Shoulder subluxation According to the Ottawa Panel.585 The large improvements in motor function produced by CIMT correlate with marked alterations in brain organization.73 This recommendation is in partial agreement with the Heart and Stroke Foundation of Ontario71 and St. which supports the use of shoulder strapping and positioning of the shoulder. In contrast to the Ottawa Panel guidelines.63. motor function.22. Joseph’s Health Care London. the consensus opinion* of St.22. The Ottawa Panel’s recommendations for CIMT are based on RCTs with relatively small sample sizes and variability in methodological quality. Ethical considerations and patient selection factors must be taken into account before prescribing CIMT. and their data analysis included the use of standardized mean difference (SMD). multicenter study (Extremity Constraint-Induced Therapy Evaluation [EXCITE]. there is strong evidence to recommend the use of FES in subacute stroke and the Henderson shoulder ring or Bobath shoulder roll in post-acute stroke for the management of shoulder subluxation. and range of motion. However. consensus opinion refers to the agreement of a group of experts on an appropriate course of treatment in the absence of evidence.92 TOPICS IN STROKE REHABILITATION/SPRING 2006 rehabilitation for improving dexterity. the Scottish Intercollegiate Guidelines Network. The Ottawa Panel also agrees with the existing reviews13. they passively elevate the arm in a movement of pure abduction that can become painful for the hemiplegic shoulder due to soft tissue impingement between the acromion and greater tuberosity. Passive ROM exercises provide a greater stabilization of the scapula and allow the humerus to direct movements using a combination of external rotation and flexion.71 because they do not provide adequate stabilization of the shoulder girdle during scapular rotation and humeral external rotation. The Ottawa Panel is in agreement with several existing guidelines that addressed CIMT. Clinical Practice Guidelines 93 board exercises. Joseph’s Health Care London. FES of the finger thumb extensors and flexors for the hand in subacute and postacute stroke. Strong evidence was found for positional feedback stimulation training of the wrist extensors in subacute and post-acute stroke. and electrical stimulation of wrist and fingers extensors in chronic stroke. FES of the posterior deltoid and supraspinatus for the shoulder in chronic stroke. Stroke survivors may not be able to voluntarily recruit motor units to the level required for performing the high-intensity exercises needed to enhance muscle function. However. . The Ottawa Panel agrees with the Heart and Stroke Panel on the Management of the Hemiplegic Arm and Hand. The Ottawa Panel recommendations are also in line with the recommendation made by the Heart and Stroke Foundation of Ontario71 for considering electrical stimulation of the wrist and the forearm and EMG-BFB to reduce motor impairment and improve functional motor recovery.600 Each of the existing meta-analyses found that FES was effective for improving muscle strength.55–59.590 also reported improvements in walking speed following intramuscular stimulation.73 and the VA/DoD75 that FES should be included in the management of shoulder subluxation during the subacute and post-acute stages of stroke. a grading of insufficient evidence (I) indicates that one cannot determine from the evidence the net benefit of the intervention. and therefore the clinician must use his or her judgment in either including or excluding the intervention in the treatment of the patient. NMES of the wrist and finger extensors in subacute and post-acute stroke. and hand motor function in chronic stroke. the Panel disagrees with the finding of the VA/DoD75 that there is insufficient evidence* as to whether multichannel FES should or should not be included as an intervention for severe hemiplegic patients with gait impairment.601 The disuse atrophy of fast twitch motor fibers observed following stroke further contrib*According to VA/DoD. The disuse atrophy of fast twitch units that may be observed following stroke is associated with such decreases in voluntary muscle recruitment. Neuromuscular stimulation is one of the therapeutic modalities available to enhance muscle performance in patients with CVA. The Ottawa Panel’s recommendation of FES for gait training in the chronic phase of stroke is in agreement with the guidelines of both the VA/ DoD75 and St. NMES of chronic stroke patients for the hand. blocked practice combined with NMES of the extensor communis digitorium/extensor carpi ulnaris/triceps brachii/anterior and middle deltoid in chronic stroke.590. and random practice combined with NMES of the extensor communis digitorium/extensor carpi ulnaris/triceps brachii/ anterior and middle deltoid in chronic stroke. either for or against. tracking accuracy. FES is thought to work by facilitating the activation of appropriate weight-bearing muscles required during the act of walking.53. Barbeau et al. the Ottawa Panel disagrees with the Royal College of Physicians that FES should not be routinely considered as an intervention for stroke patients. electrical stimulation is used to facilitate muscle activity in situations where voluntary motor unit recruitment is insufficient. FES for post-stroke patients has been extensively reviewed in the literature.73 However. FES of the anterior tibialis and gastrocnemius combined with EMG-BFB in chronic stroke. The quality of the shoulder motion can be better controlled by an experienced therapist and thus can be beneficial to avoid undesired movements that could further potentiate pain and damage of the hemiplegic shoulder. Finally. Clinically.71 St. EMGtriggered electrical muscle stimulation training in subacute stroke. the Ottawa Panel does not recommend FES of the quadriceps and rectus femoris combined with positional feedback stimulation training for improving selective ROM in post-acute stroke or NMES for feeding. Joseph’s Health Care London. Recommendations with sufficient evidence were also found for FES of the quadriceps and rectus femoris combined with positional feedback stimulation training in post-acute stroke. Electrical stimulation The Ottawa Panel recommends the use of electrical stimulation as a rehabilitation intervention for post-acute to chronic stroke patients. On the other hand. phase of stroke. However. acupuncture-like TENS to the shoulder compared with placebo. Where there were more than four RCTs and the results of only one was conflicting.617–619 To establish clear evidence for the use of TENS in stroke rehabilitation. and highintensity TENS applied to the shoulder in postacute stroke. the Ottawa Panel does not recommend low-intensity TENS applied to the upper extremity of stroke patients in the chronic phase of recovery to reduce spasticity in the wrist flexors.82. Changes in frequency recruit different opioid receptors.613 and the concomitant release of opiate observed in both animals614 and humans. The Ottawa Panel recommends considering the application of therapeutic ultrasound to the shoul- . However. The various application modes of TENS represent effective therapeutic options in post-stroke rehabilitation depending on the practitioners’ treatment goals and target outcomes. device characteristics.608–610 This effect was captured in the study involving the application of higher intensity. improving sensation.60 The neuroregulatory peripheral and central pain relieving effects604–607 of TENS have been proposed to be more effective at higher intensity applications. if nonsteroidal anti-inflammatory analgesia has no significant effect. waveform. Clinically. However. and increasing functional status at different stages of stroke recovery. TENS. extent of disuse atrophy.603 Age. highintensity TENS seems to be more effective for increasing shoulder passive ROM in the post-acute stage of stroke recovery. unless the study with conflicting results was of higher quality. and concurrent treatments are important variables that require further investigation. depending upon its intensity and frequency.611 Their pain-relieving effects are thought to be mediated by the activation of intrinsic pain-suppressive systems612. There is strong evidence to support the use of low-intensity TENS applied to the hand. neuromuscular stimulation may be used in these situations. gender. reduce shoulder stiffness. Indeed.94 TOPICS IN STROKE REHABILITATION/SPRING 2006 utes to muscle weakness. the conclusion was based on the results of the majority of the studies. and hence an awareness of the parameters used during TENS treatments is essential. and application site based on individual patient characteristics. modulation of frequency. the Ottawa Panel disagrees with the recommendation of the Royal College of Physicians72 that TENS should only be used as a routine intervention for improving muscle control for patients undergoing stroke rehabilitation in the context of ongoing trials. for example.603 Therapeutic ultrasound *According to the St. stimulation parameters.616 Several investigators have recommended that vibrator stimulation be part of TENS application. on one hand. amplitude and duration of stimulation trains.602. the Ottawa Panel agrees with the St. low-intensity TENS applied to the elbow and ankle in post-acute stroke. Finally. and dampen the perception of pain. greater clarity is needed about the optimal treatment duration.615. and lower extremity in chronic stroke. electrical stimulation protocol. Future RCTs should aim to clarify the relationship between specific patient characteristics and different stimulation protocols.605 That the stimulation parameters in TENS analgesia are important has been shown in both animal studies and human research. stimulates nerves and muscle fibers and may improve muscle tone and strength. spasticity. both conventional and acupuncture-like TENS excite afferent fibers in the A-alpha-beta range. Joseph’s Health Care London’s73 finding that there is conflicting evidence* that TENS improves a variety of outcomes. including motor recovery. Joseph’s Health Care London. total number of cycles delivered. conflicting evidence refers to a disagreement between the findings of at least two RCTs. low-intensity TENS seems to be more effective for decreasing spasticity. and ADL. foot. TENS The Ottawa Panel recommends the use of several types of TENS applications during the post-acute to chronic stages of stroke recovery. which may be indirectly related to pain relief. The Ottawa Panel recommendations are in line with the Royal College of Physicians’72 recommendation that high-intensity TENS should be included as an intervention for patients undergoing stroke rehabilitation. especially when TENS is being applied for relief of chronic pain.602. and selection of outcome have limited the strength and reliability of results reported in the literature. but needle acupuncture with manual and electrical stimulation showed positive results. The vasodilatory response associated with these thermal effects also enhances the excretion of chronic inflammatory cells. One study reported no benefit of needle acupuncture without stimulation for ankle spasticity in chronic stroke patients with spastic equinovarus deformity. with two RCTs suggesting no effect and the other RCT suggesting statistically significant and clinically important benefits.” Existing meta-analyses64–67 have all concluded that acupuncture represents a safe and promising adjuvant therapeutic modality for post-stroke pain management. The evidence for the effects of acupuncture on spasticity. They expressed a cautious statement based on consensus opinion that “acupuncture should only be used as an intervention for patients undergoing post-stroke rehabilitation in the context of ongoing trials. ROM. frequency.621 The mechanical effect of either pulsed or continuous ultrasound leads to an increase in skin permeability and facilitates the softtissue healing process. and schedule of treatment) and characteristics of the study population (age. Joseph’s Health Care London73 that adding ultrasound therapy to ROM exercises does not change functional outcomes.407 With regard to motor function. To be able to adequately compare and reproduce the results of published RCTs. Generally. acute or chronic stage of disease).620.Clinical Practice Guidelines 95 der in the chronic phase of stroke. the treatment application protocol differs between studies that used acupuncture and studies that used electroacupuncture. This fundamental difference exemplifies the lack of standardization in application methods and contributes to the difficulty of pooling data. therapeutic ultrasound has the potential to reduce shoulder pain and increase ROM in rheumatoid arthritis. intensity. quality of double-blinding. Clearly. area treated. The Royal College of Physicians72 concluded that the evidence was insufficient to make definitive statements about the role of acupuncture. Furthermore.603 Acupuncture The Ottawa Panel recommends the use of acupuncture as an adjunct to improve specific outcomes during the acute and subacute stages of stroke recovery.403 However. Joseph’s Health Care London. characteristics of the therapeutic application (including pulsed or continuous ultrasound. gender. The evidence from three RCTs that assessed functional status was also inconsistent. study duration. and balance.73 which found that “there is conflicting evidence that acupuncture is effective for improving stroke outcomes. motor function.602. another study revealed statistically signifi- cant and clinically important benefits of electroacupuncture on elbow spasticity compared to standard acupuncture in post-acute stroke. and functional status are however conflicting. pulse ratio.622 Intensity and organization of rehabilitation Stroke rehabilitation in the acute care setting should be provided by an organized and multidisciplinary team that specializes in stroke . According to clinical practice guidelines on rheumatoid arthritis developed by the Ottawa Panel. methodological issues such as randomization method. it is crucial that the following details be clearly described: characteristics of the device (such as size of the head and calibration). but they suggest that high-quality RCTs need to be conducted before they recommend its inclusion in stroke rehabilitation programs. The available evidence provides support for surface acupuncture with electrical stimulation in subacute stroke and needle acupuncture with electrical stimulation in acute and subacute stroke for improving walking mobility. Additional thermal effects produced by continuous ultrasound help reduce muscle spasm and pain. the Ottawa Panel wishes to emphasize that the available evidence is not conflicting with respect to all stroke outcomes. sample size. both pulsed and continuous ultrasound are known to reduce nerve conduction velocity in nociceptive fibers.82 The use of continuous ultrasound is supported by its documented physiological effects.” However. However. The Ottawa Panel recommendations are generally consistent with the recommendations of St. the Ottawa Panel agrees with St. surface acupuncture with electrical stimulation was not effective.602. According to Wall. The Ottawa Panel recommends considering the use of enhanced occupational therapy in subacute stroke patients. and physical therapy. the Ottawa Panel agrees with St. The available evidence also supports the use of home-based exercise training in post-acute stroke. enhanced upper-extremity treatment.73 the Ottawa Panel found that structured.72 which found good evidence that acute hospital care for stroke patients should be delivered in a ward or stroke unit by specialists with expertise in stroke management. Joseph’s Health Care London73 that there is good evidence to show that intensive rehabilitation therapies delivered in short periods of time lead to faster recovery and earlier hospital discharge. despite some differences in methodology and study selection criteria.78 The conclusions drawn by other previously published systematic reviews on the organization of stroke rehabilitation services are also consistent with the Ottawa Panel guidelines. 40. The Ottawa Panel’s recommendations are in concordance with the VA/DoD. and intensive outpatient physiotherapy rehabilitation program in chronic stroke. A large number of positive recommendations were formulated to help practitioners make decisions concerning the use of evidence-based rehabilitation interventions in their practice. there is no clear evidence in the current literature about the precise amount of therapy per day necessary to optimize the efficacy of therapeutic exercises.75 which found good evidence that early rehabilitation therapy should be provided as soon as the patient’s medical status is stable and insufficient evidence as to whether inpatient stroke rehabilitation care is superior to outpatient stroke rehabilitation. Unfortunately. Joseph’s Health Care London73 that found good evidence that additional home-based therapy does not improve the overall functional outcome scores for patients undergoing post-stroke rehabilitation.555 The Ottawa Panel found some support for homebased exercise training and home therapy (physician). Physiotherapy at high-intensity.8 min/day) is usually offered.472 the successful acquisition of new motor skills by healthy subjects requires much more than 2 hours of practice per week. A careful consideration of patient values is always essential. Conclusion Despite certain methodological limitations in the primary studies underlying these physical rehabilitation EBCPGs. the Ottawa Panel was able to analyze and include an impressive number of acceptable. enhanced assistant physiotherapist physiotherapy. although the Scottish Intercollegiate Guidelines Network74 found poor evidence to support occupational therapy treatment.62 .96 TOPICS IN STROKE REHABILITATION/SPRING 2006 management. In clinical practice. which is in disagreement with St. stroke unit care leads to better functional outcomes than care in a general ward. The Ottawa Panel is also in agreement with the Royal College of Physicians. well-designed trials that satisfied the initial selection criteria.37–43 With regard to rehabilitation intensity. Like St. stroke patients may require an even higher level of exercise intensity to reach new levels of motor performance. The Ottawa Panel guidelines provide strong evidence in favor of extended stroke unit service with early supported discharge during the acute phase of stroke as well as specialized stroke unit rehabilitation at all other phases of recovery. and enhanced occupational therapy have all been shown to be effective interventions during the subacute phase of stroke. approximately 2 hours of therapy per day (occupational therapy. which is critical for applying the available evidence appropriately to the care of individual patients under specific circumstances. Several innovative post-stroke rehabilitation interventions were not recommended by the Ottawa Panel because their effects did not appear to be sustained over time. Joseph’s Health Care London.623 also suggest that rehabilitation programs of greater intensity have better effects on functional outcomes. home intervention (rehabilitation and nursing services) in subacute stroke. Several existing reviews24–27. The Ottawa Panel recommendation for considering early supported discharge with home rehabilitation in patients with acute stroke is in concordance with the European Stroke Initiative. home therapy (physician) in chronic stroke.8 min/day. early care and early physiotherapy intervention in acute stroke. enhanced physiotherapy. 54. The recommendations of the Ottawa Panel cannot however replace clinical judgment. Compared to healthy individuals. Grimshaw JM. the Ontario Ministry of Health and Long-Term Care (career scientist salary support). Kwakkel G. The Ottawa EBCPGs Development Group is indebted to Dr. Roth EJ. Maria Delgadillo. Wang E. and the Ministry of Human Resources. David RM. 1995. University of Ottawa (conference financial support). 2004. the Council on Nutrition. A related objective is to identify ineffective treatments that lead to delays in improvement and unnecessary cost to the health care system. Epidemiology of stroke in Canada. et al. ity. Stroke. 2001. Judith Lambert. 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Appendixes 120 122 123 145 158 177 192 199 204 207 212 219 222 223 227 263 APPENDIX 1. APPENDIX 2. Literature Search Results Special Formulas for Clinical Relevance APPENDIX 3A. Characteristics of Included Studies for Therapeutic Exercise APPENDIX 3B. Characteristics of Included Studies for Task-Oriented Training APPENDIX 3C. Characteristics of Included Studies for Biofeedback APPENDIX 3D. Characteristics of Included Studies for Gait Training APPENDIX 3E. Characteristics of Included Studies for Balance Training APPENDIX 3F. Characteristics of Included Studies for Sensory Interventions APPENDIX 3G. Characteristics of Included Studies for Constraint-Induced Movement Therapy APPENDIX 3H. Characteristics of Included Studies for Shoulder Subluxation APPENDIX 3I. Characteristics of Included Studies for Electrical Stimulation APPENDIX 3J. Characteristics of Included Studies for Transcutaneous Electrical Nerve Stimulation (TENS) APPENDIX 3K. Characteristics of Included Studies for Ultrasound APPENDIX 3L. Characteristics of Included Studies for Acupuncture APPENDIX 3M. Characteristics of Included Studies for Intensity and Organization of Rehabilitation APPENDIX 4. Existing Guidelines on Stroke Rehabilitation 119 APPENDIX 1. Literature Search Results 120 Data base: Medline <1966—latest update (AutoAlert service here)> Results 37 38 (retrospective or case-control).tw. or/23-37 STUDY FILTER (LINES 23–38) 22 and 38 COMBINATION OF STROKE, PHYSIO/REHAB AND STUDY FILTER (LINE 39) 1482 80997 899180 SET Search Results SET Search TOPICS IN STROKE REHABILITATION/SPRING 2006 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 10495 4 70 388 22364 31287 122 18150 204 573 72 1540 3731 20806 433 exp cerebrovascular disorders/ (stroke or cerebrovascular or cerebral vasc (tia or transient ischemic attach$ or trans (cerebral hemorrhage or cerebral haemorrhag (intracerebral hemorrhage or intracerebral cva.tw. hemiplegia.tw,sh. (cerebr$ or cerebellar of brain$ or vertebr (inract or schaemia or schemia or thrombo 8 and 9 (cerebral or intracerebral or intracranial (hemorrhage or haemorrhage or hematoma or b 11 and 12 or/1-7 10 or 13 or 14 STROKE TERMS (LINES 1–15) gait.tw,sh. ambulation disorders$.tw. locomot$ disorders.tw. cadence.tw. exp locomotion/ or/40-44 39 and 45 activities of daily living/ task-oriented.tw. task-related.tw. ability focus$.tw. adl.tw. (activities adj2 living) .tw. or/47-52 39 and 53 TOTAL FOR GAIT = 433 (LINE 54) “biofeedback (psychology)” / biofeedback.tw. electromyography/ (electromyography or emg).tw. muscle contraction.tw. muscle relax$.tw. spastic$ control.tw. motor skills/ motor control.tw. neuromuscular.tw. or/55-64 39 and 65 TOTAL FOR BIOFEEDBACK = 131 (LINE 66) 6299 284041 131937 192625 53060 61787 7154 5900 152 102 1761 3462 366379 159080 169449 131948 54754 1510 1885 2130 717 7741 435874 206602 26108 428049 108140 21288 162100 172152 16 17 18 19 20 21 55 56 57 58 59 60 61 62 63 64 65 66 exp physical therapy/ 71533 rh.fs 77687 (physical therapy or physiotherap$). Tw. 8037 rehabilitation/ 7823 rehabilit$.tw. 38359 or/16-20 162841 PHYSIO AND REHABILITATION TERMS (LINES 16–21) 3629 2613 37921 15673 5615 6196 12 9717 1894 19228 82304 131 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 15 and 21 clinical trial . Pt. randomized controlled trial.pt. random$.tw. (double adj blind$).tw. placebo$.tw. meta-analysis.pt,sh. (meta-anal : or metaanal:).tw. (quantitativ: review: or quantitativ: overv (methodologic: review: or methodologic: ove (systematic: review: or systematic: overvie review.pt. And medline.tw. exp cohort studies/ (cohort or longitudinal or prospective).tw. exp case-control studies/ continues (endurance adj2 therap$).tw.tw.tw. wrist.tw.tw.tw.tw.tw.tw. or/67-77 39 and 78 TOTAL FOR PAIN CONTROL USING TENS.APPENDIX 1. ELECTROSTIMULATION ETC. neuromusc$ electric$.tw.tw. aerobics.tw.tw.tw.sh or/116-122 39 and 123 TOTAL FOR UPPER EXTREMITIES = 166 (LINE 124) 62019 16097 43127 10814 121408 15901 8974 209310 166 121 . or/104-106 39 and 107 TOTAL FOR FUNCTIONAL TRAINING = 6 (LINE 108) 2633 57 220 2910 6 94 95 96 97 98 99 100 101 102 103 cryotherapy. or/109-113 39 and 114 TOTAL FOR EXERCISE THERAPY = 70 (LINE 115) 11322 1771 20486 16 293 32424 70 89 90 91 92 93 facilitation.tw. 2594 ice. 72059 physical stimulation/ 7702 postural control.tw.tw. (high volt or pulsed or current). (tens or altens).sh.sh. electrostimulation. 85 and 86 39 and 87 TOTAL FOR LOWER EXTREMITIES = 15 (LINE 88 ) 9233 7624 4502 19681 49 exp exercise therapy/ (therap$ adj2 exercise$).tw.tw.sh. electroacupuncture. 594 acoustic stimulation/ 14745 photic stimulation 15537 or/94-101 115884 39 and 102 23 TOTAL FOR CYROTHERAPY AND STIMULATION = 23 (LINE 103) SET Search Results SET Search 67 68 69 70 71 72 73 74 75 76 77 78 79 exp electric stimulation therapy/ ((electric$ adj nerve) or therapy). = 368 (LINE 79) 20344 5446 107270 128546 272 80 81 82 83 84 length of stay/ length stay.tw.sh hand. range of motion. breathing exercise$.tw. electroanalgesia. Continued Results 9148 450623 23153 1686 156 1601 769 65 204406 6920 231 669977 368 104 105 106 107 108 constraint. (functional training or functional retraining) functional therap$.tw. (electromagnetic or electrotherap$).sh forearm. (program or session). 826 (tactile or brush$ or touch$ or cutaneous).tw.tw.tw.tw. ionophoresis.tw. or/80-82 39 and 83 TOTAL FOR LOS = 272 (LINE 84) 69577 61944 17708 16 109 110 111 112 113 114 115 85 86 87 88 exp leg/ (leg or ankle or foot or feet).tw 5933 sensory stimulation. articular/ range motion.tw.tw. or/89-91 39 and 92 TOTAL FOR FACILITATION AND ROM = 49 (LINE 93) Appendixes 116 117 118 119 120 121 122 123 124 exp arm/ shoulder. arm.sh elbow.tw. (electric$ adj (stimulation or muscle)). Special Formulas for Clinical Relevance Regular case Clinical relevance formula: (et – bt) – (ec – bc) ( (bt * nt) + (bc * nc) ) / (nt + nc) Legend: et = end of study value for treatment bt = baseline value for treatment ec = end of study value for control bc = baseline value for control nt = number of patients in treatment group nc = number of patients in control group Special case #1 When the baseline value was not available for an outcome. we added a sum of 1 to all the values in the formula of clinical relevance based on the assumption that: Mean of “Scale + 1” = Mean of original scale + 1 and SD of “Scale + 1” = SD of original scale. a formula was used to calculate the relative difference in change from baseline: Δt – Δc Legend: Δt = change in the value from treatment Δc = change in the value from control Special case #3 When the outcome measure was given as a change from baseline value. . a formula was used to calculate the relative difference in the change from baseline: Δt – Δc (nt * Δt + nc * Δc) / (nt + nc) Legend: Δt = change in the value from treatment Δc = change in the value from control nt = number of patients in treatment group nc = number of patients in control group Special case #4 When the baseline mean was 0. a formula was used to calculate the relative difference in the change from baseline: et – ec (nt * et + nc * ec) / (nt + nc) Legend: et = end of study value for treatment ec = end of study value for control nt = number of patients in treatment group nc = number of patients in control group Special case #2 When the outcome measure was given as a change from baseline value and the baseline value itself was not given. but the scale was known. where the baseline value was not given and the scale was unknown or nonexistent.122 TOPICS IN STROKE REHABILITATION/SPRING 2006 APPENDIX 2. 3 wk.2 wk Subacute Gr2: 63.6 Gr1: 58. the patient initiated more often. 0 Appendix 3A 123 continues . triceps press down. Therapy consisted of flexion.3 SD: 10. These arm movements are goal-directed and robotassisted. 7 L Gr2: 1 R. Hemiplegia: Gr1: 3 R. 1 Sample size Symptom Population details duration Age. and rotation movements across elbow and shoulder joints. Characteristics of Included Studies for Therapeutic Exercise Author and year Comparison group All patients received Gr1: 4 to 5 standard customary hr/wk until care. and the therapy uses a computer-generated video program that provides visual and auditory feedback. 1. W) Session frequency and duration Aisen 199799 Total: 20 Gr1: 10 Gr2: 10 Inclusion: Patients with hemiplegia admitted to the same medical ward and team of Burke Rehabilitation Hospital.3 Gr1: Patients’ hands and wrists were held in a rigid support affixed to the robotic arm. biceps curl. discharge None Gr1: 2. and flexibility exercises. The robotic device was also used to record strength and quality of movement. SD for control) Treatment Concurrent therapy Follow-up duration Quality (R. Gr2: 20 min of aerobic exercise on a upper and lower body ergometer. leg curl. extension. seated row. 0. the robot initiated the movement passively. Gr1: Same aerobic protocol as Gr2. Patients actively moved the robotic arm and were able to observe the response on the video monitor. 2 sets of 10 repetitions. and who had SD of 1 wk after a single stroke. If the arm was paralyzed. B.8 wk SD: 1. N/A 3 days/wk for 16 wk N/A Gr2: Weekly to biweekly contact with the robotic device. 0.1 wk Gr2: 3.3 wk SD: 1. 8 different strength training exercises: chest press. free weights and isokinetic machines. yr (mean. leg press.APPENDIX 3A. As function returned.5 SD: 8. shoulder front raise. White Plains. 9 L Treated area: Affected upper extremity Greater than 6 months 30–82 yr Carr 2003100 Total: 40 Stroke survivors whose ages ranged from 30 to 82 yr 1. NY. SD for control) Treatment Concurrent therapy Follow-up duration Quality (R.9 SD: 9.2 yr SD: 2.4 SD: 8. W) Session frequency and duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Chu 2004101 Total: 12 Gr1: 7 Gr2: 5 At least 1 yr poststroke from a single CVA. 30 min of moderate to high aerobic activities (shallow water walking. 6-station (7-min stations) circuit focused on gross upper limb movement (reaching). medically stable. Each session: 5-min warm-up of active upper extremity movement. Intervention: 10 min of land-based stretching. side stepping) at target heart rate prescribed for that wk (50% to 70%.0 yr SD: 2. single. theraband. 3–5.APPENDIX 3A. B. 0. 1 Sample size Symptom Population details duration Age. 5 min light cool down (marching on the spot). 75% and 80% heart rate reserve +/– 5 beats/min for wk 1–2. running.4 Gr1: Main objective: improve cardiovascular fitness in stroke patients after 8 wk of intensive water-based exercise in chest-level water.4 Gr1: 61. weights). 2. independent in walking (with or without assistive device). and 6–8. respectively). 1 hr/session Gr1: 3. 2 L . yr (mean. 5 min of light aerobic warm-up in water (marching on the spot. no previous myocardial infarction. 3 L Gr2: 3 R. 5-min cool-down from upper extremity exercises. and 10 min gentle stretching in the water.0 yr Gr2: 4. fine motor movement (adjusting small screws and bolt). 3 days/ N/A wk. and muscle strengthening of the upper extremity (using hand putty.1 yr Gr2: 63.and doublelegged hopping holding onto the pool edge). no significant musculoskeletal problems from conditions other than stroke. Continued 124 Author and year Comparison group 8 wks. Hemiplegia: Gr1: 4 R. Gr2: Main objective: N/A improve upper extremity function. Imposition activity such as effort to impose normal sensations of posture and movements in which weightbearing exercises played an important role. This was performed concurrently with an effort to initiate normal movements (automatic and voluntary). Mass-movement patterns. each treatment session lasted 30–45 min. or weights. Through “key points of control” in patients’ bodies.5 SD: 7. Passive movements were administered to immobile joints. Progress generally followed the normal developmental sequence. Gr3: Standard N/A customary care: Gait training exercises performed in anatomical planes. Practice of ADL training for independence began as early as possible. and 6 wk (end of treatment) Appendix 3A 125 continues . 66 R 3 bilateral 70. suspensions. Facilitation of postural activity by touch and proprioceptive stimuli for low or flaccid muscle tone. Gr2: Bobath: First step of treatment sessions was geared toward the inhibition of abnormal muscle tone. and use of simple and abnormal reflexes were forbidden. Progression was encouraged either by gradual increase in number of joints involved or by increased resistance to a requested movement. such as diagonal and spiral patterns and total patterns of the development sequence formed an integral part of the exercises.65 Gr1: Proprioceptive neuromuscular facilitation (PNF): Reflexes (most commonly the stretch reflex) frequently were used to elicit movements. For Gr1 and Gr2. usually through application of appropriate reflex-inhibiting patterns. Hemiplegia: 62 L. 4 wk (midtreatment). Option of using pulleys. Each treatment session lasted 30–45 min.Dickstein 1986102 Total: 131 Gr1: 36 Gr2: 38 Gr3: 57 Hemiplegic patients 16 days who had had a recent stroke. 0. Resistive exercises. At least 5 Follow2. mass movements. 0 sessions/wk for ups at 2 6 wk wk (midtreatment). 2) 15 min of balance exercises. 4 R . and receptive aphasia that interfered with the ability to follow a 3-step command. Continued 126 Author and year Comparison group Gr1: 67.5 hr/session. had home health visits. 1 Sample size Symptom Population details duration Age. Exclusion: Medical condition that interfered with outcome assessment or limited participation in submaximal exercise program. Visit included balance training. Patients instructed to continue on their own for additional 4 wk. SD for control) Treatment Concurrent therapy Follow-up duration Quality (R.6 Gr2: 67. Hemiplegia: Gr1: 6 L. living at home within 50 miles of the University of Kansas Medical Center. Gr2: Patients had approximately 39 visits. yr (mean.3 SD: 9. Mini-Mental State score <18. 2. progressive resistive exercises. 4 patients had outpatient physiotherapy). B. ambulatory with supervision and/or assistive device. Gr2: Usual care as Concurrent prescribed by their treatment: Speech physicians (6 patients therapy if needed. Gr1: 3 sessions/ None wk for 8 wk. 10min warm-up (stretching and flexibility). bimanual activities. 3) Patients encouraged to use affected upper extremity in functional activities. W) Session frequency and duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Duncan 1998103 Total: 20 Gr1: 10 Gr2: 10 Inclusion: Gr1: 66 days 30–90 days after Gr2: 56 days onset.2 Gr1: Home-based exercise training provided by PT. 1. increased theraband resistance or increased PNF manual resistance. approximatively 44 min per visit. minimal or moderately impaired sensorimotor function.APPENDIX 3A.8 SD: 7. Progression: When patient was able to complete 2x20 repetitions. 4) Progressive walking program/exercise on a bicycle ergometer x 20 min. 0. and facilitative exercises. 4 blocks: 1) Assistive and resistive exercise using PNF patterns to upper and lower extremities or theraband exercises to major muscle groups of upper and lower extremities. 4 R Gr2: 5 L. 22 L Gr2: 22 R. mild to moderate stroke deficits defined by a FuglMeyer score of 27 to 90 for upper and lower extremity. an Orpington Prognostic Scale score of 2. and trunk.2 SD: 27.7 days SD: 9. 36 sessions of 90 min. and test of oxygen saturation. vital signs. fingers. 12–14 wk N/A 2. upper extremity functional use. balance training. wrist.5 Gr1: 68. 1.2 and palpable wrist extension on the involved side.1 days SD: 11. endurance training (up to 30 min on bike). 2 sets of 10 repetitions.0 to 5. 22 L Gr1: 77.4 Total: 92 Gr1: 44 Gr2: 48 Stroke within 30 to 150 days. ankle. elbow. hip. ability to ambulate 25 feet independently. 1 Appendix 3A 127 continues . Hemiplegia: Gr1: 18 R.Duncan 2003104 Gr2: 73.0 Gr1: Exercise program: ROM and flexibility for shoulder. and Folstein Mini-Mental Status examination score > 16.5 Gr2: 70. Strengthening resistive exercises.5 SD: 28. Gr2: Standard N/A customary care: Home visits by research staff every 2 wk for health education. An additional 5 min of Kinetron was added weekly: 25 repetitions of both lower extremities was followed by rest for 1 min. Glasser 1986106 Total: 20 Gr1: 10 Gr2: 10 Inclusion: 3–6 months Patients who have hemiparesis due to stroke and who are 3 to 6 months onset. Hemiplegia: Gr1: 5 R.2 Gr1: The robot provided movement assistance. planar reaching tasks that emphasized shoulder and elbow movements while computer screen provided visual feedback. Robotic therapy 1 hr. 3 x/wk for Follow-up delivered with 6 wk Gr2 at 6 wk the MIT-MANUS. and stroke-related impairments in muscle strength of the affected shoulder and elbow between grades 2 and 4 on the Medical Research Council (MRC) motor power score. 14 L Treated area: Hemiplegic upper extremity 40–75 Gr1: Exercise program: Gr2: Control: During the first week. unilateral SD: stroke within the 12. Hemiparetic arm placed in a customized arm support and patient was asked to perform goaldirected. W) Session frequency and duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Fasoli 2003105 Total: 20 Gr1: 13 Gr2: 7 Diagnosis of a 31 months single. The magnitude of the opposing force was determined and modified according to patient’s muscle strength. B. Hemiplegia: 6 R. Therapeutic 2 sessions/day.APPENDIX 3A. 55. sufficient cognitive and language abilities to understand and follow instructions. SD for control) Treatment Concurrent therapy Follow-up duration Quality (R. 1. 0 Sample size Symptom Population details duration Age. 0. exercise program 5 days/wk for that consisted of 5 wk techniques based on neurophysiological and developmental theories.5 SD: 17.1 months past 1 to 5 yr verified by brain imaging. patients Exercise program received 1 hr and 50 min without Kinetron. of therapeutic exercise and independently exercised for 10 min on the Kinetron. yr (mean. Continued 128 Author and year Comparison group Gr2: Same goaldirected. 5 L Treated area: Lower extremity Follow-up 1. 0. 0 at end of treatment (5 wk) . planar reaching tasks while moving against an opposing force generated by the robot. 5 L Gr2: 5 R. Inaba 1973107 Total: 77 Gr1: 23 Gr2: 28 Gr3: 26 56 Gr1: 56. or intracerebral hemorrhage. hip abduction and adduction. 14 R Gr3: 13 L.9 Gr3: 56.1 kg weight on the Elgin table with the involved lower extremity. 13 R Treated area: Lower extremity Appendix 3A 129 continues . Stretching was done for hip and knee flexion contractures. Follow-ups 1. 0. and getting up from the ground. operating a wheelchair. embolus. Gr2: Progressive resistive exercise: Included mass extension of the involved lower limb in the supine position. car. and able to push a 1. Hemiplegia: Gr1: 8 L.1 Gr2: 55.9 Gr1: Active exercise: Gr3: Control: No Consisted of bilateral hip and exercise treatment knee flexion and extension was given. Functional training consisted of bed activities. able to follow verbal or demonstrated directions. tub or shower. 15 R Gr2: 14 L. 1 at 1 month (end of treatment) and 2 months (end of treatment) Hemiplegic patients 3 months or with CVA secondary less to thrombosis. transferring to and from bed. and trunk flexion. in the supine and side lying positions. assuming and maintaining sitting position. and rotation. extension. Extension was initiated from 90° of knee flexion to full knee extension Functional training 4 to 8 wk and appropriate stretching was given if contracture that interfered with function was present. Also unable to walk independently. gait training on various surfaces. toilet. Reciprocal exercise without resistance was accomplished by use of the Restorator for 15 min/day. lower limb coordination exercises. SD for control) Treatment Concurrent therapy Follow-up duration Quality (R. Intensity was limited to 60 % of heart rate reserve. first 8 wk part lasted 5 (end of days/wk for 2 treatment) wk. according to patient tolerance. and speech therapy). Second part lasted next 6 wk: exercised 3 x/wk for 30 min. Add 1 min to one or more interval working periods each day so that by end of second wk could work continuously for 20 min at low level. B. Gr1: 8 wk. 0. Hemiplegia: N/A .APPENDIX 3A. W) Session frequency and duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Katz-Leurer 2003a108 Total: 90 Gr1: 46 Gr2: 44 Patients who were Subacute hospitalized up stage to 48 hr after the initiation of clinical signs of their first stroke. 2. Continued 130 Author and year Comparison group Gr2: Control group: Regular therapy in rehab and 5 days/wk of group activity for general exercises. 2: 63 SD: 11 Gr1: Aerobic exercise training: Trained on lower extremity cycle ergometer with individualized exercise program (on the basis of initial stress test results). second part lasted 3 x/wk for 30 min Gr1. yr (mean. Regular therapy in rehab (physical therapy. 1 Sample size Symptom Population details duration Age. OT. with 1-min resting period (up to 10 min of work in first day). Training divided into 2 parts: first part lasted 5 days/wk for 2 wk: started with multiple 2-min intervals. individualized exercise program (on the basis of initial stress test results). Added 1 min to one or more interval working periods each day so that by end of second wk patient could work continuously for 20 min at low level. according to patient tolerance. N/A Gr1: 8 wk. Hemiplegia: N/A Gr1: 62 SD: 11 Gr1: Exercise-training: Gr2: Control group: Trained on lower extremity No individualized cycle ergometer with exercise program. 1 Appendix 3A 131 continues . with 1-min resting period (up to 10 min of work in first day). 0.Katz-Leurer 2003b109 Gr2: 65 SD: 11 Total: 90 Gr1: 46 Gr2: 44 Patients who were Subacute hospitalized up stage to 48 hr after the initiation of clinical signs of their first stroke. first part lasted 5 days/wk for 2 wk. second part: 30-min sessions. Intensity was limited to 60 % of heart rate reserve. Second part: lasted next 6 wk: exercised 3 x/wk for 30 min.3 x/wk Follow-up at 8 wk (end of treatment) 2. Training divided into 2 parts: First part: lasted 5 days/wk for 2 wk: started with multiple 2-min intervals. 5 Gr1: 60. and non-participation in any formal therapy program.3 yr Gr2: 3. yr (mean.2 SD: 1.5 Gr1: Isokinetic strengthening: 5 min warm-up (5 repetitions of active alternative flexion and extension of the hip. and ankle sitting in a chair followed by 5 min mild stretching of the paretic upper extremity) and 5 min cool down (mild stretching). with or without assistive device. SD for control) Treatment Concurrent therapy Follow-up duration Quality (R.APPENDIX 3A. 8 R . 3 sets of 10 repetitions of maximal effort concentric hip flexion/extension. 1 Sample size Symptom Population details duration Age. Hemiplegia: Gr1: 6 L. Participants were instructed to relax the extremity as it was moved into flexion and extension by the dynamometer.2 yr Gr2: 61. B.9 SD: 7. history of a single stroke at least 6 months before participating in the study. Gr2: Control: Same N/A warm-up and cool down. Rest break if necessary. 4 R Gr2: 2 L. W) Session frequency and duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Kim 2001110 Total: 20 Gr1: 10 Gr2: 10 Patients aged 50 yr or more. 2. and ankle dorsiflexion/plantiflexion were performed using Kin-Com Isokinetic Dynamometer for approximately 30 min. knee. Continued 132 Author and year Comparison group Three 45-min Follow-up sessions/wk for at 6 wk 6 wk (end of treatment) Gr1: 4. achievement of a minimum of stage 3 for leg and foot on the Chedoke-McMaster Stroke Assessment. 2.9 SD: 3. ability to walk independently for a minimum of 40 meters with rest intervals.4 SD: 9. 3 sets of passive ROM were performed for each joint of paretic lower extremity using Kin-Com Isokinetic Dynamometer. knee flexion/extension. activity tolerance of 45 min with rest intervals. 4 days Gr2: 70. OTs. multi-disciplinary treatment for stroke from doctors. Follow-ups 1.52 days SD: 18. The OT supported the patient’s elbow and forearm with one hand. 17 R Gr2: 11 L. Elbow.8 SD: 2. The shoulder was ranged of external and internal rotation.Kumar 1990111 Total: 28 Gr1: 12 Gr2: 8 Gr3: 8 Patients who had had a stroke recently. Treatments for both groups given for at least 40 min/session. The patient pulled the other end of the ropes and moved the arm through a range of 130–150° of abduction always parallel to the scapula. nurses.1 SD: 3. multi-disciplinary treatment for stroke from doctors. 1 session/day. The shoulder was ranged 140–150° of abduction. Care was taken to keep the upper extremity in external rotation during abduction. Gr1: 14. Followups at 2 wk (midtreatment) and 3 months (end of treatment) Gr2: Bobath: No specification. Gr1: Motor relearning program: No specification. The arm was moved through approximately 90° of forward flexion. 2.8 Gr3: 60. A skateboard with a figure eight on it was centered in front of the patient who was instructed to follow the figure eight with the affected arm. The upper extremity was positioned in 45° of abduction and was attached to one end of the rope with a mitten. 5 days/wk until discharge (followed by out patient treatments) 1.2 Range. Not specified 78 SD: 9 Range. 0. Hemiplegia: 12 L. 5 sessions/wk N/A 1. 1 Gr3: Passive ROM: Gait and ADL An OT passively training ranged the patient’s affected arm.36 days Gr1: Overhead pulley exercise: Patients were seated in wheelchair between the pulley ropes. Gr2: Skateboard: Patients were seated at a 32-in. and fingers were also ranged through full range of extension and flexion.1 Gr3: 13. Treatments for both groups given for at least 40 min/session. Gr2: Bobath: No specification. 1 session/day. 5 days/wk until discharge (followed by out patient treatments). and speech therapists.9 SD: 2. 1 at 1 year and 4 yr Appendix 3A 133 continues . nurses. and 45° of adduction. OTs. 49–95 Langhammer Total: 28 2003113 Gr1: 27 Gr2: 21 Patients who agreed Not specified 78 to participate in the first study were invited to participate in a follow-up study. Hemiplegia: Gr1: 16 L.17 R Gr1: Motor relearning program: No specification. Comprehensive.2 Gr2: 15. high table.5 43–90 SD: 1. and upper arm with the other. and speech therapists.5 64. verified clinically and by CT scan. Comprehensive. 1 Langhammer Total: 24 2000112 Gr1: 53 Gr2: 29 Patients with first-ever stroke with hemiparesis. wrist. 90° of abduction.51 days Gr1: 63. 16 R Treated area: Shoulder 14. 0. Patients in both 3 wk with five groups were trained 1-hr sessions to perform 3 sets each week of daily tasks.0 SD: 6. B. or upper limb coordination. In the first wk. In the third wk. SD for control) Treatment Concurrent therapy Follow-up duration Quality (R. patients identified their own problems for rectification through the use of mental imagery. Patients in both groups also received 1hr physiotherapy sessions for training in walking and general muscle strengthening 5 days/wk. 3) independent in performing daily activities before admission. In the second wk. 5) having given their voluntary consent. balance.3 days Gr2: 72.2 days Gr1: 71.APPENDIX 3A.4 days SD: 12.4 15. Patient were required to practice the same tasks following a sequence and training schedule similar to that of the mental imagery program. Continued 134 Author and year Comparison group N/A Gr1: 12. the focus was on practicing the rectified task perfomance using mental imagery and actual practice. 1 Sample size Symptom Population details duration Age. However. the demonstrationthen-practice method was adopted. W) Session frequency and duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Liu 2004114 Total: 46 Gr1: 26 Gr2: 20 1) Diagnosed as having had a first unilateral cerebral infarction as confirmed by a CT scan. 0.3 days SD: 5. 2) age 60 yr or older. the focus was on analyzing task sequences to facilitate motor planning and problem identification process using computer-generated pictures and movies. . In the functional retraining program. yr (mean.7 Gr2: SD: 9. There were 5 tasks in each set including mobility functioning. 2. as screened by the Cognistat. with the easiest tasks covered in the 1st wk.0 Mental imagery program: Patients were trained in the technique of mental imagery to practice specific tasks. The difficulty level was organized in ascending order. 4) able to communicate effectively. the problems encountered by patients were rectified with the help of therapists. and. active. Medically stable and fit to participate in a nonrestrictive program as determined by the attending physician.Logigian 1983115 Total: 42 Gr1: 21 Gr2: 21 Patients with stroke 7 wk or less documented by CT scan within 7 wk of onset. and vestibular stimulation activities. Treatment techniques included passive. Standard customary care emphasized strengthening the developing motion and maintaining full passive motion. Each patient received between 60 to 90 min of treatment a day.6 SD: 21 Facilitation technique: Treatment included bilateral weight-bearing and weightshifting exercises. reciprocal pulleys. and progressive resistance exercises and employed the use of upper limb skateboard. assistive. Extra ROM exercises if patients wished. utilization of reflex inhibiting patterns. Physiotherapy Daily until N/A and OT exercises discharge (time in addition to not specified) ADL and speech therapy. weighted sanders. and tactile. 0. Total: 61. and springs. vibratory. 1. 0 Appendix 3A 135 continues . 4 R . B. Hemiplegia: Gr1: 9 L. starting close to the body and ending further away. 4) directly lateral. Emphasis placed on target reaching movement. 3) Active-constrained: Robot provided viscous resistance in the direction of the desired movement and springlike forces in all other directions as the patient attempted to reach toward the target with maximal effort. Concurrent treatment: Homebased exercise regimen or community-based stroke programs they were enrolled in at the time of intake into the study.4 Gr2: 28. SD for control) Treatment Concurrent therapy Follow-up duration Quality (R. yr (mean. 4 point-to-point reaching directions trained: 1) forward medial. 1 for 24 sessions at 6 months Sample size Symptom Population details duration Age.2 SD: 6.8 SD: 6. Emphasis on reeducation of muscles using sensorimotor approach to control motor output.9 SD: 2. 2. 4 exercise modes: 1) Passive: Robot moved arm toward target. 12 targets located at shoulder or eye level. W) Session frequency and duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Lum 2002116 Total: 27 Gr1: 12M/ 1F Gr2: 8M/6F Inclusion: Diagnosis of a single CVA. 2) directly forward. Gr2: Conventional treatment based on neurodevelopmental therapy: 10 min establishing physical postural base of support coupled with assessing and facilitating the alignment of the shoulder. Continued 136 Author and year Comparison group Time since stroke onset. 3) forward lateral. Exclusion: Upper extremity joint pain or ROM limitations that would limit their ability to complete the protocols. robot manipulator attached to the splint. Progression from easiest exercise mode to most challenging. 4) Bimanual: Patient attempted a bimanual mirrorimage movement while robotassisted affected extremity.2 SD: 3. and 35 min graded application of the arm’s use in ADLs.6 Gr1: Patient seated in a wheelchair. and obvious deficit in upper-extremity motor function as a result of CVA. months: Gr1: 30. and unable to cooperate with the study tasks. torso movement limited.2 Gr2: 65. more than 6 months post-CVA. 4 R Gr2: 10 L. 2) Active-assisted: Patient triggered initiation of movement with volitional force toward the target and worked with the robot as it moved the extremity.3 Gr1: 63. 1 hr per session Follow-up 2. unstable cardiovascular/ orthopedic/ neurologic conditions. 5-min exposure to robot. affected limb strapped to forearm splint.APPENDIX 3A. 3 x/wk at 8 months 1 hr/session. Gr1: 3. Standard customary 30 min/session. 3 Follow-up x/wk for 10 wk at 1 month 2.1 SD: 27. and able to walk with or without an assistive device for a minimum of 10 meters and have an activity tolerance of 60 min with rest intervals.6 days SD: 12. Eyes closed conditions and foam surfaces were incorporated.1 Total: 133 Gr1: 68 Gr2: 65 Patients who were less than 6 months post stroke. 1 Moreland 2003118 Gr2: 38. Tasks included standing in various postures and walking with various challenges. motor recovery of the foot at stages 2.0 Total: 48 Gr1: 26 Gr2: 22 Patients aged 50 yr or more. Weight shifting: Tai chi-like movements and reaching tasks. motor recovery of the upper extremity at stages 3. 0.0 SD: 25. 4. Stretching: Major muscle groups while standing and while on floor mats. 1 care.1 Gr2: 72. Gr1: 36.Marigold 2005117 Gr2: 3.8 yr Gr2: 68. Emphasis on agility and multisensory approach.2 5-min warm up: walking and light stretching and 5-min cool down: light stretching. 4. Same as Gr1 except no external resistance. 5 or 6.8 Progressive resistance exercises with weight at waist or on lower extremities in functional patterns of movement. 0.1 SD: 9. Challenged dynamic balance and tasks were progressively increased in difficulty.8 Gr1: 69.8 SD: 2. and informed consent given by the participant or substitute decision maker.6 SD: 1.4 yr Gr1: 67. able to understand and follow instructions. 3.8 days SD: 14. rapid knee raise while standing. single stroke. at least 12 months from onset.5 SD: 7. or 5. Follow-up 2. and standing perturbations. as defined by the CMSA stages. Slow low-impact movements consisting of stretching and weight shifting. Same warm up and N/A cool down as Gr1. Additional exercises: sit-tostand movements. Appendix 3A 137 continues . Follow-ups 2. W) Session frequency and duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Mudie 2002119 Total: 40 Gr1: 10 Gr2: 10 Gr3: 10 Gr4: 10 Patients had suffered a recent stroke and consistently bore majority of weight on one side. 2. Gr4: Control: Standard customary care in physiotherapy and OT. patient required to touch target with unaffected hand at various heights and distances and patients attempted to return to symmetrical position after reaching. Gr2: Task-related reach training: Patient seated on adjustable plinth.APPENDIX 3A. grocery items at about 140% of upper extremity length were retrieved with unaffected upper extremity and placed on shelves at various heights and distances to allow reaching to extremes of seated base of support. 2 wk of daily training sessions Within 2–6 wk 72.01 Gr1: Portable computer-like BPM feedback console used to provide awareness of weight distribution during training in sitting. yr (mean. 1 at 2 and 12 wk Sample size Symptom Population details duration Age. SD for control) Treatment Concurrent therapy Follow-up duration Quality (R. 30 min session.4 SD: 9. B. Continued 138 Author and year Comparison group Gr3: Bobath-trained N/A staff physiotherapists focused on increasing trunk and pelvic ROM. normalizing trunk muscle tone. maintaining appropriate balance responses during reaching. 2 wk of training. . and improving the patient’s ability to move in and out of asymmetric posture. verbal and manual facilitation by therapist during seated reaching or lying. 0. 8 L Appendix 3A 139 continues . had sufficient verbal comprehension to participate in the study.75 unilateral cerebral SD: 49.1 hemiplegia. and free from cardiac conditions. had reached their maximum capacity of physical function and subsequently discharged from occupational and PT. Patients were encouraged to move their extremities in various directions and positions and to raise their affected extremities as high as they could in different directions (involved shoulder flexion and elbow extension). 30 min/session.5 days SD: 5. had at least stage IV Brunnstrom motor recovery in the affected upper extremity.Paul 1998120 Total: 20 Gr1: 10 Gr2: 10 Gr1: Music-making activity with upper extremity movement.to 3step directions. Hemiplegia: 12 R. participants had to find a rhythm or beat that was expressive and comfortable for them. 0 2 x/wk at 10 wk Diagnosis of 93. were able to hold a drumstick that is 5 cm in diameter and weighed 8 grams in their affected hand.4 days 61. evaluated by the ability to follow 2. Follow-ups 1. had at least 10° of limitation in active shoulder flexion and elbow extension in the involved upper extremity. Gr2: Physical exercise N/A group conducted by recreation therapists. Hemiplegia: Gr1: 8 L. All evaluation and training exercises consisted of reaching tasks in the horizontal plane that involved shoulder and elbow movements. yr (mean.N/A assisted training.4 months Gr1: 53. 0.3 months SD: 11. 5 R Gr2: 6 L. The highest load was then maintained for the final 6 wk of training. Gr2: During active. Continued 140 Author and year Comparison group Gr2: Control: Given N/A passive exercise for ROM to body joints in a systematic procedure for 30 min. Gr1: During resistance training. 43–72 yr Gr1: Exercise: Exercised on an adapted cycle ergometer for 30 min. 1. Hemiplegia: Gr1: 4 L.7 months Gr2: 52.3 SD: 16. Patients were asked to move between a center target and 8 peripheral targets arranged in circular display.4 All patients received 6 wk of robot-aided exercises. 1 Sample size Symptom Population details duration Age. the robot provided resistance to the movement of reaching.4 Gr2: 27. All the patients were required to have conclued any conventional physical or OT before enrollment in the study. training load was gradually increased from a workload representing 30%–50% of maximal effort to the highest level attainable by the patient. 1 . 0. 3 sessions/wk for 10 wk Follow-up at 10 wk (end of treatment) Range.APPENDIX 3A.5 SD: 14. residual paresis with average strength in the upper limb (measured at shoulder and elbow flexors and extensors) between 2 and 4 on the Medical Research Council grading system. B. W) Session frequency and duration Potempa 1995121 Total: 42 Gr1: 19 Gr2: 23 Patients who More than 6 had had a stroke months more than 6 months before randomization. 8 R Gr1: 27 months SD: 12. 3/wk for 1 hr N/A sessions. Medically stable and had completed a formal rehab program. SD for control) Treatment Concurrent therapy Follow-up duration Quality (R. 60 reps of each round of moving to the set of target were performed. for a total of 18 hr of robot-aided exercise training per patient TOPICS IN STROKE REHABILITATION/SPRING 2006 Stein 2004122 Total: 18 Gr1: 9 Gr2: 9 Patient who had had a single previous stroke. 11 R Gr2: 15 L. 3 R 2. During first 4 wk. the robot provided assistance in reaching each target if the patient was unable to reach independently. Patients were also given exercises to do at home and encouraged to do 3x/wk. 1 Appendix 3A 141 continues . of the affected lower extremity.42 SD: 8. with an activity tolerance of 45 min with rests.85 Total: 13 Gr1: 6 Gr2: 7 Patients with unilateral stroke with residual weakness.2 yr Gr2: 69. and ROM exercises.87 SD: 10. calisthenics.7 yr Gr1: 65. Hemiplegia: Gr1: 3 L.15 SD: 12.TeixeiraSalmela 1999123 Gr2: 6. At least 9 months post stroke.16 Gr1: Exercise: Supervised Gr2: Control: No sessions included a warm exercise treatment up (5–10 min) consisting of was given. Each session lasted 60 to 90 min. or both. spasticity.4 SD: 6. 3 R Gr2: 4 L. independently ambulatory for 15 min with or without assistive devices. 0. and a cool down period (5–10 min) consisting of muscular relaxation and stretching. and no comprehensive aphasia. mild stretching. 3 R Gr1: 9. N/A 3 x/wk for 10 wk Follow-up at 10 wk (end of treatment) 1. strength training. Aerobic exercises consisting of graded walking plus stepping or cycling at a gradually increased target heart rate of 70% maximal heart rate. The pronated forearm and palm rested on a board designed to stabilize the wrist. Gr4: Resisted grasp: A Jamar dynamometer was set up so the handles were 2. yr (mean. 3 L Gr3: 2 R.APPENDIX 3A.8 Gr4: 63. 3 L Gr2: 2 R. Each trial was repeated 10 times with a 5-s rest between trials. and who were free of pain on the affected upper extremity and medically cleared to participate. B. 1 session/ day for approximately 2 wk Follow-up at 2 wk (end of treatment) Gr1: 5. 2.4 wk Gr3: 6 wk Gr4: 11.1 wk Gr1: 67. 1 Sample size Symptom Population details duration Age. For every group verbal encouragement was given. W) Session frequency and duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Trombly 1986124 Total: 20 Gr1: 5 Gr2: 5 Gr3: 5 Gr4: 5 Patients who could grasp a 2.8 Gr3: 75. understand directions. 0. Hemiplegia: Gr1: 2 R.4 Gr2: Resisted extension: Rubber bands were placed over the middle phalanges and resistance was offered by the maximum number of rubber bands that the patient could extend fingers against and hold for 6 s.5 cm cylinder.5 cm apart or a Hand Helper exercise aid was loaded with the maximum number of elastics the patients could squeeze. 3 L Gr4: 3 R.2 wk Gr2: 3. SD for control) Treatment Concurrent therapy Follow-up duration Quality (R. Continued 142 Author and year Comparison group Gr1: Control: No N/A exercise treatment was given. The maximum grasp was held for 6 s at each trial. The forearm was in mid-position with the elbow resting on the table for support. Gr3: Ballistic extension: A ping-pong ball was placed in front of the patient’s flexed fingers (middle finger) and the patient was told to flick the ball to knock down the paper cup placed 30–45 cm away from the patient’s hand.2 Gr2: 60. 2 L Treated area: Hand . 1500 repetitions of goal-directed movement to a target. Auditory feedback indicated correct movement. 1 hr/day. A video screen provided visual feedback through targets identical to those drawn on the support board in front of the patient and that tracked the movement of the robot handle. consisting of 20 repetitions each. Similar standard customary care in PT and OT post stroke. Patients moved the handle of the tip of a robot that then moved a cursor on a screen.14 days Acute Inclusion: Patients with hemiparesis or hemiplegia of the upper extremity or lower extremity who were able to follow simple instructions. 25 sessions.12 days Gr2: 26.1 days Chronic Inclusion: Patients who had hemiparesis or hemiplegia of the upper extremity or lower extremity. 14 L Treated area: Gr1: Shoulder and elbow (affected) Gr2: Affected and unaffected upper extremity Gr1: 62 SD: 10.Volpe 1999125 Gr2: 66 SD: 5 Total: 12 Gr1: 6 Gr2: 6 Gr1: 1098.8 days SD: 191. Auditory feedback indicated correct movement. A video screen provided visual feedback through targets identical to those drawn on the support board in front of the patient and that tracked the movement of the robot handle. Patients were exposed to the robot 1 hr/wk. they used the unaffected extremity or technician assistance to complete the task. exposure to the robot except that half the trials were performed with the unaffected upper extremity.0 days SD: 7. 143 continues . 1 Gr2: Control: Standard customary 1 hr/day. Focus on shoulder. If patients did not respond. Hemiplegia: Gr1: 13R. 1500 reps of goaldirected movement to a target. 5 Patients received care in PT and OT days/wk similar initial post stroke. The robot never actively moved the patients’ limbs. Hemiplegia: Gr1: 2 L. 5 days/wk None 1. 5 R Treated area: Gr1: Shoulder and elbow (affected) Gr2: Affected and unaffected upper extremity Gr1: 54 SD: 7 Gr1: Robot treatment. Patients were exposed to the robot 1 hr/wk.95 Appendix 3A Gr1: Robot treatment: 25 sessions.2 days Gr2: 933. Focused on shoulder.5 days SD: 7. If patients did not respond. robot guided their hand to the target. Patients moved the handle of the tip of a robot that then moved a cursor on a screen. 1 Volpe 2000126 Gr2: 67 SD: 10. consisting of 20 repetitions each. elbow movement pattern organized in 3 batches. Follow-up at 3 yr 1. The robot never actively moved the patients’ extremity.5 days SD: 137. 4 R Gr2: 1 L. 17 L Gr2: 12 R. 0.20 Total: 56 Gr1: 30 Gr2: 26 Stroke onset/initial pretreatment evaluation: Gr1: 22. elbow movement pattern organized in 3 batches. they used unimpaired limb or technician assistance to complete the task. Gr2: Control: Patients received similar initial exposure to the robot except that half the trials were performed with the unaffected upper extremity. the robot guided their hand to the target. and who could follow simple instructions. 0. and when patients could not perform the task with the affected limb. and when patients could not perform the task with the affected extremity. M = male. L = left. same exercises with less resistance and greater speed. W = randomization. 0. 16 R Note: ADL = activity of daily living. ADL. or concentric muscle contractions performed in a gravity-lessened position or against gravity. progressed against resistance using free-weights. alternate days for 3 days/wk. R = right. W) Session frequency and duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Winstein 2004127 60 Gr1: 20 Gr2: 20 G3: 20 First-time stroke N/A from infarction in the anterior circulation confirmed by MRI or computed axial tomography scan. isometric. Gr = group. OT = occupational therapy. blinding. ROM = range of motion. stretching exercise. 35–75 yr: 20. theraband. x/wk = times per week. muscle facilitation exercises. or grip devices for the fingers. BPM = balance performance monitor. 2. 35–75 yr: 18. yr (mean. on other days. > 75 yr: 1 Gr3: <35 yr: 0. . 13 R Gr3: 4 L. and self-care. Continued 144 Author and year Comparison group 1 hr/day. 5 days/wk for 4 wk Follow-up at 6.APPENDIX 3A. withdrawals. B. F = female. Gr2: Functional training: Systematic and repetitive practice of tasks arranged in proximal to distal recovery patterns of reaching and grasping. PNF = proprioceptive neuromuscular facilitation. eccentric. >75 yr: 0 Gr1: Standard customary care delivered by an OT.5 to 8 months Gr1: <35 yr: 2. N/A = not available. onset of stroke from 2 to 35 days before study entry. 35–75 yr: 19. >75 yr: 0 Gr2: <35 yr: 0. 1 Sample size Symptom Population details duration Age. SD for control) Treatment Concurrent therapy Follow-up duration Quality (R. CVA = cerebrovascular accident. and a FIM instrument total score at admission of 40 to 80. 12 R Gr2: 7 L. CMSA = Chedoke-McMaster Stroke Assessment. neuromuscular electric stimulation for shoulder subluxation. B. Quality R. PT = physical therapy. Hemiplegia: Gr1: 8 L. Gr3: Strengthening N/A and motor control training. 2 Gr1: To improve sitting balance. Feedback was given. and height.9 yr SD: 2.APPENDIX 3B. distance. Hemiplegia: Gr1: 5 R. Feedback was given. The reaching task was done under systematic conditions. who can walk short distances within the home and understand instructions. who have no orthopedic problems that would interfere with the ability to perform seated reaching tasks. and who can sit unsupported for 20 min. yr (mean.7 yr SD: 5. 4 L Treated area: Affected leg Appendix 3B 145 continues . W) Session frequency Follow-up and duration duration Dean 1997159 Total: 20 Gr1: 10 Gr2: 10 Inclusion: Patients who were hemiplegic at least 12 months ago and had been discharged from all formal rehab services. Gr2: Patients N/A performed cognitivemanipulative tasks while seated in a chair with arm and back supports and forearms resting on a table. 2.9 yr Gr2: 66.8 yr Gr2: 5.9 SD: 8.2 SD: 8. direction. The number of repetitions and complexity of the tasks were increased over the 2 wk. B. Characteristics of Included Studies for Task-Oriented Training Author Sample and year size Treatment 10 sessions N/A of 30 min each for 2 wk Comparison group Gr1: 6. 1 Population details Time since onset Age. Patients performed manipulative tasks using the unaffected hand over small distances (less than 50% of arm length).2 Gr1: 68. extent of thigh support on the seat. 5 L Gr2: 6 R. Patients did an equal number of reaching movements as Gr1. Emphasis: Appropriate loading of the affected leg while practicing reaching tasks using the unaffected hand to grasp objects beyond arm’s length. movement speed. SD for control) Concurrent therapy Quality (R. The number of repetitions and cognitive difficulty of the tasks increased. 2. Variations: Location or weight of object. Patients were seated and asked to flex the paretic elbow repeatedly as fast as possible until the index finger reached the target on the board and then promptly return to the starting position. horizontal then vertical and diagonal exploration. visual and auditory signals are elicited. 9 L Gr2: 7 R. follow simple directions. 0.4 wk paretic elbow for at least 5º on an exercise board (constructed for the study). B.APPENDIX 3B. 2 hemipanels (boards) corresponding to the halves of extrapersonal space with targets. 10 N/A min every other day. 1 keyboard. Total: 800 repeated elbow movements in maximal 80º of amplitude divided in 8 equal sessions every other day. Hemiparetia: Gr1: 6 R. 6 L Dickstein Total: 27 1997161 Gr1: 15 Gr2: 12 Inclusion: Patients 4. yr (mean. static imbalance of the trunk resulting from the stroke. 8 sessions every other day for 19–21 days N/A Follow-up at 2.5 SD: 25 days SD: 17 Gr2: 27. Gr1: Repetitive training. and a pointer guided by trunk movements. and patient sitting then standing when adequate trunk control gained. W) Session frequency Follow-up and duration duration TOPICS IN STROKE REHABILITATION/SPRING 2006 De Sèze 2001160 Total: 20 Gr1: 10 Gr2: 10 Inclusion: Hemiplegia caused by a single supratentorial ischemic or hemorrhagic stroke that had occurred at least 1 month previously. Progression: decreased cueing intensity.7 days Gr2: 67. CVA type (ischemic/ hemorrhagic): Gr1: 3/7 Gr2: 4/6 Hemiplegia: Gr1: 1 R. Composed of a variable repertoire of exercises to the paretic UE aimed at improving function. alternation in rhythm and sensorial modality involved.5 SD: 8.9 wk who can flex the SD: 1.8 days Gr1: 63. and who consented to participate in study. 0. Continued 146 Author Sample and year size Treatment Standard rehab: 2 hr each wk Bobath-inspired for 4 wk approach and functional therapy Comparison group Gr1: 36. Gr2: Control. 1 8 wk (during the wk both groups still received standard rehab) Population details Time since onset Age. 10 series of 10 movements during each session. SD for control) Concurrent therapy Quality (R. Oral encouragement was given and rest periods provided between series.4 0. 9 L Gr2: 4 R. When pointer touches a target. 5 L Treated area: Paretic elbow 70. Practicing 100 elbow flex movements. 1 .7 SD: 15 days SD: 15 Gr1: 1 hr rehab with the Gr2: 2 hr standard Bon Saint Côme Device + rehab only 1 hr standard rehab (4 wk) then standard rehab (8 wk) Bon Saint Côme device: 4 parts interconnected: trunk orthosis. with sufficient functional use of 1 hand to complete the RPAB and to carry out perceptual treatment activities. 1 Appendix 3B 147 continues . 0. no discharge date planned.60 days Gr2: 31.13 days Inclusion: Patients well enough to be assessed on the Rivermead Perceptual Assessment Battery. Hemiparetic: Gr1: 24 R.5 hr/wk for N/A 6 wk 2.85 SD: 11.75 SD: 9. able to do 2 out of 4 specified activities (eat. able to transfer with a maximum of 2 nurses.38 Total: 79 Gr1: 40 Gr2: 39 Gr1: 37. drink. 16 L Gr2: 21 R.15 days SD: 10. medically stable. able to tolerate 30-min treatment sessions. 19 L Gr1: 69.10 Gr2: Perceptual training with functional approach for 2.5 hr/wk for 6 wk General OT treatment 2. toilet themselves) prior to stroke.5 hr/wk for 6 wk Gr1: Transfer training approach for 2. wash their face.68 days SD: 16.Edmans 2000162 Gr2: 67. early use of assistive device and bracing. Hemiplegia: Gr1: 8 R. progressive resistive exercises. W) Session frequency Follow-up and duration duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Gelber 1995163 Total: 27 Gr1: 15 Gr2: 12 Inclusion: Patients who were hemiparetic and had an ischemic stroke (maximum time from stroke to entry 1 month). Techniques: Passive ROM in anatomic planes. initiating normal (good quality) motor movement with progression through developmental sequences before advancing to functional activities. Practicing functional tasks as early as possible even in the presence of spasticity or abnormal posture.9 Gr1: Neurodevelopmental technique (NDT). 0 at 26 wk and 52 wk Population details Time since onset Age. 0.8 SD: 2. This treatment philosophy stresses inhibiting abnormal muscle tone. 7 L Gr2: 5 R. Resistive exercises and use of abnormal reflexes and mass movements were avoided.7 days SD: 2. Gr2: Traditional N/A functional retraining approach (TFR). and allowing patients to use their affected side to perform functional tasks.8 SD: 1. B. yr (mean. 7 L Treated area: Affected side . Continued 148 Author Sample and year size Treatment N/A Comparison group Gr1: 11. and encourages patients to use their affected side.8 days Gr2: 69. Follow-ups 1. SD for control) Concurrent therapy Quality (R.APPENDIX 3B.3 days Gr1: 73.0 Gr2: 13.1 days SD: 2. 0 SD: 9. or understanding.2 days SD: 2. 15 min/day upper extremity rehab. Sitting. Treadmill training where equipment available. memory. 17 L Gr3: 13 R. Hemiplegia: Gr1: 13 R.1 SD: 15. had no severe deficits in communication. Gr1: Immobilization of paretic arm and leg by inflatable splint applied with the patient supine for 30 min. weightbearing exercises while standing and walking.8 Total: 89 Gr1: 34 Gr2: 29 Gr3: 26 Inclusion: Patients who had stroke diagnosis (WHO definition).Kwakkel 1999164 Gr2: 7. Gr2 and 3 training was applied by OT/PT for 30 min.0 days SD: 2. had no complicating medical history.0 Gr2: Upper extremity training. 1. standing. 1 6 wk Appendix 3B 149 continues . 0.9 days Gr1: 64. were motivated to participate in the research project. Functional exercises that facilitated forced arm and hand activity such as leaning. Gr3: Lower extremity training. 24 L Gr2: 16 R. with emphasis on achieving stability and improving gait velocity.5 days Gr3: 64.5 days SD: 2. Concurrent treatment: 15 min/day lower extremity rehab. and grasping and moving objects.5 hr/wk ADL training 5 x/wk for 20 wk Follow-up at 2.8 days Gr3: 7. were 30–80 yr old.5 SD: 9. punching a ball. 18 L Gr1: 7. gave written/spoken informed consent.7 Gr2: 69. had primary firstever stroke in the territory of the middle cerebral artery. had impaired motor function of the arm and leg. unable to walk at first assessment. 0 days SD: 2. Continued 150 Author Sample and year size Treatment 30 min/day. W) Session frequency Follow-up and duration duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Kwakkel 2002165 Total: 101 Gr1: 37 Gr2: 33 Gr3: 31 Inclusion: Primary.5 hr/wk ADL training 1. N/A Logan 2003166 Total: 466 Gr1: 156 Gr2: 153 Gr3: 157 All patients were recruited after a hospital admission with stroke.7 Gr2: 69.8 days Gr3: 7.0 Gr2 (upper extremity): Focused on improvement in disabilities involving the hemiplegic upper extremity (grasping. dressing). 0 10 therapy 6 months sessions. each between 30 and 60 min duration .2 days SD: 2. Gr1 (control): Immobilization of the paretic upper extremity and lower extremity by means of an inflatable pressure splint.5 days SD: 2. had no complicating medical history such as cardiac/pulmonary/ other neurological disorders. 1 Population details Time since onset Age.APPENDIX 3B. first-ever stroke in the territory of the middle cerebral artery as shown by CT or MRI. transfers (such as turning over) and gait (performance and climbing stairs).1 SD: 15. SD for control) Concurrent therapy Quality (R. 15 min lower extremity rehab. 15 min upper extremity rehab.9 days Gr2: 7. Gr3: Control group (not reported in analysis). 18 L N/A N/A Gr1: Treated with ADL activities Gr2: Treated with to achieve ADL goals. B.0 SD: 9.5 SD: 9. leaning. 0. unable to walk at first assessment. 1. yr (mean.8 Gr1: 64. Gr3 (lower extremity): Focused on functional recovery of balance (sitting. standing balance). between 30–80 yr of age. 24 L Gr2: 16 R. Follow-ups 5 days/wk for at 3 and 6 20 wk months Comparison group Gr1: 7. reaching. and had no severe deficits in communication/ memory/ understanding. Hemiplegia: N/M Gr1 & Gr2: Follow-up at 1. leisure activities (activities done for pleasure) to achieve leisure goals. 17 L Gr3: 13 R.5 days Gr3: 64. 0. had an impaired motor function of upper as well as lower extremities. Hemiplegia: Gr1: 13R. 67 to 0.97 Hz.1 Appendix 3B 151 continues . participants pushed and pulled bilaterally. 2T-bar handles sliding in the transverse plane. 4 L Gr1: 75 months Gr2: 45. in synchrony or alternation. All patients had the ability to move the affected limb and had completed 3 to 6 months of conventional rehab.5 months Gr1: 63.Luft 2004167 Gr2: 59. weight bearing with the paretic arm.6 SD: 10. scapular mobilization. Upon auditory cues at individually determined rates of 0.5 Total: 21 Gr1: 9 Gr2: 12 Inclusion: Patients with residual upper extremity spastic hemiparesis following a single cortical or subcortical ischemic stroke. Adequate language and neurocognitive function to understand instructions. Hemiplegia: Gr1: 6 R. Gr2: DMTE N/A was based on neurodevelepmental principles and included thoracic spine mobilization.3 SD: 15.0. and opening a closed fist. 3 x/wk for 6 wk N/A 2. 3 L Gr2: 8 R.3 Gr1: BATRAC consisted of hr-long therapy sessions (four 5-min movement periods interspered with 10-min rest periods). Gr2: Patient seated on adjustable plinth. verbal and manual facilitation by therapist during seated reaching or lying. 1 Population details Time since onset Age. patients attempted to return to symmetrical position after reaching. grocery items placed at about 140% of arm’s length were retrieved with nonparetic extremity and placed on shelves at various heights and distances to allow reaching to the extremes of the seated base of support. N/A 30-min sessions for 2 wk N/A Comparison group 72.APPENDIX 3B.01 yr 2. yr (mean. Continued 152 Author Sample and year size Treatment Gr1: Portable computer-like balance performance monitor (BPM) feedback console used to provide awareness of weight distribution during training in sitting. 2. normalizing trunk muscle tone. B. .4 SD: 9. patients required to touch target with nonparetic hand at various heights and distance. W) Session frequency Follow-up and duration duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Mudie 2002119 Total: 40 Gr1: 10 Gr2: 10 Gr3: 10 Gr4: 10 Patients had suffered Within 2–6 a recent stroke and wk consistently bore majority of weight on one side. Gr3: Bobathtrained staff physiotherapists focused on increasing trunk and pelvic ROM. SD for control) Concurrent therapy Quality (R. maintaining appropriate balance responses during reaching and improving the patient’s ability to move in and out of asymmetric posture. Gr4: Control: Standard PT and OT. Then patient had 10 trials by themselves. 74 L N/B: 16 Treated area: Functional Appendix 3B 153 continues . 1 26 wk and 52 wk 68. Gr1: Instructions given: Exercise your arm by playing a dice game.5 yr Gr1: Leisure. Gr2 (rote exercises): Cap on handle weighs approximately the same as the 3 dice.5 days hemiplegia caused SD: 51. and sufficient visual perception and comprehension. 2 trials of manual guidance– therapist assisted patient in grasping firm bilateral grasp of the handle and manually guided the patient through the motion until all 3 dice dropped. reaching toward uninvolved side. no functional supination. Patients practiced the leisure tasks and any ADLs tasks necessary to achieve the leisure objective. a 3-min break and then 10 additional trials. Hemiplegia: Gr1: 71 R. pronator spasticity. 1 Parker 2001169 Total: 466 Gr1: 153 Gr2: 156 Gr3: 157 Inclusion: Acute stroke with onset of less than 6 months. duration since onset of the stroke between 9 days and 7 months. Minimum of 10 sessions lasting not less than 30 min each Follow-up at 2. reaching toward involved side. Hemiplegia: 15 R. N/A 2. 0. age of at least 45 yr. participating in a rehab program. 65 L N/B: 16 Gr3: 67 R. 0. Gr2: ADLs. Patients practiced the independent self-care tasks (preparing a meal or walking outdoors).4 SD: 11. ability to grasp a 3-cm dowel bilaterally with overlapping fingers. Rotation of the handle met with little resistance.9 by a first and only CVA. Instruction: Exercise your arm by using the handle. moving wrist from ulnar deviation to radial deviation.Nelson 1996168 Total: 26 Gr1: 14 Gr2: 12 M/F: 14/12 Inclusion: Unilateral 53. Patients were encouraged to get doubles or 3 in a row. 69 L N/B: 13 Gr2: 75 R. Preliminary 1 visit exercises: 3 reps of reaching between knees to floor. reaching forward. Control: No OT N/A treatment within the trial.2 Apparatus: Handle—when rotated to 40º first die falls noisily and the last (3rd) die falls at 90º. no contraindication to supination exercises. full passive supination after brief warm-up exercises. Slow and steady movement emphasized. 11 L Less than 6 months Gr1: Median: 72 SD: 7 Gr2: Median: 71 SD: 6 yr Gr3: Median: 72 SD: 6. had no receptive aphasia (scoring 18 or above on Body part and 13 or above on Commands section). in addition to complex bands around pelvis and shoulder girdle. B. An instruction sheet was given. could walk 10 meters with or without assistance or walking aid. not months participating in other physical rehab. Hemiparetic: 8 R. and ankle bands. had no neuro. each patient was contacted by telephone once a week. could don and doff the garments alone or with help. biceps. 0 Population details Time since onset Age. thigh. Gr2: Control. N/A After the 6-wk intervention phase. W) Session frequency Follow-up and duration duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Pomeroy 2001170 Total: 24 Gr1: 12 Gr2: 12 Inclusion: 6 months At least 6 post stroke. had no visual unilateral neglect. Worn on the paretic side only. During wk 2 to 6. Gr2: First 6 wk control then 6 wk of treatment. the 12 control patients were given the garments and asked to complete the logbooks. Continued 154 Author Sample and year size Treatment Gr1: “Weight garments”: Simple wrist. had no severe heart disease.or musculoskeletal disorder. SD for control) Concurrent therapy Quality (R. N/A Comparison group N/A 2. Patients were instructed to adjust the weights and garment on a daily basis according to how able they felt and were asked to wear the garments all day. Gr1: 6 wk with the garments for intervention phase and nothing for control phase.APPENDIX 3B. During wk 8–12 they were contacted by telephone. yr (mean. 16 L . and were not taking sedative during treatment time. had laundry access. 0. All other rehab continued as usual. Gr2: Standard customary care.3 Total: 27 Gr1: 10 Gr2: 8 Gr3: 9 Gr2: 8. had onset of first stroke within past 0–7 days (first episode of TIA lasting < 24 hr not considered a first stroke).9 SD: 8.4 days Gr1: 69.16 Gr2: 70. Hemiplegia: Gr1: 6 R. 8 L Gr2: 6 R. were between 40–80 yr old. 5 days/ wk. and had clinically identifiable middle cerebral artery syndrome of thrombo-embolic origin involving subcortical structures confirmed by CAT scan. 2 L Gr3: 3 R. and choosing clothing. Started early. performed nonintensive techniques similar to those provided to Gr3. Gr2: No treatment.35 Gr1: Dressing practice was given on a regular basis with the amount of therapy at the therapist’s discretion. 1 Gr1: 8. more intensive than experimental group but contained more standard approaches.3 SD: 11. using a red alignment of buttons. conserving energy.6 SD: 7. they were provided with an intensive and focused approach to therapy that incorporated the use of a tilt table and a limb-load monitor.3 days SD: 1. End of treatment at 3 months. 5 L Treated area: Affected and unaffected extremity Appendix 3B 155 continues . median of 8 visits at the patient’s home N/A 1.8 days Inclusion: Patients who met the following criteria: were resident within 50 km of Quebec City. Standard customary hospital care 2 sessions/ day. 0.8 days SD: 1. Hemiplegia: Gr1: 2 R. 9 L Gr2: 10 R. for 5 wk Follow-ups at 6 wk and 18 wk 1. Treatment: Teaching patients and caregivers appropriate techniques such as dressing the affected extremity first. Relatives were encouraged to continue the dressing practice between sessions.4 Gr1: Experimental: Patients started as early as possible after admission to the study. 6 L Gr1: 65.2 Gr3: 70.5 days Gr3: 13 days SD: 2. resistance exercises with a Kinetron isokinetic device and a treadmill. Gr3: Early standard customary care.3 SD: 7. 0.2 SD: 10. Started later. 0 Walker 1996172 Total: 30 Gr1: 15 Gr2: 15 Inclusion: Patients 6 months after who had been stroke discharged from the general medical care of the elderly and stroke unit.Richards 1993171 Gr2: 67. 1 hr every Follow-up at 2. B. Patient with good or poor trunk control. meters in front and above the patient’s head and forced him to make an axial rotation of the trunk under visual control to displace the pointer laterally and explore the spatial field. Part 2: A series of targets of different geometric form. hemiparesis (3). are connected to a light bulb and to a buzzer. 1 day for 20 4 wk days followed by 2–3 hr of traditional rehab: (2 hr PT and 1 hour OT) Population details Time since onset Age. none (1) Gr1: Experimental group: Part Gr2: Control: 3 1: Patient wore a vest. W) Session frequency Follow-up and duration duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Wiart 1997173 Total: 22 Gr1: 11 Gr2: 11 Patient with severe left unilateral neglect syndrome who had suffered a stroke less than 3 months ago.APPENDIX 3B. are attached to a mobile wooden panel placed in front of the patient.5 rehab each day. Continued 156 Author Sample and year size Treatment N/A Comparison group Gr1: 66 SD: 8 Gr2: 72 SD: 6 Gr1: 35 days SD: 9 days Motor impairment: hemiplegic (6). hemiparesis (2). yr (mean. SD for control) Concurrent therapy Quality (R. none (2) Gr2: 30 days SD: 4 days Motor impairment: hemiplegic (8). The –4 hr of traditional extremity of the pointer was 1. 0. Hemiplegia: Right for both groups Treated area: Trunk . When pointer is in contact with target = audible and luminous signals (biofeedback). house an electrical circuit. Gr1: <35 yr: 2 SD: 10 35–75 yr: 18 SD: 85 >75 yr: 0 SD: 0 Gr1: Standard care delivered by an OT. and an FIM instrument total score upon admission of 40 to 80. 1 9 months Note: ADLs = activities of daily living. ROM = range of motion. and self-care. progressed against resistance using free-weights. or grip devices for the fingers. 0. neuromuscular electric stimulation for shoulder subluxation. L = left. 4 wk Follow-up at 2. or concentric muscles contractions performed in a gravity-lessened position or against gravity. stretching exercise. Gr2: Functional training: Systematic and repetitive Gr2: practice of tasks arranged in <35 yr: 0 proximal to distal recovery SD: 0 patterns of reaching and 35–75 yr: 19 grasping. SD: 95 >75 yr: 1 SD: 5 Gr3: <35 yr: 0 SD: 0 35–75 yr: 20 SD: 100 >75 yr: 0 SD: 0 Gr3: Strengthening and motor control training. theraband.Winstein 2004127 Total: 60 Gr1: 20 Gr2: 20 G3: 20 First-time stroke N/A from infarction in the anterior circulation confirmed by MRI or CAT scan. UE = upper extremity. W = randomization. N/A 1 hr/day. Appendix 3B 157 . 5 days/wk. B. withdrawals. Quality R. blinding. ADL. TIA = transient ischemic attack. Gr = group. PT = physiotherapy. OT = occupational therapy. on other days. muscle facilitation exercises. isometric. N/A = not available. same exercises with less resistance and greater speed. eccentric. CVA = cerebrovascular accident. alternate days for 3 days/wk. x/wk = times per week. N/B = neither/bilateral. R = right. onset of stroke from 2 to 35 days before study entry. 75 Gr1: Experimental group: Integrated behavioral physical therapy including EMG-BFB. Gr2: Same as Gr1 except the patients received a placebo EMG-BFB. no visual or auditory defects. carpi radialis. Hemiplegia: Gr1: 7 R.00 SD: 9. SD Time since onset for control) Treatment Concurrent Comparison group therapy 2. and show a residual defect in upper extremity function. 5 x/wk for 20 min. have stable health status. Experimental technique of regular physical therapy as practiced in the hospital with the addition of EMG-BFB. have significant motivation. Characteristics of Included Studies for Biofeedback 158 Author and year Gr1: 4. B. Exercise program according to Brunnstrom’s neurophysiologic approach with a duration of 45 min/day for a period of 20 treatments.09 months SD: 10.5 months SD: 1 month Gr2: 2.92 SD: 1.53 Gr2: 4.50 Gr1: 65. N/A 3 x/wk.77 months Gr2: 57. and extensor digitorum communis of the paretic arm. 1. Surface electrodes were placed over the musculus extensors.00 SD: 1. Gr2: Control group: Standard exercise physical therapy program using a general neurophysiological approach.APPENDIX 3C. and have stage 2 or 3 hemiparesis according to the modified Brunnstrom’s scale for the hand. 6 L Treated area: Upper extremity Gr1: 3. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Armagan 2003196 Total: 27 Inclusion: Patients Gr1: 14 had to be able to Gr2: 13 communicate. Treated area: Upper extremity 2.43 months Gr1: 57. 0. have full comprehension. 0 Session frequency Follow-up and duration duration Quality (R. 20 treatment sessions in total N/A Sample size Population details Age.30 months SD: 11. be referred by family physicians.27 Gr1: Exercise program according to Brunnstrom’s approach and EMG-BFB. yr (mean. 40 min each session for 5 wk N/A Basmajian 1982197 Total: 13 Gr1: 8 Gr2: 5 (only the mild group) Patients must have had a stroke 2 to 5 months before inclusion.8 months SD: 0.00 SD: 6.9 months (all 37 patients) (all 37 patients) Gr2: 62. 1 . 7 L Gr2: 7 R. 77 SD: 13. If it had been > or = to 4 months since their stroke. Hemiplegia: Gr1: 9 R. a relatively uncomplicated medical history.07 Gr1: 16. impaired motor function of the upper extremity but with an ability to extend wrist/finger. and willing to participate. have the approval of their physician. Patients also had to be well informed. and mild motor involvement of the hemiplegic upper extremity (> or = 20 UEFT). 3) Repeated skill: Home practice of the specific skills is emphasized and the results are carefully monitored and discussed with the patient. and comprehension of simple commands and the purpose of the treatment. 4 L Gr2: 7 R. 9 L Treated area: Upper extremity continues 159 .50 Gr1: Integrated behavioral and physical therapy (EMG-BFB): 1) Conceptualization: Demonstrations and dialogue.38 wk SD: 7. patient active participant in treatment.74 wk Gr2: 63. Gr2: Standard therapeutic exercise: Techniques of facilitation and inhibition are used with selected sensory input to bring about automatic. 4) Skill transfer: Using the Cyborg BL 900 dual processor: pairs of standard surface BFB electrodes to the patient’s skin over muscles that are being targeted for either active recruitment or active inhibition. an age of 80 yr or less with an obstruction involving the territory with distribution centering on the middle cerebral artery. the mild group: or less than 4 months post-stroke with <20 (UEFT).Basmajian 1987198 Gr2: 16. 1 session. 3 months x/wk for 5 wk Appendix 3C Total: 29 Patients had to Gr1: 13 have: no previous Gr2: 16 history of stroke. 0.60 wk Gr1: 60. have had their stroke <1 year before.77 SD: 8. sufficiently motivated. highquality motor output. 2) Skill acquisition: EMGBFB goals are learned and the patient is taught how to direct cognitive skills.00 wk SD: 11. N/A 45 min/ Follow-up at 8 2. A pair of small length and meter displays provided visual feedback. yr (mean. and improve maintenance of motivation by providing EMG-BFB to the patient as soon as an activity was performed. no previous EMG-BFB training. SD Time since onset for control) Treatment Concurrent Comparison group therapy 1. maintain an active muscle contraction when the strength of a muscle contraction began to improve. including dorsiflexion paresis. B. The frequency of audio feedback (audio tone) increased with increasing muscle activity. 4-wk treatment N/A Sample size Population details Age. and no concurrent engagement in a physical therapy program. 0. Treated area: Lower extremity . have residual lower extremity motor deficits. have no signs of receptive aphasia. Continued 160 Author and year N/A Gr2: Experimental (therapeutic exercise regimen combined with EMG-BFB): EMGBFB was used to help the patient initiate a contraction when he was unable voluntarily to produce muscle activity. relax a muscle contraction in a hypertonic antagonist or in an agonist following active contraction. Gr1: Control: N/A Standardized therapeutic exercise regimen. have intact proprioception. be able to walk on level surfaces with or without assistive devices. The last patient of each group agreed to receive 12 more treatments over an additional 4 wk. 1 Session frequency Follow-up and duration duration Quality (R.APPENDIX 3C. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Binder 1981199 Total: 10 Patients had to be 16 months post Gr1: 5 at least 16 months onset Gr2: 5 post-onset. stride standing. and stage 3. single history of hemiplegia or thrombo-embolic origin. The patient’s task was to exert submaximal efforts in each of the 16 directions chosen by using a cursor that is displaced in proportion to the magnitude of effort provided and in the direction in which the effort is produced. The Gr1 was also control group for the lower extremity intervention. The Gr2 was also control group for the upper extremity intervention. Gr2: 12 aged between 21–70 yr. Importance of visual input in maintaining a stable standing posture has been shown in healthy adults. progressing from proximal to distal. 3 x/wk for 6 wk Follow-up at 8 wk 2. the patients were asked to control combinations of moments of force in two directions of either a single or two joints or to combine a moment of force in one direction with a handgrip force.1 Bourbonnais Total: 25 Resident within 35 2002200 Gr1: 13 km of the Institute.Gr1: 37.2 SD: 14. was developed to increase the level of difficulty.1 months SD: 14. Gr2: A total of N/A 16 directions were selected corresponding to predetermined combinations of flexion-extension movements starting with the hip and knee.9 Gr2: 34. 5. and stepping. 4. 0. Gr1: Using visual feedback. 0 Appendix 3C 161 continues . The knee monitor was not used in phase 2 in order to evaluate transfer of training to performance without EMG-BFB. or 6 of the arm section on Chedoke McMaster stroke assessment.3 months SD: 13.6 SD: 16. Other activities: targeting.7 months Gr2: 44. Phase 2: Standard PT (see control group treatment) for 4 wk. A sequence of 16 combinations of moments of force. reaching.3 months Gr1: 47. No visual/auditory feedback given (standard customary care). 2 L Gr2: 4 R. active control of the hip/knee/ankle. 1 months Session frequency Follow-up and duration duration Quality (R. SD Time since onset for control) Treatment Concurrent Comparison group therapy Follow-up at 3 0. 2 L . Hemiplegia: Gr1: 5 R. Treatment also encouraged normal alignment of the trunk/ hip. EMG 200 (Biodata. yr (mean.4 yr SD: N/A Gr1: EMG-BFB group: Patients were encouraged to facilitate or inhibit abnormal muscle tone via auditory or visual signals transmitted from surface electrodes placed over the appropriate muscles (on the motor point of the affected side). EMG-BFB machine was turned off and faced away from the patient and therapist to control the placebo effect. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Bradley 199850 Total: 13 Gr1: 7 Gr2: 6 (severe stroke only) Patients had to be medically stable and have unilateral weakness.6 days post stroke (for all the groups) Gr2: 68. Gr2: Same technique with the surface electrodes. Continued 162 Author and year 35. and gait reeducation. weight transfer through the affected side.0 yr SD: N/A Gr1: 72. B.APPENDIX 3C. Manchester) Standard customary care 6-wk treatment Sample size Population details Age. 2. They repeated the movement for 20 min under the therapist’s supervision. Patients were encouraged to practice walking as much as possible between sessions. Hemiplegia: Gr1: 5 R. 6-wk treatment Follow-up at 6 wk 0.45 yr SD: N/A Gr1: 71. again by using the trainer’s visual and auditory signals. If there was spasticity. 6 L Gr2: 6 R.2 yr SD: N/A Gr2: 4.Burnside 1982201 Gr2: 68. 2. Electrodes were attached over the muscle being trained at that time. patients were given gait training with or without EMG-BFB depending of their grouping). 0 Appendix 3C 163 continues .45 SD: N/A Gr2: 15 min of exercises with EMG feedback regarding their efforts. 5 L Treated area: Lower extremity Disease duration Gr1: 5. The patients sat on an adjustable chair in front of the trainer with their feet on the dual force platform and they rose up and sat down as symmetrically as possible.45 SD: N/A Total: 22 Patients had had a Gr1: 11 CVA at least 3 months Gr2: 11 before the study and had residual foot dorsiflexion paresis and a minimum passive dorsiflexion from complete plantar flexion to neutral position (with or without a cane/ brace). the 2nd machine was connected to the gastrocnemius while the 1st was connected to the tibialis anterior. Gr1: 15 min of Therapeutic exercises similar exercise to those used in Gr2. Electrodes were placed over the tibialis anterior and the machine was switched off (eventually. APPENDIX 3C. Gr4: 15 min of treatment with EMG-BFB + 15-min treatment of FES (the first 2 wk). 1. Gr3: Electrical stimulation of the tibialis anterior during the swing phase and the gastrocnemius during the stance phase of the gait cycle. Hemiplegia: Gr1: 5 R. B. Continued 164 Author and year Gr1: mean: 62 Gr2: mean: 51 Gr3: mean 52 Gr4: mean: 56 No. 1 Session frequency Follow-up and duration duration Quality (R. 2 L Gr3: 4 R. Gr1: Passive and Rehabilitation active ROM for all program: Details major joints and N/A muscle groups of both legs. 5 L Treated area: Lower extremity . who had the cognitive ability to cooperate and give informed consent and the physical ability to ambulate a short distance with the assistance of a single therapist. 3 L Gr2: 6 R. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Cozean 198851 Total: 36 Gr1: 8 Gr2: 8 Gr3: 8 Gr4: 8 Medically stable patients referred to the center for rehab following a CVA. The next 4 wk: 5 min of FES + 30 min of independent use. Patient was asked to produce a 30 s maximal contraction followed by a 1-min rest. yr (mean. of patients more than 1 year post-CVA Gr1: 5 Gr2: 4 Gr3: 4 Gr4: 3 Gr2: EMG-BFB: Electromyographic signals were received with surface electrodes over the muscle surface. 4 L Gr4: 3 R. SD Time since onset for control) Treatment Concurrent Comparison group therapy 1. 6-wk treatment Follow-up at 6 wk Sample size Population details Age. 0. Patients were also living in the Nottingham area and did not have global aphasia or dementia.e. had not already spontaneously recovered.4 SD: 10.. not a predetermined position for each muscle). Gr2: Control Standard group: There was customary care no skin or electrode preparation and the system was switched on but auditory and visual feedback were not switched on.. The electrodes’ placement was based on muscle activity at each treatment session (i. Hemiplegia: Gr1: 12 R.Crow 1989202 Gr2: 68.05 SD: 9. had some arm function (i. pectoral. silver-silver chloride Beckmann-style electrodes were used with saline conducting gel.e. Auditory and visual feedback were switched on. 8 L Gr2: 14 R. or did not have near normal movement. The system was positioned near the patient to allow for placebo effect and electrodes were placed over the upper fibers of the trapezius. at least a flicker of activity around the shoulder girdle).53 Total: 40 Patients had had a Between 2 and 8 Gr1: 20 stroke between 2–8 wk after stroke Gr2: 20 wk before inclusion. 6 L Treated area: Upper extremity Gr1: 67. or deltoid muscle. 6-wk treatment Follow-up at 6 wk 2.45 Gr1: EMG-BFB group: Biodata EMG-120 biofeedback system. 1 Appendix 3C 165 continues . B.APPENDIX 3C. Standard physical therapy (no details) 2 months N/A Sample size Population details Age. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Intiso 1994203 Total: 16 Patients were 40–85 Gr1: 8 yr old.3 months Gr1: 61. Continued 166 Author and year Gr1: 11. 3 L Treated area: Lower extremity . Sensory outputs to obtain automatic high-quality motor output. yr (mean.5 SD: 18.10 µV.3 Gr2: 8.6 months SD: 12. if 20%–50%: increase to 0. Phase 2: 2 baseline sessions to determine the “threshold value” and 15 training sessions with acoustic feedback activated every time the contraction value of the anterior tibial muscle was higher than the threshold value of the baseline session.3 SD: 12. Audio monitoring of the EMG signals: Patient instructed to activate dorsal flexion of foot during swing phase of gait cycle. had had a Gr2: 8 first ischemic stroke. For the next 15 sessions: 20 isotonic contractions lasting 5 s followed by regular intervals of 30 s of rest (flexed knee at 30º and relaxed foot). SD Time since onset for control) Treatment Concurrent Comparison group therapy 1.0 months Gr2: 53. 1 Session frequency Follow-up and duration duration Quality (R. and had a foot-drop deficit or paretic extremity. Gr2: Control: Only physiotherapy (standard exercises according to the Bobath method for dorsiflexion) (only for the control group). Hemiplegia: Gr1: 4 R. 2 baseline sessions about the technique and learning to contract the anterior tibial. 0.3 months SD: 6. Patient errors < 20%: increase the threshold of acoustic feedback 0.5 Gr1: Experimental group Phase 1: Contraction of the anterior tibial muscle to obtain acoustic BFB. 4 L Gr2: 5 R.30 µV. forearm pronators or supinators. including wrist extension.2 Gr1: EMG-BFB initiated electrical stimulation of wrist extensors: 3 sessions/wk. 36 1-hr sessions. Hemiplegia: Gr1: 2 R.0 months Gr1: 59. possessed postural stability. clinically stable. and had consented to participate according to procedures. constant current of 20–60 µV for 10 s. EMG µV threshold set at the median of the 5 contractions minus 10%.3 Total: 18 Gr1: 6 Gr2: 4 Gr3: 3 Gr4: 5 At least 1 year post-CVA.8 months SD: 11. 1 L Gr4: 1 R. In addition. or shoulder elevators or abductors according to the patient’s abilities.0 months SD: 12. Gr2: Bias/Balance Home rehab stimulation: program Respond II (no details) electrical stimulator: 5 30min sessions/wk for 3 months.4 months SD: 6. Patients were instructed to perform 3 sets (30 contractions or until fatigue) of voluntary wrist extension exercises while stimulation was applied each session. low-intensity stimulation was applied to wrist extensors muscles in 0. Auto move stimulator in 0.Kraft 1992204 Gr2: 36. Depends on the treatment Follow-up 12 months posttreatment 0. 2 L Gr3: 2 R. 1 Appendix 3C 167 continues .2 SD: 6. biphasic squarewave pulses at rates of 30–90 Hz.0 SD: 2. Gr3: PNF: Treatment encompassed the whole upper extremity.3 ms squarewave pulses at rates of 30–90 Hz.8 SD: 19.8 months Gr2: 64.3 months Gr3: 67. triggered by a lowlevel of voluntary EMG activity began as low as 5 µV and was increased gradually by the therapist as voluntary recruitment improved.5 SD: 23.6 Gr3: 14.2 ms.6 Gr4: 24. 4 L Gr2: 2 R. 0. Gr4: No treatment. Transcutaneous electrical stimulation. 4 L Gr1: 26. Stimulation was applied at an intensity that increased the patient’s voluntary range of wrist extension without producing any visible movement at rest. EMG-BFB was used over paretic finger or elbow extensors.2 months Gr4: 63.5 months SD: 3. Use of auditory and visual pacing stimuli aimed at increasing the rate of dorsi. 7 L Gr3: 8 R.7 SD: 13.8 Gr2: Auditory and visual Gr1: No treatment feedback of calf and pretibial muscle activity during active ankle movements.8 SD: 12. 5 L .and plantar flexion alternation. RP-BFB: Feedback of dorsiflexion and plantar flexion ROM. Gr3: EMG-BFB for first half of study. N/A Twice a wk for 12 wk Sample size Population details Age. 1 months Session frequency Follow-up and duration duration Quality (R. and were no longer receiving any treatment aimed at improving gait. with various classifications of lower extremity deficits. Minimum 5 reps of maximum contraction/trial.4 L Gr2: 6 R. Continued 168 Author and year Time since stroke onset: Gr1: 32 months SD: 31 months Gr2: 17 months SD: 10 months Gr3: 47 months SD: 32 months Gr3: 57. SD Time since onset for control) Treatment Concurrent Comparison group therapy Follow-up at 3 1. feedback at precise points of heel-off and swing through to reinforce correct timing events.5 SD: 14. yr (mean.APPENDIX 3C. Hemiplegia: Gr1: 7 R. 0. While walking. B.2 Gr2: 54. maximum 240 repetitions per session.9 Gr1: 56. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Mandel 1990205 Total: 37 Gr1: 11 Gr2: 13 Gr3: 13 Inclusion: Patients who met the following criteria: were a chronic hemiparetic. were at least 6 months post-stroke. followed by rhythmic positional BFB for last half. Description of a session: 1) 6-meter walk with locometer analysis.Montoya 1994206 Gr2: < 6 months Gr2: 60 SD: 2. who had motor ability allowing them to walk 50 meters without any help. 10 walks with the BFB where the imposed right and left step lengths were identical in order to correct the asymmetry. who had an absence of biomechanical malfunction of the legs. Gr2: Reference N/A group: Patients followed the same standard rehab program and walk session without BFB. Patient had to pay attention to the task and place the foot on the target. No effort was required to correct step length asymmetry or to increase step length on the deficient side. 2 sessions/wk for 4 wk N/A 1. 3) 5 and 10 6meter walks on the walkway without the BFB. 0. who had an absence of hemianopsia as stated by a complete ophthalmic examination including visual field measurement. Five 6-meter walks with BFB: the imposed right and left step lengths were the initial step length measures in the initial 6-meter walk. and who had an absence of unilateral neglect syndrome as rated by a neurological examination showing that there was no sensory trouble and astereognosia.75 Gr1: BFB group: Initial 6-meter walk with locometer analysis to obtain initial values of spatial and temporal parameters.25 Total: 14 Inclusion: Patients Gr1: 9 who had had a firstGr2: 5 ever stroke that had occurred less than 6 months before the beginning of the experimental protocol. 4) a final gait analysis under the same conditions as there were in the BFB group. who had an absence of comprehension problems as rated by a Mini Mental Status of 24. 45 min/ session. Patients were told to secure the best walking performance. 0 Appendix 3C 169 continues . 2. Treated area: Lower extremity Gr1: < 6 months Gr1: 64 SD: 2. verbal feedback.APPENDIX 3C. and demonstrated the ability to safely walk 10 meters 4 times without aids or orthoses.0 Gr1: 64. stride standing.2 SD: 10. were medically stable. 5 L . and stepping.3 Gr2: Experimental group: Phase 1: Electrogoniometric feedback as an adjunct to physical therapy for 4 wk.0 days SD: 41 days Gr2: 45. Phase 1: 4 wk Phase 2: 4 wk 8 wk N/A Sample size Population details Age. no signal). W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Morris 199216 Total: 26 Patients had suffered Gr1: 13 a CVA up to 4 Gr2: 13 months previously. reaching. Gr1: Control group: N/A Standard physical therapy that was based on the Motor Relearning Program and incorporated the use of instruction. B. demonstration. yr (mean. the auditory signal was activated (the pitch of the signal was proportional to hyperextension angle). explanation. 6 L Gr2: 8 R. visual feedback.4 SD: 11. EMGBFB during standing and gait training: when the patient hyperextended the knee.0 days SD: 23 days Gr2: 64. Phase 2: Standard PT (see control group treatment) for 4 wk. 1 Session frequency Follow-up and duration duration Quality (R. Hemiplegia: Gr1: 8 R. The knee monitor was not used in phase 2 in order to evaluate transfer of training to performance without EMG-BFB. were able to provide informed consent. A fixed high frequency warning signal sounded when knee flexion exceeded 75º to discourage overcompensation with excessive knee flexion (during normal gait training. Continued 170 Author and year Gr1: 79. 0. Importance of visual input in maintaining a stable standing posture has been shown in healthy adults. Other activities: targeting. manual guidance. SD Time since onset for control) Treatment Concurrent Comparison group therapy 0. and whole-part practice. The patients were asked to formulate their own strategies to perform better on tasks like the BTT.6 days SD: 12 days Acute phase poststroke Gr2: 68. patients were asked to describe and comment on their BTT.3 SD: 10. 1 Appendix 3C Gr1: Video EMGBFB group: Therapist videotaped the patients when performing the baking tray test (BTT).42 Gr2: Conventional N/A BFB group: The therapist gave the patients verbal and visual guidance to help them see the neglected left half of the “baking tray.” 2 days N/A 0.1 days SD: 7.67 days Gr1: 67. When they missed placing the “buns” on the left side of the tray.Tham 1997207 Gr2: 21. upside down. The therapist presented the same compensatory strategy in both video and conventional groups. The therapist commented on the performance and the results.33 Total: 14 Patients had Gr1: 7 suffered from right Gr2: 7 hemisphere CV lesions 6 to 42 days before testing Treated area: Upper extremity Gr1: 18. they could see this on the right side of the TV monitor. After video confrontation. they were given the opportunity of seeing their performance on the monitor directly after the testing. continues 171 . 0. To draw the patients’ attention to their own neglect behavior.6 SD: 12. The therapist discussed possible compensatory strategies with the patients and gave instructions on how to use tactile discrimination with the right hand to find out where the left edge on the tray was and then systematically place the buns from left to right. and as +++ if some objects in the right side were omitted. and a mean error was calculated for each patient across 15 lines. Test 3: Figure Copying Task: The severity of neglect was rated as + if objects on the left side of the drawing were omitted. the patients moved their CoG and observed the corresponding cursor movement on the computer screen. Computer corresponded to a preset target. B. Sample size Population details Age. 5 lines for each length of 25. as ++ if the entire left side was omitted.APPENDIX 3C. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Tham 1997 (continued) . SD Time since onset for control) Treatment Concurrent Comparison group therapy Session frequency Follow-up and duration duration Quality (R. Test 4: Line Bisection: Patients were presented with 15 lines in random order. Deviations from the true midpoint were measured to the nearest millimeter. and 200 mm. yr (mean. 100. Continued 172 Author and year Lines: The number of marked lines (%) was recorded. To encourage weight shifting. 20–25 min of EMG-BFB on 5 consecutive days. 2 surface electrodes placed over target muscles’ upper tendinous area of latissimus dorsi and teres major. 0.Williams 1982208 Total: 20 Patients had Between 3–16 wk Mean: 63.8 yr Gr2: 10 hemiparesis or hemiplegia secondary to vascular disease. and a reflex-inhibiting pattern (RIP) was encouraged.5 Gr1: 10 a diagnosis of SD: 11. had no previous history of shoulder pain prior to stroke. Standard customary care program (no details): 1 hr given by various physiotherapists in the department. Hemiplegia: 8 R. and patient was encouraged to relax to decrease electrical activity of muscles. had a painful shoulder on hemiplegic side. 0 Appendix 3C 173 continues . 1. and were not taking any medication to reduce spasticity. could understand English or French. 12 L Gr1: Instructions in relaxation given with the first two EMG-BFB treatments. Gr1: 5 x/wk for 1 wk Gr2: 2 x/wk for 1 wk Follow-ups at 1 wk (end of treatment) and 2 wk (end of treatment => after crossover). Jacobson method of relaxation taught in the sitting position with involved upper extremity supported on a pillow. were between 3–16 wk post stroke. ground electrode on acromion. Gr2: 30 min on 2 consecutive days at beginning of treatment week. had ability to follow instructions and did not show any signs of receptive aphasia. ambulatory activities. Gr4: Control: All patients Without had undergone intervening previous rehab treatment. Continued 174 Author and year Gr1: 2.1 SD: 13.4 yr SD: 1.2 SD: 13. The remaining patient elected to discontinue after 40 treatments.1 yr SD: 3. Protocol: Feedback to relax hyperactive muscles to recruiting weakened antagonist muscles in a proximal (hip) to distal (ankle) manner.2 yr Gr5: 4.2 SD: 11.6 yr SD: 2. 0.1 yr SD: 3.7 Gr1–3: All but one of these patients received 60 EMG-BFB sessions. and who did not have receptive aphasia.8 Gr4: 57.APPENDIX 3C.4 Gr1: 51.2 yr Gr3: 2.9 Gr3: 53.8 yr Gr6: 3.2 yr Gr4: 2.8 Gr2: 55. EMG-BFB provided by Hyperion 4080 Biocoonditioner or the Cyborg J53. Examination at 2 months.8 SD: 13. Treated area: Lower extremity . and finally. B.2 yr Gr2: 2.2 yr SD: 1.0 SD: 12.7 SD: 19. SD Time since onset for control) Treatment Concurrent Comparison group therapy 0. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Wolf 1983a209 Total: 37 Gr1: 6 Gr2: 6 Gr3: 6 Gr4: 6 Gr5: 16 Gr6: 8 Patients who had sustained a CVA at least 1 yr before their participation. 2–3 sessions/ wk around 3 months (no defined number of sessions) N/A Sample size Population details Age. Gr5: EMG-BFB treatment for the involved UE. standing. 1 Session frequency Follow-up and duration duration Quality (R. Examination at 3 months.2 yr SD: 1. Initial treatment in a supine position with progression to sitting.2 Gr5: 56. yr (mean.2 yr Gr6: 53. LE was also examined for the generalizing effect of upper extremity treatment upon lower extremity activity changes. undergone previous rehab. Gr6: General relaxation group: 20 relaxation sessions: Patients were taught autogenic phases and underwent tense-relax procedures for specific muscle groups while receiving audio BFB proportional to activity from the target muscles. N/A 6 months Examinations 0. relax specific hyperactive muscles through the provision of audio and visual EMG-BFB detected with surface electrodes (attempts to recruit weakened antagonist muscles).9 Total: 31 Patients who had Gr1: 22 sustained a CVA at Gr2: 9 least 1 yr before this study. 0.Wolf 1983b210 Gr2: 2. 5.3 SD: 14. or 8 months (approximately 6 months) Appendix 3C 175 continues .6 yr Gr1: 55.8 Gr1: Experimental group: Gr2: Control Patients were trained group: No rehab in 45 to 60 sessions to treatment.4 yr SD: 1. and no evidence of receptive aphasia. who had no previous EMG-BFB training.8 yr SD: 3.9 SD: 10.6 yr GR2: 55. Gr1: 3. Biofeedback proceeded in a proximal to distal direction with each patient progressing from isolated joint movements to manipulative efforts requiring voluntary stabilization of proximal musculature. 1 at 3. Patients received feedback from spastic muscles to reinforce previous training directed toward their inhibition. Gr = group. CVA = cardiovascular accident. SD Time since onset for control) Treatment Concurrent Comparison group therapy 1. PNF = proprioceptive neuromuscular facilitation. Patients progressed in subsequent sessions to tasks of greater difficulties based on ability to complete the task. N/M = not measured. visual fields deficits and proprioceptive deficits in the involved elbow. an absence of receptive aphasia.50 months SD: 39. UE = upper extremity. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Wolf 1994211 Total: 16 Patients who Gr1: 8 had hemiplegia Gr2: 8 secondary to a CVA. Gr2: Non-feedback N/A group: Same task performance and progression. withdrawals. UEFT = upper extremity function test. except that EMG-BFB was not used (the monitor was turned off and the program was not engaged).37 months Gr2: 62. blinding.88 SD: 16. Hemiplegia: Gr1: 3 R. . R = right. N/A = not available. 25 min/ session. 2–4 sessions/wk for a total of 10 sessions N/A Sample size Population details Age.54 months Gr1: EMG-BFB group: Uptraining of the triceps muscle during the elbow extension task. The patients worked to increase the ROM of elbow extension within the context of a task. 5 L Gr2: 5 R. Patients were encouraged to increase the output of the triceps muscle based on the visual and auditory feedback provided by the computer.39 65. x/wk = times per week. 1 Session frequency Follow-up and duration duration Quality (R. FES = functional electrial stimulation. L = left. B.63 months SD: 10. using one EMG channel of the Bioprompt program. an involved extremity in Brunnström stage 3 or 4 for longer than 6 months since the patient’s most recent session of PT or OT for UE. all patients advanced to the task of next highest difficulty after three sessions. EMG-BFB: electromyographic biofeedback.APPENDIX 3C. Continued 176 Author and year Gr1: Gr1: 63. W = randomization.00 Gr2: SD: 14. Regardless of ability. and an ability to obtain at least 60º of passive shoulder flexion and abduction. B. PT = physical therapy. LE = lower extremity. OT = occupational therapy. yr (mean. a time since onset of 1 yr or longer. 3 L Note: CoG = center of gravity.88 32. PFST = positional feedback stimulation training. 0. Quality R. ROM = range of motion. ’92 and Jan. 30 L Gr2: 29 R. SD for control) Follow-up duration 2. Gr2: Treadmill training without BWS. QC. W Ada 2003248 Total: 27 Gr1: 13 Gr2: 14 First stroke between 6 months and 5 yr previous to inclusion. 1. hemiparesis.01 Gr1: 66. walking 10 meters independently with a speed of less than 1. up to 40% BWS at the beginning and progressively decreased. 4 x/wk for 6 wk Followup at 3 months Gr2: Home exercise program to carry out 3 x/wk for 4 wk. walking on the treadmill was initiated at 0. 1 Session frequency and duration Quality R. between 50 and 80 yr of age.8 Gr1: Treadmill training while a % of their body weight was supported by an overhead harness.2 m/s. Hemiplegia: Gr1: 8 R.5 days Gr2: 78. Sample size Population details Symptom duration Age.15 km/hr.APPENDIX 3D. B. harness was worn for security.1 days SD: 26. 0. starting at 80% in wk 1 and decreasing to 50% in wk 4. Laval.7 SD: 10. 21 L 2. Hemiplegia: Gr1: 20 R. 5 L Gr2: 6 R.0 km/ hr and increased by increments of 0.5 SD: 12. exercises to lengthen and strengthen lowerlimb muscles as well as to train balance and coordination. not more than 20 min. ’95 for physical rehab after stroke.4 days SD: 30 days Gr2: 66. yr (mean. 1 Appendix 3D 177 continues . Both groups: Maximum of 3 trials. 8 L Gr1: 68. Barbeau 2003249 Total: 79 Gr1: 43 Gr2: 36 Admitted to the Jewish Rehab Hospital. Characteristics of Included Studies for Gait Training Author and year Treatment N/A 3 x/wk for 4 wk Followup at 4 months Comparison group Concurrent therapy Gr1: 28 months SD: 17 months Gr2: 26 months SD: 20 months Gr2: 66 SD: 11 Gr1: 66 SD: 11 Gr1: 30 min of treadmill walking and overground walking with the proportion of treadmill walking decreasing by 10% each wk. between Oct. and triceps brachii (for reciprocal arm swing). gluteus maximus.0 Gr1: 53. had sustained perceptual and intellectual abilities post CVA. 0.5 Gr2: Multichannel FES to the peroneal nerve (dorsiflexors). pulse frequency at 30 Hz lasting 200 µs. 9 L Area treated: Lower extremity . Sample size Population details Symptom duration Age. Continued 178 Author and year Treatment N/A 5 x/wk for 3 wk End of treatment Comparison group Concurrent therapy Gr1: 116 days SD: 66 Gr2: 104 days SD: 62 Gr2: 59. could stand independently or with therapist’s assistance (required substantial weightbearing support of one or two therapists). B. and brushing. Treatments lasted 30 min to 1 hr. Hemiplegia: Gr1: 8 R.4 SD: 11. heating. and had sufficient functional response to stimulation. 0 Session frequency and duration Quality R. SD for control) Follow-up duration 1. Gr1: Physical therapy for 1 to 2 hr a day involved a passive approach that focused on preserving the ROM of the joints and sensory input through modalities such as icing. active methods facilitated functional movement and proprioceptive neuromuscular facilitation and used BFB exercises. hamstrings. plantar flexors. quadriceps femoris.1 SD: 9. W TOPICS IN STROKE REHABILITATION/SPRING 2006 Bogataj 1995250 Total: 20 Gr1: 10 Gr2: 10 Inclusion: Patients who met the following criteria: had cardiovascular capacity sufficient to sustain therapy without harm. yr (mean.APPENDIX 3D. 2 L Gr2: 1 R. 1 Appendix 3D 179 continues . Hemiplegia: Gr1: 9 R. and who could stand unsupported.Burridge 1997251 Gr2: 61. and functional activities. Duration of treatment was not reported. 7 L Gr2: 8 R. Concurrent treatment only Both groups received ten 1-hr physiotherapy sessions during the first month of treatment. single drop foot. Two treatments/wk for 4–5 wk End of treatment. walk 10 meters (walking aids permitted but not another person).25 SD: 14. trunk control.58 yr SD: 7. no mental impairment. 8 L Gr1: 3.25 SD: 8. balance.92 yr SD: 9.83 months Stroke causing a hemiplegia of at least 6 months duration. and walk 50 meters independently prior to stroke.25 Gr1: Experimental.17 months Gr1: 52. Time was spent on arm posture.5 Total: 32 Gr1: 16 Gr2: 16 Gr2: 4. follow-up at 8–9 wk 2. sufficient dorsiflexion of the ankle. Gr2: Control. no other medical conditions that impaired walking. 0. no hypersensitivity to the sensation of stimulation. stand from sitting without help. Odstock Dropped Foot stimulator (FES) to the tibialis anterior muscle and common peroneal nerve proximal to head of fibula. W TOPICS IN STROKE REHABILITATION/SPRING 2006 Cozean 198851 Total: 36 Gr1: 8 Gr2: 8 Gr3: 8 Gr4: 8 Inclusion: Medically stable patients referred to the center for rehab following a CVA.67 SD: 13. SD for control) Follow-up duration 1. Hemiplegia: Gr1: 4 R. Training started with support of up to 30% of body weight.33 days SD: 6. Gr1: Only concurrent treatment 5 days/wk for 2–3 wk None Sample size Population details Symptom duration Age. OT: ADL training. 2. 1 Session frequency and duration Quality R.67 days SD: 7. function mobility activities (including gait training). Gr3: Electrical stimulation of the tibialis anterior during swing phase and gastrocnemius during stance phase of gait cycle in a 30-min session. Patient was asked to produce a 30-s maximal contraction followed by a 1-min rest in a 30-min session. 0. 1. 5 L Time since stroke onset Gr1: 59. Kinesiotherapy: To increase strength and endurance. Electromyographic signals were recorded with surface electrodes over the muscle belly. give informed consent.66 Gr2: 57. 2 L Gr3: 4 R. Continued 180 Author and year Treatment Rehabilitation program 3 treatments/ wk for 6 wk End of treatment Comparison group Concurrent therapy Number of patients with less than 1 year post-CVA Gr1: 5 Gr2: 4 Gr3: 4 Gr4: 3 Gr1: 62 Gr2: 51 Gr3: 52 Gr4: 56 Gr2: BFB. For the next 4 wk.56 Total: 12 Gr1: 6 Gr2: 6 Patients who had had a recent stroke (< 6 wk ago) secondary to CVA based on clinical presentation (hemiparesis) or MRI. Gr4: 15-min treatment with BFB and 15-min treatment with FES for the first 2 wk. 5 min of FES and 30 min of independent use.APPENDIX 3D. Hemiplegia: Gr1: 5 R. 1 . Concurrent treatment (1 hr each): PT: Strengthening.3 L Gr2: 6 R. and who displayed a gait speed ≤36 m/min and a score of 0–2 on FAC scale.06 Gr2: 15. B. 4 L Gr2: 2 R. Gr1: PROM and AROM for all major joints and muscle groups of both legs in a 30-min session. 4 L Gr4: 3 R.83 SD: 5.58 Gr2: Body-supported treadmill training (instead of the 20min gait training the control group received during concurrent treatment). and physical ability to ambulate a short distance with the assistance of a single therapist. yr (mean. and who had cognitive ability to cooperate. 5 L da Cunha Filho 2001252 Gr1: 14. progressively decreased as patient became more capable of more self-support. Hemiplegia: Gr1: 4 R. 1 hr/day Gr2: STAT (supported treadmill ambulation training) same as Gr1 but the gait training was done on a treadmill with an overhead harness. until discharge (average of 3 wk) N/A 2. 0. and foot placement.9 SD: 12. significant N/A gait deficit as evidenced by a gait speed of 36 m/min or less and a score of 0. FIM walking subscore of 3 or less. 3 L Gr2: 5L and 1 brainstem Gr1: 58.66 Total: 55 Gr1: 21 Gr2: 34 No prior stroke. 0. leg advancement. 45 min/day a N/A plus 45 min of physiotherapy. Once patient was able to walk 3. no neurologic or orthopedic disorder that might preclude normal walking. kinesiotherapy. speed increased and BWS decreased as tolerated.8 SD: 5. Hemiplegia: Gr1: 8 R. Therapist provided assistance with weight shifting.5 Total: 13 Gr1: 7 Gr2: 6 Recent stroke. Subjects were trained daily for 20 min. independent with ambulation before current stroke. often including bracing and walking assistive devices. Therapist prevented patient’s pelvis from shifting away from the bar. no active angina pectoris or orthostatic hypotension.7 to 7.6 meters at the hemibar. 1 Kosak 2000254 Gr2: 40 days SD: 23. and hemiparesis of the lower extremity and whose iliopsoas strength is graded as 3 or less on the Medical Research Council scale (0–5). Training started with support up to 30% of body weight support and was gradually decreased aiming for zero BWS. 16 L Bilateral: 6 Gr1: 39 days SD: 14. and stable medical condition. device was changed for hemiwalker/ quadruped cane. 3 hr/day. Affected ankle wrapped with elastic bandage into mild dorsiflexion position to avoid toe drag if needed.9 Gr1: Regular rehab: Daily sessions of physical therapy. and OT. ability to stand with or without assistance.38 Gr1: Patient asked to bear as much of own weight as possible. Appendix 3D 181 continues . 5 days/wk for ~2 wk 1. 1 N/A 5 x/wk. Gr2: Hemibar and KAFO if necessary (least restrictive brace needed).32 days Gr2: 70 SD: 11. 12 L Bilateral: 2 Gr2: 12 R. or 2 on the FAC scale.07 days Gr1: 74 SD: 9. Concurrent treatment: Physio that was functionally oriented and incorporated a variety of motor facilitation and motor control techniques. Patient walked until fatigued.da Cunha 2002253 Gr2: 57. sufficient cognition. 1. 5 days Gr3: 7. weightbearing exercises while standing and walking. 1.5 SD: 9. standing. W TOPICS IN STROKE REHABILITATION/SPRING 2006 Kwakkel 1999164 Total: 89 Gr1: 29 Gr2: 26 Gr3: 34 Inclusion: Patients who met the following criteria: had stroke diagnosis (WHO definition). gave written/spoken informed consent. have no severe deficits in communication. 24 L . 1 Session frequency and duration Quality R. Gr3: Immobilization of affected upper extremity and lower extremity by inflatable splint applied with the patient supine for 30 min.1 SD: 15.0 days SD: 2. B. punching a ball. had primary first-ever stroke in the territory of the middle cerebral artery as revealed by CT scan or MRI. are motivated to participate in the research project.8 Gr1: Upper extremity training: Functional exercises that facilitated forced-arm and hand activity such as leaning. 17 L Gr2: 13 R.2 days SD: 2. 0.0 SD: 9. or understanding. Continued 182 Author and year Treatment 5 x/wk for 20 wk Follow-up at 6 wk Comparison group Concurrent therapy Time since stroke onset Gr1: 7. Treadmill training where equipment available. have impaired motor function of the arm and leg. and grasping and moving objects. Gr1 and 2 training was applied by OT/PT for 30 min.0 Gr2: 7. 18 L Gr3: 13 R.9 days Gr1: 69. are 30–80 yr old. 15 min/day upper extremity rehabilitation. SD for control) Follow-up duration 2.APPENDIX 3D.5 hr/wk ADL training Sample size Population details Symptom duration Age.7 Gr3: 64. have no complicating medical history. Hemiplegia: Gr1: 16 R.8 days Gr2: 64.5 days SD: 2. Gr1&2: 15 min/day leg rehab. memory. Gr2: Lower extremity training: sitting. with emphasis on achieving stability and improving gait velocity. yr (mean. transfers (such as turning over).5 hr/wk ADL training.0 Total: 101 Gr1: 33 Gr1: 31 Gr3: 37 Gr2: 7.8 Gr1 Upper extremity: Focused on improvement in disabilities involving the affected upper extremity (grasping. memory. & Gr3: 15 min lower extremity rehabilitation. had no complicating medical history such as cardiac. and 1. first-ever stroke in the territory of the middle cerebral artery as shown by CT or MRI.9 days Gr1: 69. 18 L Gr3: 13 R. reaching.0 SD: 2. leaning. had an impaired motor function of upper as well as lower limbs. Gr2. pulmonary.7 Gr3: 64.5 SD: 2. Gr2 Lower extremity: Focused on functional recovery of balance (sitting or standing balance). 24 L Time since onset (days) Gr1: 7. Gr1. and gait (performance & climbing stairs).5 days Inclusion: Primary. had no severe deficits in communication.1 SD: 15. between 30–80 yr of age. or other neurological disorders. Hemiplegia: Gr1: 16 R.0 SD: 9.2 SD: 2.5 SD: 9. or dressing). unable to walk at first assessment. or understanding. 1 Appendix 3D 183 continues . 0. 17 L Gr2: 13 R. Gr3 (Control): Immobilization of the affected upper extremity and lower extremity by means of an inflatable pressure splint.8 days Gr3: 7. 5 days/wk for 20 wk Follow-up at 3 and 6 months 1. 30 min/day. 15 min upper extremity rehabilitation.Kwakkel 2002165 Gr2: 64. APPENDIX 3D. W TOPICS IN STROKE REHABILITATION/SPRING 2006 Laufer 2001255 Total: 25 Gr1: 12 Gr2: 13 Inclusion: Patients who met the following conditions: had first supratentorial strokes in ant brain circulation as evidenced by CT. Same walking time as control group. and could walk on treadmill at speed of at least 0.2 days Gr2: 66.8 days SD: 17. Continued 184 Author and year Treatment Comparison group Concurrent therapy Gr1: 35.6 SD: 7.2 km/hr with minimal to moderate assistance for 2 min without rest. OT and speech therapy if needed. and no severe cognitive/communication impairment that could hamper understanding simple instructions.3 SD: 8. Hemiplegic: Gr1: 5 R. Concurrent treatment: PT once a day. 1 Session frequency and duration Quality R.2 Gr1: 69. 5 x/wk based on Bobath approach. 8 min/day for 3rd wk. 7 L Gr2: 5 R. B. Training 5 N/A x/wk for 3 wk. no cardiac/respiratory/ medical condition that could interfere with protocol. yr (mean.3 days Gr2: 32. Training 5 x/wk. 6 min/day for 2nd wk.6 days SD: 21. Gr1: Ambulation on floor surface at comfortable speed using walking aids. 8 L . had onset of stroke no more than 90 days prior to beginning of study. assistance and resting periods as needed. Sample size Population details Symptom duration Age. Total walking time: 4 min/ day for first wk. had no additional neurological and/or orthopedic deficiencies impairing ambulation. 0. SD for control) Follow-up duration 0.1 Gr2: Ambulating on a treadmill adjusted to patient’s comfortable walking speed. 25 Total: 14 Gr1: 9 Gr2: 5 Inclusion: Patients who met the following criteria: had first stroke. Initial 6-m walk with locomotor. whereby the intensity was adjusted to the patient’s tolerance. FES was given at a frequency of 30–50 Hz and pulse duration of 0. To correct asymmetry.0 SD: 2. Functional activities: 3 days/wk for 4 wk 4 wk post treatment. The imposed right and left step lengths were the initial step-length measures in the initial 6-m walk. and exercise or functional activities 3 days/wk for 20-min sessions. Patients followed the same standard rehab program and walk sessions but without BFB. and had absence of understanding problems. biomechanical malfunction of the legs. 0. whose stroke occurred less than 6 months before the beginning of the experimental protocol. Session lasted 45 min. 8 wk from baseline 1. Five 6-m walks with BFB. Gr2: Control. or unilateral neglect.Macdonell 1994256 Gr2: 26 days SD: 6.75 Gr1: BFB. Passive.5 days Gr1: 65 SD: 9 Gr1: FES and Cyclical Electrical Stimulation (CES): Patients received CES 5 days/wk for 20-min sessions and FES 3 x/wk for 20 min to the peroneal nerve at the knee to produce dorsiflexion of the ankle in the affected leg.0 SD: 2. CES: 5 days/ wk for 4 wk. 0. Standard rehab program and walk sessions 2 sessions/wk for 4 wk End of treatment 1. Session lasted 45 min.3 ms. FES: 3 days/ wk for 4 wk. Treated area: Lower affected extremity Gr1: 25 days SD: 6. 10 walks with the BFB where the imposed right and left step lengths were identical. had motor ability allowing 50-m walking without any help. active. and active-assisted exercises and functional activities were performed. Gr1: Less than 6 months Gr2: Less than 6 months Gr1: 64. Location of hemiplegia was NR. 0 Gr2: Control: No FES-CES Both groups received a self-exercise program 5 days/wk. 0 Montoya 1994206 Gr2: 60. Appendix 3D 185 continues . Self-exercise program: 5 days/wk for 4 wk. A last 6-m walk with locomotor analysis to evaluate short-term gain of step-cycle parameters. hemianopsia. Patients were told to secure the best walking performance.5 days Gr2: 68 SD: 9 Total: 38 Gr1: 20 Gr2: 18 Patients likely to remain as inpatients for the duration of the study (4 wk). 11 L Brainstem: 4 Gr2: 18 R. W TOPICS IN STROKE REHABILITATION/SPRING 2006 Morris 199216 Total: 26 Gr1: 13 Gr2: 13 Inclusion: Patients who had suffered a CVA up to 4 months previously.3 Gr2: Phase 1: Electrogoniometric feedback during 4 wk. Sample size Population details Symptom duration Age. were medically stable. Hemiplegia: Gr1: 8 R.2 SD: 10. 1 Session frequency and duration Quality R. Gr1: Walking training on treadmill with BWS. had first stroke with residual hemiparesis. 14 L Brainstem: 5 Gr1: 22 days Gr2: 17 days Gr1: 54 Gr2: 56 2.APPENDIX 3D. 2 therapists assisted patient’s leg and trunk movement. could provide informed consent and demonstrate ability to safely walk 10 m four times without aids or orthoses. Approach according to a motor relearning program for stroke by Carr and Shepherd. Continued 186 Author and year Treatment Physiotherapy 5 sessions/wk for 4 wk Follow-up at end of treatment (4 wk) Comparison group Concurrent therapy Gr1: 79.4 SD: 11. 0.0 days SD: 23 days Gr2: 64. Standard PT based on the Motor Relearning Program. When the patient hyperextended the knee. 5 x/wk for approximately 10 wk Followup at 10 months Gr1: Control. A fixed high frequency warning signal sounded when knee flexion exceeded 75° to discourage over compensation with excessive knee flexion. Hemiplegia: Gr1: 21 R. Approximately 30min sessions. BWS gradually decreased and speed increased as fast as possible (adjusted to the improvement). and were within 8 wk of stroke onset. 6 L Gr2: 5 R. 1 .0 Gr1: 64. the auditory signal was activated. Concurrent PT: Transfers.0 days SD: 41 days Gr2: 45. 8 L Nilsson 2001257 Total: 60 Gr1: 28 Gr2: 32 Inclusion: Patients who met the following criteria: were <70 yr. approximately 30min sessions. SD for control) Follow-up duration 1. ROM exercises. Gr2: Standard gait training. B. EMG-BFB during standing and gait training. 30 min/day of treatment plus 30 min/day of PT. 0. yr (mean. techniques to improve motor function in paretic side. 1 SD: 13.2 SD: 10. 1 Appendix 3D 187 continues . had no or slight spasticity (Ashworth score 0 or 1).2 wk SD: 16. Hemiplegia: Gr1: 4 R. had impaired gait. which saw an increase of 10% over Vt1.5 wk Gr3: 16. speed increased by no more than 5% of maximum initial walking speed each wk. Gr1: Had 45 min of control gait training using PNF and Bobath concepts. and whose time required to walk 10 m >5 and <60 s. 0. belt speed increased to highest speed at which patient could walk safely (Vt1) and was held for 10 s. had hemiparesis lasting for >4 wk. and so on until Vt5 (during each phase speed increased by 10%). If speed was not kept up for 10 s. over 1–2 min.10 wk SD: 18. 16 L Gr2: 4 R.Pohl 2002258 Gr2: 16. Recovery period —during which patient’s pulse returned to resting level— occurred before Vt2 phase. could walk without personal assistance.6 SD: 10. speed decreased by 10% in next phase. 15 L Gr1: 16. Gr3: 30 min of speed-dependent treadmill training.9 Total: 60 Gr1: 20 Gr2: 20 Gr3: 20 Inclusion: Patients who met the following criteria: had hemiparesis caused by R or L supratentorial ischemic stroke or intracerebral hemorrhage.5 wk Gr1: 61.8 wk SD: 20. maximum overground walking speed was determined. Patient tried to hold speed for 10 s then had recovery time. 16 L Gr3: 5 R.5 Gr2: 57.6 Gr2: 30 min of limited progressive treadmill training. then halved for 5-min warm-up on treadmill.4 wk Gr3: 58. Standard customary care in PT (not described) 8 times for 45 min 3 x/wk for 4 wk N/A 2. SD for control) Follow-up duration 2. able to walk 20 min without any assistive device. no signs of Parkinson’s disease or Huntington’s disease. B. 0. Hemiplegia: Gr1: 4 R. Sample size Population details Symptom duration Age. 20 min each day N/A Comparison group Concurrent therapy Gr1: 53 days Gr2: 67 days Gr2: 61 SD: 12 Gr1: 59 SD: 12 Gr1: Practiced walking with music. did not exhibit any severe cognitive or communication impairment. Music motor feedback device: sensor insoles that detect the ground contact of the heels and portable music player. stepping sideways and backwards. etc. Music was played at an adjustable speed that was estimated from the time interval between 2 consecutive heel strikes. and willing to walk with music. Gr2: Control: 20min training session each day: warming up and common exercises led by a therapist (such as slow walking with support of parallel bars and hand rails. Continued 188 Author and year Treatment Neurodevelopmental therapy (45 min/ day) Total: 15 sessions 5 days/wk. 1 Session frequency and duration Quality R.). 5 L . W TOPICS IN STROKE REHABILITATION/SPRING 2006 Schauer 2003259 Total: 23 Gr1: 11 Gr2: 12 Inclusion: Patients who suffered from stroke in the middle cerebral artery distribution and could execute at least task 7 but failed at task 11 or higher of the Rivermead Motor Assessment (RMA). 7 L Gr2: 7 R.APPENDIX 3D. yr (mean. 5 L Gr2: 3 R.5. and any other neurologic condition other than unilateral stroke.5.6 months Gr1: 70. time since stroke onset > 6 months. Exclusion: Subjects were excluded if they were receiving any physical therapy. assistance. 1. 6 L Gr1: 0. 5 L Gr3: 2 R. Rest periods allowed at any time.2 months SD: 13.6 months SD: 21. Gr2: 0. had musculoskeletal impairments that limited full knee extension or ankle plantarflexion to neutral.51 months SD: 3. 2. living within the community.9 SD: 9.4 SD: 13. Hemiplegia: Gr1: 3 R.4 Total: 24 Gr1: 8 Gr2: 8 Gr3: 8 Gr2: 27. and walking speed reported to be slower than before stroke.5 SD: 13.0 mph Inclusion: Patients who have unilateral stroke within the middle cerebral artery or basilar artery distribution resulting in unilateral hemiparesis.0 mph Gr3: 2.7 months Gr1: 22. Assistance of 1 therapist and 1 aide to provide stability. 1 Appendix 3D 189 . 0.Sullivan 2002260 Gr2: 66. and monitor posture/ weight shift/limb position.9 Gr3: 64.5 mph N/A 4 x 5 min walking/ session.8 Up to 40% bodyweight-support was provided initially & progressively decreased as the subject increased activity tolerance and could maintain proper limb kinematics throughout stance & swing. no orthosis. 12 sessions over 4–5 wk N/A 1.5 months Gr3: 27. 1. able to ambulate 10 m with or without an assistive device and no more than standby physical assistance.0. 5 L Gr2: 5 R. 1 . 4 x/wk for 6 wk. Exclusion: Patients who met the following criteria: who had normal gait pattern. Assistance for proper trunk alignment.8 yr Gr1: Gait training on treadmill with BWS up to 40% (progressively decreased as walking ability improved). Speed increased as walking ability improved.0 days Gr2: 73 SD: 7. 2 sessions a day. Stroke location: Gr1: 20 R.7 yr SD: 10.5 days Gr1: 66.4 days SD: 30.1 yr Total: 100 Gr1: 50 Gr2: 50 Inclusion criteria not mentioned.1 days SD: 4. 21 L Gr1: 68.7 days SD: 4. matched rhythm frequency for first quarter of the session. and who had onset CVA > 6 months.0 days Gr2: 16.0 Gr1: 72 SD: 8. 30 L Gr2: 29 R. Concurrent treatment: PT to maximize function. Continued 190 Author and year Treatment Concurrent treatment: PT based on neurodevelopmental treatment approach.5 yr SD: 12. W TOPICS IN STROKE REHABILITATION/SPRING 2006 Thaut 1997261 Total: 20 Gr1: 10 Gr2: 10 Inclusion: Patients within 3 wk post CVA who could complete 5 strides with hand-held assistance. and limb control. or cerebellar/ bilateral/brainstem CVA. 5%–10% rhythm frequency increase during second and third quarter.APPENDIX 3D. B. Hemiplegia: Gr1: 5 R. 5 L Visintin 1998262 Gr2: 78. 1–2 min warm-up walk. SD for control) Follow-up duration 1.0 Gr2: Rhythmic auditory stimulation (RAS) using metronome or specially prepared music tapes. yr (mean. 0. who were readmitted during study period and not ambulating before stroke.0 days Gr2: 66. 5 x/wk for 6 wk N/A Comparison group Concurrent therapy Gr1: 15. whose anticipated length of stay < 4 wk. severe cardiac problem. stepping.1 days SD: 26. Gr2: As experimental group but with no BWS. with a maximum duration of 20 min per session 2. last quarter RAS intermittently faded. weight shifting. whose treadmill training is contraindicated. 0. 1 Session frequency and duration Quality R. Followup at 3 months Gr1: Gait training for same amount of time as experimental group and with equivalent instructions but without RAS. Sample size Population details Symptom duration Age. who are unable to understand simple commands. 5 days Gr3: 70. Quality R. 191 . able to understand simple instructions and the meaning of the study. 2.3 SD: 8.4 yr SD: 7. Patients and family were instructed to practice gait as much as possible. 60 min physiotherapy based on NDT and OT focused on ADL x 5 wk.1 months Range. treated 3 days after being transferred from acute hospital.7 Standard rehab 60 min PT based on NDT and OT focused on ADL x 5 wk. 2. 2. 5 days/wk x 3 wk Gr1: 2 dual-channel stimulation connected with a timer to form one stimulating unit for FES.3-ms pulses at 30 HZ.5–8.8 days Gr3: 9. W = randomization. and PT for 40 min/session. Surface electrodes were applied on quadriceps. PT = physiotherapy.7 yr Gr1: 30 treadmill training sessions with BWS (progressively decreased as soon as possible to enable full load of the lower limbs. 7 L Gr1: 8. No exclusion criteria were mentioned Hemiplegia: Gr1: 5 R. PNF = proprioceptive neuromuscular facilitation.6 yr Gr2: 73. 1 Gr1: 4.7 days SD: 5.1 Gr1: 68. 0. Gr = group. tibialis anterior and medial gastrocnemius. OT = occupational therapy. hamstrings. unilateral stroke within the corotid artery system according to CT. Gr2: Received 15 treadmill training sessions with BWS with no additional PT. Gr1: 30 treadmill training session: 30 min/session. 0. FAC = functional ambulatory category. max tolerance intensity using an activation sequence that mimicked normal gait. Appendix 3D Note: ADL = activity of daily living. BFB = biofeedback. x/wk = times per week. EMG = electromyographic.2 SD: 7.5–7.8 days Gr2: 10.Werner 2002263 Total: 28 Gr1: 14 Gr2: 14 Gr2: 5. After return to their homes they received outpatient PT 2–3 x/wk. CVA = cerebrovascular accident. nonambulatory (required continuous or intermittent support). no other orthopedic or neurological diseases impairing mobility. BWS = body weight support. 0. 1 Yan 2005264 Total: 41 Gr1: 13 Gr2: 15 Gr3: 13 Inclusion: First acute stroke. Gr2: Stimulation from electrical stimulation device with disconnected circuit. Gr1: 30 min/ 5 wk day. FES = functional electrical stimulation. NDT = neurodevelopmental therapy. 5 days/wk x 3 wk Gr2: 60 min/ day. blinding. 9 L Gr2: 7 R. participation in a comprehensive 9 wk inpatient rehab program. Both groups participated in comprehensive rehab program for another 3 wk. 5 x/wk for a total of 30 sessions Gr2: 15 treadmill sessions. independent in daily activities before stroke. 5 x/wk for a total of 3 wk. AROM = active range of motion. aged 45 to 85 yr old. Added to single session of physiotherapy: gait preparatory maneuvers in sitting and standing following Bobath principles and the practice of gait on floor or on the stairs. PROM = passive range of motion. NR = not reported. B.2 Inclusion: Subjects had to be within 8 wk post stroke and no more than 9 months after a first supratentorial stroke. withdrawals.2 months Range.1 days SD: 3. KAFO = knee-ankle-foot orthosis. Gr3: Standard rehab. 10 subjects needed 5%–15% BWS until the end). each 30 min long for 3 wk Followup at 4 months 2.1 days SD: 2.5 54. N/A = not available. trunk stabilization.19 Gr1: Visual feedback balance training with the Smart Balance Master. Chen 2002285 Gr2: 5. 20 min/day. SD for control) Concurrent therapy Follow-up duration 1.78 months Gr1: 58. 1.4 Sample size Population details Symptom duration Age. 0.APPENDIX 3E. 5 days/wk for 2 wk 6 months Gr1&2: Standard customary gait training 10 days. 0. Encouraged to maintain their posture steadily and to maintain symmetric weight bearing while adapting to different static sensory conditions through verbal or tactile cues.0 days SD: 1. Gr2: Control group: Idem to concurrent treatment. Characteristics of Included Studies for Balance Training 192 Author and year Treatment Gr1: Feedback information on base of support as an adjunct to conventional gait therapy.34 SD: 3. and facilitation of muscle in the lower extremity). Gr2: Standard customary gait training (pregait training focused on weight shifting. 11 L Gr1: 3. Dynamic function training: Practice controlling their weight shifts by tracing the moving targets on the screen in every main direction while the limits of stability condition was set at 50%. 10 L Gr2: 7 R. B. 0 .7 SD: 0. Hemiplegia: Gr1: 13 R. followed by 3–4 ambulations that did not exceed 15–18 m with rest periods of 2–3 min in between.8 days 65.5–6 m with assistance of physical therapist and ability to understand and follow verbal instructions. yr (mean. 2 x/day for 25 min each time N/A Comparison group 18.78 Total: 41 Gr1: 23 Gr2: 18 Ambulatory stroke patients admitted to the rehab ward. Device: 2 sensors that were strapped to the subject’s lower extremities below the knees and next to tibial tuberosity with Velcro tape and a main unit that provides distinct signals (tone of 500 Hz) every time the distance between the 2 sensors is less than previously established threshold. stepping. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Aruin 2003284 Total: 16 Gr1: 8 Gr2: 8 Ability to stand and walk up to 4.33 SD: 1. 0 Session frequency and duration Quality (R. Gr1&2: Standard customary care: PT and OT programs.00 months Gr2: 3. patients performed a sit-tostand movement. Gr2: Control group: Training program of rising and sitting down with vertical ground reaction force without BFB. to stand for 1 min and to sit down again. 6 L 1 wk to 3 months Gr1: 67 SD: 6. have adequate hearing. 15 min/ session 3 sessions/ day 5 days/wk for 6 wk treatment duration Appendix 3E 193 continues . Patients stood in front of the table with their feet on the force platform and their paretic hand fixed by an elastic bandage to the handle of a weight loaded box and they pushed and pulled the box. mat exercises. 1 Engardt 1994287 Gr2: 65 SD: 8.9 months SD: 1.8 Gr2: Training group: Standing postural symmetry and repetitive sit-to-stand training through use of a standing BFB trainer. 10 L Gr2: 8 R. could stand up independently and walk with or without a cane. Gr1&2: Individual standard customary care 33 months 1. The patient placed one foot firmly on each platform right above the strain gauge force transducers. 17 L Gr1: 63. could adequately comprehend our instructions.2 months Gr2: 2. 1 Gr1: Control group: Standard stroke rehab program (neuromuscular facilitation techniques.Cheng 2001286 Gr2: 62. 11 L Gr2: 13 R. Gr1 & Gr2: Standard customary care 3-wk program Followup at 6 months 1. stood up with ataxia or who had severe cognitive deficits Hemiplegia: Gr1: 6 R. 0. After a 15-min rest. functional electric stimulation.46 Total: 30 Gr1: 16 Gr2: 14 Inclusion: Able to understand and follow instructions. The patients supported by the auditory BFB signal received knowledge of performance immediately when the load of the paretic leg reached the preset body-weight distribution. and other therapeutic exercises). The patient was instructed to stand-up.8 months SD: 1.4 months Medically stable.0 Total: 54 Gr1: 24 Gr2: 30 Gr1: 2. Hemiplegia: Gr1: 13 R.05 Gr1: BFB group: The patient sat in a standardized position on an adjustable armless chair with a back support. 0.1 SD: 7. and able to stand up independently.3 SD: 8. Exclusion: Normal motor function in the lower extremities. They were instructed to maintain a symmetric upright posture according to the trainer’s visual and auditory signals. and diagonal weight shifts to the subjects’ affected side as well as weight shifting sequentially to the targets. a period of stationary standing with eyes open and eyes closed. and mobility. lateral.APPENDIX 3E. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Geiger 2001288 Total: 13 Gr1: 7 Gr2: 6 Hemiplegia as a result of stroke.8 days SD: 203. posterior. 50-min session Sample size Population details Symptom duration Age.4 days Gr1: 61.8 SD: 16. and able to follow instructions. and balance activities. Gr2: PT interventions to improve muscle force. 1 Session frequency and duration Quality (R. to make the representation of their center of gravity reach the target(s) presented visually. Continued 194 Author and year Treatment Gr1&2: Received the same physical therapy intervention 4-wk treatment N/A Comparison group Gr1: 99. balance. yr (mean. B. The subjects were instructed to maintain or shift their weight. as appropriate. Emphasis was placed on anterior. weight-bearing or shifting and standing lowerextremity exercise in parallel bars.9 days SD: 96. stretching and strengthening. SD for control) Concurrent therapy Follow-up duration 2.0 days Gr2: 58. Hemiplegia: Gr1: 2 R. able to maintain a stationary standing position with or without an assistive device for a minimum of 2 consecutive min without manual assistance.8 Gr2: 133. 0. These interventions include mat activities. 5 L Gr2: 3 R. ROM.7 SD: 14. 3 L .9 Gr1: EMG-BFB group: The training session begins with a warm-up period. Interventions were individualized for each subjects based on his-her impairments. No training on the platform and concurrent treatment only. Gr2: Standard customary balance training. Peak-topeak amplitude was adjustable within a range of 1–16 cm. Movement velocity profile was sinusoidal. In the first 5 min. Exclusion: Completely flaccid or spastic patients. Hemiplegia: Gr1: 5 R.5 Hz. shifting the CoG toward the perimeter of the LoS. Standing with each foot on a force platform (23 x 46 cm) and shifting a cursor representing the center of gravity (CoG) within the theoretical limit of stability (LoS). and the frequency was 0. Apparatus was a 60 x 60 cm platform that could move back and forth along a horizontal line.Grant 1997289 Total: 16 Gr1: 8 Gr2: 8 Inclusion: Patients who can follow directions (scores >21 points on the Modified Folstein Mini-Mental State) and who have no neurological. Progression: Reaching. Gr1&2: Standard customary physical therapy Details: N/R 15 sessions over 3 wk None 1. and increasing the required speed of weight shifts. reaching. Appendix 3E 195 continues . vestibular. or orthopedic problem that could affect balance. Tasks became more difficult: changing base of support (BoS). having targets placed close to the LoS. 6 L Gr1: Platform training. increasing the speed of performance. weight shifting. Gr2: Control. in the second. Goal: To attain symmetrical weight distribution. Based on activity. and have appropriate judgment. Hemiplegia: NR 33 days SD: 5 days post-stroke 65 SD: 3 Gr1: Visual feedback balance training on the Balance Master. Functional balance activities included locomotion with an altered BoS and stepping over obstacles. 5 days/wk as inpatient (3 wk minimum) and 2 days/wk as outpatient (maximum 8 wk) Follow-up at 4 wk 2. 1 Gr1&2: Standard customary physiotherapy. stepping in place. 0. Details: N/A Gr1 & Gr2: 30-min balance training (either standard or experimental) per day for 19 sessions. and performing functional activities that challenged balance. they stood perpendicular to the movement axis. patients stood parallel to the movement axis. 0. or altering visual input. can stand on the platform for a 2min period with the platform moving back and forth. 8 L Gr2: 5 R. Each session comprised two 5-min sessions. 1 Hocherman 1984290 Total: 24 M/F Gr1: 7/6 Gr2: 6/5 N/A N/A Inclusion: Patients who suffered a CVA in the anterior cerebral circulation 10–21 days before entry to the study. Progression: Symmetrical weight distribution. and stabilizing the CoG position within predefined targets spatially oriented within the LoS. Subject seated on plinth. yr (mean. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Mudie 2002119 Total: 40 Gr1: 10 Gr2: 10 Gr3: 10 Gr4: 10 Subjects had suffered a recent stroke and consistently bore majority of weight on one side. grocery items of approximately 140% of upper extremity’s length were retrieved with unaffected extremity and placed on shelves at various heights & distances to allow reaching. normalizing trunk muscle tone. . SD for control) Concurrent therapy Follow-up duration 2. Gr2: Task-related reach training: tests extremes of seated base of support. and improving the subject’s ability to move in and out of asymmetric posture. verbal & manual facilitation by therapist during seated reaching or lying. subject required to touch target with non paretic hand at various heights and distances.APPENDIX 3E. Gr4: Control: Standard customary PT and OT. subjects attempted to return to symmetrical position after reaching. N/A All groups: 2 wk. 2. 1 Session frequency and duration Quality (R. Continued 196 Author and year Treatment Gr1: Portable computer-like BPM feedback console used to provide awareness of weight distribution during training in sitting. B.01 Sample size Population details Symptom duration Age. one 30-min session/day N/A Comparison group Within 2–6 wk 72. maintaining appropriate balance responses during reaching. Gr3: Bobath-trained staff physiotherapists focused on increasing trunk & pelvic ROM.4 SD: 9. 3 Gr1: Experimental training from a therapist using EMG-BFB program of the Nottingham Balance Platform (NBP). 5 days/wk until discharge Followup at 1 month 2. 0.3 Gr3: 65.8 SD: 12. Gr2: Standard customary care: Extension of the regular rehab program.9 Total: 46 Gr1: 16 Gr2: 16 Gr3: 14 Duration of disease: Gr1: 65. subjects were instructed to shift their weight until the bars on the computer corresponded to a preset target. Gr1: 65.4 SD: 13.1 wk SD: 15. 0. Each column moved upwards with an increase in weight on the corresponding foot. N/A 2 hr/day. knees.3 days Gr3: 42. When the columns were within 5% of each other. 9 L Gr3: 5 R. BFB signals displaying weight distribution and weight shift activity were continuously presented to the patient in the form of 2 vertical red columns.4 days SD: 19.8 wk SD: 19. 9 L Gr2: 7 R. N/A 4-wk treatment N/A 2.8 Hemiplegia: Gr1: 7 R.3 wk Gr2: 67. Use of stool to increase weight bearing on the affected side. allowing for age and gender). and trunk (erect posture with no observable leaning to one side).1 days SD: 22.2 Total: 26 Gr1: 13 Gr2: 13 Able to stand for 1 min and displayed an abnormal stance symmetry (outside 2 SD.0 days SD: 13. The task progressed through to the addition of an upper extremity activity or introduction of trunk rotation. Hemiplegia: Gr1: 4 R. To increase weight bearing on the affected extremity.8 wk Gr1: 60.9 SD: 9. 1 Gr2: The patients practiced similar activities to the treatment group but without the visual BFB of at least one therapist.8 SD: 9. 1 Walker 2000292 Gr2: 62. 9 L Gr2: 8 R. Appendix 3E 197 continues . in need of balance training according to the judgment of their senior physical therapist. Weight shifting. Gr3: Control: Standard customary PT program and no additional balance training. Therefore. the targeting and balancing column exercise were performed using the subjective impressions of the patient and therapist. could stand unassisted 1 min.Sackley 1997291 Gr2: 18. a red triangle appeared confirming that stance symmetry had been achieved. 9 L Gr1: Visual EMG-BFB training: Use of the Balance Master consisting of 2 force plates positioned side by side. Symmetrical weight distribution was encouraged through verbal and tactile cues and was made more difficult by the addition of arm activities or actions requiring trunk rotation.5 days Gr2: 35.4 days Inpatient with hemiparesis secondary to a first stroke. 5 L Gr1: 20. within 4 months of their stroke.4 SD: 13. Tactile and verbal cues were provided as necessary to ensure proper alignment and stability of the hips. 90 min/day. 15 L Note: ADL = activity of daily living. Hemiplegia: Gr1: 9 R.0 wk Gr1: 53. PT = physical therapy. 12 L Gr2: 6 R. B. are medically stable. B. coordination.9 SD: 3.APPENDIX 3E. have the potential for functional locomotion with rehab. walking). BPM = balance performance monitor. 1 Session frequency and duration Quality (R. EMG-BFB = electromyography-biofeedback. OT = occupational therapy. SD for control) Concurrent therapy Follow-up duration 0. and were to have at least 3 wk inpatient stay. 3) lateral weight shifting.2 Gr2: Standing feedback training.4 Gr2: 7. ROM = range of motion. functional training (transfers. W = randomization. 5 x wk. show ability to stand without external support for at least 30 s. 4) anteroposterior weight shifting with affected extremity forward. M = male. Quality R. R = right.3 wk SD: 0.8 SD: 3.7 wk Gr2: 51. and 5) stepping in place. motor control. Sample size Population details Symptom duration Age. Training: 30–45 min/ day. L = left. Continued 198 Author and year Treatment Gr1: Standard customary standing balance and weightshifting training. Gr = group.7 wk SD: 1. 2) sitting to standing with equal weight distribution. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Winstein 1989293 Total: 42 Gr1: 21 Gr2: 21 Inclusion: Patients who have been diagnosed with unilateral hemiparesis. N/A = not available. Concurrent treatment: Physical therapy exercises (sitting balance. strengthening). N/R = not reported. and functional electric muscle stimulation when indicated. x/wk = times per week. blinding. Static standing progressed to stepping: 1) equal weight distribution. CVA = cerebral vascular accident. withdrawals. 5 x/wk for 3–4 wk None Comparison group Time since stroke onset: Gr1: 6. BFB = biofeedback. 0. F = female. yr (mean. . Subject was instructed to count the number of As and was asked questions about these slides. B. SD for control) Comparison group Concurrent therapy Follow-up duration 1. 1 Session frequency and duration Quality (R. 2 hr and 40 min/wk for 4 wk at 40 min/day.3 SD: 10. Characteristics of Included Studies for Sensory Interventions Author and Year Treatment N/A N/A Gr1: 1.APPENDIX 3F.1 SD: 7. Gr2: Control: Did not receive any treatment for their visual inattention or other perceptual deficits for 4 wk.7 Gr1: Feedback group: The eye movement is detected with glasses connected to a feedback device that delivered auditory signals in the form of a continual beep (if the subject did not look left within a fixed interval [15 s]). visual neglect Appendix 3F 199 continues . 2–3) With 6 letter As. right hemisphere stroke.0 months SD: 0.7 months Gr2: 0. W) Fanthome 1995297 Total:18 Gr1: 9 Gr2: 9 Subjects were not blind. were not too ill to be assessed. 20 min in the morning and 20 min in afternoon Sample size Population details Time since onset Age. 0. and scored <130 on Behavioral Inattention Test (BIT).6 Gr1: 66. yr (mean. Treated area: Eyes. had no history of dementia or psychiatric problems.0 months Gr2: 71. Left hemiplegic. had a score of more than 6 on Abbreviated Mental Test. 4) Pictures from the Western Aphasia Battery. Eye movements were recorded while looking at slides: 1) Practice slide with 3 letter As. were right-handed.6 month SD: 1. 5–6) Two short passages. under 80 yr old. 14 SD: 10.02 days SD: 6. Gr2: Patients also positioned in a rocking chair. 1 . 1 Session frequency and duration Quality (R. SD for control) Comparison group Concurrent therapy Follow-up duration 2.03 Gr1: 65. obvious motor deficit of the upper extremity (Brunnstrom-FuglMeyer score on the subscale of the upper extremity lower than 46). no additional stimulation. 0. totaling 30 sessions Follow-up at 5 yr Feys 2004298 Total: 62 Gr1: 33 Gr2: 29 A diagnosis of ischemic brain damage or intracerebral hemorrhage. Placebo: Shortwave diathermy.62 SD: 11. pushing with the affected arm. Rocking movement performed. 30 L Treated area: Upper extremity N/A Gr1: 62.78 SD: 12. Continued 200 Author and Year Treatment Therapeutic intervention: Patient was in a rocking chair with the affected arm in inflatable splint. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Feys 1998299 Total: 100 Gr1: 50 Gr2: 50 Inclusion: Diagnosis of ischemic brain damage or intracerebral hemorrhage.33 Gr2: 58. 28 L Gr2: 20 R. ability to sit independently or with a minimum of support. B. rocking chair with the arm rested on a cushion on patient’s lap.40 days SD: 5. an obvious motor deficit of the upper extremity.98 days Gr2: 62. Patients also received standard customary care performed by same therapists in both groups.94 days Gr2: 24. 30 min a session. 0. 1.86 Gr1: Patients were positioned in a rocking chair with the arm supported by an inflatable long-arm splint in a position contrary to the typical pattern of spasticity. 30 min/ treatment once/day for 6 wk. and the ability to perform the experimental treatment independently.APPENDIX 3F. and ability to perform the experimental treatment independently. Patients were asked to perform rocking movements. yr (mean. they received fake short-wave therapy of the shoulder during rocking. Sample size Population details Time since onset Age.34 SD: 11. Hemiplegia: Gr1: 22 R.81 Control group: Standard customary Patient was in a care in rehab. 5 days/wk for 6 wk Followups at 17 wk and 43 wk Gr1: 21. 0. eye tracking. activities with numbers or letters. 201 continues . pick up objects from different places). neutral warmth. 46 L Treated area: Upper and lower extremities 40 days SD: 42 days 71. Patient preparation: A) normalized tone (brushing. used cues.32 SD: 9. medical. 4 L Bilateral: 1 Treated area: Vestibular system Between 3 wk and 6 months Gr1: 71. vibration). B) splinting.9 SD: 7 Gr1: Passive vestibular Gr2: Control: No training: Patients were vestibular training. joint compression.Fiebert 1979300 Gr2: 71. a weakness in the UE + LE on one side of the body on admission. 2. tolerance. Hemiparesis: Gr1: 5 R. The chair was rotated to the right. 2) adaptation: modification of environment.2 SD: 6. cards. Gr1: Sensory integrative approach 1. were not admitted to an extended care setting before the stroke. After 20 s of continued rotation.07 Appendix 3F Gr2: Functional approach: Emphasized the practice of particular tasks (ADL: dressing. 1) compensation. Standard customary care (nursing. 1 Standard customary care in rehab. Hemiplegia: 44 R. A) participated in functional activities to increase function. 4 L Bilateral: 1 Gr2: 5 R. 1x/day for 2 wk: ROM exercises. A rest period of at least 20 s followed. but their heads were not secured. B) approximation to improve equal weight bearing and trunk rotation activity. 5 days/wk for 8 wk NA 1. 2. and facilitated developmental sequence. mobility. B) made activity meaningful. The chair was than rotated to the left for 8 rotations in 20 s and once again stopped abruptly. the chair was stopped abruptly. brushing of the involved extremities. Treatment: A) provided sensory stimulation: patient had to be actively involved (bilateral activities. ex: taught onehanded techniques and assistive devices to ensure independent function. bathing. toileting. and balance. grooming. Another rest period of 20 s followed. and balance activities. and PT) 40 min/day. Once a day for 2 wk N/A 0. at a velocity of 8 rotations in 20 s. 1 Jongbloed 1989301 Total: 90 Gr1: 43 Gr2: 47 Admitted to the hospital within 12 wk after a first CVA. and were not severely aphasic. and homemaking). strapped into a rotary chair.5 Total: 20 Gr1: 10 Gr2: 10 Had had a CVA 3 wk to 6 months before study. 15 mm thickness) sponge rubbers of identical shape and material composition were placed under the sole of the foot.4 days SD: 18. a software program presented on a large touch-screen computer that measure 3 aspects of visual attention: speed of visual processing. Hemiplegia: Gr1: 6 R.9 Gr1: 65. 2. Gr2: Received visuoperceptual retraining with commercially available computer software.3 SD: 11. shift of the weight loads to the non-affected and affected side of the foot on the health meter.0 Total: 26 Gr1: 12 Gr2: 14 Patients who were receiving hospital rehab and whose standing maintenance was becoming independent. 1 Session frequency and duration Quality (R. 20 sessions. and had a desire to return to driving. Concurrent treatment: All subjects from both groups received 4 sessions of physical training on the Baltimore Therapeutic Equipment work simulator.5 SD: 11.APPENDIX 3F. Rehab program (PT that included ordinary postural control exercises. Othello.4 Gr1: Received a visual information-processing training program using the UFOV.8 days Gr2: 66. yr (mean. 25 L Gr2: 25 R.6 days Gr1: 62. 2. 5 L Gr1: 65. They were instructed to estimate hardness of sponge. 1 . and OT). Mastermind. divided attention. and selected attention. B. Three 30-cm² (5. They were selected so that they targeted perceptual and cognitive skills but not the elements of speed of visual processing. Simulation of turning the steering wheel and pressing the gas and brake pedals was provided to refine motor skills and familiarize with the adaptive equipment. 25 L Morioka 2003303 Gr2: 61. Continued 202 Author and Year Treatment 2–4x/wk for 20 sessions N/A Gr1: 91.7 days SD: 28. such as Tetris.10. Gr1: Everyday for 10 days over 2 wk N/A Sample size Population details Time since onset Age. Subjects were in standing posture and were blindfolded. SD for control) Comparison group Concurrent therapy Follow-up duration 2.3 Gr1: Perceptual learning exercise: Exercises to discriminate the hardness of sponge rubber placed under the sole of the foot.6 SD: 13. 1. Hemiplegia: Gr1: 22 R. Gr2: Control group: No exercise. 30–60 min.9 days SD: 20. were licensed to drive before the referent stroke.8 days Gr2: 61. on the same large screen computer as the UFOV. such as maintenance of standing.2 days Gr2: 66.5 SD: 8.2 days SD: 51. and Jigs@w puzzle. 6 L Gr2: 9 R. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Mazer 2003302 Total: 86 Gr1: 41 Gr2: 45 Hemispheric stroke that occurred within the previous 6 months. had driven in the 6 months before the stroke. Page 2000304 Total: 16 Gr1: 8 Gr2: 8 Stroke onset between 1–3 yr. Gr2: Listened to a 20-min tape with instructions and information requiring the patient’s attention and participation. Note: ADL = activity of daily living. withdrawals. OT = occupational therapy. blinding. hand 6. 4 wk N/A 2. 0. and texture of objects or materials placed in their hand. Patients >55 yr of age. R = right. Appendix 3F Gr1: Feedback group: 45min sessions. B. 1–3 yr 63. Identify the number of touches or lines and of numbers and letters drawn on the arm and hand. 3 sessions/wk for 6 wk.2 yr SD: 4 yr Chronic Gr1: 64 SD: 9. UFOV = useful field of view. L = left. 1 Both groups received OT 3 x/wk in 30-min outpatient sessions for 4 wk. CVA = cerebrovascular accident. The therapist held his hand and a pencil and drew with it. provided with recorded information on the causes and pathology of stroke. Hemiplegia: Gr1: 10 R. no communication problems or significant cognitive or emotional disturbance. Quality R. 203 . 0. UE = upper extremity. N/A 45-min sessions. ROM = range of motion. 10 L Gr2: 9 R. BIT = Behavioral Inattention Test. weight. They alternated between functional and paretic hands. Treatment consisted of 40% neurodevelopmental techniques and 60% compensatory strategies using the ipsilateral. Gr = group. 10 L Treated area: Sound and paretic arm.25 Total: 39 Gr1: 20 Gr2: 19 2 or more yr after a major stroke with persisting sensory deficit in the hand. W = randomization. LE = lower extremity. 1 Yekutiel 1993305 Gr2: 67 SD: 9. Difficulty increased as proprioception improved. unaffected extremity.” Discrimination of shape. The course of stroke and the outcomes that they could anticipate from regular participation.2 SD: 4 Gr1: Tape-recorded imagery intervention: 5 min of relaxation followed by 10 min of suggestions for external cognitive visual images related to using the affected arm in weight-bearing and functional tasks that were being practiced during OT sessions and finally 5 min of refocusing into the room. Blindfolded “find your (paretic) thumb.25 Gr2: Control: No treatment for any possible learning effect of repeating the sensory examination. Patient had to identify the figure drawn by choosing from 4 figures on a card. Treated area: Affected arm 1. Passive drawing: Patient is unable to see his hand. N/A = not available. 3 sessions/wk for 6 wk N/A 0.8 yr Range. PT = physiotherapy. Right arm hemiparesis. Sample size Population details Time since onset Age. communication.5 SD: 13. Patients also participated in a circuit-training program. and neglect items of the NIHSS).APPENDIX 3G.4 SD: 5. yr (mean.3 Gr1: CIMT circuit training encouraged the use of the hemiplegic arm with a variety of UE and functional tasks. UE strength. 0. 3 L Gr2: 6 R. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Dromerick 2000319 Total: 20 Gr1: 11 Gr2: 9 Inclusion: Admission to Equal or less inpatient rehab within 14 than 14 days days of ischemic stroke. allowing them to perform bilateral self-ROM and functional activities in a supervised setting. B. SD for control) Comparison group Concurrent therapy Follow-up duration 2. and ROM and traditional positioning.7 Gr2: 71. 1 Session/ frequency and duration Quality (R. and no upper extremity injury or condition that limited use before the stroke. Exclusion: Hemorrhagic stroke. 3 L . Characteristics of Included Studies for Constraint-Induced Movement Therapy 204 Author and year Treatment Gr1&Gr2: Routine interdisciplinary stroke rehab. Treatment Gr1 and Gr2: 2 hr a day. 5 x/wk for 2 wk N/A Gr1: 61. Persistent hemiparesis leading to impaired upper extremity function (score of 1 or 2 on the motor arm item of the National Institute of Health Stroke Scale). Presence of a protective response (score of > or = to 3 on the upper-arm item of the Motor Assessment Scale). Subjects wore padded mitten for at least 6 hr/day to discourage them from using their unaffected hand outside of therapy. Hemiplegia: Gr1: 8 R. Gr2: Standard customary OT treatment that included compensatory techniques for ADL. Evidence of preserved cognitive function (0 or 1 on the consciousness. OT treatment focused on ADLs and UE training. Gr2: Same as Gr1 except that the shaping procedure was 3 hr/day. on the uninvolved hand. 4) motor control of upper extremity not more than stage 6 on ChedokeMcMaster.7 yr Gr1: 49. 5 L 4. The protocol of wear was progressive. Mini-Mental State Examination score > 20. 5. On the weekend. minimal balance problems. and 6 wk 1.Ploughman 2004320 Gr2: 61.8 yr SD: 4. 4 R N/A Gr1: 57. Gr2: Conventional treatment involving facilitation of proximal motor control progressing to skilled-task training.4 SD: 7. 0. Every weekday during 2 wk.62 SD: 5. no receptive aphasia.5 Gr1: CIMT standard protocol with constraint of the unaffected arm for a target of 90% of waking hr and 6 hr of daily training by using a shaping procedure. 3) no more than 16 wk postroke.65 Gr1: Wearing a thumbless mitten that extended from the fingertips to just below the elbow. fingers: 10º).9 SD: 18. Appendix 3G 205 continues .68 Total: 23 Gr1: 10 Gr2: 13 Inclusion: 1) first ischemic or hemorragic stroke. N/A 5x/wk for 2 wk Followups at 3. gait training. Hemiplegia: Gr1: 1 R. functional electric stimulation. 6 L Gr2: 3 R. Hemiplegia: Gr1: 4 L. beginning with 1 hr/day and increasing to 6 hr/day by wk 2 of rehab and continuing at that level for the remaining rehab period. 6 R Gr2: 9 L.8 SD: 10. 0. and education. as appropriate. only minor spasticity of the affected hand. 1 Sterr 2002321 Gr2: 68. 2) currently receiving physical rehab at least 2x/wk as inpatient or outpatient. 4. The mitten discouraged use of the uninvolved arm and hand but permitted bilateral activities and use of sound arm to stabilize when walking. 1 N/A N/A N/A 2.0 Total: 15 Gr1: 7 Gr2: 8 Capability of extending the affected hand against gravity (wrist: 20º. Subjects also received strength and endurance training. and post-stroke interval > 12 months. only the constraint was worn and no training was provided. 2 types of constraints were used: Resting hand splint and arm sling together (for patients without balance problem) or a specially designed half glove (for patients with balance problems). no severe aphasia. withdrawals. N/A N/A Gr2: Control group. Gr2: 8 days of 3 hr of therapy and 2 weekend days of rest. Symmetrical posture and inhibiting inappropriate “synergistic” movements were emphasized. 5 L Gr2: 25 R. 1 Note: ADL = activity of daily living. NDT = neurodevelopmental treatment.7 yr SD: 2. 41–81 Gr1: CIMT group. Quality R. occupational. 2. OT = occupational therapy. L = left. ROM = range of motion. Sample size Population details Time since onset Age. Passive therapy (stretching and heat) to the affected upper extremity for 1 hr during weekday sessions. Training of the affected arm focused on functional tasks for 10 sessions. B. 1 Session/ frequency and duration Quality (R. and if necessary the affected arm was supported with the unaffected hand. Age 18– 80 yr. Gr2: Control group. CIMT = constraint-induced movement therapy. Patients had their healthy UE immobilized in a splint and a closed arm sling. the stroke resulting in hemiparesis on the dominant side. 12– 48 months Gr1: 34 months Range. All activities were performed bimanually. Gr1: 8 days of 6 hr and 2 weekend days of 4 hr. a minimum of 20º of active wrist extension and 10º of finger extension.8 yr Gr2: 62. The duration of immobilization was 6 hr/ day. Hemiplegia: Gr1: 26 R. 0. Attention was paid to avoiding associated proximal movement and to relaxing through verbal guidance. 16– 86 months Gr1: 65 Range. no major balance problems. SD for control) Comparison group Concurrent therapy Follow-up duration 2. 50–75 Exclusion: Patients without voluntary extension of at least 10º of the affected fingers or 20º of the wrist. yr (mean. Able to walk indoors without a walking aid.8 SD: 8 Gr1: 59.APPENDIX 3G. x/wk = times per week. W = randomization.45 yr Gr2: 2. Therapist’s assistant was there to give verbal feedback and hands-on facilitation and to inhibit inappropriate muscle contraction. . blinding. B. Progressively improving motor task performance by a successive approximation procedure during combined physical. Patients were treated according to the NDT. Gr = group. UE = upper extremity. 0. 6 L Wittenberg 2003323 Total: 16 Gr1: 9 Gr2: 7 Gr2: 63 Range. and no severe cognitive impairment. N/A = not available. 1 yr Gr1: 3.4 yr SD: 2. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 van der Lee 1999322 Total: 62 Gr1: 31 Gr2: 31 Single stroke at least 1 yr before the start of the study. and recreational therapy. Sensory disorders and hemineglect were recorded.6 SD: 6 Gr1: Constraint-induced training of the upper extremity. R = right. Continued 206 Author and year Treatment N/A 5x/wk for 2 wk 4 wk. Restraint of unaffected upper extremity (using hand splint and sling ensemble) during waking hr and task-oriented therapy of affected upper extremity. Hemiplegia: N/A Gr2: 28 months Range. max tolerable ext rotation. 4 electrodes.2 SD: 10.7 SD: 12. B. yr (mean.3 SD: 14.4 days Gr1: 58. social work. Conventional rehab therapy according to the Bobath concept 3 sequences/ day for 24 months N/A Comparison group Gr1: 52. Participants were followed for 24 months as inpatients during their hospitalization and then as outpatients after discharge. and able to comprehend and use VAS for pain. cylinder in hand to provide a web space stretch. elbow ext. passive ROM shoulder abduction and flexion >90°. current rectangular biphasic wave. pulse width: 350 µs. shoulder ABD to 90°. Hemiplegia: Gr1: 6 L. no pre-morbid restriction of shoulder movement.9 days Gr2: 58. Gr1: FES. Gr2: Control: No treatment. 90 min. same in 4th and 5th wk. sequence 1 and 2 increases of 5 min each. 3rd = 1Hz. 2nd = 40Hz. 0. elbow flexed. score of less than 5 on the upperarm function item of the Motor Assessment Scale for stroke.1 days SD: 13. duty cycle: 1:5. 20 min in each position: 1) supine.3 days SD: 11. 7 R 207 continues .5 Gr1: Prolonged positioning of the affected shoulder. 2) supine. no pre-morbid shoulder pain. 30 min. 1 Session frequency and duration Quality (R. SD for control) Concurrent therapy Follow-up duration 0. W) Chantraine 1999340 Total: 120 Gr1: 60 Gr2: 60 Participants were diagnosed with a subluxated and painful hemiplegic shoulder. 0. 4 channels. 3) sitting. In 2nd and 3rd wk. 3 sequences: 1st = 8Hz. Characteristics of Included Studies for Shoulder Subluxation Author and year Treatment Gr2: Control: No treatment. Hemiplegia: 75 L.4 Patients were followed in the rehab service starting between the 2nd and 4th wk after the causal lesion was diagnosed. 2. shoulder forward flexed at 90°. OT. and speech therapy as indicated). Concurrent therapy: Multidisciplinary therapy (PT. 55 R Dean 2000335 Gr2: 35.5 Total: 28 Gr1: 14 Gr2: 14 Gr1: 32. 5 days/wk for 6 wk None Sample size Population details Time since onset Age. 130 min for the 1st wk. wrist ext.6 Gr2: 52. psychology. Active training of reaching and manipulation determined by the treating therapist.1 SD: 12. 1 Appendix 3H Inclusion criteria: Fewer than 10 wk from the onset of stroke. elbow flexed. shoulder in max tolerable ABD and ext rotation.APPENDIX 3H. 4 R Gr2: 6 L. 5 cm above elbow. 1 . 0. Conventional physical therapy 6 wk.2 days SD: 7. for 6 wk.9 days Gr1: 79. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Faghri 1994336 Total: 26 Gr1: 13 Gr2: 13 Participants had recent hemiplegic stroke or patients with shoulder muscle flaccidity/paralysis. active electrode over posterior deltoid and passive electrode over supraspinatus. frequency of 35 Hz.5–6 hr/day. Continued 208 Author and year Treatment Gr2: Control: No treatment. contraction/ relaxation ratio progressively increased (10/12 s to 30/2 s ON-OFF). 22 R Gr2: 24 L. yr (mean. moving arm front and back crossing at top of shoulder.8 SD: 7. Side of hemiplegia: left: 17 Gr1: 8 Gr2: 9 Hanger 2000337 Gr2: 12. posterior tape anchored down past clavicle. 7 days/ wk Posttreatment follow-up done at 6 wk Comparison group Gr1: 16 days SD: 5 days Gr2: 17 days SD: 4 days Gr2: 69 SD: 12 Gr1: 65 SD: 13 Gr1: FES: 1. Technique: 2 main supporting tapes. Replaced every 2–3 days.1 SD: 8. whereas the tape from the anterior aspect came across the shoulder and down past the spine of scapula. 2. Side of hemiplegia: Gr1: 27 L. B.3 Total: 98 Gr1: 49 Gr2: 49 Participants had acute hemiplegic stroke (excluding subarachnoid hemorrhage) in the preceding 4 wk. Gr2: Control: No strapping.9 days Gr2: 77. 0 Session frequency and duration Quality (R. and 3rd main tape applied from medial 1/3 of clavicle. 0. intensity set to obtain the desired motion of humeral elevation with some abduction and extension to pull the head of the humerus into the glenoid cavity. SD for control) Concurrent therapy Follow-up duration 1. 7 days/wk. N/A 7 days/wk and 24 hr/ day for 6 wk Followups at wk 6 and 14 Sample size Population details Time since onset Age.APPENDIX 3H.2 Gr1: Strapping: 6 wk or until able to achieve abduction to 90° against gravity for 2 s or until discharged from hospital.4 days SD: 6. around surgical neck of humerus and along spine of scapula (medial 2/3). 25 R Gr1: 12. 15 s ON. 45 min in wk 2–3. 15 s OFF. Pulse duration: 0. Gr2: FES on the middle deltoid: active electrode: 5 cm distal from acromion on the middle deltoid.3 wk SD: 57. and recruitment and all initial measurements must have been completed and treatment commenced within 48 hr of admission. Side of hemiplegia: Gr1: 3 R.2 SD: 9. 0. passive: posterior part of the axilla.5 wk Gr3: 190. ramp down: 3 s Gr2: Control: No treatment.1 wk Gr1: 59. 0.2 wk SD: 65. with a minimum of 2 hr between sessions. 15 s ON. no cardiac pacemaker or metal in situ.5 wk Gr3: 53. asymmetrical biphasic pulses. ramp up/down: 3 s/2 s. CVA had to have resulted in significant motor deficit of upper limb with a grade of ≤ 2 on Manual Muscle Test. 30 Hz. 15 s OFF ramp up: 3 s.3 SD: 7. . 60 min in wk 4. 4 times/day. adequate communication ability. 2 electrodes on supraspinous fossa and posterior aspect of upper arm. Conventional physical therapy 2 times/day. 1 Linn 1999338 Total: 40 Gr1: 20 Gr2: 20 Participants had no previous pathology to the shoulder.2 Gr2: 69. who showed downward subluxation on a stress X-ray. passive electrode: acromion.3 ms.4 Total: 17 Gr1: 6 Gr2: 6 Gr3: 5 Patients with hemiplegia as a result of a stroke. 5 days/wk for 6 wk 0.1 Gr1: FES to the supraspinatus: active electrode: 5 cm from acromion. Conventional PT and OT 4 times/day for 4 wk treatment and 8 wk of concurrent therapy only Follow-up at 8 wk 1. on the supraspinatus fossa. 300 µs.3 SD: 13. negative monophasic rectangular pulses. 3 L Gr2: 5 R. 30 min in wk 1. no women of childbearing age.0 wk SD: 90. 3 L Gr1: 60. 5–15 min Gr1: FES. 1 Gr3: Control: No treatment. 1 L Gr3: 2 R. frequency: 20 Hz. Side of hemiplegia: Gr1: 4 R Gr2: 5 R N/A Gr1: 71 Gr2: 73 Appendix 3H 209 continues .Kobayashi 1999341 Gr2: 95. 5 mm of acromiohumeral distance. FES for 6 wk. 6 wk without. frequency set to create a tetanized muscle contraction. 2 groups short duration: symptoms lasting <21 days.4 SD: 6. and 6 wk with it again Sample size Population details Time since onset Age.2 days Gr2: 14. 10–24 pulses/s. increases of ON time by 2 s every 1 or 2 days.7 Gr3: 58. N/A N/A Comparison group Gr1: 15.9 days SD: 2. 0 Session frequency and duration Quality (R. Side of hemiplegia: Gr1: 4 R Gr2: 5 R Gr3: 3 R Gr4: 3 R . duty cycle: 1: 3.5 days Gr4: 433. when a 24-s decrease of OFF time by 2 s every 1 or 2 days until 2 s. routine therapy for 6 wk.4 Gr1: 56.0 Gr2: 56. 6 wk with FES.APPENDIX 3H. active electrode on supraspinatus. yr (mean.6 days SD: 47. 5 days/wk.1 SD: 7. SD for control) Concurrent therapy Follow-up duration 1. long duration: >365 days.4 days Gr4: 58. FES: Asymmetric biphasic waveform stimulation of supraspinatus and posterior deltoid. 0.1 SD: 6.9 days SD: 3.7 days Gr3: 427 days SD: 45. 6 hr.4 SD: 8. Continued 210 Author and year Treatment Gr2&4: Control: No treatment. B. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Wang 2000339 Total: 32 Gr1: 8 Gr2: 8 Gr3: 8 Gr4: 8 Participants were required to demonstrate a minimum of 9.4 Gr1&3: FES for 6 wk. Gr2: Henderson shoulder ring: 1.5 cm in diameter placed inside a piece of stockinette 4-cm wide and long enough to pass under both axillae and form a figure eight across the back. R = right. joining the section from axilla to form a ring. impaired motor function of the affected upper extremity. ROM = range of motion. B. FES = functional electrical stimulation. Side of hemiplegia: 16 L.4 Gr1: Bobath shoulder roll: A strip of foam-rubber padding 1-cm thick and 14-cm wide secured into a roll 5. clinically subluxated GHJ of that extremity as determined by finger palpation. With teardrop extension lying across chest wall. N/A = not available. Appendix 3H 211 . longer straight section molded over superior and posterior aspects of shoulder.9 days SD: 30. W = randomization. 0. OT = occupational therapy. withdrawals. Quality R. the foam was molded around the shoulder.1 SD: 9. 10 R 64.25-cm thick piece of polyethylene foam modified to the size of subjects. Shorter end contoured under paralyzed axilla. L = left. PT = physiotherapy.0 days 66. Gr = group. warmed in oven until flexible. N/A 1 session (1 day) N/A 0.Williams 1988342 Total: 26 Participants had a diagnosis of hemiplegia. 0 Note: CVA = cerebrovascular accident. blinding. based upon his/her level of endurance. 0. yr (mean. NA 5 sessions/wk for 6 wk Followup at 3 months post treatment Treatment Sample size Population details Age. Location of hemiplegia was not reported Area treated: Hemiplegic wrist 2. as compared with radiographs of their uninvolved extremity. generally involved PROM exercises. Gr1: Standard customary “hemi-slings” or wheelchair arm supports when sitting or standing. while sitting. Both groups received standard customary care of the hand and wrist that. Physical therapy was given 5 days/ wk for 4 wk. which the subject was instructed to repeat between 20 and 100 times. and 20-s rest. and training for ADL. B. 0 . twice daily for 30 min. active resistive exercise. Gr1: Control: Standard customary physical therapy (no PFST). classic neuromuscular facilitation. 0 Session frequency and duration Quality (R. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Baker 1986356 Total: 63 Gr1: 32 Gr2: 31 All subjects were required to demonstrate a minimum of 5 mm of shoulder subluxation in their involved upper extremity. while individualized. 0.APPENDIX 3I. SD for control) Comparison group Concurrent therapy Follow-up duration 1. Characteristics of Included Studies for Electrical Stimulation 212 Author and year Time since onset Gr1: 46 days SD: 51 days Gr2: 49 days SD: 32 days Gr2: 56 SD: 13 Gr1: 55 SD: 12 Gr2: NMES of the posterior deltoid and supraspinatus muscles. 10 sessions/wk for 4 wk N/A Bowman 1979357 Total: 30 Gr1: 15 Gr2: 15 Patients had: 1) unilateral hemiplegia as a result of either a thrombotic or embolic CVA ranging from 3 wk to 4 months. with full PROM. 15 R Treated area: Hemiplegic shoulder Ranged from 3 wk N/A to 4 months Gr2: Received a combination of positional feedback and electrical stimulation (referred to as PFST) to the wrist extensor muscles. The stimulator had a duty cycle of 6–8 on. and 3) sufficient cognition to follow instructions. Hemiplegia: Gr1: 18 L. 2) a minimum of 5° and a maximum of 30° active extension at the wrist from normal posturing position. The stimulation would result in wrist extension. 14 R Gr2: 16 L. 7 L Gr3: 4 R. Gr3: 90 min/ day over 4 days. and shoulder joint abduction. Hemiplegia: Gr1: 8 R. 10 consecutive movement trials (blocked practice) were executed before the electrodes were disconnected and replaced with electrodes for another set of muscles. Settings for stimulation: 1 s ramp up.82 Gr1: Surface electrodes were attached to 3 sets of muscles in the impaired upper extremity: extensor communis digitorum/ extensor carpi ulnaris. Automove EMG facilitator provided an electrical stimulation that assisted the muscles through full range. 5 s of biphasic stimulation at 50 Hz. currently not participating in another upper extremity rehab protocol. Gr3: Did not receive any active stimulation. 2 L Treated area: Upper extremity Gr1: 3.03 yr Gr1: 65. 25 s of rest between trials. 1 session = 3 sets of 30 successful active neuromuscular stimulation trials with 3 movements executed 10 times/set. Gr2: Same as Gr1 except that electrodes for different muscles were changed after each trials (random practice). elbow extension. 1 s ramp down.29 yr Gr3: 3. triceps brachii. 0. a lower limit of 10º of voluntary wrist/finger extension from a 90º wrist flexed position. 1. anterior/middle deltoid. initial threshold 50 microV.28 Gr3: 65. subjects voluntarily generated a target threshold level of EMG activity.Cauraugh 2003358 Total: 34 Gr1: 14 Gr2: 14 Gr3: 6 Inclusion: Diagnosis of no more than 2 strokes. Each joint/set of muscles were passively moved and subjects attempted to voluntarily execute wrist/finger extension. 6 L Gr2: 7 R. For each movement.15 Gr2: 67. 0 Appendix 3I 213 continues . absence of other neurological deficits.18 yr Gr2: 3. an 80% upper limit of motor recovery as assessed by rectified EMG activation patterns and force generation while directly comparing the impaired and unimpaired limbs. N/A Gr1 & Gr2: 2 days of 90 min training for each of 2 wk with at least 24 hr of rest between sessions. common dynamic gait problem of spastic. 4 L Gr4: 3 R. ability to ambulate a short distance with the assistance of a single therapist. Passive and active ROM. and strengthening exercises were practiced with all major joints and muscle groups of both legs. 5 L Treated area: Lower hemiplegic leg . Gr3: FES to produce the contraction of the anterior tibialis during swing phase and gastrocnemius during the stance phase. Gr1: Control: Standard physical therapy for 30min session. SD for control) Comparison group Concurrent therapy Follow-up duration 1. 2 L Gr3: 4 R. In the subsequent wk. followed by a 1-min rest during 30-min sessions. 1. Continued 214 Author and year Time since onset (No of subjects greater than 1 year post stroke) Gr1: 5 yr Gr2: 4 yr Gr3: 4 yr Gr4: 3 yr Gr1: 62 Gr2: 51 Gr3: 52 Gr4: 56 SD: N/A Gr2: BFB to the anterior tibialis: subject was asked to repeatedly produce a maximum contraction for 30 s. and had suffered cortical or subcortical infarction or hemorrhage. 3 sessions/wk for 6 wk Follow-up at 4 wk from end of treatment/ 10 wk from baseline Treatment Sample size Population details Age. 1 Session frequency and duration Quality (R. FES was used for 5 min. Special attention was paid to ankle and foot control in the affected limb. 3 L Gr2: 6 R.APPENDIX 3I. cognitive ability to give consent. while pulse frequency was set at a level where maximum contraction was achieved within tolerable levels of discomfort. 15 min were devoted to each modality. Treatments lasted 30 min and were given by a Medtronic Respond II stimulator. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Cozean 198851 Total: 32 Gr1: 8 Gr2: 8 Gr3: 8 Gr4: 8 Medically stable patients. Standard customary care as prescribed for each patient. Hemiplegia: Gr1: 5 R. yr (mean. B. Specific ambulation training was also conducted to overcome dynamic gait abnormalities. equinus posturing of the affected leg. GR4: BFB and FES: Within the 30-min sessions. with 30 min provided for independent use of the stimulator post treatment sessions. and supraspinatus muscle for 1. 0 Gr1: 14. Hemiplegia: Gr1: 3 R. 1 Faghri 1997360 Total: 26 Gr1: 13 Gr2: 13 Recent hemiplegic stroke patients with shoulder muscle flaccidity/paralysis. NESS Handmaster was used: 5 surface electrodes with external control box connected to the splint with a cable. 4) using a tilt table for a sense of verticality. Alternating stimulation of extensor and flexor muscles for 6 wk. 10 L Gr2: 8 R. 5) active assisted ROM to the sound side. between 18–80 yr old. utilizing a configuration that minimizes activation of the upper trapezius muscle. and stable general health status.De Kroon 2004359 Gr2: 21. 0. 7 L Treated area: Affected upper extremity Gr1: 17 days SD: 4 days Gr2: 16 days SD: 5 days Gr2: 65 SD: 13 Gr1: 69 SD: 12 Gr2: Functional NMES of the posterior.8 months Gr1: 58 SD: 17.4 months SD: 16. deltoid muscle. 4 R Gr2: 8 L. impaired function of the upper extremity due to spastic paresis.7 SD: 9. duty cycle: 40%. Hemiplegia: Gr1: 9 L. 0. 7 sessions/wk for 6 wk Follow-up at 6 wk post treatment 1. exercise mode was used. N/A 3 x/wk a starting with 20 min/session. Extensors only: Same as GR1 except that the exercise/open mode was used and subjects received stimulation of the extensor muscles only. 2) head/trunk control.7 Total: 28 Gr1: 13 Gr2: 15 Patients had interval of more than 6 months since unilateral stroke in territory of middle cerebral artery.5 to 6 hr/day. Standard customary care: 1) bed mobility. 3) sitting balance. and during first 10 days. Gr1: Control: No neuromuscular stimulation. Electrodes were placed over the deltoid muscle and the supraspinatus muscle.3 Extensors and flexors: Splint was prepared in which the electrode position was individually adjusted to evoke optimal finger movements according to randomization. Frequency: 36 Hz. voluntary extension of wrist (at least 10°) and fingers.7 months SD: 11. stimulation time was gradually increased to a maximum of 1 hr/session Follow-up at 6 wk 2. 5 R Treated area: Hemiplegic shoulder Appendix 3I 215 continues .1 months Gr2: 61. Also standard customary care: See control group description. 0. and ankle extensors) to produce joint movement. large supra tentorial cerebrovascular lesions . N/A 4-wk treatment N/A Treatment Sample size Population details Age. 15 stimulations/session for each group of muscle. B.6 days SD: 40 days Acute phase poststroke Gr2: 54 SD: 11 Gr1: 50. Continued 216 Author and year Time since onset Gr1: 56. and a constant current of 20–60 mA for 1 s. 45 min/session. Also OT at least 3 hr/wk and up to 2 hr of group therapy.3 ms biphasic sinus-waved pulses at 80 Hz. parameters of stimulation were 0.1 SD: 14 Gr1: EMG-BFB: Transcutaneous electrical stimulation was triggered by voluntary EMG-activity in the target muscles (upper arm/forearm/ hand extensors. yr (mean. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Heckmann 1997361 Total: 28 Gr1: 14 Gr2: 14 Right-handed stroke patient. 0 Session frequency and duration Quality (R.APPENDIX 3I.1 days SD: 24 days Gr2: 61. knee flexors. Gr2: Standard customary care only: Treatments based on Bobath’s principles. SD for control) Comparison group Concurrent therapy Follow-up duration 1. 7–74 months SD: 16. Subjects maintained records of use to show compliance. pulse duration: T = 200 µs. 5 R Gr4: 2 L. 4–11 wk Gr2: Range.75 months Gr2: Range. requiring him or her to trigger a stimulated response. 5 R Gr2: 1 L. subjects were instructed to try to functionally use a toothbrush.5 Gr1: NMES: First visit. while the other half of the time was spent with the machine automatically stimulating the muscles to contract cyclically without any volitional trigger from the patient. were above age 18. comb. thumb extensor. Standard customary care. During the sessions.Kimberley 2004362 Total: 16 Gr1: 8 Gr2: 8 Gr2: Range. Frequency: 50 Hz. 33–75 SD: 10. 41–78 SD: 9. Gr2: 30 min of supervised daily exercise with the paretic arm and hand. Hemiplegia: Gr1: 3 L. Half of the treatment time was spent with active effort on the subject’s part. 1 Gr2: Same instructions as Gr1 but the machine did not deliver any current. Four channels of electrical stimulation were applied over the finger flexors. finger extensors. 50–68 Gr2: Range. the subjects were asked to lift the hand actively when the light came on and the “stimulation” started. and the thenar muscle group. 217 continues .75 months Gr1: Range. were able to give informed consent. Gr4: Same as Gr2. 4 R Gr1: Range. small food. 5–11 wk Gr1: Range. Hemiplegia: Gr1: 4 R. and were able to understand how to apply electrical stimulation for controlling the grasp. intensity: 20mA–45mA. pen. 1. 23 wk posttreatment 2. etc. 45–72 Appendix 3I Gr1: The exercise was assisted with a neural prosthesis that controlled the opening. Half the hr of treatment.10. 4–8 wk Gr3: Range. patients were instructed in the operation of the electrical stimulator. 30-min long exercise with the paretic arm and hand every day for 3 wk Follow-ups at 3. telephone receiver. 1 Popovic 2003363 Total: 28 Gr1: 8 Gr2: 8 Gr3: 6 Gr3: 6 Had >2 wk and <6 months following the first CVA that was caused by ischemia or hemorrhagia and confirmed by MRI or CT. 4 L Gr2: 4 R.25 Subjects at least 6 months post stroke with at least 10º of active flexion/extension movement at the metacarpophalangeal joint of the index finger. 0. Same tasks as the FES group without a neural prosthesis. 37–75 Gr4: Range. Gr3: Same as Gr1. N/A 6 hr/day for 10 days over the course of 3 wk (total 60 hr) Follow-up at 3 wk (end of treatment) 1. grasping. must have score of at least 25 out of a possible 30 in Mini-Mental State Examination. 4 L Treated area: Hemiplegic forearm Gr1: Range. 7 R Gr3: 1 L. 4–11 wk Gr4: Range. 53–72 Gr3: Range. and releasing functions by mimicking natural movement. 11–58 months SD: 11. 4 SD: 12. R = right. blinding. 12 R Area treated: Hemiplegic wrist Gr1: 59 days SD: 40 days Gr2: 45 days SD: 38 days Gr2: 57 SD: 13 Gr1: 60 SD: 10 Gr2: 1) PFST of the quadriceps femoris muscle and rectus femoris muscle for 30 min.9 days SD: 5. Electrical stimulation: 28 sessions/wk for 4 wk N/A TOPICS IN STROKE REHABILITATION/SPRING 2006 Winchester 1983365 Total: 40 Gr1: 20 Gr2: 20 1) Minimum of 5° of active knee extension in antigravity position. Gr1: Control: No electrical stimulation and PFST. OT = occupational therapy. Quality R. FES = functional electrical stimulation. B. 10 R Gr2: 18 L. progressive resistive exercises. x/wk = times per week. 2) No greater than a 25° knee flexion contracture. Hemiplegia: Gr1: 20 L. SD for control) Comparison group Concurrent therapy Follow-up duration 2. and at 2 to 4 wk after onset.8 Gr1: 66. EMG = electromyography. 0.g. Physical therapy 5 days/wk. ROM = range of motion. L = left. Standard treatment from ward rehab team (e. CVA = cerebrovascular accident. PFST: 7 sessions/wk for 4 wk.2 Gr2: FES of wrist and finger extensors. PFST = positional feedback stimulation training. PT = physiotherapy. Continued 218 Author and year Time since onset Gr1: 22. B. BFB = biofeedback. PROM = passive range of motion. Hemiplegia: Gr1: 8 L. yr (mean. W) Powell 1999364 Total: 60 Gr1: 30 Gr2: 30 Hemiparesis due to acute stroke with Medical Research Council power of wrist extension grade of 4/5 or worse. 13 R Area treated: Hemiplegic leg 1. .5 days Gr2: 23.9 days SD: 7.APPENDIX 3I. 12 R Gr2: 7 L. 0. Gr = group. as determined by observation of the patient’s response to a quick stretch of the quadriceps femoris muscle. 1 Session frequency and duration Quality (R. and weightbearing activities.0 SD: 10. 3) Absence of severe quadriceps femoris muscle tone. Standard customary PT. NMES = neuromuscular electrical stimulation. 1 Note: ADL = activities of daily living. It included neuromuscular facilitation techniques. 2) Cyclical electrical stimulation. W = randomization. Standard customary PT. CES = cyclical electrical stimulation. 3 half-hour periods daily for 8 wk Followup at 24 wk post treatment/ 32 wk from baseline Treatment Sample size Population details Age. Gr1: Control: No FES. involving the quadriceps femoris muscle.. 4 times daily.7 days Gr2: 69. N/A = not available. withdrawals. contact with physiotherapists and occupational therapists). but were able to stand or walk if assisted.40 Gr2: 65. no history of previous neurological disorder. SD for control) Concurrent therapy Follow-up duration 1. Gr2: Low intensity TENS.88 months Gr3: 3. Intensity: N/A Gr1: 26. high frequency (100 Hz) on the shoulder muscles and the glenohumeral joint. spasticity in lower extremity.72 months SD: 1. and no pain or major sensory impairment in lower limb. Intensity: 125 µs Gr2: Placebo: Subthreshold TENS. yr (mean. 4 L Gr2: 3 R. 3 sessions/wk for 4 wk Followup done 1 month post treatment Treatment Comparison group Sample size Population details Age. all were affected by a discrete loss of motor function.6 Gr1: 58.7 SD: 10.17 Gr2: 2. 1 Appendix 3J 219 continues . but display showed appropriate values and current.2 months SD: 17. Hemiplegia: Gr1: 7 R.APPENDIX 3J. 14 R Gr3: 7 L. 13 R Gr2: 6 L. Basic physical treatment every day in the morning (no other details available). Characteristics of Included Studies for Transcutaneous Electrical Nerve Stimulation (TENS) Author and year Time since onset Gr1: 3. 60 min/ day. while the circuit was interrupted.30 SD: 5. N/A 5 days/wk for 3 wk N/A Standard customary care. 0.42 months SD: 2. B.9 months Gr2: 29. 3 L Treated area: Hemiparetic lower extremity 1.90 SD: 7. Hemiplegia: Gr1: 7 L.17 months SD: 2.2 months Gr2: 64. 13 R Treated area: Hemiplegic shoulder Levin 1992390 Total: 13 Gr1: 7 Gr2: 6 Spastic hemiparesis due to CVA. high frequency (100 Hz) on the shoulder muscles and the glenohumeral joint.94 Gr1: 67.01 Gr1: High intensity TENS. posterior to the head of the fibula on the hemiparetic lower extremity. 2.65 SD: 4. W) Leandri 199068 Total: 60 Gr1: 20 Gr2: 20 Gr3: 20 Patients suffering from hemiplegic shoulder pain following ischemic stroke.5 SD: 14.4 months SD: 21. Gr3: Placebo: Patients undergoing sham stimulation were connected to the stimulator whose output was loaded with 3 kOhm resistor.72 months Gr3: 64.7 Gr1: TENS to the common peroneal nerve. Patients received no stimulus. Minimum 10° passive ankle dorsiflexion. 0 Session frequency and duration Quality (R. Frequency: 99 Hz. SD for control) Concurrent therapy Follow-up duration 0. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Peurala 2002393 Gr1: 32 Gr2: 19 Gr3: 8 Hemiplegia: 14 L. Gr2: Cutaneous stimulation delivered to affected lower extremity with a sock electrode as Gr1. 0 .4 SD: 10 Gr1: Cutaneous stimulation delivered to affected upper extremity with a glove electrode. Standard customary care at a day care center twice a wk. 2 Session frequency and duration Quality (R. 0. Intensity: N/A Follow-up done 3 months post treatment (treatment group only) 1. 0.1 months Gr1: 73 SD: 3. 20 min each time for 3 wk. 5 sessions/wk for 3 months (total = 60 sessions) Gr3: Placebo stimulation was delivered in the same way but no current was applied. Hemiplegia: Gr1: 7 L. following their firstever stroke occurring 6–12 months previous to the study. Monophasic constant current twin pulses at 50 Hz.7 Hz) for 60 min on the elbow extensors and wrist extensors.0 Total: 44 Gr1: 18 Gr2: 26 Nondemented patients who had a paretic upper extremity (score of 0–50 in the Fugl-Meyer motor performance scale: 0 points means no motor function. The intensity was adjusted to just below sensory threshold. 11 R Gr2: 10 L.APPENDIX 3J. yr (mean.2 months Gr2: 71 SD: 6. 80% had electrodes placed over the elbow extensors and the shoulder abductors. 35 R Sonde 1998391 Gr2: 9.1 months SD: 2. Intensity: N/A Gr1: Control (no TENS).5 Gr2: Low intensity TENS (1. 16 R Treated area: Hemiplegic upper extremity Gr1: 8.3 months SD: 2.3 yr 54. N/A 3 wk N/A Treatment Comparison group Sample size Population details Age. B. 66 points means normal motor function). Continued 220 Author and year Time since onset 3. 40 sessions over 8 wk N/A 1. Hemiplegia: Gr1: 16 R. W = randomization. 0.1 Gr1: Low TENS to post-stroke paretic arm: elbow flexor muscle.1 SD: 3. L = left.8 days SD: 11. Gr2: Placebo TENS: sham stimulation: patients were connected to stimulator with a resistor and display that showed results.9 SD: 7. Appendix 3J 221 .3 days SD: 13. withdrawals. 13 L Treated area: Hemiparetic upper and lower extremity Note: CVA = cerebrovascular accident. B. Todd Davies exercise program—a basic neurophysiological treatment program. 200 µs to extensor muscles of elbow and common peroneal nerve posterior to the head of the fibula on the hemiparetic lower extremity.7 Hz) TENS on the paretic arm for 3 months starting 6 months after stroke. Gr2: Control: no TENS. wrist flexor muscle. 0 Gr1: 47 months SD: 7 months Gr1: 70.4 SD: 6.4 days Gr2: 44. 1 Tekeoolu 1998392 Total: 60 Gr1: 30 Gr2: 30 1) Stroke with hemiplegia or hemiparesis. blinding. Gr = group.1 days Gr2: 52. for half an hour a day.0 Gr1: 100 Hz TENS. Daily rehab (no other information available). however.2 SD: 5.4 Gr1: 55. 7 sessions/wk for 12 wk Follow-up at 3 yr 1. TENS = transcutaneous electrical stimulation. and blood screen. R = right. CT.7 Total: 28 Gr1: 18 Gr2: 10 Patients who had participated in a randomized trial of daily treatment with low frequency (1. the patients received no current. 14 L Gr2: 17 R. 3) patients affected by discrete loss of motor function but who were able to stand or walk if assisted.Sonde 2000397 Gr2: 47 months SD: 7 months Gr2: 72. 1. Quality R. Location of hemiplegia was not reported Treated area: Post-stroke paretic arm Gr1: 40. 2) diagnosis determined by physical and laboratory examination including radiological examination. N/A = not available. and with troughs. ROM = range of motion. 2. W = randomization. . SD for control) Comparison group Follow-up duration Quality (R. Self-ROM exercises for shoulder flexion. withdrawals. 4 R Gr2: 6 L. and external rotation were performed with pulley equipment 3x/ day. 1 Sample size Population details Time since onset Age. L = left. B. repeating each motion five times during each session. Positioning programs were attempted 24 hr/day. Characteristics of Included Studies for Ultrasound 222 Author and year Treatment 7 sessions/wk for 4 wk N/A Concurrent therapy Gr1: 7 months SD: 9 months Gr2: 3 months SD: 2 months Gr3: 4 months SD: 3 months Gr3: 58 SD: 11 Gr2: 59 SD: 10 Gr1: 57 SD: 8 Gr2: Ultrasound to the paravertebral and shoulder joint areas for one 5-min treatment prior to exercise. The arm was positioned in maximum pain-free abduction and external rotation through the use of pillows or slings when the patient was in bed. 4 R Gr3: 3 L.APPENDIX 3K. overhead suspension slings. blinding. 1. abduction. 7 R Treated area: Hemiplegic shoulder Note: Gr = group. yr (mean. or pillows when he was in a wheelchair. All groups received ROM exercises and arm positioning. W) Session frequency and duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Inaba 1972399 Total: 33 Gr1: 13 Gr2: 10 Gr3: 10 Subjects chosen were patients with hemiplegia who had shoulder pain occurring within the range of 0 to 90° of flexion or abduction of the arm. B. Gr1: Control (only concurrent treatment). N/A = not available. Gr3: Placebo: Ultrasound with the energy turned off prior to exercises. R = right. Quality R. Hemiplegia: Gr1: 9 L. 2 months Gr2: 64. 0.2 months SD: 48. It is not visible that the blunt placebo needle is not inserted into deeper tissue layers. an electrical stimulation of 2 Hz was used and increased gradually to achieve muscle contraction. Threshold Modified Ashworth Scale (MAS) score required for admittance to this study was 1 or more. GosmanHedstrom 1998404 Total: 104 Gr1: 37 Gr2: 34 Gr3: 33 Gr2: M: 76 F: 82 Gr3: M: 74 F: 78 Less than 1 wk before randomization Mean age: Gr1: M: 77 F: 75 Patients 40 and over with acute focal ischemic nonhemorrhagic lesion. 2. yr (mean. on the nonparetic side they were stimulated manually every 5 min. and at SP6 and LU9 bilaterally. Deep acupuncture: 10 acupuncture points were used according to traditional Chinese medicine. Patient could not walk without support and/or could not eat/dress without assistance. 0. The needles were 30-mm long. No details provided. On the paretic side. A cube-shaped elastic foam was used to fix the needle on the skin. No acupuncture control: No acupuncture treatments. but the blunt tip on the skin may be felt.3 months Gr2: 61. and when it touches the skin.0 SD: 11. Stroke onset less than 1 wk before randomization. patients feel a pricking sensation. according to traditional Chinese medicine criteria at ST36 and LI10 of the affected limbs. Placebo control (superficial) acupuncture): 4 short needles (15 mm) placed just under the skin in each extremity and left for 30 min. W) Session frequency and duration Fink 2004403 Total: 25 Gr1: 13 Gr2: 12 All patients had hemiparesis and spastic equinovarus deformity of the affected leg. In addition. until the “de chi” sensation was achieved. GV20 was needled in 10 of 13 patients.3 SD: 8. The tip of the needle is blunt. B. LI4 of the affected limbs. N/A 2 treatments/ wk. 2 x/wk for 10 wk 10 months Gr2: Placebo: To avoid transdermal stimulation. and. Patient able to cooperate mentally and willing to participate. The needles (maximum of 15 needles per patient and treatment) were left in place for 30 min after insertion without further manipulation. 4 wk N/A Treatment Comparison group 1.4 Gr1: 56. Each treatment last 30 min. depending on additional symptoms. Standard customary care. GB39. placebo needles were inserted at defined nonacupoints. simulating puncturing of the skin. 1 Appendix 3L 223 continues . 0 Sample size Population details Age. Characteristics of Included Studies for Acupuncture Author and year Time since onset Gr1: 66.APPENDIX 3L.5 months SD: 50. SD for control) Concurrent therapy Follow-up duration Quality (R.8 Gr1: Acupuncture: Verum needles were inserted at acupuncture points GB34. LR3. if indicated. The intensity of electrical stimulation was adjusted to induce muscle contraction. Kjendahl 1997406 Total: 41 Gr1: 21 Gr2: 20 Patients with hemiparesis. they had to be independent for ADL before the stroke. yr (mean. However. Contralateral motor and sensory areas of the scalp were treated with high frequency electrical acupuncture.5 days Gr2: Median: 58 SD: 16. Needles were left in place and stimulated for 30 min. No details provided. Location of stroke: 35 L. Daily PT and OT. Manual stimulation of needles was performed in most cases.APPENDIX 3L. multidisciplinary rehab program. 10 points according traditional Chinese medicine acupuncture. 0. Patients’ paresis had to extend to the point that patient could not walk without support and could not eat and dress without help. Electrical stimulation was performed on 4 needles on the paretic side at 2–5 Hz. 3–4 sessions/wk for 6 wk 12 months Control: No acupuncture treatment. Acupuncture was given on both sides.5 Gr1: Median: 57 SD: 17 Acupuncture: Sites were selected for the treatment of stroke in compliance with traditional Chinese medicine. manually and electrically. following a first ever stroke. only if they had a sufficient understanding for participating in the study. Control: No acupuncture treatment. 8 R Gr2: 11 L. Continued 224 Author and year Time since onset Wthin 10 days of onset Gr2: 75 Gr1: 76 Acupuncture: Treatment began 4 to 10 days after stroke. 1 . W) Session frequency and duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Johansson 1993405 Total: 78 Gr1: 40 Gr2: 38 Patient able to cooperate during examination and tests. Location of stroke: Gr1: 13 L. Individually adapted. B. 43 R Gr1: median: 39 days SD: 22. SD for control) Concurrent therapy Follow-up duration Quality (R. Patients with global aphasia. 0. low-frequency electrical stimulation (2–4 Hz) was applied or moxibustion was added. 30 min/ session. 9 R 2.5 days Gr2: median: 43 days SD: 22. 1 Sample size Population details Age. 2 x/wk for 10 wk NA Treatment Comparison group 1. Clips were attached to the needles but they were not connected to the electrical stimulation machine.9 Total: 35 Gr1: 15 Gr3: 10 Gr2 is not defined here because we did not use values of this group (moxibustion).1 SD: 7. Patients had to have greatly reduced arm and leg power with reduced or no voluntary isolated finger movement 1.25 SD: 8. 1–3 months Gr1: 61. Low-frequency electrical stimulation (1–2 Hz) was used on selected points on the paralyzed size. Affected side: Gr1: 8 R.7 months SD: 3. 3–4 x/wk N/A 1. 0. 5 days/wk for 4 wk N/A Patients with elbow spasticity who were more than 5 wk out from the onset of stroke. 2. Given on both paretic and nonparetic side during 30 min each time.8 Gr1: Electro acupuncture group: Electrical stimulation was applied every other day for 15 days (total of 8 sessions). 0 Naeser 1992408 Total: 16 Gr1: 10 Gr2: 6 Patients who had suffered a left-hemispheric infarction and had significant hemiparesis. Frequency of 50 Hz was given to 4 needles on the paretic side for 30 min. Needles were inserted into these normal resistance points and left in place for 20 min.Moon 2003407 Gr3: 2. 1 Appendix 3L 225 continues . Amplitude strong enough for patients to feel stimulation but not to elicit visible muscle contractions. 7 L Gr2: 5 R. All 3 groups: Same acupuncture therapy for stroke and ROM exercises once a day. which had been ongoing since admission. Placebo: Points of normal electrical resistance on the nonparalyzed upper and lower extremities were identified with a Fluke Ohm meter.6 Gr2: 61 SD: 8 15 to 16 needles of 34 gauge were inserted into standard acupuncture points on the scalp and body and left in place for 20 min. Gr3: Routine acupuncture therapy for stroke and ROM exercises. 5 L Gr3: 4 R.2 SD: 10.7 months Gr1: 58.4 months Gr3: 65.7 months SD: 1. Daily physical therapy. 6 L Gr1: 3. Continued 226 Author and year Time since onset 10 to 14 days Gr1: 60. 28 R Gr2: 25 L. 0. B. B. Gr = group. x/wk = times per week. physically stable. yr (mean. with a clear consciousness and no complications during medical course. 5 x/wk for 2 wk N/A Treatment Comparison group 1. M = male.6 SD: 10. . treatment lasting 30 min. to induce muscle contraction. N/A = not available. ROM = range of motion. withdrawals.APPENDIX 3L. 31 R Note: ADL = activities of daily living. blinding. The magnitude of stimulation was set at a level sufficient to induce muscle contraction (10–20 mV) Control: No acupuncture treatment. Standard customary rehab program with multidisciplinary approaches. W) Session frequency and duration TOPICS IN STROKE REHABILITATION/SPRING 2006 Wong 1999409 Total: 118 Gr1: 59 Gr2: 59 First stroke. including OT and PT for more than 2 hr every day until discharge. Quality R. complicated by physical symptoms of hemiplegia. SD for control) Concurrent therapy Follow-up duration Quality (R. F = female. W = randomization. Stimulation was of 20 to 25 Hz.1 Gr2: 60. L = left. 1 Sample size Population details Age. PT= physiotherapy. OT = occupational therapy.4 SD: 11. Affected side: Gr1: 31 L. R = right.8 Electrical acupuncture: was given at 8 acupuncture points via adhesive surface electrodes of 4 x 5 cm squared at 4 points on the upper extremity and 4 points on the lower extremity on the paretic side. This group then received services at home from multidisciplinary team of geriatricians. Rehab focused on participants’ individual interests. Gr2: Patients received standard stroke care and rehab services in the general ward of the same hospital that provided home hospitalization services for the experimental group. B. nurse. resided in the study catchment area. A physician and a nurse remained on call 24 hr a day. and social workers who specialize in stroke care. yr (mean. Characteristics of Included Studies for Intensity and Organization of Rehabilitation Author and year Treatment Gr1: Patients were immediately transported home after being stabilized.APPENDIX 3M. N/A N/A 6 months N/A 70 or older Sample size Population details Time since onset Age. SD for control) Comparison group Concurrent therapy Follow-up duration 1. and physical therapist visits. Such care included daily physician. 0 Session frequency and duration Quality (R. and had a caregiver available. 0. Appendix 3M 227 continues . W) Ahrens 2004422 Total: 120 Gr1: 60 Gr2: 60 Age 70 or older. and caregivers were encouraged to participate. nurses. therapists. 1 Session frequency and duration Quality (R.4 Gr3: 68.3 SD: 12. Instruction given to relatives and caregivers. SD for control) Comparison group Concurrent therapy Follow-up duration 2. 6. Gr2: An average of three 1-hr sessions over a 6-wk period.1 SD: 11. Gr3: N/A Sample size Population details Time since onset Age. maintenance of functional capacity. outpatient rehab by hospital physician or GP and home care to compensate for disability (no follow-up home visits). Gr2: Instruction and reeducation by hospital PT.9 Gr1: Visits focused on early detection and treatment of complications.3 Gr1: 69.APPENDIX 3M. 19L . and psychological and social adjustment to a new life. Gr3: Standard aftercare. evaluation of range of functions related to indoor and outdoor mobility and ADLs. impaired motor capacity (SSS score of <58 at discharge). 28 L Gr2: 26 R. Continued 228 Author and year Treatment N/A Followup at 6 months (end of treatment) 3 months Acute Gr2: 74. Hemiplegia: Gr1: 21 R. Discussions. discharge to own home. yr (mean. patients and caregivers were provided with info on stroke-related issues. 0. B. Gr1: Three 1-hr sessions at 2. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Andersen 2000423 Total: 155 Gr1: 51 Gr2: 44 Gr3: 43 Admitted with acute stroke as defined by WHO criteria. and 12 wk postdischarge. 20L Gr3: 22 R. medical exam if needed.8 SD: 9. 1 SD:11. patients and caregivers were provided info on stroke related issues. impaired motor capacity (SSS score of <58 at discharge) Hemiplegia: Gr1:19 R. 0. 6.8 SD: 9. 24 L 0 cerebellum 5 brainstem Gr3:15 R. 14 L 1 cerebellum 1 brainstem Gr2:15 R. N/A Gr1: 3 sessions x 1 hr at 2.Andersen 2002424 Gr2: 74.9 Gr1: Visits focused on early detection and treatment of complications. Instruction to relatives and caregivers. evaluation of range of functions related to indoor and outdoor mobility and ADLs. and 12 wk postdischarge. Gr3: N/A 6 months end of treatment 2. 1 brainstem Lesion type: Haemorrhage/ infarction/no lesion Gr1: 7/28/12 Gr2: 7/37/6 Gr3: 6/28/8 N/A Outcomes were taken 6 months after discharge Gr1: 69. 1 Appendix 3M 229 continues . maintenance of functional capacity.3 Total: 155 Gr1: 51 Gr2: 44 Gr3: 43 Admitted with acute stroke as defined by WHO criteria. medical exam if needed. psychological and social adjustment to a new life with stroke related disability. outpatient rehab by hospital physician or GP and home care to compensate for disability (no follow-up home visits).3 SD: 12.4 Gr3: 68. Discussion concerning health conditions/strokerelated symptoms/ functional capacity. 17 L 1 cerebellum. discharge to own home. Gr2: 3 sessions average x 1 hr over 6-wk period. Gr2: Instruction and reeducation by hospital PT. Gr3: Standard customary aftercare. 1 Session frequency and duration Quality (R. Continued 230 Author and year Treatment N/A Follow-up at 1 year N/A Gr1: 79 SD: 6 Gr2: 76 SD: 9 Gr1: Patients received treatment from all categories of personnel that are requested in rehab (PT. B. SD for control) Comparison group Concurrent therapy Follow-up duration 0. 0. admission/ discharge from the rehab program. The patients were assessed and followed up by a PT and an OT.APPENDIX 3M. 1996 and January 8. yr (mean. speech therapist). All patients had a diagnosis of stroke and needed continuous rehab after discharge from the acute ward. hospital social worker. Sample size Population details Time since onset Age. OT. the assessments were made at admission/ discharge from the acute ward. 1998. and at 6 and 12 months poststroke. . Gr2: The acute N/A ward was located in one hospital and the rehab ward located in another hospital. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Andersson 2002425 Total: 124 Gr1: 56 Gr2: 68 Patients admitted either to the University Hospital in Linkoping between November 27. They spent their initial acute care period in a stroke unit. or to Eksjo County Hospital between September 15. 1997 and May 18. nurse. but under the same management. 1998. N/A 6. Corr. In principle. the subject could continue this program throughout the following wk.1 Gr2: Home therapy: Therapists devised a program of exercises and activities in collaboration with the subject. The mobile team was based within the stroke unit and consisted of a nurse. Hemiplegia: Gr1: 23 R. This was a functional approach that incorporated. Followups at 6 wk and 3 months (end of treatment) Appendix 3M 231 continues . as far as possible.7 SD: 9. able and willing to provide informed consent. and the consulting service of a physician. 0. inclusion within 72 hr after admission to the stroke unit and within 7 days after the onset of symptoms. 1 Baskett 1999428 Gr2: 67. an OT. together with Kielhofner’s model of human occupation. 27 L Gr2: 16 R. 34 L N/A Acute Gr1: 71. N/A Gr1: 76. 52 wk 2. N/A Gr1: 5 hr/ session. but the cooperating mobile team was only available to the extended service patients. goals set toward restoration or improvement of normal activities within the home and extending the boundaries of limitation that people had set for themselves.6 Total: 100 Gr1: 50 Gr2: 50 A need for ongoing PT and/or OT after discharge as determined by the treating clinicians. SSS score > 2 points and <58 points.9 Gr2: 76. 26.3 Gr1: The extended service consists of stroke unit treatment combined with a home-based program of follow-up care coordinated by a mobile stroke team that offers early supported discharge and works in close cooperation with the primary health care system during the first 4 wk after discharge. and Shepherd. subjects were residents in a private home or rest home (residential homes for frail elderly people) within the health service region of the hospital. 0. the same primary health care system was available to both the ordinary service and the extended service patients.Askim 2004426 Total: 62 Gr1: 31 Gr2: 31 Diagnosis of an acute stroke according to the WHO definition of stroke. Gr1: Outpatient group: Multidisciplinary team assessment followed by goal setting. living at home before the stroke. 1 Gr2: The ordinary service consists of treatment in a combined acute and rehab stroke unit and further follow-up organized by rehab clinics and/or the primary health care system. subjects were able to travel to the hospital outpatient therapy departments. 2–3x/ wk Gr2: 13 wk of treatment 2.8 SD: 11. PT practice followed principles outlined by Bobath. OT practice was centered mainly on Bobath neurodevelopmental and Corr and Shepherd motor relearning treatments. a PT. 0. One of these 3 (primary contact) started immediate preparations for discharge and continued rehab provided by the general community services organized in 11 different local areas. B.1 Gr2: 79. Gr2: General Ward: Received conventional acute medical care. Patients in need of prolonged rehab were transferred to geriatric SU. 74 L Gr2: 37 R. 23 L Gr2: 23 R. yr (mean.APPENDIX 3M. Hemiplegia: Gr1: 85 R. living in their own homes in Göteborg. N/M 3 and 6 months follow-up N/A Acute Gr2: 78. and a PT. N/A Patients in need of prolonged rehab were transferred to geriatric stroke units.0 SD: 4. 72 hr poststroke).0 Gr1: 79. no other medical condition likely to preclude rehab and medically stable (Barthel score 5–19. Patients received significantly more occupational and physical therapy than the General Ward group. Sample size Population details Time since onset Age. home-dwelling and not severely disabled prior to the stroke. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 BautzHolter 2002427 Total: 82 Gr1: 42 Gr2: 40 All patients with acute stroke (onset less than 6 days prior to hospitalization). Caring for the group was encouraged to establish a multidisciplinary team for each patient and support offered. and OT. 1 . Gr1: Stroke Unit (SU): The treatment program was built on the principal of SU care with a team work concept for nursing and rehab. Sweden. Hemiplegia: Gr1: 16 R.7 0. 0.5 SD: 7. as was the focus on the patients’ needs and participation in the treatment. although not within the framework of a structured stroke unit care approach. 35 L Speech disorder: Gr1: 79 Gr2: 41 Less than 7 days Gr1: 80. Continued 232 Author and year Treatment Initial care in acute stroke unit. Support and information for relatives was an important part of the program. Follow-up after 12 months Gr2: Conventional rehab: Patients received the conventional procedures for discharge and continued rehab. PT. 1 Session frequency and duration Quality (R. 14 L Claesson 2000429 Total: 249 Gr1: 166 Gr2: 83 Patients aged 70 yr or over. without recognized need of care.5 Gr1: Early supported discharge: Patients were assessed by a hospitalbased multidisciplinary project team consisting of a nurse. an OT. acute stroke within 7 days before admission. SD for control) Comparison group Concurrent therapy Follow-up duration 2. 95 Gr2: 70.75 days Gr1: 58.1 SD: 13.75 days Gr1: 75. 16.44 days SD: 17. 0. 14 L Gr3: 8 R. Included: teaching new skills. although they could receive any available services as required.80 days Gr3: 68.5 days Gr2: 10 days SD: 12. 12 L 1 bilateral Gr2: 7 R. and 24 wk after discharge. Follow-up at 1 year post-stroke 2. Gr2: Standard customary OT: OT activities such as transfers.10 SD: 6. No contact with researcher. the visits were checkup visits and subjects were questioned about their progress and any existing problems.52 days SD: 21.95 SD: 13. facilitating more independence in ADL.38 days SD: 10. 0.Corr 1995430 Gr2: 75. referring to or liaising with other agencies.69 Total: 128 Gr1: 21 Gr2: 21 Gr3: 23 Hemiplegia: Gr1: 8 R.65 SD: 9. 15 L Gr1: 29.11 Gr3: Control No additional input over which they were receiving from hospital and social services.) 233 continues . 1 Gr2: Control group: No special intervention or follow-up. Appendix 3M Gr1: Leisure rehab: The treatment program reflected personal preferences and abilities. and perceptual treatment. In situations where subjects were virtually independent. enabling patients to use equipment supplied by other agencies.43 days Gr3: 25. (Same time as time of Gr1 with therapist. Interventions based on the model of human occupation. This model was in addition to any other follow-up services and community PT. giving information to the patient and caregiver. Days from stroke onset to stroke unit admission: Gr1: 11 days SD: 21.75 Gr1: Intervention group: Rehab at home by an OT. then 30 min of treatment a fortnight for 3 months. N/A Gr1: Patients were assessed by an OT at 2. facilitating return of function. Hospital and social services Gr1&2: Once a wk Follow-ups at 3 and 6 months 2.8 SD: 10 Total: 110 Gr1: 55 Gr2: 55 Patient discharged alive between April 1991 and January 1992 from 2 stroke units in South Glamorgan. 8. washing and dressing practice. 1 Drummond 1995432 Gr2: 28. irrespectively of discharge destination. 30 min of treatment per wk for first 3 months. Hemiplegia: N/A 1. no history of dementia. and providing physical assistance. W) Drummond 1996a431 Total: 315 Gr1: 176 Gr2: 139 Patients admitted with diagnosis of stroke between January 1. such as transfers and dressing practice. 0. did not need to be transferred for further medical treatment. and liaison with specialist org.69 Gr3: 68. and had an address in the Nottingham District Health Authority. Continued 234 Author and year Treatment Gr1: Stroke unit (no description of specific treatment received). 1993. had no severe comprehension problems. 1 Session frequency and duration Quality (R. B. N/A Gr1: 58. then 30 min a fortnight for 3 months TOPICS IN STROKE REHABILITATION/SPRING 2006 Drummond 1996b433 Total: 65 Gr1: 21 Gr2: 21 Gr3: 23 Patients who spoke English. 30 min a session at least once a wk for 3 months after discharge.95 Gr1: Leisure rehab: Advice and help falling into the following broad categories: treatment. Control: Gr3: No intervention. such as referral to volunteer agencies. Gr2: Standard customary ward (no description of specific treatment received). advice on obtaining financial assistance and transport. 1 .65 SD: 9.1 SD: 6. yr (mean.11 Gr2: 70.APPENDIX 3M. provision of equipment. 0. 1991 and June 30. Gr2: Received standard customary OT activities. such as practice of transfers needed for leisure pursuits. SD for control) Comparison group Concurrent therapy Follow-up duration 1. Hospital and social services Follow-ups at 3 and 6 months N/A N/A Follow-ups at 3 and 6 months Within 5 wk of acute stroke N/A Sample size Population details Time since onset Age. positioning.95 SD: 13. 5 R 1 brain stem Treated area: Upper/ lower extremity N/A Gr1: 67.2 Total: 20 Gr1: 10 Gr2: 10 30–90 days after onset. facilitative exercises. Mini-Mental State score <18. 2) 15 min of balance exercise. bimanual activities. N/A 2. approximately 44 min a visit. 1. Gr2: Patients had approximately 39 visits.Duncan 1998103 Gr2: 67. Patients instructed to continue on their own for additional 4 wk.8 SD: 7. progression when patient able to complete 2 x 20 reps. receptive aphasia that interfered with the ability to follow a 3step command. Hemiplegia: Gr1: 4 L. 0.6 yr Gr1: Home-based exercises program provided by PT.3 SD: 9. 1 Appendix 3M 235 continues . N/A Gr1: 3 sessions/wk for 8 wk. Visit included balance training. 4 patients had outpatient PT). 3) patients encouraged to use affected upper extremity. Gr2: Usual care as prescribed by their physicians (6 patients had home health visits.5 hr a session. 4 blocks: 1) assistive and resistive exercise using PNF patterns to upper and lower extremities or theraband exercise to major muscle groups of upper and lower extremities. Exclusion: Medical condition that interfered with outcome assessment or that limited participation in submaximal exercise program. 10-min warm-up (stretching and flexibility). 6 R Gr2: 4 L. increased theraband resistance or increased PNF manual resistance. and living at home within 50 miles of the University of Kansas Medical Center. ambulatory with supervision and/or assistive device. minimal or moderately impaired sensorimotor function. progressive resistive exercises. an Orpington Prognostic Scale score of 2. and test of O2 saturation. 22 L Gr2: 22 R. elbow. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Duncan 2003104 Total: 92 Gr1: 44 Gr2: 48 Stroke within 30 to 150 days. upper extremity functional use. yr (mean.5 SD: 28. vital signs. strengthening resistive exercises: 2 sets of 10 repetitions. ability to ambulate 25 feet independently.0 to 5. and trunk. SD for control) Comparison group Concurrent therapy Follow-up duration 2. balance training. hip.5 SD: 9.0 Gr1: Exercise program: ROM and flexibility for shoulder.APPENDIX 3M. and Folstein Mini-Mental Status examination score >16. fingers. Gr2: Standard customary care: Home visits by research staff every 2 wk for health education. Sample size Population details Time since onset Age.1 days Gr2: 70. and endurance training (up to 30 min on bike): 36 sessions of 90 min. 1.7 days Gr2: 73. mildto-moderate stroke deficits defined by a Fugl-Meyer score of 27 to 90 for upper and lower extremity. 1 Session frequency and duration Quality (R.2 SD: 11.4 Gr1: 68. 22 L . Continued 236 Author and year Treatment N/A 12–14 wk N/A Gr1: 77.2 and palpable wrist extension on the involved side. ankle. Hemiplegia: Gr1: 18 R.5 SD: 27. wrist. B. 4 SD: 12. and liaison with patients and relatives. goal setting. Usual care team members from each discipline individually evaluated the patient.6 SD: 11. CPM used to plan. Gr2: Control: Functioned more like a multidisciplinary team (discipline oriented). 0. N/A Follow-ups at 2 and 11 months 1. Individualized rehab plan with clearly defined goals based on joint assessments.6 Gr4: 73. The generic nursing and therapy staff on the ward provided rehab. 1 Falconer 1993435 Gr2: 21.Evans 2002434 Gr2: 76.7 days SD: 15.6 SD: 8.5 days Gr2: 67. and control the patient’s program and progress.4 SD: 13. Hemiplegia: N/A N/A Gr1: 74. planning of treatment.8 Gr1&3: Care provided by a stroke physician and multidisciplinary team with specialist experience in stroke management. mobility. or self-care abilities and requiring multidisciplinary treatment. Hemiplegia: N/A Gr1: 23.6 SD: 7. discharge arrangement. Confirmed diagnosis of stroke.5 Total: 267 Gr1: 80 Gr2: 84 Gr3: 49 Gr4: 54 Moderately severe stroke was defined as persistent neurological deficit affecting continence.5 days SD: 22. but the specialist team provided input for assessments.3 days Gr1: 68. Semimonthly meeting to update patient status. Appendix 3M 237 continues . monitor.6 SD: 14. teams were comparable in seniority and specialist experience and had access to similar resources in the hospital and community. CPM designed to facilitate interdisciplinary communication and coordination. Gr2&4: Care provided by general wards from admitting physicians.9 Total: 121 Gr1: 53 Gr2: 68 Adults admitted to Rehabilitation Institute of Chicago with diagnosis of recent (within 120 days) stroke. N/A N/A N/A 1. Treatment after discharge was provided by community services.2 Gr3: 75.9 Gr1: Critical Path Method (CPM) (method for visually charting the steps that must be completed to carry out the project): Functioned more like an interdisciplinary team (team oriented). 0. 1 In the same hospital. Continued 238 Author and year Treatment N/A Gr1: 45 min/ day. OT. Gr2: Therapy provided off the units in separate therapeutic facilities.61 days SD: 77. 5 days/ wk for 4 wk Followup at 6 months 1 wk post stroke Gr2: 61. Initiated within the first wk after stroke onset.94 Gr1: Therapy included Bobath techniques and passive movement training of the affected limb.49 SD: 10. B. Gr1: Stroke unit. 0. Most of the staff had rotated through the stroke unit.14 SD: 11. No specific cognitive or acupuncture therapy was administered. 460 none Gr2: 35R.74 Total: 667 Gr1: 589 Gr2: 78 Patients with stroke admitted for rehab. Family teaching was emphasized on all units. 1 . yr (mean. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Fang 2003436 Total: 128 Gr1: 50 Gr2: 78 Stroke was defined as an acute onset of neurological deficits lasting more than 24 hr or leading to death with no apparent cause other than cerebrovascular disease.03 SD: 10. PT. Confirmed CVA diagnostic. Gr2: Did not receive professional or regular physiotherapy during the whole hospitalization period.APPENDIX 3M.94 Gr1: 65. 9 none Gr1: 64. 0.8 SD: 10.75 days SD: 47. 33L.81 days Acute Gr2: 69. 1 Session frequency and duration Quality (R. 10 both.65 days Gr1: 67. SD for control) Comparison group Concurrent therapy Follow-up duration 2. and speech therapy. Hemiplegia: Gr1: 266 R. Same standardized protocols utilized throughout the hospital for nursing. 150 both. Feigenson 1979437 Gr2: 48.73 All groups: Similar therapeutic programs. N/A N/R Follow-up at 6 wk (end of treatment) Sample size Population details Time since onset Age. therapy on the unit. 262 L. 0. Stroke-related symptoms and complications were treated with the help of a multidisciplinary team (the same for Gr1). 239 continues . 0. and balancing was usually instituted early. 0 Fjaertoft 2003439 Gr1: 160 Gr2: 160 Within 72 hr of admission and less than 7 days after the onset of symptoms N/A Gr1: Further follow-up was organized by the primary health care system. Training was given in ambulation and self-care activities. Both groups received similar stroke unit care during the acute phase with focus on early mobilization/ rehab combined with a standardized acute medical treatment program. Norway. 37–82 Gr2: Range. demonstrate a nontransient neuromuscular deficit. 36–80 Gr1: Rehab program prescribed by a physician on the staff in the Department of Physical Medicine and Rehabilitation. Gr2: Control: Program of functionally oriented medical care supervised by the personnel of the medical and neurological wards. Training in sitting. ability to live independently before the onset of stroke. inclusion within 72 hr of admission and less than 7 days after the onset of symptoms. The programs were prescribed individually and were varied according to patients’ needs and progress. N/A Follow-up at 52 wk 2. Social and vocational services were provided when indicated through the hospital social service or community agencies. The prime limitation was the patient’s ability to participate. admitted to the stroke unit with signs and symptoms of an acute stroke. SSS score between 2 and 57 points. standing. be admitted to hospital within 2 months of the onset of hemiparesis. and no participation in other trials.Feldman 1961438 Gr1: 42 Gr2: 40 Have a diagnosis of hemiparesis secondary to cardiovascular disease. Gr2: Comprehensive follow-up stroke service organized by a mobile team. Appendix 3M Patients from the city of Trondheim. 0. 0 N/A N/A N/A 2. N/A Gr1: Range. 14 L Gr2: 15 R. ability to tolerate minimum of 3 hr of therapy per day.7 SD: 7. B. and potential for improvement in function. domino playing. yr (mean. cognitive activities.25 Gr1: Occupational adaptation group: Received combination of occupational readiness (ROM. When transferred to rehab unit. cooking). 0. were seen for OT treatment starting in acute care and followed through rehab at the same facility. Gr2: Control: N/A ROM exercises and facilitation for the affected upper extremity. Continued 240 Author and year Treatment N/A Follow-up at 3 wk (end of treatment) N/A Acute Gr2: 73. subjects received kitchen activity. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Gibson 1997440 Total: 50 Gr1: 25 Gr2: 25 Patients hospitalized in acute care after onset of CVA. Hemiplegia: 24/26 Gr1: 11 R.5 SD: 5. Sample size Population details Time since onset Age. bedside ADL) and occupational activities that stimulate occupational environment/role (OE/R) tasks (gardening. and received the customary amount of OT intervention in acute care. a community outing. 1 Session frequency and duration Quality (R. and ADL focused treatment. and bedside ADL. follow directions.75 Gr1: 74.APPENDIX 3M. 10 L . SD for control) Comparison group Concurrent therapy Follow-up duration 0. were at least age 60 yr. The other patients who for socioeconomic reasons or a lack of rehab beds received no rehab were recruited in the 2nd group. caregivers and local OT staff. Side of hemiplegia: Gr1: 13 R. Inpatient multidisciplinary rehab predischarge home visit for selected patients. 0 Gr2: Control group: Routine service (routine follow-up). N/A Gr1: 10 visits within 6 wk Gr2: N/A Followups at 8 wk and 6 months from baseline 2. 8 L Gr2: 11 R. OT worked with patient to achieve these goals and also liaised with other agencies for advice.Gilbertson 2000441 Gr2: 23 days SD: 13. 1 Gürsel 1998442 Total: 43 Gr1: 21 Gr2: 22 Patients with no previous history of completed stroke and with relatives who agreed to take the patient to the clinic for a 2nd evaluation 6 months later. Gr2: Patients were informed about the disease and instructed to exercise according to program at home. admitted to a Glasgow royal infirmary NHS trust. Gr1: Rehab program for a mean time of 14 wk. 33 L Gr2: 33 R.5 Gr1: Intervention service: Designed to be clientcentered. N/A Gr1: 14 wk in rehab program Followup at 6 months (end of treatment) 0.25 days Gr2: 71 SD: 58 Total: 138 Gr1: 67 Gr2: 60 Clinical diagnosis of stroke. regular multidisciplinary review at a stroke clinic. 0. services. 0. and discharge date had been set. 6 wk domiciliary program (approximately 10 visits lasting 30–45 min). developed through focus group sessions with patient. 11 L N/A M/F: Gr1: 12/9 Gr2: 14/8 Age: Gr1: 63 (11) Gr2: 59 (13) Appendix 3M 241 continues . The same standard customary therapy techniques were applied to all patients. 38 L Gr1: 31 days SD: 10 days Gr1: 71 SD: 30. tailored to recovery goals identified by the patient such as regaining self-care or domestic or leisure activities. Hemiplegia: Gr1: 34 R. and equipment. and selected patients referred to a medical hospital. provision of support services and equipment. Gr1 was formed by patients admitted to the rehab unit in the early phase. had been to the OT department. bladder elimination. feeding. dressing. prophylaxis against pressure sores. personal hygiene. SD for control) Comparison group Concurrent therapy Follow-up duration 2. prophylaxis against contracture. B. 0. 1. The following were emphasized: psychological activation. All evaluated and treated by same physical therapist. 10 L Gr2: 7 R. 0 . W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Hamrin 1982443 Total: 59 Gr1: 33 Gr2: 26 N/A Hayes 1986444 Gr2: 70 SD: 9 Total: 30 Gr1: 15 Gr2: 15 All participants had diagnoses of acute CVA upon admission to a large metropolitan teaching hospital. 0. Continued 242 Author and year Treatment Gr2: Control: General medical ward without activation program in nursing. Hemiplegia: Gr1: 5 R. 6 L N/A Acute Gr1: 70 SD: 12 Gr2: Received standard rehabilitative treatment between 4–15 days after admission. 1 Session frequency and duration Quality (R. N/A Follow-up at end of treatment Sample size Population details Time since onset Age. N/A Gr1: For 4 wk Followup at 11 months N/A Gr1: 73 SD: 10 Gr2: 72 SD: 11 Gr1: Activation program in nursing. ambulation. verbal communication. movement therapy. Gr1: Received an early intervention of rehab care within 72 hr of hospital admission. yr (mean.APPENDIX 3M. and bowel elimination. or self-directed activities. The program emphasized a taskand context-oriented approach.6 Gr1: Rehab at home. supervised. the case manager (a therapist) was responsible for coordination of discharge procedure. Managed in the wards before randomization Total duration: 3 to 4 months N/A Followup at 3 months (end of treatment) 2. and/or outpatient care to others introduced during the study period. Heterogeneous set of interventions ranging from the best established in the hospital. Team: 2 PTs. independence in feeding and continence. 1 Appendix 3M 243 continues . Gr2: Routine rehab: All patients in this group were also admitted to the Department of Neurology. which implies that the patient performs guided. 14 L 5 to 7 days Gr1: 70.Holmqvist 1998445 Gr2: 72. liaison between therapists. one speech therapist. for example. 24 L Gr2: 23 R.8 SD: 7. MiniMental State Examination score of >23. Hemiplegia: Gr1: 15 R. dysphasia.6 SD: 8. impaired motor capacity and/or. In each case. daily afferent sensory stimulation by low-frequency TENS and homebased rehab. and a social worker on a consulting basis. at-home therapy. day care. and contact with neurologist responsible.9 Total: 81 Gr1: 41 Gr2: 40 Acute stoke. 0. 2 OTs. 8 Sample size Population details Time since onset Age. and a physician offering parttime services. The service includes: systematic diagnostic evaluation. very early mobilization and rehab in a stroke unit.APPENDIX 3M. in a day clinic. B. living at home before stroke. Continued 244 Author and year Treatment Gr1: Extended Stroke Unit Service (ESUS). provision of informed consent. PT. Team: nurse. The team tried to establish a service and support system that allowed the patient to live at home as soon as possible after the stroke and to continue necessary training and rehab at home. standardized observation of vital signs and neurological deficits. N/A N/A Follow-ups at 6 and 26 wk Acute onset Gr1: 74. 1. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Indredavik 2000446 Total: 320 Gr1: 160 Gr2: 160 Signs and symptoms of acute stroke according to the WHO definition of stroke. the team also offered training and support at home in addition to service from other agencies. OT. 1 Session frequency and duration Quality (R. included within 72 hr after admission to the stroke unit and within 7 days after the onset of symptoms. an acute medical treatment program. Stroke unit treatment – according to evidence-based recommendations – combined with further inpatient rehab when more long-term rehab is necessary. lack of participation in other trials. SD for control) Comparison group Concurrent therapy Follow-up duration 1. Stroke unit treatment similar to OSUS combined with service from a mobile team that offers early supported discharge and coordinates further rehab and followup in close cooperation with the primary health care system.0 Gr2: 73. For some patients with more extensive needs. or by a combination of these 2 alternatives. and a follow-up program organized by the primary health care system after discharge. SSS score between 2 and 57 points. . Gr2: Ordinary Stroke Unit Service (OSUS). yr (mean. Hemiplegia: Gr1: 18 R. 4 bilateral Follow-up at 3 yr 1. 2 bilateral Gr2: 19 R. 14 L. had completed a rehab program. were not on antidepressant medications. N/A Acute 69. None N/A Gr2: Control: Subjects were visited by an OT and asked questions about leisure activity involvement throughout their life span. focused on problems affecting ADLs and mobility in the context of home environment and support. 1.6 Total: 40 Gr1: 20 Gr2: 20 Patients had incurred a stroke within the past 15 months. 8 L N/A Gr1: 77. Gr2: Treatment according to existing general ward practices (no details available). The therapist also asked each person about the effects of the stroke on his or her life. 8 L Gr2: 12 R. 0 Kalra 1995448 Total: 71 Gr1: 34 Gr2: 37 Inclusion: Stroke patients with Orpington Prognostic Score >5 and referred for rehab on a stroke unit. Hemiplegia: Gr1: 12 R.6 SD: 11 Gr1: Experimental leisure activities including individual or social activities carried out in the home or community environment. 1 Appendix 3M 245 continues .2 SD: 8 yr Gr2: 80.4 SD: 12. 0. and had a close relative or friend who was willing to participate in the study.1 yr Gr1: Individualized rehab program reviewed on a daily basis. N/A Five 1-hr visits at home over a 5-wk consecutive period Follow-ups at 5 wk (end of treatment) and 13 wk 1. were not severely aphasic.Jongbloed 1991447 Gr1: 68.2 Gr2: 69. 14 L. mobility. and ability to look after themselves. PT. yr (mean. B. and speech and language therapists.APPENDIX 3M. The team undertook stroke assessments and collaborated with wardbased nursing and therapy staff in goal setting.3 SD: 6 Gr3: 77. 0. arrangements. Continued 246 Author and year Treatment None Tx for 3months 9 months <72 hr Gr1: 75 SD: 6 Gr2: 77. and liaison with patients and relatives. Day-to-day treatment was provided by staff on the ward. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Kalra 2000449 Total: 447 Gr1: 148 Gr2: 150 Gr3: 149 Inclusion: Patients with moderately severe stroke (persistent neurological deficit affecting continence. and planned discharges. and social services. 76 L Gr2: 76 R. planning of treatment. All patients were seen by a specialist team with experience in stroke management. nurse. requiring multidisciplinary treatment) who could be supported at home with nursing. OT. SD for control) Comparison group Concurrent therapy Follow-up duration 2. 76 L . Patients were under the joint care of the stroke team. Routine management involved joint assessments and goal setting. therapy. discharge. Gr3: Domiciliary care patients were managed in their own home by a specialist team consisting of a doctor. Hemiplegia: Gr1: 69 R. 1 Session frequency and duration Quality (R. coordinated treatment. which was reviewed at weekly multidisciplinary meetings.7 SD: 8 Gr1: Stroke unit care provided by a stroke physician supported by a multidisciplinary team with specialist experience in stroke management. 67 L Gr3: 70 R. with support from a district nursing and social services for nursing and personal care needs. Gr2: Stroke team patients were managed on general wards and remained under the care of admitting physicians. Sample size Population details Time since onset Age. Each patient had an individualized care plan outlining activities and the objectives of treatment. 1:8 (summer vacation). N/A Once a wk for 10 wk Follow-ups at 11 wk and 22 wk 1.9 SD: 14. N/A Gr1: 62. Nurses were dedicated to stroke patients.23 SD: 15. Stabilized patients were transferred in subacute care-bed: nurse/patient ratio 1: 4 (day). 0. 3 PTs evaluated patients on admission and followed up on them until discharge. ADL training.6 months Gr2: 62.4 Gr2: 62. One stroke fellow patient and 2 residents took part in the daily management. functional ambulation training with gait correction. Followup on patient weekly (by multidisciplinary staff). but 10 wk later (control group for the first 10 wk). 8 R 247 continues . and living in the Nan-Tou County area during the research. Appendix 3M Hemiplegia: Gr1: 3 L. motor facilitation.2 Home-based physical therapy administered by PTs.Krespi 2003450 Gr2: 61. severe to moderate residual disability with Barthel Index score 5–14. physio) were not different from the rest of the patients having other neurological diseases.8 months SD: 9. The main aspects of care (nursing. 0 Hemiplegia: N/A Gr1: All hospitalized acute stroke patients were followed for at least 48 hr in the Stroke Intermediate Care Unit: nurse/patient ratio 1:4 (day). Total:19 Gr1: 9 Gr2: 10 Stroke onset greater than 1 yr. consisting of: 50–60 min/session. postural control training. 1:12 (night). 0. 1:24 (night). 2 residents took part in the management. ability to follow verbal instructions. not involved in any kind of rehab program in the past 6 months. PTs were consulted when needed. 6 R Gr2: 2 L.4 N/A N/A N/A 0. Lin 2004451 Gr1: 44. and daily exercise programs tailor-made for patients’ needs. Nurses were not dedicated to stroke patients.4 months Gr1: 61. Gr2: Same as Gr1.8 SD: 9.4 SD: 11.47 Total: 704 Gr1: 352 Gr2: 352 Inclusion: Patients admitted between January 1997 and August 2000 to the Istanbul Medical Faculty Neurology Department. 1 Gr2: Nurse/patient ratio 1:12 (day).0 months SD: 29. 5 hr sessions. SD for control) Comparison group Concurrent therapy Follow-up duration 1.APPENDIX 3M. 1 Session frequency and duration Quality (R.5 SD: 10 Gr1: 73.5 SD: 7. N/A Acute Gr2: 65. . and wash own face. no planned discharge date within 2 wk. able to drink. no subsequent follow-up done. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Lincoln 1996452 Total: 76 Gr1: 39 Gr2: 37 No other medical problems requiring continued treatment on an acute medical or geriatric ward. Continued 248 Author and year Treatment Standard customary stroke unit treatment. N/A N/A 6–16 wk.5 Sample size Population details Time since onset Age. and independent for toileting before stroke. yr (mean. able to transfer from bed to chair with help from no more than 2 nurses. Standard customary ward treatment. able to tolerate rehab (in . 0. B. 2 hr/day). eat. This therapy follows a Bobath approach predominantly. 0. specific neuromuscular techniques.2 Gr1: Enhanced OT service: Patients were seen and treated by a single research OT. were able to feed themselves and wash their own faces before the stroke. and functional rehab. N/A Acute Gr2: 74 SD: 11. Diagnosis checked with Nottingham stroke register. 1 NA Median age: Gr1: 73 (IQR: 65–81) Gr2: 73 (IQR: 6–80) Gr3: 73 (IQR: 64–80) Gr1: Qualifiedphysiotherapist (QPT) group: The patients received standard PT in addition to being treated by a senior research PT. 24 L Gr2: 32 R.Lincoln 1999453 Total: 282 Gr1: 95 Gr2: 94 Gr3: 93 Patients had no planned discharge date from the hospital within the next 7 days. 26 L Appendix 3M 249 continues . Hemiplegia: Gr1: 29 R. did not have premorbid dementia. Gr2: Standard customary OT service: All patients were prioritized by the senior OT. had no premorbid severe impairment of the affected upper limb. 1 Logan 1997454 Total: 111 Gr1: 53 Gr2: 58 First-time stroke patients discharged from hospital and referred to the city of Nottingham’s and the Boroughs of Gelding and Beeston’s social services OT departments. Gr1& 2: Patients received standard PT under the supervision of a senior research assistant. Ongoing assessments and specialized advice were given at each treatment. were able to speak or to understand English before the stroke.5 Gr1: 71 SD: 10. Motor and functional tasks had to be practiced between therapy sessions. Follow-ups at 8 wk and 20 wk 2. Gr2: Therapy sessions for approximately 2 hr/wk by a PT assistant. Gr1: Senior research PT gave specific sessions for approximately 2 hr/wk. and most patients received treatment. others were placed on a waiting list. Gr3: Routine physiotherapy (RTP) group (control): Patients received standard PT as is given at the City hospital. and were reported by the physiotherapists as being able to tolerate a half-hour session of PT daily. Gr3: PTsessions each weekday for approximately 30–45 min. but had some impairment of arm function. N/A Varied according to each patient Followups at 3 months (end of treatment) and 3 months 2. Gr2: Assistantphysiotherapist (APT) group: Patients were treated by a trained PT assistant. provided more frequent visits to patients than control. No additional treatment by the research PT. 0. all broadly based on the Bobath approach. All urgent cases were seen immediately. This additional treatment consisted of facilitation. Access to aids and budgets for adaptations. 1. SD for control) Comparison group Concurrent therapy Follow-up duration 2. 1 Session frequency and duration Quality (R. 1 .6 Total: 155 Gr1: 73 Gr2: 82 Stroke survivors after an average of 13 days in an acute care setting Hemiplegia: Gr1: 35 R. and responsible for restoring his own well-being. Concurrent treatment: Standard inpatient rehab program consisting of half an hour of PT and OT 5 days/wk. 37 L Gr2: 37 R. The intervention was based on a written guidebook based on Orem’s model of selfcare.8 SD: 7. Continued 250 Author and year Treatment N/A Variable per individual N/A Gr1: 70. 12 wk 3 months Follow-ups at 1 month (end of treatment) and 3 months Sample size Population details Time since onset Age. It emphasized the broad care approach that believes in the ability of a person to be active. dietician). 2. responsible for his or her condition.APPENDIX 3M.ST) as requested by patient’s care provider and offered through extended acutecare hospital stay. but private care was also possible. 0. inpatient or outpatient rehab.3 SD: 12. Gr Control: Concurrent treatment only. OT.7 Gr2: 69. and home care via local community health clinics. PT. Individualized treatment. Nursing students met with the patients 1x/wk for 12 consecutively weekly session of 1–2 hr each.8 Gr1: Concurrent treatment and a structured written nursing intervention program. 1x/wk.7 Gr1: Prompt discharge from hospital with immediate provision of follow-up services by multidisciplinary team (nursing.OT. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Mayo 2000455 Total: 114 Gr1: 58 Gr2: 56 Persons who had persistent motor deficits after stroke and who had caregivers willing and able to provide live-in care for the subjects over a 4-wk period after discharge from hospital. yr (mean. Gr2: Regular discharge service (PT.6 SD: 12. Hemiplegia: N/A Nir 2004456 Gr2: 73. 45 L 13 days Gr1: 72. ST. B.3 SD: 6. Gr2: Assistant physiotherapy (APG) group: Patients received additional treatment from a trained supervised assistant trained with the help of a manual.Parry 1999457 Total: 282 12 days N/A Gr1: 94 Gr2: 93 Gr3: 95 Patients had to be able to participate in at least 30 min of routine PT per day and to have motor impairment of a previously functional arm. 0. Exclusion: N/A Hemiplegic: N/A Gr1: Qualified physiotherapy (QPT) group: Patients received additional treatment from a qualified PT. 1 Appendix 3M 251 continues . Gr1&2: Patients received additional PT. Gr1&2: 10 hr additional treatment over a 5-wk period Followup at 5 wk post treatment (6 months) 1. Gr3: Routine physiotherapy (RPT) group: No additional therapy was given. The additional PT aimed to reflect current British practice. Principles of treatment followed those of the Bobath approach. with some influence of movement science-based approaches. Aims of treatment with the Bobath concept: midline alignment. Hemiplegia: 53 R. balance reeducation. 0 Session frequency and duration Quality (R. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Partridge 2000458 Total: 114 Gr1:54 Gr2: 60 All patients with a diagnosis of stroke.5 Sample size Population details Time since onset Age. of positive support reaction. Inhibitions. Working to improve base of support. Maintenance of full range of movement. admitted over a 2-year period to the Canterbury Stroke Unit. Gr2: Standard amount of therapy. modifying muscle tone. and stability and transfer of weight. Continued 252 Author and year Treatment Gr1: Standard amount of therapy. All aspects of reeducation. Working on shoulder girdle and scapulohumeral rhythm. SD for control) Comparison group Concurrent therapy Follow-up duration 2. according to WHO criteria. Duration: 60 min/day. 60 L . facilitating all aspects of transfers.5 SD: 8. 0. plus higher intensity of rehab. sequencing of movements. postural adjustment.APPENDIX 3M. B. Facilitating functional hand/ arm movement. Duration: 30 min/day. Gr1: 60 min/ day Gr2: 30 min/ day Followups at 6 wk and 6 months (end of treatment) N/A 76. and symmetry and control. yr (mean. they needed to be able to perform functional independent transfer. Patients allocated to continue with their treatment. and community nurse visits for specific tasks. generic domiciliary PT and speech and language therapy. On discharge patients were referred to standard customary services resources. The community therapy team comprised a senior PT grade 1 with neurological training. and outpatient care in the normal way. The patients were assessed for rehab needs before discharge in conjunction with the hospital-based therapists to set initial objectives and to ensure continuity of care. discharge planning. Outpatient resources available to them included a hospital-based stoke clinic. Gr2: Standard customary care. OT. A consultant physician coordinated the team and chaired the weekly clinical meeting. 0. with visits as frequently as considered appropriate (maximum 1 daily visit from each therapist). which was reviewed at a weekly team meeting. Followups at 3 months (end of treatment) and 9 months 2.Rudd 1997461 Gr2: 72 SD: 12 N: 231 Gr1: 167 Gr2: 164 If patients lived alone. meals on wheels. a halftime ST with adult neurological training. N/A Gr1 : Maximum duration of 3 months. and a full-time therapy aide. and if they lived with a willing caregiver they needed to be able to perform transfer with assistance. a home help for personal care. After discharge. 1 Appendix 3M 253 continues . and speech therapy. Each patient had an individual care plan. Gr2: Maximum duration of three 1-hr visits daily. geriatric day hospital. hospital outpatient PT and the usual community resources. N/A Gr1: 70 SD: 11 Gr1: Community therapy team. About half of the patients who were admitted received treatment in general medical or elderly care wards. a senior OT grade 1. patients were given a planned course of domiciliary PT. No time limit involved for the duration of the home care program. and social services as were provided as appropriate. outpatient services.96 Sample size Population details Time since onset Age. The 7th day was open for rest and visitation. 1 Gr1: 46 Gr2: 46 Gr2: 73 Range. 44–91 Patient had to have a home address in Newcastle. could not be living in residential or nursing home care prior to the incident stroke. Before each discharge. 47–93 Gr1: Early supported discharge group: Stroke discharge team consisted of OT. had to be medically stable with a Barthel Activities of Daily Living Index between 5–19 at 72 hr post stroke. Followup at 3 months post stroke . Gr1: The discharge rehab service was available 5 days/wk. Hemiplegic: N/A Median age Gr1: 73 Range. W) Ruff 1999462 Total: 113 Gr1: 57 Gr2: 56 N/A TOPICS IN STROKE REHABILITATION/SPRING 2006 Rodgers 1997460 Total: 92 Within 48 hr of admission 2. SW. and community rehab services. and speech therapy. Gr1: Standard customary 6day treatment regiment. a member of the team would do a home visit without the patient and the day of the discharge a team member would bring the patient home. and OT technician. every day if required. The team was based in the community to establish a relationship with referred stroke patients and their families early in hospital stay. Gr2: Standard care group: Inpatient and outpatient care was provided by standard hospital and community services. comprised of occupational. physical. Discharge planning and services post discharge arranged and provided according to the usual practice of each participating ward or unit. B. N/A N/A Gr1: 6 x/wk Gr2: 7 x/wk None N/A Gr1: 78. PT. Continued 254 Author and year Treatment Gr2: 7 days/wk treatment program. ST. with the patients receiving necessary nursing and medical attention. but home care component of the service was available all day. SD for control) Comparison group Concurrent therapy Follow-up duration 1. Community support was provided by the primary care team. Received an additional 7th day of rehab treatments. yr (mean. 0. 0. 0 Session frequency and duration Quality (R. could not be severely handicapped prior to the incident stroke (Oxford Handicap Scale 0–3).APPENDIX 3M.98 Gr2: 70. had no other condition likely to preclude rehab. Rodgers 2003459 Gr2: 5 days (2) median 626 Gr1: 5 days (2. 0. Exclusion: not medically stable within 10 days. significant communication difficulties.5 SD:10. twice a day when in the medical ward of the University Hospital. Gr1: 30 min/ session. The principle of the treatment was that PT should be given as long as functional recovery was taking place or the patient could perform independently at home.5) median Gr1: 62 Gr2: 61 Stroke in the previous 10 day resulting in upper extremity impairment due to one or more of the following: weakness.1 SD: 9. 34 L Gr2: 26 R. The guiding principle was. sensory loss. 35 L 1 wk Gr1: 71. 15 days/ month. Follow-up at 1 wk (end of treatment) 2. 0.1 Gr1: Intensive treatment (IT): One department was redesigned as a rehab unit with the especial purpose of treating stroke patients. 15 days/ month. to old age homes or chronic care departments of community hospitals where some of them were able to obtain PT. The patients received the normal physical therapy in the standard customary medical wards. cognitive problems. 1 Sivenius 1985463 Total: 95 Gr1: 50 Gr2: 45 N/A Appendix 3M Gr2: Normal treatment (NT): The patients were discharged from these departments to their homes or. 255 continues . or visual impairment. if it was not possible.5 Gr2: 70. 5 days/ wk for 6 wk Gr2: N/A Follow-ups at 6 wk and 18 wk 2. 4 sessions/wk. 0 Median age Gr1: 74 Gr2: 75 Gr1: Enhanced upper limb therapy time: 30 min of rehab from PT and OT 5 days/wk for 6 wk. Gr2: 3 sessions/wk. Hemiplegia: Gr1: 28 R. that no patient’s condition worsened as a result of study. ataxia. persistent impaired conscious level in days 0–10 (Glasgow coma scale). and severe handicap prior to stroke. The remaining patients were treated in neurological wards of the University Hospital. the duration and amount of which was determined by the internists. Gr1: Enhanced upper extremity therapy for 30 min. Gr2: Control Gr1&2: Interdisciplinary treatment program: Current stroke unit PT (Bobath based) and OT practice combining a normal movement approach within meaningful activity and task analysis. however. total number of treatment sessions: 37. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Smith 1981464 Total: 133 Gr1: 46 Gr2: 43 Gr3: 44 Inclusion: Confirmed diagnosis of stroke. Patients should be able to manage the most intensive of the 3 treatment regimens.6 days of PT.8 hr of PT. Gr2: 3 times per half day for up to 6 months. 36.3 days of OT. light and communication. dependent patients.APPENDIX 3M. independent patients. duration: 34.5 Gr1: Stroke unit.6 hr of PT. total number of treatment sessions: 35.1 days of PT. 0 . B. indoor mobility. toileting and personal hygiene. Patients too old or too frail for intensive rehab. dressing. 1 Session frequency and duration Quality (R.4 days of OT. Patients were classified as independent if they could carry out the following 7 activities without human assistance: getting in and out of bed. Gr4: General ward. dependent patients.2 days of PT. independent patients. 98. total number of treatment sessions: 128. referred back to hospital or other services if necessary. 0. < 60 days 72. yr (mean. regularly visited at home by a health visitor. 1.2 hr of PT. 125. 0.7 days of OT.9 hr of OT.1 hr of PT. 93. Gr3: Control: No routine rehab. 71.8 hr of OT. and encouraged to continue with exercises taught while in hospital. Gr2: General ward. total number of treatment sessions: 82. Exclusion: Patients making a full recovery while in hospital. 39. cooking a simple hot meal. Gr3: N/A Followup at 3 months (end of treatment) Gr1: 35 days Gr2: 41 days Gr3: 37 days Gr1: 63 Gr2: 66 Gr3: 65 Sample size Population details Time since onset Age. Patients living outside the district. 70. duration: 41.1 days of OT. Smith 1982465 Total: 307 Gr1: 78 Gr2: 47 Gr3: 49 Gr4: 60 Patients who were conscious and had an established or developing hemiplegia at the time of assessment.7 days of PT. SD for control) Comparison group Concurrent therapy Follow-up duration 1. Continued 256 Author and year Treatment Gr1&2: PT and OT treatment in groups and individually. duration: 127. Gr3: Stroke unit. duration: 67.2 hr of OT. feeding oneself. and controlling heat.8 hr of OT. N/A N/A N/A None Gr1: 4 full days/wk for up to 6 months. 56. 5 days/ wk. 7 days/wk.8 Gr2: 64. passive ROM exercises for affected side and muscle strengthening exercises for unaffected side. and the time taken to achieve these goals were discussed in weekly multidisciplinary meetings and changed on the basis of patients’ progress. Therapeutic activities. Standard customary rehab: 40 min of PT. Key goal for each therapeutic intervention and the time estimated to achieve these were defined in advance.1 days Gr1: 62. Patients freely ambulated in the corridor. 0. and speech therapy 5 days/wk. goals. and speech therapy 5 days/wk. 0. patients were encouraged to stay out of sleeping area during daytime. days since onset to admission ranged from 30–80.7 FIT program: 40 min of PT and 40 min of OT similar to conventional rehab. spoke and interacted with each other. < 2 wk Gr1: 75 SD: 11 Gr1: Integrated care pathways: Therapeutic activities were grouped according to stage and predicted patients’ needs. 40 min of OT. and had a cognitive subscore of the FIM greater than 25. N/A N/A Followup at 6 months 1. In addition. and selfinitiated exercises and self-care activities. The integrated care pathway covered all aspects of inpatient rehab from admission to discharge. Appendix 3M 257 continues . orthoses used if necessary.8 days Gr2: 54. 0 N/A Gr1: 7 days/wk Gr2: 5 days/wk N/A 0. 0 Sulch 2002467 Gr2: 74 SD: 10 Total: 152 Gr1: 76 Gr2: 76 Patients transferred to a stroke rehab unit within 2 wk of the acute event. Gr2: Multidisciplinary team care: Patients were assessed for individual needs and a customized rehab program was designed under the supervision of a consultant.Sonada 2004466 Total: 106 Gr1: 58 Gr2: 48 Stroke patients. These goals were discussed in weekly multidisciplinary meetings and changed on the basis of patients’ progress. Gr1: 49. gait exercises related to ADLs. had a motor subscore of the FIM less than 80. Used behavioral methods to encourage the patient and family to be active participants in arm rehab and to help the patient avoid becoming a passive recipient of expert therapy. Emphasis was placed on giving the patient tasks of graded difficulty and providing objective feedback on performance. The emphasis is on expert handson treatment by the therapist and patients are not routinely instructed to exercise between therapy sessions. Patients who had suffered previous strokes were only included if it was clear that they had full use of the arm before the present episode. yr (mean. to prevent learned non-use of the affected UE. Specific aims were to promote greater adherence to self-directed exercise programs. Hemiplegia: Gr1: 22 R. supported by CT scan when available. W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Sunderland 1992468 Total: 137 Gr1: 36 Gr2: 35 Gr3: 29 Gr4: 32 Clinical diagnosis of unilateral acute stroke.APPENDIX 3M. and to facilitate learning of new motor skills.25 days Gr3: 9 days SD: 7. 1 Session frequency and duration Quality (R.25 days Gr2: 10 days SD: 7. Based on the neurophysiological techniques described in the text by Bobath and Johnstone. An eclectic approach was taken in selection of treatment techniques. Sample size Population details Time since onset Age. Active movement may not be encouraged until abnormal muscle tone is well controlled. B. and goal-setting. Continued 258 Author and year Treatment Standard customary OT. Inability to complete the Nine Hole Peg test (NHPT) within 18 s when using the affected hand despite visual and verbal prompts to try to overcome any visual neglect. Being well and alert enough to receive active therapy. This text describes the major techniques used. Patients received more than double the amount of therapy for the UE.25 days Gr4: 70 yr SD: 12. 14 L Gr2: 19 R. to combat overprotectiveness from spouses.5 yr Gr2: 68 yr SD: 8 yr Gr1: 65 yr SD: 14 yr Gr1&3: Enhanced therapy. N/A Follow-up at end of 6 months Gr1: 8 days SD: 8. which included Bobath exercises. SD for control) Comparison group Concurrent therapy Follow-up duration 2. More intensive treatment for the arm. They also received more encouragement to practice between sessions. EMG biofeedback. 15 L . microcomputer games. 14 L Gr4: 17 R. 16 L Gr3: 15 R.25 yr Gr3: 67 yr SD: 11. 0.5 days Gr4: 8 days SD: 7. Gr2&4: Conventional therapy. 0. N/A N/A 0. 6L Gr1: 24 days SD: 25. outpatient care.97 Gr1: Home therapy 2–3 x/day. when the home therapy program could be reviewed following reassessment.Teng 2003469 Total: 114 Gr1: 58 Gr2: 56 Persons with persistent motor deficits after stroke who had caregivers willing and able to provide live-in care for the subject over 4-wk period after discharge from hospital. 3L Gr2: 6R. The patients were asked to practice their exercises at the agreed times until the next visit.86 Total: 22 Gr1: 10 Gr2: 12 Participants who achieved less than 95% of normal performance on a task requiring a repeated reaching action (a peg transfer test). which were considered to be appropriate to their individual stage of recovery and to the problems they experienced. Appendix 3M 259 continues . Gr2: Control: Patients were visited at home for assessment only. Both groups followed regimes recommended by the hospital rehab staff.8 days Gr1: 59 SD: 11. and perceptual or cognitive impairments had to be able to understand instructions.1 days Gr2: 58 SD: 6. inpatient rehab. 1 Turton 1990470 Gr2: 16 days SD: 6. 1 N/A N/A Followup at 3 months 1. and home care provided by local community health service center). 0. Those with sensory or proprioceptive problems in addition to motor deficits. private care. The patients were provided with a booklet and a program of exercises. Gr2: Standard customary care: Current practice for discharge planning and referral for followup services (such as extended acute-care hospital stay. Hemiplegia: Gr1: 7R. Both groups followed regimes recommended by the hospital rehab staff. apraxia. Hemiplegia: N/A N/A N/A Gr1: Home group: 4wk tailor-made home program of rehab and nursing services. APPENDIX 3M. Continued 260 Author and year Treatment N/A N/A Follow-up at 1 month < 1 month Gr1: 73.6 yr SD: 8.1 yr Gr2: 75.1 yr SD: 8.6 yr Gr1: Standard OT: The aim of therapy was independence in personal and instrumental ADLs. Personal care included activities such as bathing, feeding, dressing, and stair mobility. Instrumental ADLs included activities such as outdoor mobility, driving a car, traveling by public transport, and household chores. The focus of therapy was active intervention rather than assessment or liaison. A series of 10 exercises to promote an efficient gait pattern and weight transfer was designed hierarchically in terms of complexity. Gr1: Patients had PT for 1 hr twice a wk. The exercises were taught by the PT who provided feedback and corrected the patient. Gr2: Patients performed the same exercises as Gr1, at home with supervision from their spouse. PT monitored the home exercise program to provide the spouse with clarification on matters arising. Gr3: PT and home-supervised: Patients attended PT for 1 hr once a wk to undertake the exercises under the supervision of a PT. The patients also performed the exercises once a wk in their home under the supervision of their spouse. Gr4: Control: No exercise treatment was given. N/A Each exercise lasted 5 min: 1.75 min performing 10 repetitions and a 45-s rest. A total of 10 exercises were performed in 1 hr with a 5-min rest interval after 15 min of exercises. Before treatment, at 1-month intervals during treatment, and for 3 months after treatment Gr2: No OT: Patients received no additional input from the research therapist, but may have received input from existing services, as would occur in routine practice. Sample size Population details Time since onset Age, yr (mean, SD for control) Comparison group Concurrent therapy Follow-up duration 2, 0, 1 Session frequency and duration Quality (R, B, W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Walker 1999471 Total: 185 Gr1: 84 Gr2: 79 Hemiplegia: Gr1: 39 R; 45 L Gr2: 41 R; 40 L Wall 1987472 Total: 20 Gr1: 5 Gr2: 5 Gr3: 5 Gr4: 5 Inclusion: Subjects demonstrated a reduced support phase time on the affected lower extremity; all were capable of walking with or without a cane. Treated area: Lower extremity 18 months to 10 yr 45–70 yr 1, 0, 1 Werner 1996279 Gr2: 3.3 wk SD: 1.9 wk Acute Gr2: 66 SD: 13 Total: 54 Gr1: 33 Gr2: 21 Between 6 months and 5 yr after hospital discharge following an acute middle cerebral artery vascular event (CT scan/clinical presentation); functional comprehension; no medically significant comorbidities that would compromise functional status beyond the effects of the stroke; no generalized sensory deficit; no history of recurrent stroke; no ongoing therapeutic rehab intensity in past 4 months; or ADL limitation. Hemiplegia: N/A Gr1: 2.9 wk SD: 1.8 wk Gr1: 59 SD: 19 Gr1: Interventions oriented toward functional tasks such as transfers, walking, self-care, and feeding by using modalities such as: strengthening, stretching, mobilization, muscle retraining/facilitation; given by trained OT and PT. Gr2: No outpatient therapy. N/A Session/wk: 2 hr of OT/PT 4 x/wk a for 12 wk Followups at 3 months (end of treatment) and 3 months post treatment 2, 0, 1 Appendix 3M 261 continues APPENDIX 3M. Continued 262 Author and year Treatment N/A N/A N/A Gr1: 12.7 days SD: 1.1 days Gr2: 17.5 days SD: 1.3 days Gr2: 74.6 SD: 91.8 Gr1: 74.0 SD: 1.5 Gr2: Rehab governed by FIM. Repeated assessments using an FIM instrument were done by the staff to determine the rehab planning and fix goal making on an individual patient-by-patient basis. Gr1: Standard customary methods of rehab. Standard customary method of assessment following the Bobath concept. The Bobath concept underlines the need for inhibiting the stroke patient in specific ways so that he or she will have to relearn normal movements, which makes the patient dependent on ward staff for a longer period of time. Gr2: Day hospital. The patients received standard PT. N/A Gr1: 11 sessions in 8 wk. Gr2: 2 x/wk for a total of 15 sessions in 8 wk. N/A Sample size Population details Time since onset Age, yr (mean, SD for control) Comparison group Concurrent therapy Follow-up duration 1, 0, 1 Session frequency and duration Quality (R, B, W) TOPICS IN STROKE REHABILITATION/SPRING 2006 Wikander 1998473 Total: 34 Gr1: 13 Gr2: 21 Incontinent stroke patients Hemiplegia: Gr1: 9 R; 12 L Gr2: 4 R; 9 L Young 1993474 Total: 95 Gr1: 52 Gr2: 43 (Inclusion criteria from a previous study): Over 60 yr of age; and about to be discharged home after a new stroke that had caused persisting disability. Exclusion: N/A Gr2: 70 Range, 60–88 N/A Median age: Gr1: 69 Range, 60–89 Gr1: Home PT. The patients received active hands-on standard treatments by PT for a total of 11 sessions in 8 wk. 1, 0, 0 Note: ADL = activities of daily living; CVA = cerebrovascular accident; EMG-BFB = electromyographic biofeedback; F = female; GP = general practitioner; Gr = group; IQR = interquartile range; L = left; M = male; N/A = not available/not applicable; N/M = not measured; N/R = not reported; OT = occupational therapy; PT = physiotherapy; Quality R, B, W = randomization, blinding, withdrawals; R = right; SSS: Scandinavia Stroke Scale; ST = speech and language therapist; SW = social worker; PNF = proprioceptive neuromuscular facilitation; ROM = range of motion; TENS = transcutaneous electrical nerve stimulation; UE = upper extremity; WHO = World Health Organization; x/wk = times per week. APPENDIX 4. Existing Guidelines on Stroke Rehabilitation Rehabilitation intervention Levels I and II Levels I and II N/A N/A Evidence-Based Clinical Practice Guidelines Royal College of St. Joseph’s Health Care London (2004)73 Physicians (2004) 72 Department of Veterans Affairs / Department of Defense US Army (VA/ DoD) (2003)75 Heart and Stroke Foundation of Ontario (2002) 71 Scottish Intercollegiate Guidelines Network (SIGN) (2002) 74 Therapeutic exercises Good evidence existing on enhancing sensorymotor recovery of the upper limb as an intervention. Fair evidence about avoiding the use of overhead pulleys for patients with motor impairments and moderate shoulder pain. Limited evidence that the restorative approach increases the number of patients who are institutionalized, and that the Bobath treatment improves the quality of gait. Strong evidence that strength training improves gait, that balance training improves outcomes, and that sensorymotor training with robotic devices improves functional and motor outcomes of the shoulder and elbow. Moderate evidence that aggressive range of motion therapy, commonly using overhead pulleys, results in markedly increased shoulder pain, and that the gentler range of motion program is preferred. Level I Levels I and II N/A N/A Quality of published evidence Levels I, II, and III evidence (see Table 2) Clinical recommendations Existing good evidence that the use of overhead pulleys should be avoided. Fair evidence to support that stroke patients should participate in a regular strengthening and aerobic exercise program. Poor evidence to support that strengthening should be included in the acute phase. Biofeedback Quality of published evidence Electromyography (EMG) biofeedback should be included as an intervention for patients who have a high level of motor return for reducing motor impairment and improving functional motor recovery. Level I Levels I and II Level I Clinical recommendations There is insufficient evidence as to whether routine use of biofeedback should or should not be used as an intervention for patients undergoing stroke rehabilitation. Strong evidence that biofeedback training improves gait and standing. Existing evidence that biofeedback systems should be routinely excluded as an intervention for post-stroke rehabilitation. Existing fair evidence that EMG biofeedback should not be used routinely in the rehabilitation of function and movement. Appendix 4 263 continues APPENDIX 4. Continued 264 Rehabilitation intervention N/A Level I Level I N/A Evidence-Based Clinical Practice Guidelines Royal College of St. Joseph’s Health Care London (2004)73 Physicians (2004) 72 Department of Veterans Affairs / Department of Defense US Army (VA/ DoD) (2003)75 Heart and Stroke Foundation of Ontario (2002) 71 Scottish Intercollegiate Guidelines Network (SIGN) (2002) 74 Acupuncture Quality of published evidence N/A Conflicting evidence that acupuncture is effective for improving stroke outcomes. Insufficient evidence to make definitive statements about the role of acupuncture. Acupuncture should only be used as an intervention for patients undergoing post-stroke rehabilitation in the context of ongoing trials. N/A N/A N/A TOPICS IN STROKE REHABILITATION/SPRING 2006 Clinical recommendations N/A Balance training N/A N/A Level I Existing strong evidence that balance training post-stroke improves outcomes. Quality of published evidence N/A N/A Level I N/A Clinical recommendations N/A N/A N/A N/A N/A Constraintinduced movement therapy N/A Quality of published evidence Level I Clinical recommendations This therapy should be considered as a treatment for a select group of patients with 20º of wrist extension and 10º of finger extension, who have no sensory and cognitive deficits. This therapy should be included as an intervention for patients undergoing stroke rehabilitation. N/A N/A and post-acute stroke patients. Therapy for shoulder subluxation There is existing good evidence that FES should be included as an intervention for the reduction of shoulder subluxation in sub-acute stroke patients. Proper positioning of the hemiplegic shoulder helps in the prevention of subluxation. Existing good evidence that FES should be included as an intervention for the reduction of shoulder subluxation in subacute stroke patients. Shoulder strapping and prolonged positioning do not result in significant reductions in pain or improvements in upper limb function or range of motion. N/A Quality of published evidence Levels I and II Level I Level I Level I N/A Clinical recommendations Recommendation for the use of functional electrical stimulation (FES) for gait training. N/R Levels I and II N/A N/A Recommendation for the use of FES for gait training. There is insufficient evidence as to whether multi-channel FES should or should not be included as an intervention for severe hemiplegic patients with gait impairment. FES should be included as an intervention for the treatment of the shoulder in sub. There is limited evidence that shoulder slings influence clinical outcomes. FES should be included as an intervention for the treatment of the shoulder in sub.Electrical stimulation FES should be included as an intervention for the treatment of the shoulder in sub. FES should not be routinely considered as an intervention for stroke patients. Quality of published evidence N/A Clinical recommendations N/A N/A N/A Appendix 4 265 continues .and postacute stroke patients.and post-acute stroke patients. There is limited evidence that shoulder slings influence clinical outcomes. Electromyography (EMG) biofeedback and electrical stimulation of the wrist and the forearm should be included as an intervention to reduce motor impairment and improve functional motor recovery. if non steroidal anti-inflammatory analgesia has no significant effect. N/A N/A Quality of published evidence N/A TOPICS IN STROKE REHABILITATION/SPRING 2006 Clinical recommendations N/A Therapeutic ultrasound N/A Quality of published evidence N/A N/A Level I N/A Clinical recommendations N/A Existing evidence that adding ultrasound therapy to range of motion exercises does not change outcomes. N/A N/A . Recommendation that high-intensity TENS should be included as an intervention for patients undergoing stroke rehabilitation. Continued 266 Rehabilitation intervention N/A Level I Level I N/A Evidence-Based Clinical Practice Guidelines Royal College of St. spasticity and ADL. Joseph’s Health Care London (2004)73 Physicians (2004) 72 Department of Veterans Affairs / Department of Defense US Army (VA/ DoD) (2003)75 Heart and Stroke Foundation of Ontario (2002) 71 Scottish Intercollegiate Guidelines Network (SIGN) (2002) 74 Transcutaneous electrical nerve stimulation (TENS) N/A There is conflicting evidence that TENS improves a variety of outcomes.APPENDIX 4. including motor recovery. TENS should only be used as a routine intervention for improving muscle control in the context of ongoing trials. Appendix 4 267 continues . and for the use of rhythmic auditory stimulation in patients post-stroke. N/A Quality of published evidence Level I Clinical recommendations There is insufficient evidence to recommend for or against neurodevelopmental training compared to other approaches for motor retraining post. Level I Level I N/A Level I Task-oriented training Existing evidence to encourage functional task training for stroke patients with functional deficits in affected limbs. and insufficient evidence to recommend multichannel FES for severe hemiplegic patients with gait impairment. Stroke Prevention and Educational Awareness Diffusion (SPREAD) Collaboration (2000)76 Quality of published evidence Evidence to encourage functional task training for stroke patients with functional deficits in affected limbs. N/A Levels I and II N/A Level I Level I N/A Clinical recommendations Treadmill training with partial body weight support should be included as an adjunct to conventional therapy for patients undergoing stroke rehabilitation. Agency for Health Care Policy and Research (AHCPR) (1995)70 Level II Conclusion that the benefit of leisure therapy post-stroke is uncertain. Strong evidence was found to include FES for patients undergoing stroke rehabilitation.stroke. Treadmill training with partial body weight support should be included as an adjunct to conventional therapy for patients undergoing stroke rehabilitation. Level I Clinical recommendations Existing evidence to encourage functional task training for stroke patients with functional deficits in affected limbs. Existing evidence to support the use of task-specific training to improve task performance.Gait training Quality of published evidence N/A Conflicting evidence on the use of treadmill training. and body-weight support and treadmill training. Conflicting evidence for FES for gait training following stroke. Joseph’s Health Care London (2004)73 Physicians (2004) 72 Department of Veterans Affairs / Department of Defense US Army (VA/ DoD) (2003)75 Heart and Stroke Foundation of Ontario (2002) 71 Scottish Intercollegiate Guidelines Network (SIGN) (2002) 74 Sensory intervention N/A For sensory function training of the hand. strong evidence was found that perceptual training interventions improve perceptual functioning. Existing conflicting evidence that external sensory interventions such as eye movement feedback are beneficial in the treatment of visual neglect. Continued 268 Rehabilitation intervention N/A Level I N/A N/A Evidence-Based Clinical Practice Guidelines Royal College of St. N/A N/A Quality of published evidence N/A TOPICS IN STROKE REHABILITATION/SPRING 2006 Clinical recommendations N/A . For visual attention retraining. there is strong evidence that visual scanning techniques improve visual neglect with associated improvements in function.APPENDIX 4. There is poor evidence to support that occupational therapy treatment should be based on an assessment of the individual’s unique problems..Intensity and organization of rehabilitation N/A Existing good evidence that: a faster recovery and an earlier discharge from the hospital can result from intense therapies delivered in short periods of time within the post-stroke rehabilitation process. post-stroke rehabilitation provided by specialized stroke units enables patients to maintain both short. European Stroke Initiative (2003)78 Intensity and organization of rehabilitation (continued) Quality of published evidence Level not reported Clinical recommendations Appendix 4 The evidence is poor as to whether stroke patients for whom care services are able to provide adequate and flexible support within 24 hrs should be considered for a home management program. care pathways do not reduce hospital costs or decrease the length of hospital stays for patients undergoing post-stroke rehabilitation. There is good evidence that stroke patients in the acute phase should be treated in a multidisciplinary stroke unit. these patients should be admitted to the hospital for initial care and assessment. patients undergoing post-stroke rehabilitation can maintain and even improve functional outcomes for up to 1 year. There is also good evidence that stroke patients should only be managed at home if the services delivered at home are part of a stroke service provided by specialists and that otherwise. care pathways do not improve post-stroke rehabilitation outcomes. There is good evidence that acute care for patients undergoing post-stroke rehabilitation in a hospital should be delivered in a ward or ward area with specialists with expertise in stroke management (i. a stroke unit).and long-term functional improvements.78 N/A = not applicable. when compared with general medical units. Quality of published evidence Level I N/A Levels I and II Level I Levels I and III Clinical recommendations There is insufficient evidence as to whether inpatient stroke rehabilitation care demonstrates superiority in outcomes when compared to outpatient stroke rehabilitation. The evidence is fair as to whether the improvement of patients’ functional outcomes is a direct result of an early admission to post-stroke rehabilitation. additional home-based therapy does not improve the overall functional outcome scores for patients undergoing post-stroke rehabilitation.e. 269 Note: This previously existing clinical practice guideline was looked at though it was deemed not applicable: the European Stroke Initiative (2003). N/C = not considered. N/R = not reported (N/R). There is also good evidence that early rehabilitation therapy should be provided as soon as the patient’s medical status is stable. .