Repetitive Transcranial Magnetic Stimulation (rTMS)
Introduction
Transcranial magnetic stimulation is a pain-free, non-invasive technique used to stimulate the central nervous system. The electric currents necessary to stimulate the brain are produced by rapidly changing magnetic fields that are initiated by a brief high-intensity electric current that passes through a wire coil held over the scalp. The subsequent magnetic field is projected perpendicular to the electric current and is able to passes through the layers of human tissue (skin, bone, cortex) with very little impedence. TMS can be delivered via single-pulse, double-pulse, paired-pulse and repetitive pulse (rTMS).
rTMS is the method currently under investigation for use as a treatment for stroke mainly due to its ability to modulate excitability in the cerebral cortex over longer time periods (compared to other types of TMS). It can also enhance some cognitive processes, regulate activity in specific brain regions and provide causal information about the roles of different cortical regions in behavioural performance. The use of rTMS can also enhance neuroplasticity during motor training.
Theta burst stimulation is a type of rTMS that has been found to effectively induce synaptic long-term potentiation and depression and is also currently under investigation for use as a treatment therapy for stroke.
According to some experimental studies, a stroke would cause a relative hyperactivity of the unaffected hemisphere due to the release from reciprocal inhibition by the opposite hemisphere which would explain some of the dysfunctions observed in this population. (Brighina et al, 2003). This phenomenon is called "interhemispheric inhibitory interactions". Thus inhibitory stimulation (low frequency rTMS) to the unaffected hemisphere could work to curb this problem. In addition, other researchers like Talelli et al. (2007) suggest that excitation of the affected hemisphere (with high frequency rTMS) enhances corticospinal output and leads to promising therapeutic results. Nevertheless, there is still a clear lack of knowledge on the exact mechanisms of TMS.
Note: Only the studies that looked at rTMS as a rehabilitation intervention were considered in this module.
Authors*: Adam Kagan, B.Sc., Sarah Bouchard-Cyr, Mylène Boudreau, Amélie Brais,Valérie Hotte, Jo-Annie Paré, Anne-Marie Préville, Mylène Proulx.
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
Patients less than a month post-stroke are identified as in acute stage of recovery.
Patients between 1-6 months post-stroke are identified as in sub-acute stage of recovery.
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
A randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
Patients less than a month post-stroke are identified as in acute stage of recovery.
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
Patients between 1-6 months post-stroke are identified as in sub-acute stage of recovery.
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
Patients between 1-6 months post-stroke are identified as in sub-acute stage of recovery.
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
A randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
Patients longer than 6 months post-stroke are identified as in chronic stage of recovery.
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
Patients longer than 6 months post-stroke are identified as in chronic stage of recovery.
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
Patients longer than 6 months post-stroke are identified as in chronic stage of recovery.
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
Patients longer than 6 months post-stroke are identified as in chronic stage of recovery.
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
Patients longer than 6 months post-stroke are identified as in chronic stage of recovery.
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
Patients longer than 6 months post-stroke are identified as in chronic stage of recovery.
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
Patients longer than 6 months post-stroke are identified as in chronic stage of recovery.
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
Patients longer than 6 months post-stroke are identified as in chronic stage of recovery.
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
Patients longer than 6 months post-stroke are identified as in chronic stage of recovery.
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
A randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
Patients longer than 6 months post-stroke are identified as in chronic stage of recovery.
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
A randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.
Patients between 1-6 months post-stroke are identified as in sub-acute stage of recovery.
1a (Strong)
Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings
1b(Moderate)
1 RCT of high quality (PEDro ≥ 6)
2a (Limited)
At least 1 fair quality RCT (PEDro = 4-5)
2b (Limited)
At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.)
3(Consensus)
Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results
4 (Conflicting)
Conflicting evidence of 2 or more equally well-designed studies
5 (No evidence)
No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines)
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
A randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
Patients between 1-6 months post-stroke are identified as in sub-acute stage of recovery.
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
A randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
Patients between 1-6 months post-stroke are identified as in sub-acute stage of recovery.
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
Patients between 1-6 months post-stroke are identified as in sub-acute stage of recovery.
An experimental study in which the participants are not randomized to receive treatments and as such the investigators lack control over allocation to interventions. This study design is inferior to a randomized controlled trial (RCT) but is valuable in answering research questions when an RCT is not possible either because of ethical constraints or logistic restraints.
| 1a (Strong) | Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings |
| 1b(Moderate) | 1 RCT of high quality (PEDro ≥ 6) |
| 2a (Limited) | At least 1 fair quality RCT (PEDro = 4-5) |
| 2b (Limited) | At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) |
| 3(Consensus) | Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results |
| 4 (Conflicting) | Conflicting evidence of 2 or more equally well-designed studies |
| 5 (No evidence) | No well-designed studies - only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) |
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
A randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.
Patients less than a month post-stroke are identified as in acute stage of recovery.
Administration of two or more experimental therapies one after the other in a specified or random order to the same group of patients.
Patients between 1-6 months post-stroke are identified as in sub-acute stage of recovery.
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
A randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.
Patients less than a month post-stroke are identified as in acute stage of recovery.
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
A randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.
Patients less than a month post-stroke are identified as in acute stage of recovery.
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
A randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.
Patients less than a month post-stroke are identified as in acute stage of recovery.
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
A randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.
Patients between 1-6 months post-stroke are identified as in sub-acute stage of recovery.
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
A randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.
Patients between 1-6 months post-stroke are identified as in sub-acute stage of recovery.
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
A randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.
Patients between 1-6 months post-stroke are identified as in sub-acute stage of recovery.
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
A randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.
Patients longer than 6 months post-stroke are identified as in chronic stage of recovery.
An experimental study in which the participants are not randomized to receive treatments and as such the investigators lack control over allocation to interventions. This study design is inferior to a randomized controlled trial (RCT) but is valuable in answering research questions when an RCT is not possible either because of ethical constraints or logistic restraints.
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
A randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.
Patients longer than 6 months post-stroke are identified as in chronic stage of recovery.
*high quality = PEDro score 6-10
*fair quality = PEDro score 4-5
*poor quality = PEDro score ≤ 3
The PEDro scale was developed by the Physiotherapy Evidence Database to determine the quality of clinical trials. The PEDro scale consists of a checklist of 10 scored yes-or-no questions pertaining to the internal validity and the statistical information provided. Please click on the link for more information: http://www.pedro.org.au/english/downloads/pedro-scale/
A randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness.
Patients longer than 6 months post-stroke are identified as in chronic stage of recovery.
A study in which subjects typically receive differing treatments and outcomes are then compared. No randomization is done in the assignment of treatment groups.
Administration of two or more experimental therapies one after the other in a specified or random order to the same group of patients.
A study in which subjects typically receive differing treatments and outcomes are then compared. No randomization is done in the assignment of treatment groups.