Acupuncture

Evidence Reviewed as of before: 11-08-2017
Author(s)*: Tatiana Ogourtsova, PhD(c) OT; Marc-André Roy, MSc; Nicol Korner-Bitensky, PhD; Robert Teasell, MD; Norine Foley, BASc; Sanjit Bhogal, MSc; Jamie Bitensky, MSc OT; Mark Speechley, MD; Annabel McDermott, OT
Patient/Family Information Table of contents

Introduction

Acupuncture is an ancient Chinese therapy involving the stimulation of specific trigger points along the body’s 18 meridian lines to help regulate the flow of Qi (energy). The meridian lines represent the normal flow of Qi through the body. It is believed that when this energy is disrupted, disease ensues. The use of thin metal needles or other acupuncture techniques is proposed to conduct Qi through its correct paths. The trigger points used are areas of the skin where Qi flows close to the surface and thus can be reached by the various acupuncture therapies.

While the exact mechanisms are not well defined in terms of Western medicine, there are biological responses that occur directly at the stimulus point and indirectly at other parts of the body. In addition to the use of fine needles, other methods of acupuncture include:

  • electro-acupuncture (current through the needles),
    L'électro-acupuncture
    Pictures courtesy of Ricardo Miranda,L.Ac
  • cupping (suction cups on trigger points),
    les ventouses
    Pictures courtesy of Ricardo Miranda,L.Ac
  • acupressure using trigger points (applying pressure with fingers or instruments),
  • reflexology (using pressure on the soles of the feet and inferior ankle to stimulate various parts of the body),
  • moxibustion (heat at trigger points, often combined with needles),la moxibustion
    la moxibustion
    Pictures courtesy of Ricardo Miranda,L.Ac
  • auriculotherapy (stimulating trigger points on the ear to affect other parts of the body),
  • laserpuncture and sonopuncture (using sound waves over trigger points).

Acupuncture has been used to treat many types of health problems and in the past decade has been advocated by some for the treatment of stroke. Recently, a number of studies have explored the use of acupuncture in stroke rehabilitation.

Patient/Family Information

Author: Tatiana Ogourtsova, PhD(c) OT, Marc-André Roy, MSc

What is acupuncture?

Acupuncture comes from ancient Chinese medicine. It has been used to treat pain in China for about 3000 years. The Chinese explanation involves Qi (pronounced Chee), an energy that flows through the body. The belief is that when this Qi is balanced (Yin and Yang), then the body is healthy. Qi flows through different lines within your body called “meridians”. With the most common form of acupuncture, an expert puts very small needles into specific areas of your body where Qi flows close to the surface of the skin.

There is some evidence that acupuncture works after operations to stop pain, after chemotherapy to stop feeling sick and vomiting, during pregnancy to stop feeling sick and after dental surgery for dental pain. It has also been used to treat headaches, tennis elbow, fibromyalgia (general muscle pain), low back pain, carpal tunnel syndrome and asthma.

While we are not sure exactly how it works, 3 possible explanations have been given:

  • Acupuncture blocks pain from traveling in your nerves
  • Acupuncture causes your body to make chemicals that prevent pain
  • Acupuncture opens or closes your veins and arteries in important areas of the body

Are there different kinds of acupuncture?

The most popular acupuncture is performed by putting thin metal needles into the skin. Other forms of acupuncture include:

  • electro-acupuncture, which again uses needles through which very small electrical currents are passed;L'électro-acupuncturePictures courtesy of Ricardo Miranda,L.Ac
  • auriculotherapy, which uses either needles or pressure on different spots of the ear which are trigger points for the entire body;
  • moxibustion, which uses heat at different spots on the body;moxibustion moxibustionPictures courtesy of Ricardo Miranda,L.Ac
  • sonopuncture, which uses sound waves at different spots on the body
  • cupping, which uses suction cups over areas such as the back or the legs to pull blood and other fluids in the area under the skin;cuppingPictures courtesy of Ricardo Miranda,L.Ac
  • acupressure, which uses pressure on different spots on the body;
  • reflexology, which uses pressure under the feet or the back part of the ankles.

Why use acupuncture after a stroke?

Acupuncture has been used after a stroke to treat spasticity (stiffness of muscles caused by the stroke), loss of function, loss of mobility, depression, aphasia (loss of speaking and writing skills), hemiplegia (loss of feeling and/or power to move one side of the body) and for pain reduction.

Does it work for stroke?

Experts have done some experiments to compare acupuncture with other treatments to see whether acupuncture helps people who have had a stroke.

In individuals with ACUTE stroke (< 4 weeks after stroke)
Thirteen high quality studies and 7 fair quality studies found that acupuncture:

  • Was not more helpful than other treatments for improving cognitive skills (e.g. memory, language); mood (e.g. depression); self-care skills (e.g. dressing, shopping); quality of life; physical skills (e.g. strength, range of motion, sensation, motor function of arms and legs); or mobility (e.g. balance, walking speed); but
  • Was more helpful than the usual treatment for improving swallowing skills and swallowing safety.

In individuals with SUBACUTE stroke (1 to 6 months after stroke)
One high quality study found that acupuncture:

  • Was not more helpful than pretend acupuncture for improving range of motion.

In individuals with CHRONIC stroke (> 6 months after stroke)
Three high quality studies and 1 low quality study found that acupuncture:

  • Was not more helpful than pretend acupuncture for improving mood (e.g. depression); self-care skills (e.g. dressing); mobility (e.g. walking endurance); physical skills (e.g. spasticity, range of motion, strength) or pain.

What can I expect?

Most people find that having acupuncture treatment causes very little pain, if any. In most cases you feel the needle going in, but it doesn’t hurt. Some people say they feel cramping, heaviness or tingling at the needle site or up the “meridian”.

The acupuncturist may use other treatments once the needles are in place. This depends on his/her training.

Side effects/risks?

As with any other use of needles, sanitation is very important to not spread germs. All acupuncturists should use new, individually packaged, disposable needles. If these are not used, don’t agree to treatment.

There is little risk related to acupuncture if done by a qualified professional. Side effects could include dizziness, feeling sick and feeling tired after treatment. There could also be a little bleeding at the needle site and some slight bruising. There is always a slight risk of infection when putting needles in the skin.

Who provides the treatment?

Acupuncture should be performed by a trained health professional. A variety of health professionals provide acupuncture as part of their treatment including doctors and physical therapists. Individuals known as acupunturists only use acupuncture as their main treatment.

How many treatments?

This depends on the reason you are getting acupuncture. You should discuss the treatment plan with the acupuncturist before starting treatment. You might receive anywhere from one to 15 treatment sessions.

How much does it cost? Does insurance pay for It?

Acupuncture is not paid for by provincial insurance plans. However, it is covered by some private insurance plans. The cost for each session may vary from $40.00 to $90.00.

Is acupuncture for me?

Although the benefits of acupuncture have been talked about for hundreds of years, there is no strong scientific evidence that it works to reduce spasticity, loss of function, loss of mobility, depression, aphasia or pain. Yet, there are some people who say they have found it helpful.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

The current module includes 35 RCTs including 25 high quality RCTs, nine fair quality RCTs and one poor quality RCT. Numerous outcome measures were used throughout studies and outcomes include balance, cognitive function, dexterity, depression, functional independence, motor function, quality of life, swallowing function, etc. Studies conducted with patients in one phase of stroke recovery, be it the acute, subacute, or chronic phases of stroke recovery, predominantly reported that acupuncture was not more effective than comparison interventions in improving most outcomes (with the exception of dysphagia and swallowing function). By comparison, studies that included patients across stages of stroke recovery (e.g. patients in the acute or subacute phases of stroke recovery) generally reported that acupuncture was more effective than comparison interventions in improving outcomes (especially those related to cognitive function, health related quality of life, insomnia, mobility and swallowing function).

Results Table

View results table

Outcomes

Acute Phase

Balance
Not effective
1b

One high quality RCT (Hsieh et al., 2007) and one fair quality RCT (Johansson et al., 1993) investigated the effect of acupuncture on balance in patients with acute stroke.

The high quality RCT (Hsieh et al., 2007) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Balance was measured by the Fugl-Meyer Assessment (FMA – Balance) during treatment (2 weeks), at post-treatment (4 weeks), and follow-up (3 and 6 months post-stroke). No significant between-group differences were found at any time point.

The fair quality RCT (Johansson et al., 1993) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Balance was measured by the modified Chart for Motor Capacity Assessment – Balance at mid-treatment (1 month post-stroke), and follow-up (3 months post-stroke); measures were not taken at post-treatment (10 weeks). Significant between-group differences were found at both time points, favoring electroacupuncture vs. no acupuncture.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than a comparison intervention (conventional rehabilitation with no acupuncture) in improving balance in patients with acute stroke.
Note: 
However, one fair quality RCT found that acupuncture was more effective than no acupuncture in improving balance in patients with acute stroke; the studies differed in duration of the intervention (4 weeks vs. 10 weeks) and outcome measures used to assess balance.

Cognitive function
Not effective
1a

Two high quality RCTs (Rorsman & Johansson, 2006Chen et al., 2016) investigated the effect of acupuncture on cognitive function in patients with acute stroke.

The first high quality RCT (Rorsman & Johansson, 2006) randomized patients to receive acupuncture (including electroacupuncture), high intensity/low frequency transcutaneous electrical nerve stimulation TENS) or low intensity (subliminal)/high frequency TENS. Cognitive function was measured by the Mini-Mental State Examination (MMSE) at follow-up (3 and 12 months post-stroke); measures were not taken at post-treatment (10 weeks). No significant between-group differences were found at either time point.

The second high quality RCT (Chen et al., 2016) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Cognitive function was measured by the MMSE and the Montreal Cognitive Assessment (MOCA) at baseline, at post-treatment (3 weeks) and at follow-up (7 weeks). There were no significant between-group differences on either measure at post-treatment. There were significant differences in change scores on both measures from baseline to follow-up, favoring acupuncture vs. no acupuncture.

Conclusion: There is strong evidence (Level 1a) from 2 high quality RCTs that acupuncture is not more effective than comparison interventions (TENS, conventional rehabilitation with no acupuncture) for improving cognitive function in patients with acute stroke.
Note: 
However, one of the high quality RCTs reported gains in favour of acupuncture at follow-up.

Depression
Not effective
1b

One high quality RCT (Rorsman & Johansson, 2006) investigated the effect of acupuncture on depression in patients with acute stroke. The high quality RCT randomized patients to receive acupuncture (including electroacupuncture), high intensity/low frequency TENS or low intensity (subliminal)/high frequency TENS. Depression was measured at follow-up (3- and 12-months post-stroke) by the Hospital Anxiety and Depression Scale and the Comprehensive Psychiatric Rating Scale; measures were not taken at post-treatment (10 weeks). No significant between-group differences were found on either measure at either follow-up time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than comparison interventions (high intensity/low frequency TENS, low intensity/high frequency TENS) in improving depression in patients with acute stroke.

Dexterity
Not effective
1a

Two high quality RCTs (Johansson et al., 2001Park et al., 2005) investigated the effect of acupuncture on dexterity in patients with acute stroke.

The first high quality RCT (Johansson et al., 2001) randomized patients to receive electroacupuncture, high intensity/low frequency TENS or low intensity (subliminal)/high frequency TENS; all groups received conventional rehabilitation. Dexterity was measured by the Nine Hole Peg Test (NHPT) at follow-up (3 and 12 months post-stroke); measures were not taken at post-treatment (10 weeks). No significant between group differences were found at either follow-up time point.

The second high quality RCT (Park et al., 2005) randomized patients to receive manual acupuncture or sham acupuncture. Dexterity was measured by the NHPT at post-treatment (2 weeks). No significant between-group differences were found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that acupuncture is not more effective than comparison interventions (TENS, sham acupuncture) in improving dexterity in patients with acute stroke.

Dysphagia
Effective
1b

One high quality RCT (Xia et al., 2016) investigated the effect of acupuncture on functional severity of dysphagia in patients with acute stroke and subsequent dysphagia. This high quality RCT randomized patients to receive acupuncture or no acupuncture; both groups received standard swallowing training. Functional severity of dysphagia was measured by the Dysphagia Outcome and Severity Scale at post-treatment (4 weeks). Significant between-group differences were found, favoring acupuncture vs. no acupuncture.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that swallowing training with acupuncture is more effective than a comparison intervention (swallowing training with no acupuncture) in improving functional severity of dysphagia in patients with acute stroke and subsequent dysphagia.

Functional independence
Not effective
1a

Ten high quality RCTs (Gosman-Hedstrom et al., 1998Johansson et al., 2001Sze et al., 2002Park et al., 2005Hsieh et al., 2007Hopwood et al., 2008Zhu et al., 2013Li et al., 2014Liu et al., 2016Xia et al., 2016) and six fair quality RCTs (Hu et al., 1993Johansson et al., 1993Wong et al., 1999Pei et al., 2001Min et al., 2008Wang et al., 2014) investigated the effect of acupuncture on functional independence in patients with acute stroke.

The first quality RCT(Gosman-Hedstrom et al., 1998) randomized patients to receive deep electroacupuncture, superficial acupuncture or no acupuncture; all groups received conventional rehabilitation. Functional independence was measured by the Barthel Index (BI) and Sunnaas Index at post-treatment (3 months) and at follow-up (12 months). No significant between-group differences were found on any measure at either time point.

The second high quality RCT(Johansson et al., 2001) randomized patients to receive electroacupuncture, high intensity/low frequency TENS or low intensity (subliminal)/high frequency TENS; all groups received conventional rehabilitation. Functional independence was measured by the BI at follow-up (3 and 12 months post-stroke); measures were not taken at post-treatment (10 weeks). No significant between group differences were found at either follow-up time point.

The third high quality RCT(Sze et al., 2002) randomized patients to receive manual acupuncture or no acupuncture; both groups received conventional rehabilitation. Functional independence was measured by the BI and the Functional Independence Measure (FIM) at post-treatment (10 weeks). No significant between-group differences were found on any measure.

The forth high quality RCT (Park et al., 2005) randomized patients to receive manual acupuncture or sham acupuncture. Functional independence was measured by the BI at post-treatment (2 weeks). No significant between-group differences were found.

The fifth high quality RCT (Hsieh et al., 2007) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Functional independence was measured by the FIM (total, self-care, social, mobility, locomotion, sphincter control, communication) during treatment (2 weeks), at post-treatment (4 weeks), and follow-up (3- and 6-months post-stroke). A significant between-group difference was found on only one score (FIM – social) during treatment (2 weeks), favoring electroacupuncture vs. no acupuncture. There were no other significant between-group differences on any measure, at any time point.

The sixth high quality RCT (Hopwood et al., 2008) randomized patients to receive electroacupuncture or placebo electroacupuncture. Functional independence was measured by the BI during treatment (3 weeks) and at several follow-up time points (6, 12, 25, and 52 weeks); measures were not taken at post-treatment (4 weeks). No significant between-group differences were found at any time point.

The seventh high quality RCT(Zhu et al., 2013) randomized patients to receive acupuncture or no acupuncture; both groups received conventional rehabilitation. Functional independence was measured by the BI at mid-treatment (1 month), post-treatment (3 months) and follow-up (6 months). No significant between-group differences were found at any time point.

The eighth high quality RCT (Li et al., 2014) randomized patients to receive verum acupuncture or sham acupuncture. Functional independence was measured by the modified BI and the modified Rankin Scale (mRS) at baseline, at mid-treatment (2 weeks), post-treatment (4 weeks), and follow-up (12 weeks). Significant between-group differences were found at post-treatment (both measures) and at follow-up (BI only), favoring verum acupuncture vs. sham acupuncture.
Note: Differences at post-treatment reflect change scores from baseline to post-treatment; differences at follow-up reflect scores at that time point as well as change scores from baseline to follow-up.

The ninth high quality RCT (Liu et al., 2016) randomized patients to receive manual acupuncture or no acupuncture. Functional independence was measured by the BI,the mRS and the FIM at post-treatment (2 weeks: FIM) and at follow-up (3 weeks: FIM; 1 month: FIM; 3 months: MRS, BI). No significant between-group differences were found on any measure at any time point.

The tenth high quality RCT (Xia et al., 2016) randomized patients to receive acupuncture or no acupuncture; both groups received standard swallowing training. Functional independence was measured by the modified BI at post-treatment (4 weeks). Significant between group differences were found, favoring acupuncture vs. no acupuncture.

The first fair quality RCT (Hu et al., 1993) randomized patients to receive acupuncture or no acupuncture; both groups received conventional rehabilitation. Functional independence was measured by the BI at post-treatment (4 weeks) and at follow-up (3 months). No significant between-group differences were found at either time point.

The second fair quality RCT (Johansson et al., 1993) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Functional independence was measured by the BI at mid-treatment (1 month post-stroke) and at two follow-up timepoints (3 and 12 months post-stroke); measures were not taken at post-treatment (10 weeks). Significant between-group differences were found at all time points, favoring electroacupuncture vs. no acupuncture.

The third fair quality RCT (Wong et al., 1999) randomized patients to receive electroacupuncture or no acupuncture. Functional independence was measured by the FIM (total, self-care, locomotion, sphincter control, transfers, communication, social interaction) at post-treatment (2 weeks). Significant between-group differences were found (FIM total, self-care, locomotion), favoring electroacupuncture vs. no acupuncture.

The forth fair quality RCT (Pei et al., 2001) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Functional independence was measured by the BI mid-treatment (1 and 2 weeks), at post-treatment (4 weeks) and at follow-up (3 months). Significant between-group differences were found at all time points, favoring electroacupuncture vs. no acupuncture.

The fifth fair quality RCT (Min et al., 2008) randomized patients to receive acupuncture or no acupuncture; both groups received conventional rehabilitation. Functional independence was measured by the modified BI at post-treatment (3 months). Significant between-group differences were found, favoring acupuncture vs. no acupuncture.

The sixth fair quality RCT (Wang et al., 2014) randomized patients to receive electroacupuncture or no electroacupuncture; both groups received conventional rehabilitation. Functional independence was measured by the BI at follow-up (3 and 6 months); measures were not taken at post-treatment (4 weeks). Significant between-group differences were found at 6-month follow-up only, favoring electroacupuncture vs. no electroacupuncture.

Conclusion: There is strong evidence (Level 1a) from eight high quality RCTs and one fair quality RCT that acupuncture is not more effective than comparison interventions (superficial acupuncture, no acupuncture, TENS, conventional rehabilitation, sham or placebo acupuncture) in improving functional independence in patients with acute stroke.
Note:
However, two high quality RCTs and five fair quality RCTs found that acupuncture was more effective than comparison interventions (sham acupuncture, standard swallowing training, no acupuncture, conventional rehabilitation) in improving functional independence in patients with acute stroke.

Health-related quality of life (HRQoL)
Not effective
1a

Five high quality RCTs (Gosman-Hedstrom et al., 1998; Johansson et al., 2001; Park et al., 2005; Hopwood et al., 2008Li et al., 2014) and one fair quality RCT (Johansson et al., 1993) investigated the effect of acupuncture on health-related quality of life (HRQoL) in patients with acute stroke.

The first high quality RCT (Gosman-Hedstrom et al., 1998) randomized patients to receive deep electroacupuncture, superficial acupuncture or no acupuncture; all groups received conventional rehabilitation. HRQoL was measured by the Nottingham Health Profile (NHP – energy level, pain, emotional reaction, sleep, social isolation, physical abilities) at post-treatment (3 months) and at follow-up (12 months). There were no significant between-group differences at post-treatment; there was a significant between-group difference in one component of HRQoL (physical abilities) at follow-up, favoring deep electroacupuncture vs. no acupuncture.

The second high quality RCT (Johansson et al., 2001) randomized patients to receive electroacupuncture, high intensity/low TENS or low intensity (subliminal)/high frequency TENS; all groups received conventional rehabilitation. HRQoL was measured by the NHP at follow-up (3 and 12 months post-stroke); measures were not taken at post-treatment (10 weeks). No significant between group differences were found at both follow-up time points.

The third high quality RCT (Park et al., 2005) randomized patients to receive manual acupuncture or sham acupuncture. HRQoL was measured by the EuroQoL (EuroQoL5 – Visual Analogue Scale) at post-treatment (2 weeks). No significant between-group differences were found.

The forth high quality RCT (Hopwood et al., 2008) randomized patients to receive electroacupuncture or placebo electroacupuncture. HRQoL was measured by the NHP during treatment (3 weeks) and at follow-up (6, 12, 25, and 52 weeks). There was a significant between-group difference in one score (NHP – Energy) during treatment and at all follow-up time points, favoring electroacupuncture vs. placebo acupuncture.

The fifth high quality RCT (Li et al., 2014) randomized patients to receive verum acupuncture or sham acupuncture. HRQoL was measured by the Stroke Specialization Quality of Life Scale (SS-QoL) at baseline, at mid-treatment (2 weeks), post-treatment (4 weeks), and at follow-up (12 weeks). Significant between-group differences were found at post-treatment and at follow-up, favoring verum acupuncture vs. sham acupuncture.
Note: Differences at post-treatment reflect change scores from baseline to post-treatment; differences at follow-up reflect scores at that time point as well as change scores from baseline to follow-up.

The fair quality RCT (Johansson et al., 1993) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. HRQoL was measured by the modified NHP at follow-up (3, 6 and 12 months post-stroke); measures were not taken at post-treatment (10 weeks). There were significant between-group differences in some components of HRQoL at 3 months post-stroke (energy, mobility, emotion, social isolation), at 6 months post-stroke (energy, mobility, emotion, social isolation, sleep), and at 12 months post-stroke (mobility, emotion), favoring electroacupuncture vs. no acupuncture.

Conclusion: There is strong evidence (Level 1a) from four high quality RCTs that acupuncture is not more effective than comparison interventions (superficial acupuncture, no acupuncture, TENS, sham or placebo acupuncture) in improving health-related quality of life in patients with acute stroke.
Note
: However, one high quality RCT found that acupuncture was more effective than a comparison intervention (sham acupuncture); this study used the SS-QoL to measure quality of life, rather than the NHP used by most other studies. In addition, one fair quality RCT found that acupuncture was more effective than no acupuncture in improving some components of the health-related quality of life.

Instrumental activities of daily living (IADLs)
Not effective
1b

One high quality RCT (Park et al., 2005) investigated the effect of acupuncture on IADLs in patients with acute stroke. This high quality RCT randomized patients to receive manual acupuncture or sham acupuncture. IADLs were measured by the Nottingham Extended ADL scale at post-treatment (2 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than a comparison intervention (sham acupuncture) in improving IADLs in patients with acute stroke.

Language function
Not effective
1b

One high quality RCT (Rorsman & Johansson, 2006) investigated the effect of acupuncture on language function with acute stroke. This high quality RCT randomized patients to receive acupuncture (including electroacupuncture), high intensity/low frequency TENS or low intensity (subliminal)/high frequency TENS. Language function was measured by the Token Test and FAS Word Fluency Test at follow-up (3 and 12 months post-stroke); measures were not taken at post-treatment (10 weeks). No significant between-group differences were found on any measure at either follow-up time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than comparison interventions (TENS) in improving language function in patients with acute stroke.

Memory
Not effective
1b

One high quality RCT (Rorsman & Johansson, 2006) investigated the effect of acupuncture on memory in patients with acute stroke. This high quality RCT randomized patients to receive acupuncture (including electroacupuncture), high intensity/low frequency TENS or low intensity (subliminal)/high frequency TENS. Memory was measured by the Rey Auditory Verbal Learning Test and Facial Recognition Memory Test at follow-up (3 and 12 months post-stroke); measures were not taken at post-treatment (10 weeks). No significant between-group differences were found on either measure of memory at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than comparison interventions (TENS) in improving memory in patients with acute stroke.

Mobility
Not effective
1b

One high quality RCT (Johansson et al., 2001) and one fair quality RCT (Johansson et al., 1993) investigated the effect of acupuncture on mobility in patients with acute stroke.

The high quality RCT (Johansson et al., 2001) randomized patients to receive electroacupuncture, high intensity/low TENS or low intensity (subliminal)/high frequency TENS; all groups received conventional rehabilitation. Mobility was measured by the Rivermead Mobility Index at follow-up (3 and 12 months post-stroke); measures were not taken at post-treatment (10 weeks). No significant between-group differences were found at either follow-up time point.

The fair quality RCT (Johansson et al., 1993) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Mobility was measured by the modified Chart for Motor Capacity Assessment (Walking) at mid-treatment (1 month post-stroke) and at follow-up (3 months post-stroke); measures were not taken at post-treatment (10 weeks). Significant between-group differences were found at both time points, favoring electroacupuncture vs. no acupuncture.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that electroacupuncture is not more effective than comparison interventions (TENS) in improving mobility in patients with acute stroke.
Note: 
However, one RCT found that acupuncture was more effective than no acupuncture in improving mobility in patients with acute stroke.

Motor function
Conflicting
4

Five high quality RCTs (Sze et al., 2002Hsieh et al., 2007Tan et al., 2013Li et al., 2014Liu et al., 2016) and three fair quality RCTs (Johansson et al., 1993Pei et al., 2001Min et al., 2008) investigated the effect of acupuncture on motor function in patients with acute stroke.

The first high quality RCT (Sze et al., 2002) randomized patients to receive manual acupuncture or no acupuncture; both groups received conventional rehabilitation. Motor function measured by the Fugl-Meyer Assessment (FMA) at post-treatment (10 weeks). No significant between-group differences were found.

The second high quality RCT (Hsieh et al., 2007) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Motor function was measured by the FMA (total score) at mid-treatment (2 weeks), post-treatment (4 weeks), and follow-up (3 and 6 months post-stroke). Significant between-group differences were found at mid-treatment, post-treatment and at 3 months post-stroke, favoring electroacupuncture vs. no acupuncture.

The third high quality RCT (Tan et al., 2013) randomized patients to receive electroacupuncture or no electroacupuncture. Motor function was measured by the FMA at post-treatment (14 days). Significant between-group differences were found at post-treatment, favoring electroacupuncture vs. no electroacupuncture.

The fourth high quality RCT (Li et al., 2014) randomized patients to receive verum acupuncture or sham acupuncture. Motor function was measured by the FMA – Upper and Lower Extremity scores combined at baseline, at mid-treatment (2 weeks), at post-treatment (4 weeks), and at follow-up (12 weeks). Significant between-group differences were found at post-treatment and at follow-up, favoring verum acupuncture vs. sham acupuncture.
Note: Differences at post-treatment reflect change scores from baseline to post-treatment; differences at follow-up reflect scores at that time point as well as change scores from baseline to follow-up.

The fifth high quality RCT (Liu et al., 2016) randomized patients to receive manual acupuncture or no acupuncture. Motor function was measured by the FMA at follow-up (1 month); measures were not taken at post-treatment (2 weeks). No significant between-group differences were found.

The first fair quality RCT (Johansson et al., 1993) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Motor function was measured by the modified Chart for Motor Capacity Assessment (motor function) at 1 and 3 months post-stroke (follow-up); measures were not taken at post-treatment (10 weeks). No significant between group differences were found at either time point.

The second fair quality RCT (Pei et al., 2001) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Motor function was measured by the FMA at mid-treatment (1 and 2 weeks), post-treatment (4 weeks) and at follow-up (3 months). Significant between-group differences were found at all time points, favoring electroacupuncture vs. no acupuncture.

The third fair quality RCT (Min et al., 2008) randomized patients to receive acupuncture or no acupuncture; both groups received conventional rehabilitation. Motor function was measured by the FMA at post-treatment (3 months). A significant between-group difference was found at post-treatment, favoring acupuncture vs. no acupuncture.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of acupuncture on motor function. Two high quality RCTs and one fair quality RCT reported that acupuncture is not more effective than no acupuncture, whereas two other high quality RCTs and two fairquality RCTs found that acupuncture was more effective than comparison interventions (no/sham acupuncture) in improving motor function in patients with acute stroke. A fifth high quality RCT also reported of significant differences in change scores at post-treatment and follow-up.
Note:
There was significant variation between studies in type, frequency and duration of acupuncture.

Motor function (lower extremity)
Not effective
1a

Three high quality RCTs (Hsieh et al., 2007Zhu et al., 2013Chen et al., 2016) and two fair quality RCTs (Wong et al., 1999Min et al., 2008) investigated the effect of acupuncture on lower extremity motor function in patients with acute stroke.

The first quality RCT (Hsieh et al., 2007) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Lower extremity motor function was measured by the Fugl Meyer Assessment (FMA – hip/knee/ankle motor function, lower extremity coordination and speed) at mid-treatment (2 weeks), post-treatment (4 weeks), and follow-up (3 and 6 months post-stroke). No significant between-group differences were found at any time point.

The second high quality RCT (Zhu et al., 2013) randomized patients to receive acupuncture or no acupuncture; both groups received conventional rehabilitation. Lower extremity motor function was measured by the Fugl-Meyer Assessment – Lower Extremity (FMA-LE) at mid-treatment (1 month), post-treatment (3 months), and at follow-up (6 months). No significant between-group differences were found at any time point.

The third high quality RCT (Chen et al., 2016) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Lower extremity motor function was measured by the FMA-LE at baseline, at post-treatment (3 weeks) and at follow-up (7 weeks). There were no significant differences at post-treatment; there were significant differences in change scores from baseline to follow-up, favoring acupuncture vs. no acupuncture.

The first fair quality RCT (Wong et al., 1999) randomized patients to receive electroacupuncture or no acupuncture. Lower extremity motor function was measured using Brunnstrom’s lower limb motor recovery at post-treatment (2 weeks). Significant between-group differences were found, favoring electroacupuncture vs. no acupuncture.

The second fair quality RCT (Min et al., 2008) randomized patients to receive acupuncture or no acupuncture; both groups received conventional rehabilitation. Lower extremity motor function was measured by the FMA–LE at post-treatment (3 months). Significant between-group difference were found, favoring acupuncture vs. no acupuncture.

Conclusion: There is strong evidence (level 1a) from 3 high quality RCTs that acupuncture is not more effective than a comparison intervention (no acupuncture) for improving lower extremity motor function in patients with acute stroke.
Note: 
One of the high quality RCTs reported a significant difference in change scores at follow-up, in favour of acupuncture vs. no acupuncture. Further, two fair quality RCTs reported that acupuncture was more effective than no acupuncture. There was significant variation in the frequency and duration of interventions.

Motor function (upper extremity)
Not effective
1a

Three high quality RCTs (Hsieh et al., 2007Zhu et al., 2013Chen et al., 2016) and two fair quality RCTs (Wong et al., 1999Min et al., 2008) investigated the effect of acupuncture on upper extremity motor function in patients with acute stroke.

The first high quality RCT (Hsieh et al., 2007) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Upper extremity motor function was measured by the Fugl Meyer Assessment (FMA – shoulder / elbow / wrist / hand motor function, upper extremity coordination and speed) during treatment (2 weeks), at post-treatment (4 weeks), and follow-up (3 and 6 months post-stroke). Significant between-group differences were found during treatment (FMA – hand motor function, upper extremity coordination and speed), post-treatment (FMA – wrist motor function, hand motor function, upper extremity coordination and speed), and at both follow-up time points (FMA – wrist motor function, hand motor function, upper extremity coordination and speed), favoring electroacupuncture vs. no acupuncture.

The second high quality RCT (Zhu et al., 2013) randomized patients to receive acupuncture or no acupuncture; both groups received conventional rehabilitation. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity scale (FMA-UE) at mid-treatment (1 month), post-treatment (3 months) and follow-up (6 months). No significant between-group differences were found at any time point.

The third high quality RCT (Chen et al., 2016) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Upper extremity motor function was measured by the FMA-UE at post-treatment (3 weeks) and follow-up (7 weeks). No significant between-group differences were found at either time point.

The first fair quality RCT (Wong et al., 1999) randomized patients to receive electroacupuncture or no acupuncture. Upper extremity motor function was measured by Brunnstrom’s upper limb motor recovery at post-treatment (2 weeks). Significant between-group differences were found, favoring electroacupuncture vs. no acupuncture.

The second fair quality RCT (Min et al., 2008) randomized patients to receive acupuncture or no acupuncture; both groups received conventional rehabilitation. Upper extremity motor function was measured by the FMA-UE at post-treatment (3 months). A significant between-group difference was found, favoring acupuncture vs. no acupuncture.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that acupuncture is not more effective than a comparison intervention (no acupuncture) in improving upper extremity motor function in patients with acute stroke.
Note: 
However; one high quality RCT and two fair quality RCTs found that acupuncture was more effective than a comparison intervention (no acupuncture) in improving upper extremity motor function in patients with acute stroke. Studies varied in terms of the intervention, frequency (2-6 times/week) and duration (2 weeks – 3 months) of the intervention, and outcome measures used.

Range of motion
No effective
1b

One high quality RCT (Hsieh et al., 2007) investigated the effect of acupuncture on range of motion in patients with acute stroke. This high quality RCT randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Range of motion was measured by the Fugl Meyer Assessment (FMA – range of motion) at mid-treatment (2 weeks), post-treatment (4 weeks), and follow-up (3 and 6 months post-stroke). There was a significant between-group difference in range of motion at 3 months post-stroke only, favoring electroacupuncture vs. no acupuncture.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that electroacupuncture is not more effective than a comparison intervention (no acupuncture) in improving range of motion in patients with acute stroke.

Sensation
Not effective
1b

One high quality RCT (Hsieh et al., 2007) investigated the effects of acupuncture on sensation in patients with acute stroke. The high quality RCT randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Sensation was measured by the Fugl Meyer Assessment (FMA – sensation) at mid-treatment (2 weeks), post-treatment (4 weeks), and follow-up (3 and 6 months post-stroke). No significant between-group differences were found at any time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than a comparison intervention (no acupuncture) in improving sensation in patients with acute stroke.

Spasticity
Conflicting
4

Two high quality RCTs (Park et al., 2005; Li et al., 2014) investigated the effect of acupuncture on spasticity in patients with acute stroke.

The first high quality RCT (Park et al., 2005) randomized patients to receive manual acupuncture or sham acupuncture. Spasticity was measured by the Modified Ashworth Scale (MAS) at post-treatment (2 weeks). No significant between-group differences were found.

The second high quality RCT (Li et al., 2014) randomized patients to receive verum acupuncture or sham acupuncture. Spasticity was measured by the MAS at baseline, at mid-treatment (2 weeks), post-treatment (4 weeks), and follow-up (12 weeks). Significant between-group differences in spasticity were found at post-treatment and follow-up, favoring verum acupuncture vs. sham acupuncture.
Note: Differences at post-treatment reflect change scores from baseline to post-treatment; differences at follow-up reflect scores at that time point as well as change scores from baseline to follow-up.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of acupuncture on spasticity in patients with acute stroke. While one high quality RCT found manual acupuncture (2 weeks duration) was not more effective than sham acupuncture, a second high quality RCT reported a significant difference in change scores following verum acupuncture (4 weeks duration), in improving spasticity in patients with acute stroke.

Strength
Not effective
1a

Two high quality RCTs (Park et al., 2005; Hopwood et al., 2008) investigated the effect of acupuncture on strength in patients with acute stroke.

The first high quality RCT (Park et al., 2005) randomized patients to receive manual acupuncture or sham acupuncture. Strength was measured by the Motricity Index (MI) at post-treatment (2 weeks). No significant between-group differences were found.

The second quality RCT (Hopwood et al., 2008) randomized patients to receive electroacupuncture or placebo electroacupuncture. Strength was measured by the MI at mid-treatment (3 weeks) and at follow-up (6, 12, 25, and 52 weeks); measures were not taken at post-treatment (4 weeks). No significant between-group differences were found at any time point.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that acupuncture is not more effective than comparison interventions (sham acupuncture, placebo electroacupuncture) in improving strength in patients with acute stroke.

Stroke outcomes
Not effective
1a

Seven high quality RCTs (Gosman-Hedstrom et al., 1998; Park et al., 2005; Tan et al., 2013; Li et al., 2014; Zhang et al., 2015; Chen et al., 2016, Liu et al., 2016) and three fair quality RCTs (Si et al., 1998; Pei et al., 2001; Wang et al., 2014) investigated the effect of acupuncture on stroke outcomes in patients with acute stroke.

The first high quality RCT (Gosman-Hedstrom et al., 1998) randomized patients to receive deep electroacupuncture, superficial acupuncture or no acupuncture; all groups received conventional rehabilitation. Stroke outcomes were measured by the Scandinavian Stroke Study Group – Neurological score at post-treatment (3 months) and follow-up (12 months). No significant between-group differences were found at either time point.

The second high quality RCT (Park et al., 2005) randomized patients to receive manual acupuncture or sham acupuncture. Stroke outcomes were measured by the National Institutes of Health Stroke Scale (NIHSS) at post-treatment (2 weeks). No significant between-group differences were found.

The third high quality RCT (Tan et al., 2013) randomized patients to receive electroacupuncture or no electroacupuncture. Stroke outcomes were measured by the Modified Edinburg Scandinavian Stroke Scale and the NIHSS at post-treatment (14 days). Significant between-group differences were found on both measures at post-treatment, favoring electroacupuncture vs. no electroacupuncture.

The forth high quality RCT (Li et al., 2014) randomized patients to receive verum acupuncture or sham acupuncture. Stroke outcomes were measured by the NIHSS at mid-treatment (2 weeks), post-treatment (4 weeks), and follow-up (12 weeks). No significant between-group differences were found at any time point.

The fifth high quality RCT (Zhang et al., 2015) randomized patients to receive acupuncture or no acupuncture. Stroke outcomes were measured by the Scandinavian Stroke Scale at post-treatment (3 weeks). Significant between-group differences were found, favoring acupuncture vs. no acupuncture.
Note: Results were significant only for participants who had received 10 or more acupuncture sessions.

The sixth high quality RCT (Chen et al., 2016) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Stroke outcomes were measured by the NIHSS at baseline, during treatment (1 week), at post-treatment (3 weeks), and follow-up (7 weeks). There were no significant differences between groups during treatment or at post-treatment. There was a significant between-group difference in change scores from baseline to follow-up, favoring acupuncture vs. no acupuncture.

The seventh high quality RCT (Liu et al., 2016) randomized patients to receive manual acupuncture or no acupuncture. Stroke outcomes were measured by the NIHSS at post-treatment (2 weeks) and follow-up (3, 4, 12 weeks). No significant between-group differences were found at any time point.

The first fair quality RCT (Si et al., 1998) randomized patients to receive electroacupuncture or no acupuncture. Stroke outcomes were measured by the Chinese Stroke Scale (CSS – total score, motor shoulder/hand/leg, level of consciousness, extraocular movements, facial palsy, speech, walking capacity) at discharge from hospital (average of 37±12 days). Significant between group differences in some stroke outcomes (CSS – total, motor shoulder/hand/leg) were found at discharge, favoring electroacupuncture vs. no acupuncture.

The second fair quality RCT (Pei et al., 2001) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Stroke outcomes were measured by the CSS during treatment (1 and 2 weeks), at post-treatment (4 weeks) and at follow-up (3 months). Significant between-group differences in stroke outcomes were found at 2 weeks, 4 weeks and 3 months, favoring electroacupuncture vs. no acupuncture.

The third fair quality RCT (Wang et al., 2014) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Stroke outcomes were measured by the NIHSS at post-treatment (4 weeks) and at follow-up (3 months). Significant between-group differences were found at post-treatment, favoring electroacupuncture vs. no electroacupuncture. These differences were not maintained at follow-up.

Conclusion: There is strong evidence (Level 1a) from five high quality RCTs that acupuncture is not more effective than comparison interventions (superficial/no/sham acupuncture) in improving stroke outcomes in patients with acute stroke.
Note:
However, two high quality RCTs and three fair quality RCTs found that acupuncture is more effective than a comparison intervention (no acupuncture) in improving stroke outcomes in patients with acute stroke. Differences between studies, including variation in the type of acupuncture, treatment frequency/duration and outcome measures used may account for this discrepancy in findings.

Swallowing function
Effective
1a

Three high quality RCTs (Park et al., 2005; Chen et al., 2016; Xia et al., 2016) investigated the effect of acupuncture on swallowing function in patients with acute stroke.

The first high quality RCT (Park et al., 2005) randomized patients to receive manual acupuncture or sham acupuncture. Swallowing function was measured by the Bedside Swallowing Assessment (BSA) at post-treatment (2 weeks). Significant between group differences were found, favoring sham acupuncture vs. manual acupuncture (i.e. participants who received manual acupuncture presented with a higher incidence of unsafe swallow than participants who received sham acupuncture).

The second high quality RCT (Chen et al., 2016) randomized patients to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Swallowing function was measured by the BSA at post-treatment (3 weeks) and follow-up (7 weeks), and by Videofluoroscopic Swallowing Study (VFSS) at follow-up (7 weeks). Significant between-group differences were found at post-treatment (BSA) and at follow-up (BSA, VFDSS), favoring acupuncture vs. no acupuncture.

The third high quality RCT (Xia et al., 2016) randomized patients to receive acupuncture or no acupuncture; both groups received standard swallowing training. Swallowing function was measured by the Standardized Swallowing Assessment at post-treatment (4 weeks). Significant between-group differences were found, favoring acupuncture vs. no acupuncture.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that acupuncture is more effective than a comparison intervention (no acupuncture) in improving swallowing function in patients with acute stroke.
Note:
However, one high quality RCT found that acupuncture was LESS effective than a comparison intervention (sham acupuncture) in improving swallowing function in patients with acute stroke.

Swallowing-related quality of life
Effective
1b

One high quality RCT (Xia et al., 2016) investigated the effects of acupuncture on swallowing-related quality of life in patients with acute stroke and subsequent dysphagia. This high quality RCT randomized patients to receive acupuncture or no acupuncture; both groups received standard swallowing training. Swallowing-related quality of life was measured with the Swallowing Related Quality of Life scale at post-treatment (4 weeks). Significant between-group differences were found, favoring acupuncture vs. no acupuncture.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is more effective than a comparison intervention (no acupuncture with standard swallowing training) in improving swallowing related quality of life in patients with acute stroke and subsequent dysphagia.

Unilateral spatial neglect
Not effective
1b

One high quality RCT (Rorsman & Johansson, 2006) investigated the effect of acupuncture on unilateral spatial neglect in patients with acute stroke. This high quality RCT randomized patients to receive acupuncture (including electroacupuncture), high intensity/low frequency TENS or low intensity (subliminal)/high frequency TENS. Unilateral spatial neglect was measured by the Star Cancellation Test and Time Perception Test at follow-up (3 and 12 months post-stroke); measures were not taken at post-treatment (10 weeks). No significant between-group differences were found on any measure at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than comparison interventions (TENS) in improving unilateral spatial neglect in patients with acute stroke.

Walking speed
Not effective
1b

One high quality RCT (Park et al., 2005) investigated the effect of acupuncture on walking speed in patients with acute stroke. This high quality RCT randomized patients to receive manual acupuncture or sham acupuncture. Walking speed was measured by the 10 Meter Walk Test at post-treatment (2 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than a comparison intervention (sham acupuncture) in improving walking speed in patients with acute stroke.

Subacute phase

Range of motion
Not effective
1b

One high quality RCT (Naeser et al., 1992) investigated the effect of acupuncture on range of motion in patients with subacute stroke. This high quality RCT randomized patients to receive electroacupuncture or sham acupuncture. Isolated active range of motion was measured at post-treatment (4 weeks). No significant between-group differences were found.
Note: A subgroup analysis of patients with the lesion in half or less than half of the motor pathway areas revealed significant between-group differences, favoring electroacupuncture vs. sham acupuncture.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that electroacupuncture is not more effective than a comparison intervention (sham acupuncture) in improving isolated active range of motion in patients with subacute stroke.

Chronic phase

Depression
Not effective
1a

Two high quality RCTs (Fink et al., 2004; Wayne et al., 2005) investigated the effect of acupuncture on depression in patients with chronic stroke. This first high quality RCT (Fink et al., 2004) randomized patients to receive acupuncture or placebo acupuncture. Depression was measured by the von Zerssen Depression Scale at post-treatment (4 weeks) and follow-up (3 months). No significant between-group differences were found at either time point. 

The second high quality RCT (Wayne et al., 2005) randomized patients to receive acupuncture or sham acupuncture. Depression was measured by the Center for Epidemiological Surveys Depression at post-treatment (12 weeks). No significant between-group differences were found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that acupuncture is not more effective than a comparison intervention (placebo/sham acupuncture) in improving depression in patients with chronic stroke.

Functional independence
Not effective
1b

One high quality RCT (Wayne et al, 2005) investigated the effect of acupuncture on functional independence in patients with chronic stroke. This high quality RCT randomized patients to receive acupuncture or sham acupuncture. Functional independence was measured by the Barthel Index at post-treatment (12 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than a comparison intervention (sham acupuncture) in improving functional independence in patients with chronic stroke.

Gait parameters
Not effective
1b

One high quality RCT (Fink et al., 2004) investigated the effect of acupuncture on gait parameters in patients with chronic stroke. This high quality RCT randomized patients to receive acupuncture or placebo acupuncture. Gait parameters (step length, cadence, mode of initial foot contact) were measured at first treatment, post-treatment (4 weeks), and follow-up (3 months). No significant between-group differences were found at any time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than a comparison intervention (placebo acupuncture) in improving gait parameters in patients with chronic stroke.

Grip strength
Not effective
1b

One high quality RCT (Wayne et al, 2005) investigated the effect of acupuncture on grip strength in patients with chronic stroke. This high quality RCT randomized patients to receive acupuncture or sham acupuncture. Grip strength was measured by Jamar dynamometer at post-treatment (12 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than a comparison intervention (sham acupuncture) in improving grip strength in patients with chronic stroke.

Health-related quality of life (HRQoL)
Not effective
1a

Two high quality RCTs (Fink et al., 2004; Wayne et al., 2005) investigated the effect of acupuncture on HRQoL in patients with chronic stroke.

This first high quality RCT (Fink et al., 2004) randomized patients to receive acupuncture or placebo acupuncture. HRQoL was measured by the Nottingham Health Profile and the Everyday Life Questionnaire at post-treatment (4 weeks) and follow-up (3 months). No significant between-group differences were found on either measure at either time point. 

The second high quality RCT (Wayne et al, 2005) randomized patients to receive acupuncture or sham acupuncture. HRQoL was measured by the Nottingham Health Profile at post-treatment (12 weeks). No significant between-group differences were found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that acupuncture is not more effective than a comparison intervention (placebo/sham acupuncture) in improving health-related quality of life in patients with chronic stroke.

Impression of improvement
Not effective
1b

One high quality RCT (Fink et al., 2004) investigated the effect of acupuncture on impression of improvement in patients with chronic stroke. This high quality RCT randomized patients to receive acupuncture or placebo acupuncture. Impression of improvement was measured by the Clinical Global Impressions Scale at first treatment, post-treatment (4 weeks), and follow-up (3 months). Significant between-group differences in patients’ impression of improvement were found at post-treatment, favoring placebo acupuncture vs. acupuncture.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than a comparison intervention (placebo acupuncture) in increasing the impression of improvement in patients with chronic stroke. In fact, patients who received acupuncture showed lower impression of improvement as compared to those who received placebo acupuncture.

Mobility
Not effective
1b

One high quality RCT (Fink et al., 2004) investigated the effect of acupuncture on mobility in patients with chronic stroke. This high quality RCT randomized patients to receive acupuncture or placebo acupuncture. Mobility was measured by the Rivermead Mobility Index at first treatment, post-treatment (4 weeks), and follow-up (3 months). No significant between-group differences were found at any time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than a comparison intervention (placebo acupuncture) in improving mobility in patients with chronic stroke.

Motor function
Not effective
1a

Two high quality RCTs (Fink et al., 2004, Wayne et al., 2005) investigated the effect of acupuncture on motor function in patients with chronic stroke.

This first high quality RCT (Fink et al., 2004) randomized patients to receive acupuncture or placebo acupuncture. Motor function was measured by the Rivermead Motor Assessment at first treatment, post-treatment (4 weeks), and follow-up (3 months). No significant between-group differences were found at any time point.

The second high quality RCT (Wayne et al., 2005) randomized patients to receive acupuncture or sham acupuncture. Motor function was measured by the Fugl-Meyer Assessment at post-treatment (12 weeks). No significant between-group differences were found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that acupuncture is not more effective than a comparison intervention (placebo/sham acupuncture) in improving motor function in patients with chronic stroke.

Pain
Not effective
1b

One high quality RCT (Fink et al., 2004) investigated the effect of acupuncture on pain in patients with chronic stroke. This high quality RCT randomized patients to receive acupuncture or placebo acupuncture. Pain was measured by Visual Analogue Scale at first treatment, post-treatment (4 weeks), and follow-up (3 months). No significant between-group differences were found at any time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than a comparison intervention (placebo acupuncture) in improving pain in patients with chronic stroke.

Range of motion (upper extremity)
Not effective
1a

Two high quality RCTs (Wayne et al., 2005, Schaechter et al., 2007) investigated the effect of acupuncture on upper extremity range of motion in patients with chronic stroke.

The first high quality RCT (Wayne et al., 2005) randomized patients to receive acupuncture or sham acupuncture. Upper extremity range of motion (shoulder, elbow, forearm, wrist, thumb, digits) was measured at post-treatment (12 weeks). No significant between-group differences were found.

The second high quality RCT (Schaechter et al., 2007) randomized patients to receive acupuncture with electroacupuncture or sham acupuncture with sham electroacupuncture. Upper extremity active assisted range of motion was measured at 2 weeks post-treatment (12 weeks). No significant between-group differences were found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that acupuncture is not more effective than comparison interventions (sham acupuncture, sham electroacupuncture) in improving upper extremity range of motion in patients with chronic stroke.

Spasticity (lower extermity)
Not effective
1b

One high quality RCT (Fink et al., 2004) investigated the effect of acupuncture on lower extremity spasticity in patients with chronic stroke. This high quality RCT randomized patients to receive acupuncture or placebo acupuncture. Ankle spasticity was measured by the Modified Ashworth Scale and the Hoffman’s reflex (Hmax/Mmax ratio of the spastic leg) using the Nicolet Viking II device at first treatment, post-treatment (4 weeks), and follow-up (3 months). Significant between-group differences in spasticity (Hoffman’s reflex) were found at post-treatment, favoring placebo acupuncture vs. acupuncture. These differences were not maintained at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than a comparison intervention (placebo acupuncture) in reducing ankle spasticity in patients with chronic stroke. In fact, patients who received acupuncture showed greater spasticity in their affected ankle as compared to those who received placebo acupuncture.

Spasticity (upper extermity)
Not effective
1a

Two high quality RCTs (Wayne et al., 2005; Schaechter et al., 2007) and one poor quality crossover RCT (Mukherjee et al., 2007) investigated the effect of acupuncture on upper extremity spasticity in patients with chronic stroke.

The first high quality RCT (Wayne et al., 2005) randomized patients to receive acupuncture or sham acupuncture. Spasticity in the elbow and wrist was measured by the Modified Ashworth Scale at post-treatment (12 weeks). No significant between-group differences were found.

The second high quality RCT (Schaechter et al., 2007) randomized patients to receive acupuncture with electroacupuncture or sham acupuncture with sham electroacupuncture. Upper extremity spasticity was measured by the Modified Ashworth Scale at 2 weeks post-treatment (12 weeks). No significant between-group differences were found.

The poor quality crossover RCT (Mukherjee et al., 2007) randomized patients to receive electroacupuncture or no electroacupuncture; both groups received strengthening exercises. Spasticity of the wrist was measured at post-treatment (6 weeks). Significant between-group differences on one measure of wrist spasticity were found, favoring electroacupuncture vs. no electroacupuncture.
Note: Other measures of spasticity were taken, however between-group analyses were not performed.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that acupuncture is not more effective than comparison interventions (sham acupuncture, sham electroacupuncture) in reducing upper extremity spasticity in patients with chronic stroke.
Note
: However, a poor quality crossover RCT found a significant difference on one measure of wrist spasticity, in favour of electroacupuncture + strengthening exercises alone vs. strengthening exercises alone.

Walking endurance
Not effective
1b

One high quality RCT (Fink et al., 2004) investigated the effect of acupuncture on walking endurance in patients with chronic stroke. This high quality RCT randomized patients to receive acupuncture or placebo acupuncture. Walking endurance was measured by the 2-Minute Walk Test at first treatment, post-treatment (4 weeks), and follow-up (3 months). No significant between-group differences were found at any time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than a comparison intervention (placebo acupuncture) in improving walking endurance in patients with chronic stroke.

Phase not specific to one period

Balance
Not effective
1b

One high quality RCT (Alexander et al., 2004) investigated the effect of acupuncture on balance in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive acupuncture or no acupuncture for 2 weeks; both groups received conventional rehabilitation. Balance was measured by the Fugl-Meyer Assessment (FMA – Balance) at discharge from hospital. No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than a comparison intervention (no acupuncture) in improving balance in patients with stroke.

Cognitive function
Effective
1b

One high quality RCT (Jiang et al., 2016) investigated the effect of acupuncture on cognitive function in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive acupuncture (AC) + conventional rehabilitation (CR), computerized cognitive rehabilitation (COG) + CR, combined AC+COG+CR, or CR alone. Cognitive function was measured by the Mini Mental State Examination and the Montreal Cognitive Assessment (MOCA) at baseline and at post-treatment (12 weeks). Significant between-group differences in change scores from baseline to post-treatment were found on both measures, favoring AC+CR vs. CR alone. There were no significant between-group differences between AC+CR vs. COG+CR.
Note: Significant between-group differences in change scores of both measures were also found in favour of COG+CR vs. CR alone; AC+COG+CR vs. CR alone; AC+COG+CR vs. AC+CR; and AC+COG+CR vs. COG+CR.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is more effective than a comparison intervention (conventional rehabilitation) in improving cognitive function in patients with stroke.
Note:
Combined acupuncture + computerized cognitive training was also found to be more effective than comparison interventions (acupuncture alone, computerized cognitive training alone, conventional rehabilitation) in improving cognitive function in patients with stroke.

Functional independence
Not effective
1a

Five high quality RCTs (Sallstrom et al., 1996 – and a follow-up by Kjendahl et al., 1997 –; Alexander et al., 2004; Schuler et al., 2005; Zhuang et al., 2012; Jiang et al., 2016) and one fair quality RCTs (Hegyi & Szigeti, 2012) investigated the effect of acupuncture on functional independence in patients with stroke.

The first high quality RCT (Sallstrom et al., 1996) randomized patients with acute/subacute stroke to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Functional independence was measured by the Sunnaas Index at post-treatment (6 weeks) and at 1 year post-discharge from hospital (Kjendahl et al., 1997, follow-up study). Significant between-group differences were found at post-treatment and at follow-up, favoring electroacupuncture vs. no acupuncture.

The second high quality RCT (Alexander et al., 2004) randomized patients with acute/subacute stroke to receive acupuncture or no acupuncture for 2 weeks; both groups received conventional rehabilitation. Functional independence was measured by the Functional Independence Measure (FIM) at discharge from hospital. A significant between-group difference was found in only one measure of functional independence (tub/shower transfer), favoring acupuncture vs. no acupuncture.

The third high quality RCT (Schuler et al., 2005) randomized patients with acute/subacute stroke to receive electroacupuncture or placebo acupuncture. Functional independence was measured by the Barthel Index at post-treatment (4 weeks) and at follow-up (6 months). No significant between-group differences were found at either time point.

The forth high quality RCT (Zhuang et al., 2012) randomized patients with acute/subacute stroke to receive acupuncture, conventional rehabilitation or combined acupuncture with conventional rehabilitation. Functional independence was measured by the modified Barthel Index at mid-treatment (2 weeks) and at post-treatment (4 weeks). No significant between-group differences were found at either time point.

The fifth high quality RCT (Jiang et al., 2016) randomized patients with acute/subacute stroke to receive acupuncture (AC) + conventional rehabilitation (CR), computerized cognitive rehabilitation (COG) + CR, combined AC+COG+CR, or CR alone. Functional independence was measured at baseline and at post-treatment (12 weeks) by the FIM. Significant between-group differences were found in FIM change scores from baseline to post-treatment, favoring AC+CR vs. CR alone. There were no significant differences between AC+CR vs. COG+CR.
Note: Significant differences in FIM change scores were also found in favour of COG+CR vs. CR alone; AC+COG+CR vs. CR alone; AC+COG+CR vs. AC+CR; and AC+COG+CR vs. COG+CR.

The fair quality RCT (Hegyi & Szigeti, 2012) randomized patients with acute/subacute stroke to receive acupuncture or no acupuncture for the time of hospitalization (duration not specified); both groups received conventional physical therapy. Functional independence was measured by the Barthel Index at 2 years post-stroke. Significant between-group differences were found, favoring acupuncture vs. no acupuncture.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs that acupuncture is not more effective than comparison interventions (no/placebo acupuncture, conventional rehabilitation) in improving functional independence in patients with stroke.
Note:
However, two high quality RCTs and one fair quality RCT found that acupuncture was more effective than a comparison intervention (no acupuncture, conventional rehabilitation alone) in improving functional independence in patients with stroke.

Health-related quality of life (HRQoL)
Effective
1b

One high quality RCT (Sallstrom et al., 1996; and Kjendahl et al., 1997 follow-up study) and one fair quality RCT (Hegyi & Szigeti, 2012) investigated the effect of acupuncture on HRQoL in patients with stroke.

The high quality RCT (Sallstrom et al., 1996) randomized patients with acute/subacute stroke to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. HRQoL was measured by the Nottingham Health Profile (NHP – Part I, Part II) at post-treatment (6 weeks) and at 1 year post-discharge from hospital (Kjendahl et al., 1997 follow-up study). Significant between-group differences were found at post-treatment (NHP Part I: sleep, energy) and at follow-up (NHP Part I: emotion, sleep, physical movement, energy; Part II), favoring electroacupuncture vs. no acupuncture.

The fair quality RCT (Hegyi & Szigeti, 2012) randomized patients with acute/subacute stroke to receive acupuncture or no acupuncture for the time of hospitalization (duration not specified); both groups received conventional physical therapy. HRQoL (general and physical statuses) was measured by Visual Analogue Scale at 2 years post-stroke. A significant between-group difference was found, favoring acupuncture vs. no acupuncture.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that electroacupuncture is more effective than a comparison intervention (no acupuncture) in improving health-related quality of life in patients with stroke.

Insomnia
Effective
1b

One high quality RCT (Kim et al., 2004) investigated the effect of acupuncture on insomnia in patients with stroke. This high quality RCT randomized patients with stroke (stage of recovery not specified) and insomnia to receive intradermal acupuncture or sham acupuncture. Symptoms of insomnia were measured by the Morning Questionnaire (MQ – sleep latency, sleep quality, condition upon awakening, ability to concentrate, ease of falling asleep, morning sleepiness), the Insomnia Severity Index (ISI) and the Athens Insomnia Scale (AIS) at mid-treatment (1 day) and post-treatment (2 days). Significant between-group differences were found at both time points (MQ – sleep quality, condition upon awakening, ability to concentrate, morning sleepiness; ISI; AIS), favoring intradermal acupuncture vs. sham acupuncture.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is more effective than a comparison intervention (sham acupuncture) in improving symptoms of insomnia in patients with stroke and insomnia.

Joint pain
Not effective
1b

One high quality RCT (Alexander et al., 2004) investigated the effect of acupuncture on joint pain in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive acupuncture for 2 weeks or no acupuncture; both groups received conventional rehabilitation. Joint pain was measured by the Fugl-Meyer Assessment (FMA – upper and lower extremity joint pain) at discharge from hospital. No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than a comparison intervention (no acupuncture) in improving joint pain in patients with stroke.

Mobility
Effective
2a

One fair quality RCT (Hegyi & Szigeti, 2012) investigated the effect of acupuncture on mobility in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive acupuncture or no acupuncture for the time of hospitalization (duration not specified); both groups received conventional physical therapy. Mobility was measured by the Rivermead Mobility Index at 2 years post-stroke. Significant between-group differences were found, favoring acupuncture vs. no acupuncture.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that acupuncture is more effective than a comparison intervention (no acupuncture) in improving mobility in patients with stroke.

Motor function
Not effective
1a

Three high quality RCTs (Sallstrom et al., 1996; and Kjendahl et al., 1997 follow-up study), Alexander et al., 2004, Zhuang et al., 2012) investigated the effect of acupuncture on motor function in patients with stroke.

The first high quality RCT (Sallstrom et al., 1996) randomized patients with acute/subacute stroke to receive electroacupuncture or no acupuncture; both groups received conventional rehabilitation. Motor function was measured by the Motor Assessment Scale at post-treatment (6 weeks) and at 1 year post-discharge from hospital (Kjendahl et al., 1997 follow-up study). Significant between-group differences were found, at both time points, favoring electroacupuncture vs. no acupuncture.

The second high quality RCT (Alexander et al., 2004) randomized patients with acute/subacute stroketo receive acupuncture for 2 weeks or no acupuncture; both groups received conventional rehabilitation. Motor function was measured by the Fugl-Meyer Assessment (FMA-total) at discharge from hospital. No significant between-group differences were found.

The third high quality RCT (Zhuang et al., 2012) randomized patients with acute/subacute stroke to receive acupuncture, conventional rehabilitation or combined acupuncture with conventional rehabilitation. Motor function was measured by the FMA at mid-treatment (2 weeks) and at post-treatment (4 weeks). No significant between-group differences were found at either time point.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that acupuncture is not more effective than a comparison intervention (no acupuncture, conventional rehabilitation) in improving motor function in patients with stroke.
Note:
However, one high quality RCT found that acupuncture was more effective than a comparison intervention (no acupuncture) in improving motor function in patients with stroke.

Motor function (lower extremity)
Effective
1b

One high quality RCT (Alexander et al., 2004) investigated the effect of acupuncture on lower extremity motor function in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive acupuncture for 2 weeks or no acupuncture; both groups received conventional rehabilitation. Lower extremity motor function was measured by the Fugl-Meyer Assessment (FMA – lower extremity motor function) at discharge from hospital. Significant between-group differences were found, favoring acupuncture vs. no acupuncture.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is more effective than a comparison intervention (no acupuncture) in improving lower extremity motor function in patients with stroke.

Motor function (upper extremity)
Not effective
1b

One high quality RCT (Alexander et al., 2004) investigated the effects of acupuncture on upper extremity motor function in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive acupuncture for 2 weeks or no acupuncture; both groups received conventional rehabilitation. Upper extremity motor function was measured by the Fugl-Meyer Assessment (FMA – Upper extremity motor function) at discharge from hospital. No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than a comparison intervention (no acupuncture) in improving upper extremity motor function in patients with stroke.

Range of motion
Not effective
1b

One high quality RCT (Alexander et al., 2004) investigated the effect of acupuncture on range of motion in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive acupuncture for 2 weeks or no acupuncture; both groups received conventional rehabilitation. Joint motion was measured by the Fugl-Meyer Assessment (FMA – upper/lower extremity joint motion) at discharge from hospital. No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than no acupuncture in improving upper and lower extremity range of motion in patients with stroke.

Sensation
Not effective
1b

One high quality RCT (Alexander et al., 2004) investigated the effect of acupuncture on sensation in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive acupuncture for 2 weeks or no acupuncture; both groups received conventional rehabilitation. Sensation was measured by the Fugl-Meyer Assessment (FMA – upper/lower extremity sensation) at discharge from hospital. No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that acupuncture is not more effective than a comparison intervention (no acupuncture) in improving sensation in patients with stroke.

Stroke outcomes
Not effective
1a

Two high quality RCTs (Schuler et al., 2005; Zhuang et al., 2012) investigated the effect of acupuncture on stroke outcomes in patients with stroke.

The first high quality RCT (Schuler et al., 2005) randomized patients with acute/subacute stroke to receive electroacupuncture or placebo acupuncture. Stroke outcomes were measured by the European Stroke Scale at post-treatment (4 weeks) and at follow-up (6 months). No significant between-group differences were found at either time point.

The second high quality RCT (Zhuang et al., 2012) randomized patients with acute/subacute stroke to receive acupuncture, conventional rehabilitation or combined acupuncture with conventional rehabilitation. Stroke outcomes were measured by the Neurologic Defect Scale at mid-treatment (2 weeks) and at post-treatment (4 weeks). No significant between-group differences were found at either time point.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that acupuncture is not more effective than comparison interventions (placebo acupuncture, conventional rehabilitation) in improving stroke outcomes in patients with stroke.

Swallowing function
Effective
2b

One fair quality RCT (Mao et al., 2016) investigated the effect of acupuncture on swallowing function in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke and dysphagia to receive acupuncture + standard swallowing training or standard swallowing training alone. Swallowing function was measured by the Video Fluoroscopic Swallowing Study (VFSS), Standardized Swallowing Assessment (SSA) and the Royal Brisbane Hospital Outcome Measure for Swallowing (RBHOMS) at post-treatment (4 weeks). Significant between-group differences were found in two measures of swallowing function (VSFF, SSA), favoring acupuncture + standard swallowing training vs. standard swallowing training alone.

Conclusion: There is limited evidence (Level 2b) from one fair quality RCT that acupuncture with swallowing training is more effective than a comparison intervention (standard swallowing training alone) in improving swallowing function in patients with stroke.

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Kjendahl A., Sallstrom S., Egil Osten P., & Kvalvik Stanghelle J. (1997). A one year follow-up study on the effects of acupuncture in the treatment of stroke patients in the subacute stage: a randomized, controlled study. Clinical Rehabilitation, 11, 192-200.
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Li, H., Liu, H., Liu, C., Shi, G., Zhou, W., Zhao, C., … & Sun, J. (2014). Effect of “Deqi” during the study of needling “Wang’s Jiaji” acupoints treating spasticity after stroke. Evidence-Based Complementary and Alternative Medicine2014.
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Liu, C. H., Hsieh, Y. T., Tseng, H. P., Lin, H. C., Lin, C. L., Wu, T. Y., … & Zhang, H. (2016). Acupuncture for a first episode of acute ischaemic stroke: an observer-blinded randomised controlled pilot study. Acupuncture in Medicine34(5), 349-355.
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Mao, L. Y., Li, L. L., Mao, Z. N., Han, Y. P., Zhang, X. L., Yao, J. X., & Li, M. (2016). Therapeutic effect of acupuncture combining standard swallowing training for post-stroke dysphagia: A prospective cohort study. Chinese Journal of Integrative Medicine22(7), 525-531.
https://link.springer.com/article/10.1007/s11655-016-2457-6

Min, M., Xin, C., Yuefeng, C., Ping, R., & Jian, L. (2008). Stage-oriented comprehensive acupuncture treatment plus rehabilitation training for apoplectic hemiplegia. Journal of Traditional Chinese Medicine28(2), 90-93.
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Mukherjee M., McPeak L.K., Redford J. B., Sun C., & Liu W. (2007). The effect of electro-acupuncture on spasticity of the wrist joint in chronic stroke survivors. Archives of Physical Medicine and Rehabilitation, 88, 159-166.
https://www.ncbi.nlm.nih.gov/pubmed/17270512

Naeser M.A., Alexander M.P., Stiassny-Eder D., Galler V., Hobbs J., & Bachman D. (1992). Real versus sham acupuncture in the treatment of paralysis in acute stroke patients: a CT scan lesion site study. Journal of Neuroengineering and Rehabilitation 6(4), 163-173.
http://www.bu.edu/naeser/acupuncture/publications/Naeser_RealvsSham_1992.pdf

Park J., White A.R., James M.A., Hemsley A.G., Johnson P., Chambers J., & Ernst E. (2005). Acupuncture for subacute stroke rehabilitation. A sham-controlled, subject and assessor-blind, randomized trial. Archives of Internal Medicine, 165, 2026-2031.
https://www.ncbi.nlm.nih.gov/pubmed/16186474

Pei, J., Sun, L., Chen, R., Zhu, T., Qian, Y., & Yuan, D. (2001). The effect of electro-acupuncture on motor function recovery in patients with acute cerebral infarction: a randomly controlled trial. Journal of Traditional Chinese Medicine21(4), 270-272.
http://europepmc.org/abstract/med/12014128

Rorsman I. & Johansson B. (2006). Can electro-acupuncture or transcutaneous nerve stimulation influence cognitive and emotional outcome after stroke? Journal of Rehabilitation Medicine, 38, 13-19.
https://www.ncbi.nlm.nih.gov/pubmed/16548081

Sallstrom S., Kjendahl A., Osten P.E., Stanghelle J.H., & Borchgrevink C.F. (1996). Acupuncture in the treatment of stroke patients in the subacute stage: a randomized, controlled study. Complementary Therapies in Medicine, 4, 193-197.
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Schaechter J.D., Connell B.D., Stason W.B., Kaptchuk T.J., Krebs D.E., Macklin E.A., Schnyer R.N., Stein J., Scarborough D.M., Parker S.W., McGibbon C.A., & Wayne P.M. (2007). Correlated change in upper limb function and motor cortex activation after verum and sham acupuncture in patients with chronic stroke. Journal of Alternative and Complementary Medicine. 13, 527-532.
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Schuler M.S., Durdak C., Hosl N.M., Klink A., Hauer K.A., & Oster P. (2005). Acupuncture treatment of geriatric patients with ischemic stroke: a randomized, double-controlled, single-blind study. Journal of the American Geriatrics Society, 53, 549-550.
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Si Q.C., Wu G.C., & Cao X.D. (1998). Effects of electroacupuncture on acute cerebral infarction. Acupuncture and Electro-therapeutics Research, 23, 117-124.
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Sze F.K., Wong E., Yi X., & Woo J. (2002). Does acupuncture have additional value to standard poststroke motor rehabilitation? Stroke, 33, 186-194.
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Tan, F., Wang, X., Li, H. Q., Lu, L., Li, M., Li, J. H., … & Zheng, G. Q. (2013). A randomized controlled pilot study of the triple stimulation technique in the assessment of electroacupuncture for motor function recovery in patients with acute ischemic stroke. Evidence-Based Complementary and Alternative Medicine2013.
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Wang, C., Wu, Z., Li, N., Zhao, Y., Tian, F., Zhou, X., & Wang, Z. (2014). Clinical curative effect of electric acupuncture on acute cerebral infarction: a randomized controlled multicenter trial. Journal of Traditional Chinese Medicine34(6), 635-640.
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Wayne P. M., Krebs D. E., Macklin E. A., Schnyer R., Kaptchuk T. J., Parker S. W., Scarborough D.M., McGibbon C.A., Schaechter J.D., Stein J., & Stason W.B. (2005). Acupuncture for upper-extremity rehabilitation in chronic stroke: a randomized sham-controlled study. Archive of Physical Medicine Rehabilitation, 86, 2248-2255.
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Wong A.M., Su T.Y., Tang F.T., Cheng P.T., & Liaw M.Y. (1999). Clinical trial of electrical acupuncture on hemiplegic stroke patients. American Journal of Physical Medicine and Rehabilitation, 78, 117-122.
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Xia, W., Zheng, C., Zhu, S., & Tang, Z. (2016). Does the addition of specific acupuncture to standard swallowing training improve outcomes in patients with dysphagia after stroke? a randomized controlled trial. Clinical Rehabilitation30(3), 237-246.
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Zhang, S., Wu, B., Liu, M., Li, N., Zeng, X., Liu, H., … & Wang, D. (2015). Acupuncture Efficacy on Ischemic Stroke Recovery. Stroke46(5), 1301-1306.
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Aerobic Exercise – Chronic

Evidence Reviewed as of before: 22-11-2011
Author(s)*: Adam Kagan, B.Sc.; Anita Petzold, BSc OT; Nathalie Serrat, BSC PT; Amanda Ischayek BSc PT; Sabrina Ianni, BSc, PT; Caroline Labelle, BSc PT; Sukhdeep Johal, Bsc PT; Monica Trozzo BSc. PT; Elissa Sitcoff, BA BSc; Annabel McDermott, OT; Nicol Korner-Bitensky, PhD OT
Expert Reviewer: Janice Eng, PhD PT; Pamela Duncan, PhD PT(C)
Patient/Family Information Table of contents

Introduction

It has been shown that patients with stroke have been shown to have low endurance during exercise, likely due to both the event and also as a secondary reaction to forced inactivity. It is also known that there is a positive connection between aerobic capacity and functional performance (Katz-Leurer et al. 2003). This module will focus on aerobic exercise for people who are in the chronic phase (longer than 6 months post stroke) of recovery.

  • Click here to view the AEROBICS 2019 Update Best Practice Recommendations.
  • Click here to access the CPSR 2013 Clinicians’ guide.
  • Click here to access the CPSR 2013 Patients’ guide.

Patient/Family Information

Authors: Erica Kader; Adam Kagan, B.Sc.; Nathalie Serrat, BSC PT; Amanda Ischayek BSc PT; Sabrina Ianni, BSc, PT; Caroline Labelle, BSc PT; Sukhdeep Johal, Bsc PT; Monica Trozzo BSc. PT; Elissa Sitcoff, BA BSc; Nicol Korner-Bitensky, PhD OT

What is aerobic exercise?

Aerobic exercise refers to physical activity that requires the body to use oxygen to generate energy. Participating in aerobic exercise is important to maintain a healthy body. A major benefit of aerobic exercise is that it conditions the heart and lungs. It does so by increasing the oxygen available to the body and enabling the heart to use oxygen more efficiently. In addition, aerobic exercise can also control body fat, increase energy, decrease tension, increase stamina, and improve mood. There are several different types of aerobic exercises that can be done at different levels of intensity for varying periods of time. Any activity that lasts longer than 3 minutes is considered aerobic (such as golf, biking, walking, and swimming). Note: While other forms of exercises (such as those focused on flexibility and muscles training) are equally important, only those focusing on aerobic exercise will be addressed in this module.

Why is exercise important after I have had a stroke?

After a stroke, it is common to experience continued difficulties in mobility, for example in walking. It is important to continue to exercise despite these challenges to avoid a vicious cycle, where difficulty in mobility leads to lack of exercise, and lack of exercise leads to further muscle weakening and reduced fitness. Inactivity can contribute to physical complications, including osteoporosis and decreased circulation. It can also lead to loss of independence, depression, and social isolation. The more inactive you are, the harder it is to maintain cardiovascular, mental, and neurological health.

Can exercise still be useful in the chronic phase?

While traditional belief was that most of an individual’s physical recovery occurred within the first several months after having a stroke, recent research has shown that an exercise program after this period, including in the chronic phase, can be beneficial as well. Research studies have shown that exercise during the chronic phase post stroke can lead to an improvement of one’s physical and mental well being, heart function, endurance, general quality of life, and movement. In addition, exercise can help to lower blood pressure, create a healthy balance of fats in the blood, help the body to maintain a healthy level of insulin, and minimize depression.

How do I begin to exercise after a stroke?

Before beginning an exercise program, it is recommended that you undergo a comprehensive medical evaluation to assess your specific needs. Your medical or rehabilitation team can work with you to develop an appropriate exercise regime (including types of activities, how often you should participate in activities and for how long) based on your individual needs and abilities.

What kind of activities should I do?

You should pick an activity that you will have fun doing. Examples of aerobic exercise activities include:

  • Golf
  • Walking
  • Dancing
    With permission of Dr. Patricia McKinley, McGill School of Physical and Occupational Therapy
  • Swimming
  • Cycling
  • Tennis
  • Bowling




Gardening and housework are also great forms of aerobic exercise. Try adding exercise to your daily routine, for example, parking your car further away from your destination. Any form of physical activity can be beneficial as long as it is done regularly and consistently. When it comes to bicycling, many people find it difficult or are afraid to fall. This problem can be solved by using a stationary bicycle. Stationary bicycles are a safe and effective means of low-impact, or light, aerobic exercise, so they are a good choice for people who have had a stroke. They can also be altered to fit your individual needs. Treadmills are also helpful for walking, providing that there is a bar to hold on to, and a way to modify speed and intensity. A treadmill is especially useful to retrain people who have had a stroke to walk again.

Can I participate in the same exercise as before?

After a stroke, it may be difficult to resume the same activities that you enjoyed before. You may need to change your previous exercise regime, which may mean discovering new exercise activities that are perhaps less physically demanding. Things that you may need to modify are:

  • The level of difficulty of exercise
  • Length of time you exercise
  • How often you exercise

These will depend on your needs and abilities and should be assessed by a rehabilitation team. Certain equipment can also be used to facilitate exercising, such as handrails and assistive devices. For example, you may enjoy swimming but may need to find a pool that has special safety equipment and adaptations.

Who can help me resume my exercise activities?

While rehabilitation staff, such as occupational therapists, physiotherapists, social workers, recreation therapists, and psychologists will start you on your new exercise program, your family and friends are an excellent source of support to help you continue with success. Exercising with a friend or family member is motivating, encouraging, and of course more fun.

How much exercise should I do?

According to the American Heart Association, the recommended frequency of training is 3 to 7 days a week, with a duration of 20 to 60 minutes per day, depending on the patient’s level of fitness. ** Once again, however, it is very important that you seek medical advice before beginning an exercise program and get advice on how often and for how long you should be doing the activities. Where can I participate in exercise? While in the hospital or rehabilitation centre, you will participate in exercise programs developed and assisted by your rehabilitation team. When you are ready to go home, the team may show you how to continue with this exercise on your own, may recommend that you join an exercise program, or a combination of the two. Day centers, local community centers, and gyms in your area may be able to provide appropriate programs and support that you need.

Here is a link to an online Stroke Class.

Is it effective after stroke?

Researchers have studied how aerobic exercise can help with stroke in the sub-acute phase and found the following:

  • Aerobic Capacity: this is the highest amount of oxygen consumed during maximal exercise. Studies showed that aerobic exercise improved aerobic capacity.
  • Heart rate: with aerobic exercise, heart rate did not increase in patients with chronic stroke. This is a positive outcome.
  • Walking: in some studies, aerobic exercise was shown to improve walking distance and speed.
  • Endurance: strong evidence has shown aerobic exercise improves endurance in people with sub-acute stroke.
  • Depression: studies have shown that aerobic exercise can improve depressive symptoms in individuals with sub-acute stroke, but only in the short term.
  • Quality of Life: performing aerobic exercise also seemed to improve the quality of life of people with sub-acute stroke.
  • Balance: aerobic exercise was shown to improve some aspects of balance in people with sub-acute stroke.

Are there any side effects or risks?

While exercise is mostly risk-free, it is important to stay within your own personal threshold. As mentioned before, it is best to consult with your doctor or therapist before beginning an exercise program. They will assist you in determining how often you should exercise, what activities you should participate in, and how intense they should be. If you were physically active before the stroke, you may or may not be able to continue with the same activities. You may simply need to modify those activities so they are easier for you. If you feel dizzy, have pain (especially in your chest) or have difficulty breathing, stop exercising immediately and tell your healthcare provider.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.
Note: Only studies that included at least one outcome measure for aerobic capacity (VO2, heart rate and/or workload during either a maximal stress test on a treadmill or a cycle ergometer) are included in this report. The only exception is when there is a follow-up of the study groups at a later date using other outcome measures such as depression, quality of life etc. All studies to date that have examined the effect of aerobic exercise on chronic stroke featured a “cocktail” of different types of treatment (e.g. strength training, flexibility training as well as a strong aerobic training component) so it is important to note that the effects of these interventions may be due in part to the combination of different treatments and not the aerobic component specifically. As well it should be noted that some of the studies contain small sample sizes, which can lead to inconclusive results. More studies with larger sample size are needed before conclusive result can be found.

The studies that meet the inclusion criteria (four high quality RCTs, five fair quality RCTs, two quasi-experimental studies, one pre-post design study, one repeated measures study and one non-controlled intervention study) suggest that a sustained exercise program containing an aerobic component provided over a period of at least 8 weeks, 3 x per week, may improve aspects of physiological function, physical function, and emotional well-being in patients with chronic stroke.

Outcomes

Activity and participation
Not effective
1b

One high quality RCT (Pang et al., 2005) and one quasi-experimental non-randomized trial (Sunnerghagen, 2007) examined the effects of aerobic exercise on activity and participation in patients with chronic stroke.

One high quality RCT (Pang et al., 2005) investigated the effect of aerobic exercise on activity and participation in patients with chronic stroke. No significant difference in scores on the Physical Activity Scale for Individuals with Physical Disabilities was found between the intervention group who received 19 weeks of cardiorespiratory fitness, mobility, balance and leg muscle strength exercise (the FAME program), and the control group who received a 19-week seated upper extremity exercise program.

In the quasi-experimental non-randomized trial, Sunnerghagen (2007) investigated the effect of circuit training on strength, aerobic capacity, and activity and participation in community-living “young” males with chronic stroke. The experimental group trained for 45 minutes 3x/week for 8 weeks on strength, endurance and aerobic capacity whereas the controls received no treatments. At post treatment non-significant differences were found within the experimental group for activities of daily living (ADLs) as measured by the Functional Independence Measure and Instrumental Activity Measure and for physical activity level as assessed with the Physical Activity Scale for the Elderly.
Note: The quasi-experimental non randomized trial did not report between group differences and is therefore not included in determining level of evidence.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that aerobic exercise does not improve activity and participation in patients with chronic stroke.

Ambulation and transfers
Effective
1b

One high quality RCT (Quaney et al., 2009) found a significant improvement in ambulation and transfers (as measured by the Get Up and Go test) in favour of the intervention group immediately following an 8-week progressive, resistive stationary bicycle exercise program, compared to the control group that completed an 8-week upper and lower extremity stretching program.
Note: This difference between groups was not seen on follow-up assessment 8 weeks later.

Conclusion: There is moderate evidence (level 1b) from one high quality study that aerobic exercise improves ambulation and transfer skills in patients with chronic stroke versus a stretching program, in the short term.

Attention
Insufficient evidence
5

One pre-post design study (Kluding et al., 2011) investigated the effect of aerobic exercise on attention in patients with chronic stroke and found no significant improvement in attention (measured by the Flanker Test – recognition of congruent and incongruent stimuli), from baseline to post-intervention following a 12-week aerobic and strengthening exercise program.
Note: This study did not compare aerobic training to a non-aerobic control, therefore it was not used to determine the level of evidence for the effectiveness of aerobic training.

Conclusion: There is insufficient evidence (level 5) regarding the efficacy of aerobic exercise on attention. However, one non-controlled study reported no improvement in attention following an aerobic exercise program.

Balance
Not effective
1a

Three high quality RCTs (Chu et al., 2004, Pang et al., 2005, Quaney et al., 2009) and one fair quality RCTs (Janssen et al., (2008) investigated the effect of aerobic exercise on balance in patients with chronic stroke.

In the first high quality RCT, Chu et al., (2004) found no significant post-intervention difference for balance (measured by the Berg Balance Scale) between the intervention group who received an 8-week chest-deep water-aerobic program compared to the control group who received arm and hand exercises while sitting.
Note: The authors pointed out that the lack of significant improvements for balance may have been due to the buoyancy of the water during the training aiding the participants too much. As well pre-test scores on the Berg Balance Scale were quite high which may have led to a ceiling effect (inability to detect further improvement in those already scoring at the top of the Scale initially).

In the second high quality RCT, Pang et al., (2005) found no significant difference in balance (as measured by the Berg Balance Scale) between the intervention group who followed the FAME program (19 weeks of cardiorespiratory fitness, mobility, balance and leg muscle strength exercises), and the control group who followed a 19-week seated upper extremity exercise program.
Note: Pre-test scores on the Berg Balance Scale were quite high which may have led to a ceiling effect (inability to detect further improvement in those already scoring at the top of the Scale initially).

The third high quality RCT, Quaney et al., 2009 investigated the effects of aerobic exercise on balance (as measured by the Berg Balance Scale). Patients with chronic stroke were randomized to an intervention group that completed an 8-week progressive resistive stationary bicycle exercise program, or a control group that completed an 8-week upper and lower extremity stretching program. A trend towards a significant difference in balance scores was seen immediately following completion of the program (8 weeks) that reached significance at follow-up assessment (16 weeks), in favour of the intervention group.

In the fair quality RCT, Janssen et al., (2008) investigated the effectiveness of functional electrical stimulation FES- assisted leg cycling training on improving aerobic capacity, maximal power output, muscle strength and functional performance in patients with chronic stroke. Both groups received cycling training in conjunction with FES twice a week for 6 weeks. However, the treatment group received FES evoking muscle contractions while the control group received sensible FES which could be felt but did not evoke muscle contractions. At post treatment there was no statistically significant difference between groups in balance as measured by the Berg Balance Scale.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs and one fair quality RCT that aerobic exercise does not improve balance in individuals with chronic stroke.
Note:
Pretest scores on the Berg Balance Scale were quite high which may have led to a ceiling effect (inability to detect further improvement in those already scoring at the top of the Scale initially).
Note: One high quality RCT found differences approaching significance on completion of the aerobic exercise program, which then became significant 8 weeks after completion of the program. Two high quality studies note that high pretest scores on the Berg Balance Scale may have led to a ceiling effect, influencing the results of the studies.

Blood lipid profile
Effective
2b

One quasi-experimental study (Rimmer et al., 2009) found an improvement in triglycerides (lowered) and low-density lipoprotein cholesterol (lowered) in favour of both moderate intensity shorter duration (MISD) exercise or low-intensity longer duration exercise (LILD) compared to conventional therapeutic exercise (TE) following 14 weeks of intervention.

Conclusion: There is limited evidence (level 2b) from one quasi-experimental study that aerobic exercise can improve the blood lipid profile of those with chronic stroke.

Blood pressure
Effective
2a

One fair quality RCT (Potempa et al., 1995) and one quasi-experimental study (Rimmer et al., 2009) investigated the effect of aerobic exercise on blood pressure in patients with chronic stroke.

One fair quality RCT (Potempa et al., 1995) investigated the effect of aerobic exercise on blood pressure in an intervention group that received a 10-week progressive aerobic training program on a bicycle ergometer, and a control group that received a 10-week range of motion training program. While no overall significant between group differences were found for resting and sub-maximal blood pressure, a significant between group differences in sub-maximal systolic blood pressure was found in favour of a subgroup of patients in the intervention group who were able to work at a peak workload of at least 40 watts.

One quasi-experimental study (Rimmer et al., 2009) found an improvement in diastolic blood pressure following moderate intensity shorter duration exercise compared to conventional therapeutic exercise (TE), but no difference between low-intensity longer duration exercise (LILD) and TE, following 14 weeks of intervention.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT demonstrating that aerobic exercise at a peak workload of at least 40 watts improves sub-maximal systolic blood pressure in patients with chronic stroke. However, no effect was found for resting blood pressure or sub-maximal blood pressure. Furthermore, one quasi-experimental study found that aerobic exercise (moderate intensity and short duration) can improve the blood pressure of patients with chronic stroke.

Body composition
Effective
2a

One fair quality RCT with a pre-post lag-control design (Rimmer et al., 2000) investigated the effect of aerobic exercise on body composition, defined as a combination of body weight, body mass index, and total skinfold, in predominantly African-American patients with chronic stroke. A significant reduction in body weight, body mass index, and total skinfold (indicating an improvement in body composition as most of the patients were considered overweight), was found in favor of the intervention group following a 12-week aerobic, strength and flexibility exercise training program, compared to the control group who received no intervention.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that aerobic exercise improves body composition by reducing body weight, body mass index, and total skinfold in patients with chronic stroke.

Bone mineral density
Effective
1b

One high quality RCT (Pang et al., 2005) investigated the effect of aerobic exercise on bone mineral density in patients with chronic stroke. A significant difference in femoral neck bone mineral density on the paretic side (as measured using dual-energy x-ray absorptiometry), was found in favour of the intervention group who followed the FAME program (19 weeks of cardiorespiratory fitness, mobility, balance and leg muscle strength exercises), compared to the control group who followed a 19-week seated upper extremity exercise program. No significant difference was found on the non-paretic side.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT reporting that aerobic exercise improves femoral neck bone mineral density on the paretic side, but not the non-paretic side, in patients with chronic stroke.

Carbon dioxide production
Effective
2a

One fair quality RCT (Potempa et al., 1995) investigated the effect of aerobic exercise on carbon dioxide production. A significant between group difference was found for peak VCO2 in favour of the intervention group that received a 10-week progressive aerobic training program on a bicycle ergometer, compared to the control group that received a 10-week range of motion training program.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT demonstrating that aerobic exercise increases VCO2 in patients with chronic stroke.

Depression
Insufficient evidence
5

One repeated measures study (Rand et al., 2010) investigated the effect of aerobic exercise on depression symptoms in patients with chronic stroke, as measured using the Geriatric Depression Scale. No significant change in depressive symptoms was seen at 3 or 6 months.

Conclusion: There is insufficient evidence (level 5) to indicate whether aerobic exercise is effective in improving depression in patients with chronic stroke. However, one repeated measures study found that aerobic exercise and recreation does not improve depression symptoms.

Disability related to mobility
Not effective
2a

One fair quality RCT (Macko et al., 2005) investigated the effect of aerobic exercise on disability related to bodily mobility in patients with chronic stroke. The intervention group received a 6-month progressive treadmill training program with a target of 35 minutes at 60-70% heart rate reserve, and the control group received a stretching program combined with 5-minutes of low-intensity treadmill training at 30-40% heart rate reserve. No significant between group difference was found on the Rivermead Mobility Index, indicating no effect on disability related to bodily mobility.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT indicating that aerobic exercise does not improve disability related to bodily mobility (as measured by the Rivermead Mobility Index) in patients with chronic stroke.

Endurance
Effective
2a

Two fair quality RCTs (Potempa et al., 1995, Rimmer et al., 2000) investigated the effect of aerobic exercise on endurance in patients with chronic stroke.

In the first fair quality RCT, Potempa et al. (1995) found a significant increase in exercise time (indicating an improvement in endurance) in favour of the intervention group who received a 10-week progressive aerobic training program on a bicycle ergometer, compared to the control group who received a 10-week range of motion training program.

In the second fair quality RCT, using a lag-control design, Rimmer et al. (2000) found a significant increase in time to exhaustion, (indicating an improvement in endurance) in favour of the intervention group following a 12-week aerobic, strength and flexibility training program, compared to the control group who received no intervention.

Conclusion: There is limited evidence (level 2a) from two fair quality RCTs that aerobic exercise improves endurance in patients with chronic stroke.

Executive function
Not effective
1b

One high quality RCT (Quaney et al., 2009) and one repeated measures study (Rand et al., 2010) investigated the effect of aerobic exercise on executive function in patients with chronic stroke.

The high quality RCT (Quaney et al., 2009) randomized patients with chronic stroke to an intervention group that completed an 8-week progressive, resistive stationary bicycle exercise program, or a control group that completed an 8-week upper and lower extremity stretching program. No significant between-group differences in executive function were found on completion of the program (8-weeks) or on follow-up assessment (16-weeks), as measured by the Wisconsin Card Sorting Task, Stroop task and Trail-Making task.

The repeated measures study (Rand et al., 2010) investigated the effect of a 6-month aerobic and recreation program on executive function, as measured by the Stroop Test, Verbal Digital Span Backward Test (VDSBT), Trail Making Test (Part B), Walking While Talking test (WWT), and Rey Auditory Verbal Learning Test (RAVLT). In comparison to baseline scores, significant improvements were seen on the Stroop Test, WWT and RAVLT – long delay at 3 months, and persisted on the Stroop Test at 6 months.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that aerobic exercise does not improve executive function in patients with chronic stroke, when compared with a stretching program.
NOTE: However, one repeated measures study found that participation in an exercise and recreation program can improve performance of dual tasks, response inhibition and memory in patients with chronic stroke.

Flexibility
Effective
2a

One fair quality RCT with a pre-post lag-control design (Rimmer et al., 2000) investigated the effect of aerobic exercise on flexibility in patients with chronic stroke. A significant improvement in hamstring and low back flexibility (as assessed by the sit and reach test), was found in favour of the intervention group following a 12-week aerobic, strength and flexibility exercise training program, compared to the control group who received no intervention. No significant gain in shoulder flexibility of the affected and unaffected extremity was reported pre/post exercise.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that an aerobic exercise improves hamstring and low back flexibility, but does not improve shoulder flexibility in patients with chronic stroke.
Note:
The program included a flexibility component making it difficult to differentiate the effect of the aerobic exercise alone.

Gait speed
Conflicting
4

Two high quality RCT (Chu et al., 2004, Lee et al., 2008), two fai quality RCTs (Macko et al., 2005, Luft et al., 2008) and two non-controlled intervention studies (Rand et al., 2010, Kluding et al., 2011) examined the effect of aerobic exercise on gait speed.

One high quality RCT (Chu et al., 2004) investigated the effect of aerobic exercise on functional mobility as measured by walking speed in patients with chronic stroke. A significant increase in walking speed (measured by self-selected gait speed over 8 meters) was found in favour of the intervention group following an 8-week chest-deep water-aerobic program, compared to the control group who received arm and hand exercises while sitting.

The second high quality (Lee et al., 2008) found no significant improvement in walking speed following 10 to 12 weeks of aerobic cycling compared to sham cycling.

The first fair quality RCT (Macko et al., 2005) investigated the effect of aerobic exercise on gait speed in patients with chronic stroke. The intervention group received a 6-month progressive treadmill training program with a target of 35 minutes at 60-70% heart rate reserve, and the control group received a stretching program combined with 5-minutes of low-intensity treadmill training at 30-40% heart rate reserve. No significant between group difference was found for the 30-foot walking speed (at both usual pace or at fast pace), or the speed subscale of the Walking Impairment Questionnaire.

A second fair quality RCT (Luft et al., 2008) found a significant increase in peak effort treadmill walking velocity and average walking velocity over 6-minutes (over ground), for a group of patients who received 6 months of progressive task-repetitive treadmill training with a target of 40 minutes at 60% heart rate reserve, compared to a control group who received a therapist assisted stretching program for a comparable duration. No significant between group difference was found for fastest walking velocity over 10-meters (over ground).

One repeated measures study (Rand et al., 2010) investigated the effect of a 6-month aerobic and recreation program on gait speed in patients with chronic stroke, as measured by the 5-meter walk test. A significant improvement in gait speed was seen at 3 months and a non-significant trend was seen on re-assessment at 6 months, as compared to baseline measures.

A pre-post design study (Kluding et al., 2011) found no significant improvement in self-selected gait speed (measured by the 10-m walk test) from baseline to post-intervention following a 12-week aerobic and strengthening exercise program.
Note: This study did not compare aerobic training to a non-aerobic control, therefore it was not used to determine the level of evidence for the effectiveness of aerobic training.

Conclusion: There is conflicting evidence (level 4) as to whether aerobic exercise improves gait speed in patients with chronic stroke. While 1 high quality RCT and 1 fair quality RCT found that aerobic exercise improves aspects of gait speed, another high quality RCT and one fair quality RCT found no improvement in gait speed.
NOTE: The high quality RCT that found positive results provided chest-deep water-aerobic program as part of the intervention, while the high quality RCT that did not find positive results used aerobic cycling as the intervention.

Memory
Insufficient evidence
5

One pre-post design study (Kluding et al., 2011) investigated the effect of aerobic exercise on memory in patients with chronic stroke and found a significant improvement in working memory (measured by the Digit Span Backwards task) but no significant improvement in self-reported memory (measured by the Stroke Impact Scale memory component) from baseline to post-intervention following a 12-week aerobic and strengthening exercise program.
Note: This study did not compare aerobic training to a non-aerobic control, therefore it was not used to determine the level of evidence for the effectiveness of aerobic training.

Conclusion: There is insufficient evidence (level 5) regarding the efficacy of aerobic exercise on memory. However, one non-controlled study reported improved working memory following an aerobic exercise program.

Mobility
Insufficient evidence
5

One pre-post design study (Kluding et al., 2011) investigated the effect of aerobic exercise on mobility in patients with chronic stroke (measured by the Stroke Impact Scale mobility subscale) and found a strong trend toward significant improvement from baseline to post-intervention following a 12-week aerobic and strengthening exercise program.
Note: This study did not compare aerobic training to a non-aerobic control, therefore it was not used to determine the level of evidence for the effectiveness of aerobic training.

Conclusion: There is insufficient evidence (level 5) regarding the efficacy of aerobic exercise on mobility. However, one non-controlled study reported a strong trend towards improved mobility following an aerobic exercise program.

Motor learning
Effective
1b

One high quality RCT (Quaney et al., 2009) investigated the effect of an aerobic exercise program on conditional learning (as measured by predictive force accuracy using Predictive Grip Force Modulation tasks) and on implicit learning (as measured by sequence-specific and random-sequence reaction times on the Serial Reaction Timed Task). Patients with chronic stroke were randomized to an intervention group that completed an 8-week progressive resistive stationary bicycle exercise program, or a control group that completed an 8-week upper and lower extremity stretching program. Significant between-group differences in both predictive force accuracy (conditional learning) and sequence-specific reaction time (implicit learning) were found in favour of the intervention group immediately following completion of the exercise program (8 weeks) but these differences were not maintained at follow-up assessment (16 weeks). No significant group differences were seen for random-sequence reaction time (implicit learning).

Conclusion: There is moderate evidence (level 1b) from one high quality study that aerobic exercise improves conditional learning and some aspects of implicit learning (sequence-specific reaction times) in patients with chronic stroke in the short term, when compared with a stretching program.

Peak heart rate
Not effective
1b

One high quality RCT (Lee et al., 2008), one fair quality RCT (Potempa et al., 1995) and one quasi-experimental non-randomized trial (Sunnerghagen, 2007) investigated the effect of aerobic exercise on peak heart rate in patients with chronic stroke.

The high quality RCT (Lee et al., 2008) found no significant improvement in peak rate (during a test of maximal effort on a bicycle ergometer) following 10 to 12 weeks of aerobic cycling compared to sham aerobic cycling. However, it should be noted that a trend toward significance was found (p=.07) and that the non-significant result may be due to a small N.

One fair quality RCT (Potempa et al., 1995) found no significant difference was found for peak heart rate during a maximal test on a bicycle ergometer between the intervention group, who received a 10-week training program on an adjusted bicycle ergometer and the control group who received a passive range of motion exercise program.

In the quasi-experimental non-randomized trial, Sunnerghagen (2007) investigated the effect of circuit training on strength, aerobic capacity, and activity and participation in community-living “young” males with chronic stroke. The experimental group trained for 45 minutes 3x/week for 8 weeks on strength, endurance and aerobic capacity whereas the controls received no treatments. At post treatment non-significant differences were found within the experimental group for peak heart rate as tested while on the electrical bicycle ergonometer.
Note: The quasi-experimental non randomized trial did not report between group differences and is therefore not included in determining level of evidence.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one fair quality RCT that aerobic exercise does not increase peak heart rate in patients with chronic stroke.

Peak VO2
Effective
1a

Four high quality RCTs (Chu et al., 2004, Pang et al., 2005, Lee et al., 2008, Quaney et al., 2009), five fair quality RCTs (Potempa et al., 1995, Rimmer et al., 2000, Macko et al., 2005, Janssen et al., 2008, Luft et al., 2008), two quasi-experimental non-randomized trial (Sunnerghagen, 2007, Rimmer et al., 2009) and two non-controlled intervention studies (Macko et al., 2001, Kluding et al, 2011) investigated the effect of aerobic exercise on peak VO2 in patients with chronic stroke.

In the first high quality RCT, Chu et al. (2004) found a significant increase in peak VO2 during a test of maximal effort on a bicycle ergometer (indicating an improvement in aerobic capacity) in favour of the intervention group following an 8-week chest-deep water-aerobic program, compared to the control group who received 8 weeks of arm and hand exercises while sitting.

In the second high quality RCT, Pang et al. (2005) found a significant increase in peak VO2 during a test of maximal effort on a bicycle ergometer (indicating an improvement in aerobic capacity) in favour of the intervention group immediately following a 19-week program of cardiorespiratory fitness, mobility, balance and leg muscle strength exercises (the FAME program), compared to the control group who followed a 19-week seated upper extremity exercise program.

The third high quality RCT (Lee et al., 2008) showed a significant improvement in peak VO2 (during a test of maximal effort on a bicycle ergometer) following 10 to 12 weeks of aerobic cycling compared to sham aerobic cycling.

The fourth high quality RCT (Quaney et al., 2009) found a significant improvement in peak VO2 on metabolic stress testing in favour of the intervention group immediately following an 8-week progressive, resistive stationary bicycle exercise program, compared to the control group that completed an 8-week upper and lower extremity stretching program.
Note: This difference between groups was not seen on follow-up assessment 8 weeks later.

The first fair quality RCT (Potempa et al. (1995) found a significant increase in peak VO2 during a test at maximal effort on a bicycle ergometer (indicating an improvement in aerobic capacity) in favour of the intervention group following a 10-week training program on an adjusted bicycle ergometer compared to the control group who received a passive range of motion exercise program.

The second fair quality study (Rimmer et al. (2000) – using a lag-control design – found a significant increase in peak VO2 during a test of maximum effort on a bicycle ergometer (indicating an improvement in aerobic capacity) in favour of the intervention group following a 12-week aerobic, strength and flexibility training program, compared to the control group who received no intervention.
Note: The control group then went on to receive the intervention as indicated by the “lag-control” study design.

The third fair quality RCT (Macko et al. (2005) found a significant increase in peak VO2 during a treadmill stress test (indicating an improvement in aerobic capacity) in favour of the intervention group following a 6-month progressive treadmill training program with a target length of 35 minutes at 60-70% heart rate reserve, compared to the control group who received a stretching program combined with 5-minutes of low-intensity treadmill training at 30-40% heart rate reserve.

A fourth fair quality study, Janssen et al. (2008) investigated the effectiveness of FES-assisted leg cycling training on improving aerobic capacity, maximal power output, muscle strength and functional performance in patients with chronic stroke. Both groups received cycling training in conjunction with FES twice a week for 6 weeks. However, the treatment group received FES evoking muscle contractions while the control group received sensible FES, which could be felt but did not evoke muscle contractions. At post treatment there was no statistically significant difference between groups in aerobic capacity as measured by VO2 max.
Note: This study did not compare aerobic training to a non-aerobic control, therefore it was not used to determine the level of evidence for the effectiveness of aerobic training.

In the fifth fair quality RCT, Luft et al. (2008) found a significant increase in peak VO2 during a treadmill stress test, for a group of patients who received 6 months of progressive task-repetitive treadmill training with a target of 40 minutes at 60% heart rate reserve, compared to the control group who received a therapist assisted stretching program for a comparable duration.

In the quasi-experimental non-randomized trial, Sunnerghagen (2007) investigated the effect of circuit training on strength, aerobic capacity, and activity and participation in community-living “young” males with chronic stroke. The experimental group trained for 45 minutes 3x/week for 8 weeks on strength, endurance and aerobic capacity whereas the controls received no treatments. At post treatment non-significant differences were found within the experimental group for peak VO2.
Note: The quasi-experimental non-randomized trial did not report between group differences and is therefore not included in determining level of evidence.

The second quasi-experimental (Rimmer et al., 2009) found no difference in peak VO2 between moderate intensity, shorter duration (MISD) exercise or low-intensity longer duration exercise (LILD) compared to conventional therapeutic exercise (TE) following 14 weeks of intervention.

One non-controlled intervention study (Macko et al., 2001) investigated the effect of aerobic exercise on peak VO2 in patients with chronic stroke. A significant increase in peak VO2 during a treadmill stress test, indicating an improvement in aerobic capacity, was found for 23 patients who received a 6-month progressive treadmill training program with a target of approximately 40 minutes at 60-70% heart rate reserve.

A pre-post design study (Kluding et al., 2011) found a strong trend toward significantly improved peak VO2 from baseline to post-intervention following a 12-week aerobic and strengthening exercise program.
Note: This study did not compare aerobic training to a non-aerobic control, therefore it was not used to determine the level of evidence for the effectiveness of aerobic training.

Conclusion: There is strong evidence (level 1a) from four high quality RCTs, four fair quality RCTs, and one non-controlled intervention study that aerobic exercise significantly increases peak VO2 (indicating an improvement in aerobic capacity) in patients with chronic stroke when compared with a range of control therapies including stretching exercises, sham aerobic activity, conventional therapy and no intervention.

Peak volume of total exhalation
Effective
2a

One fair quality RCT (Potempa et al., 1995) investigated the effect of aerobic exercise on volume of exhalation (VE). A significant between group difference was found for peak VE in favour of the intervention group that received a 10-week progressive aerobic training program on a bicycle ergometer, compared to the control group that received a 10-week range of motion training program.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT demonstrating that aerobic exercise increases peak VE in patients with chronic stroke.

Peak workload
Effective
1a

Two high quality RCTs (Chu et al., 2004, Lee et al., 2008), three fair quality RCTs (Potempa et al., 1995, Rimmer et al., 2000, Janssen et al., 2008), one quasi-experimental non-randomized trial, (Sunnerghagen, 2007) and one non-controlled intervention study (Macko et al., 2001) investigated the effect of aerobic exercise on peak workload in patients with chronic stroke.

One high quality RCT (Chu et al., 2004) investigated the effect of aerobic exercise on peak workload in patients with chronic stroke. A significant increase in peak workload during a test of maximal effort on a bicycle ergometer, indicating an improvement in aerobic capacity, was found in favour of the intervention group following an 8-week chest-deep water-aerobic program, compared to the control group who received arm and hand exercises while sitting.

A second high quality RCT (Lee et al., 2008) showed a significant improvement in peak power output (during a test of maximal effort on a bicycle ergometer) following 10 to 12 weeks of aerobic cycling compared to sham aerobic cycling.

The first fair quality RCT (Potempa et al. 1995) found a significant increase in peak workload during a maximal test on a bicycle ergometer (indicating an improvement in aerobic capacity) in favour of the intervention group following a 10-week training program on an adjusted bicycle ergometer compared to the control group that received a passive range of motion exercise program.

The second fair quality RCT (Rimmer et al. (2000), using a lag-control design, also found a significant increase in peak workload (indicating an improvement) in favour of the intervention group following a 12-week aerobic, strength and flexibility exercise training program, compared to the control group which received no intervention.

In the third fair quality study, Janssen et al. (2008) investigated the effectiveness of FES- assisted leg cycling training on improving aerobic capacity, maximal power output, muscle strength and functional performance in patients with chronic stroke. Both groups received cycling training in conjunction with FES twice a week for 6 weeks. However, the treatment group received FES evoking muscle contractions while the control group received sensible FES which could be felt but did not evoke muscle contractions. At post treatment there was no statistically significant difference between groups in maximal power output as measured by PO max.
Note: This study did not compare aerobic training to a control of non-aerobic training, therefore it was not used in determining level of evidence.

In the quasi-experimental non-randomized trial, Sunnerghagen (2007) investigated the effect of circuit training on strength, aerobic capacity, and activity and participation in community-living “young” males with chronic stroke. The experimental group trained for 45 minutes 3x/week for 8 weeks on strength, endurance and aerobic capacity whereas the controls received no treatments. At post treatment non-significant differences were found within the experimental group for peak workload as tested while on the electrical bicycle ergometer.
Note: The quasi-experimental non randomized trial did not report between group differences and is therefore not included in determining level of evidence.

One non-controlled intervention study (Macko et al., 2001) investigated the effect of aerobic exercise on peak workload in patients with chronic stroke. A significant increase in peak workload during a treadmill stress test, indicating an improvement in aerobic capacity, was found for 23 patients who received a 6-month progressive treadmill training program with a target of approximately 40 minutes at 60-70% heart rate reserve.

Conclusion: There is strong evidence (level 1a) from two high quality RCT, 2 fair quality RCTs, and one non-controlled intervention study, that aerobic exercise significantly increases peak workload – indicating an improvement in aerobic capacity – in patients with chronic stroke. However, one fair quality RCT found that the use of FES- assisted cycling training compared to cycling training alone does not improve maximal power output in patients with chronic stroke. Note that in this study, both groups performed cycling on a bicycle ergometer.

Perceived self-efficacy in functional mobility
Not effective
1b

One high quality RCT (Lee et al., 2008) investigated the effect of aerobic exercise on perceived self-efficacy in functional mobility and found no improvement following 10 to 12 weeks of aerobic cycling compared to sham cycling.

Conclusion: There is moderate evidence (level 1b) from one high quality study that aerobic exercise does not improve perceived self-efficacy in functional mobility when compared to sham activity.

Quality of life
Not effective
1b

One high quality RCT (Lee et al. 2008) investigated the effect of aerobic exercise on quality of life and found no improvement following 10 to 12 weeks of aerobic cycling compared to sham cycling.

Conclusion: There is moderate evidence (level 1b) from one high quality study that aerobic exercise does not improve quality of life.

Respiratory exchange ratio
Not effective
1b

One high quality RCT (Pang et al., 2005) and one fair quality RCT (Potempa et al., 1995) and one quasi-experimental non-randomized trial (Sunnerghagen, 2007) examined the effect of aerobic exercise on respiratory exchange ratio in patients with chronic stroke.

The high quality RCT (Pang et al., 2005), investigated the effect of aerobic exercise on respiratory exchange ratio in patients with chronic stroke. No significant difference was found for respiratory exchange ratio between the intervention group who followed the FAME program (19 weeks of cardiorespiratory fitness, mobility, balance and leg muscle strength exercises), and the control group who followed a 19-week seated upper extremity exercise program.

The fair quality RCT (Potempa et al., 1995), investigated the effect of aerobic exercise on respiratory exchange ratio. No significant between group differences were found between the intervention group who received a 10-week progressive aerobic training program on a bicycle ergometer, and the control group who received a 10-week range of motion training program.

In the quasi-experimental non-randomized trial, Sunnerghagen (2007) investigated the effect of circuit training on strength, aerobic capacity, and activity and participation in community-living “young” males with chronic stroke. The experimental group trained for 45 minutes 3x/week for 8 weeks on strength, endurance and aerobic capacity whereas the controls received no treatments. At post treatment non-significant differences were found within the experimental group for respiratory exchange ratio.
Note: The quasi-experimental non randomized trial did not report between group differences and is therefore not included in determining level of evidence.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one fair quality RCT demonstrating that aerobic exercise has no significant effect on respiratory exchange ratio in patients with chronic stroke.

Resting heart rate
Not effective
2a

One fair quality RCT (Potempa et al., 1995) investigated the effect of aerobic exercise on resting heart rate. No significant between group differences in resting heart rate were found between the intervention group who received a 10-week progressive aerobic training program on a bicycle ergometer, and the control group who received a 10-week range of motion training program.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that aerobic exercise has no significant effect on resting heart rate in patients with chronic stroke.

Sensorimotor function
Not effective
1b

One high quality RCT (Quaney et al., 2009), one fair quality RCT (Potempa et al., 1995) and one non-controlled study (Kluding et al., 2011) investigated the effect of aerobic exercise on sensorimotor function in patients with chronic stroke.

The high quality RCT (Quaney et al., 2009) investigated the effects of aerobic exercise on motor function (as measured by the Fugl-Meyer sensorimotor test). Patients with chronic stroke were randomized to an intervention group that completed an 8-week progressive, resistive stationary bicycle exercise program, or a control group that completed an 8-week upper and lower extremity stretching program. No significant between-group difference in sensorimotor function was found on completion of the program (8-weeks) or on follow-up assessment (16-weeks).

The fair quality RCT (Potempa et al., 1995) found no significant overall difference in sensorimotor function (as measured by the Fugl-Meyer Index (FMI) between the intervention group, who received a 10-week progressive aerobic training program on a bicycle ergometer, and the control group, who received a 10-week range of motion training program. It is of note, however, that a significant correlation was found between improvement in aerobic capacity (as evaluated by peak VO2) and improvement in sensorimotor function, indicating that exercise training may benefit those who can train at an intensity that improves aerobic capacity.

A pre-post design study (Kluding et al., 2011) found a significant improvement in motor function (as measured by the Fugl-Meyer test and Stroke Impact Scale) from baseline to post-intervention following a 12-week aerobic and strengthening exercise program.
Note: This study did not compare aerobic training to a non-aerobic control, therefore it was not used to determine the level of evidence for the effectiveness of aerobic training.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one fair quality RCT that aerobic exercise does not significantly improve sensorimotor function in patients with chronic stroke when compared with range of motion therapy.

Stair climbing
Not effective
2a

One fair quality RCT (Macko et al., 2005) investigated the effect of aerobic exercise on stair climbing in patients with chronic stroke. The intervention group received a 6-month progressive treadmill training program with a target of 35 minutes at 60-70% heart rate reserve, and the control group received a stretching program combined with 5-minutes of low-intensity treadmill training at 30-40% heart rate reserve. No significant between group difference was found for the stair climbing subscales of the Walking Impairment Questionnaire.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT indicating that aerobic exercise does not improve stair climbing in patients with chronic stroke.

Strength (Lower extremity)
Conflicting
4

Three high quality RCTs (Chu et al., 2004, Pang et al., 2005, Lee et al., 2008), two fair quality RCT (Rimmer et al., 2000, Janssen et al., 2008), one quasi-experimental non-randomized trial (Sunnerghagen, 2007) and one repeated measures study (Rand et al., 2010) investigated the effect of aerobic exercise on lower extremity muscle strength in patients with chronic stroke.

In the first high quality RCT, Chu et al. (2004) found a significant increase in strength on the paretic lower limb (measured with a dynamometer for isokinetic flexor and extensor muscle strength) in favour of the intervention group following an 8-week chest-deep water-aerobic program, compared to the control group who received arm and hand exercises while sitting. However, no significant between group difference was found for the non-paretic side.

In the second high quality RCT, Pang et al. (2005) found a significant difference in leg muscle strength as measured by a hand-held dynamometer for isometric knee extension, in favour of the intervention group following 19 weeks of cardiorespiratory fitness, mobility, balance and leg muscle strength exercises (the FAME program), compared to the control group who followed a 19-week seated upper extremity exercise program.

The third high quality RCT (Lee et al., 2008) found no significant improvement in lower extremity strength (measured by stair climbing power and lower limb weight lifting ability) following 10 to 12 weeks of aerobic cycling compared to sham aerobic cycling.

In one fair quality RCT, using a pre-post lag-control design, Rimmer et al. (2000) investigated the effect of aerobic exercise on strength in predominantly African-American patients with chronic stroke. A significant increase in the amount of weight the patients were able to lift during a bench press and a leg press, indicating an improvement in strength, was found in favour of the intervention group following a 12-week aerobic, strength and flexibility exercise training program, compared to the control group who received no intervention.

In the second fair quality RCT, Janssen et al., (2008) investigated the effectiveness of FES- assisted leg cycling training on improving aerobic capacity, maximal power output, muscle strength and functional performance in patients with chronic stroke. Both groups received cycling training in conjunction with FES twice a week for 6 weeks. However, the treatment group received FES evoking muscle contractions while the control group received sensible FES which could be felt but did not evoke muscle contractions. At post treatment there was no statistically significant difference between groups in strength as measured by Maximum Voluntary Contraction.
Note: This study did not compare aerobic training to a control of non-aerobic training, therefore it was not used in determining level of evidence.

In the quasi-experimental non-randomized trial, Sunnerghagen (2007) investigated the effect of circuit training on strength, aerobic capacity, and activity and participation in community-living “young” males with chronic stroke. The experimental group trained for 45 minutes 3x/week for 8 weeks on strength, endurance and aerobic capacity whereas the controls received no treatments. Strength was measure pre and post intervention using a dynamometer to assess isometric knee extension and flexion. At post treatment there was a significant improvement for strength in the paretic leg but not for the non-paretic leg as measured by a dynamometer.
Note: The quasi-experimental non randomized trial did not report between group differences and is therefore not included in determining level of evidence.

In the repeated measures study, Rand et al., 2010 investigated the effect of a 6-month aerobic and recreation program on isometric muscle knee strength in patients with chronic stroke, as measured by a dynamometer. Significant improvement in strength was seen at 3 months and a non-significant trend was seen on re-assessment at 6 months, as compared to baseline data.
Note: This study did not specify whether muscle strength was measured on the paretic side only or on both the paretic and non-paretic limbs.

Conclusion: There is conflicting evidence (level 4) as to whether aerobic exercise improves lower extremity strength in patients with chronic stroke. While 1 high quality RCT found no improvement in strength, 2 high quality RCTs and 1 fair quality RCT found that aerobic exercise improves lower extremity strength.
Note: The two high quality RCTs and the fair quality RCT that found an improvement in strength involved a strength-training component.

Strength (Upper extremity)
Effective
2a

In one fair quality RCT, using a pre-post lag-control design, Rimmer et al. (2000) investigated the effect of aerobic exercise on strength in predominantly African-American patients with chronic stroke. A significant increase in the amount of weight the patients were able to lift during a bench press, indicating an improvement in strength, was found in favour of the intervention group following a 12-week aerobic, strength and flexibility exercise training program, compared to the control group who received no intervention. No significant between group differences in hand grip strength in the affected and unaffected extremity was reported.

Conclusion: There is limited evidence (level 2a) from 1 fair quality RCT that aerobic exercise is effective in improving upper extremity strength but not hand grip strength in patients with chronic stroke.

Submaximal VO2
Not effective
2b

One quasi-experimental (Rimmer et al., 2009) found no difference in submaximal VO2 between moderate intensity, shorter duration (MISD) exercise or low-intensity longer duration exercise (LILD) compared to conventional therapeutic exercise (TE) following 14 weeks of intervention.

Conclusion: There is limited evidence (level 2b) from one quasi-experimental study that aerobic exercise does not improve submaximal VO2 in patients with chronic stroke.

Walking distance
Conflicting
4

Two high quality RCTs (Pang et al., 2005, Lee et al., 2008) and two fair quality RCTs (Macko et al., 2005, Janssen et al., 2008) examined the effect of aerobic exercise on walking distance.

The first high quality RCT (Pang et al., 2005) investigated the effect of aerobic exercise on walking distance in patients with chronic stroke. A significant increase in walking distance, measured by the 6-minute walk test, was found in favour of the intervention group who followed the FAME program (19 weeks of cardiorespiratory fitness, mobility, balance and leg muscle strength exercises), compared to the control group who received a 19-week seated upper extremity exercise program.

The second high quality (Lee et al., 2008) found no significant improvement in walking distance following 10 to 12 weeks of aerobic cycling compared to sham cycling.

In the first fair quality RCT, Macko et al. (2005) investigated the effect of aerobic exercise on walking distance in patients with chronic stroke. The intervention group received a 6-month progressive treadmill training program with a target of 35 minutes at 60-70% heart rate reserve, and the control group received a stretching program combined with 5-minutes of low-intensity treadmill training at 30-40% heart rate reserve. A significant difference was found in favour of the intervention group for 6-minute walking distance and the distance subscale of the Walking Impairment Questionnaire compared to the control group.

In the second fair quality RCT, Janssen et al., (2008) investigated the effectiveness of FES- assisted leg cycling training on improving aerobic capacity, maximal power output, muscle strength and functional performance in patients with chronic stroke. Both groups received cycling training in conjunction with FES twice a week for 6 weeks. However, the treatment group received FES evoking muscle contractions while the control group received sensible FES which could be felt but did not evoke muscle contractions. At post treatment there was no statistically significant difference between groups in walking distance as measured by the 6-minute walking test.
Note: This study did not compare aerobic training to a control of non-aerobic training, therefore it was not used in determining level of evidence.

Conclusion: There is conflicting evidence (level 4) between 1 high quality RCT and one fair quality RCT that found aerobic exercise improves walking distance and 1 high quality RCT that found no improvement in walking distance following aerobic exercise, in patients with chronic stroke. It should be noted that the high quality RCT that found no improvement involved aerobic cycling, whereas the other studies involved more gait related aerobic activities.

Walking economy
Effective
2b

One non-controlled intervention exercise study (Macko et al., 2001) investigated the effect of aerobic exercise on walking economy in patients with chronic stroke. A significant increase in VO2 during sub-maximal walking, indicating an improvement, was found for 23 patients following a 6-month progressive treadmill training program with a target of approximately 40 minutes at 60-70% heart rate reserve.

Conclusion: There is limited evidence (level 2b) from one non-controlled exercise study reporting that aerobic exercise improves walking economy in patients with chronic stroke.

Walking endurance
Insufficient evidence
5

Two non-controlled studies (Rand et al., 2010, Kluding et al., 2011) investigated the effect of aerobic exercise on walking endurance in patients with chronic stroke.

One repeated measures study (Rand et al., 2010) found a significant improvement in walking endurance, as measured by the 6 Minute Walk Test at 3 and 6 months, as compared to baseline, following a 6-month aerobic and recreation program.

A pre-post design study (Kluding et al., 2011) found a strong trend toward significantly improved aerobic fitness (measured by the 6 Minute Walk Test) from baseline to post-intervention following a 12-week aerobic and strengthening exercise program.
Note: This study did not compare aerobic training to a non-aerobic control, therefore it was not used to determine the level of evidence for the effectiveness of aerobic training.

Conclusion: There is insufficient evidence (level 5) to indicate whether aerobic exercise is effective in improving walking endurance in patients with chronic stroke. However, two non-controlled studies found that aerobic exercise may be effective in improving walking endurance.

References

Chu KS, Eng JJ, Dawson AS, Harris JE, Ozkaplan A & Gylfadottir S. (2004). Water-based exercise for cardiovascular fitness in people with chronic stroke: A randomized controlled trial. Archives of Physical Medicine & Rehabilitation, 85, 870-874.

Janssen TW, Beltman JM, Elich P, Koppe PA, Konijnenbelt H, de Haan A, Gerrits KH. (2008). Effects of electric stimulation-assisted cycling training in people with chronic stroke. Arch Phys Med Rehabil , 89:463-469.

Kluding, P. M., Tsen, B. Y., & Billinger, S. A. (2011). Exercise and executive function in individuals with chronic study: A pilot study. Journal of Neurologic Physical Therapy, 35, 11-17.

Lee M., Kilbreath S.L., Singh M.F., Zeman B., Lord S.R., Raymond J., & Davis G.M. (2008). Comparison of Effect of Aerobic Cycle Training and Progressive Resistance Training on Walking Ability After Stroke: A Randomized Sham Exercise-Controlled Study. J Am Geriatr Soc, 56, 976-985.

Luft AR, Macko RF, Forrester LW, Villagra F, Ivey F, Sorkin JD, Whitall J, McCombe-Waller S, Katzel L, Goldberg AP, Hanley DF. (2008). Treadmill exercise activates subcortical neural networks and improves walking after stroke: a randomized controlled trial. Stroke, 39(12), 3341-3350.

Macko R, Smith G, Dobrovolny L, Sorkin J, Goldberg A & Silver K (2001). Treadmill Training Improves Fitness Reserve in Chronic Stroke Patients. Archives of Physical Medicine & Rehabilitation, 82, 879-84.

Macko RF, Ivey FM, Forrester LM, Hanley D, Sorkin JD, Katzel LI, Silver KH & Goldberg AP (2005). Treadmill exercise rehabilitation improves ambulatory function and cardiovascular fitness in patients with chronic stroke: A randomized, controlled trial. Stroke, 36, 2206- 2211.

Pang MYC, Eng JJ, Dawson AS, McKay HA & Harris JE (2005). A community-based fitness and mobility exercise program for older adults with chronic stroke: a randomized, controlled trial. Journal of American Geriatrics Society, 53(10), 1667-1674.

Potempa K, Lopez M, Braun LT, Szidon P, Fogg L & Tincknell T (1995). Physiological outcomes of aerobic exercise training in hemiparetic stroke patients. Stroke, 26(1), 101-105.

Rand, D., Eng, J. J., Liu-Ambrose, T., & Tawashy, A. E. (2010). Feasability of a 6-month exercise and recreation program to improve executive functioning and memory in individuals with chronic stroke. Neurorehabilitation and Neural Repair, 24, 722-729.

Rimmer JH, Riley B, Creviston T & Nicola T (2000). Exercise training in a predominantly African-American group of stroke survivors. Medicine & Science in Sports & Exercise, 32(12), 1990-1996.

Rimmer J, Rauworth A, Wang E, Nicola T & Hill B. (2009). A Preliminary Study to Examine the Effects of Aerobic and Therapeutic (Nonaerobic) Exercise on cardiorespiratory Fitness and Coronary Risk Reduction in Stroke Survivors. Arch Phys Med Rehabil, 90, 407-12.

Quaney, B. M., Boyd, L. A., McDowd, J. M., Zahner, L. H., He, J., Mayo, M. S., & Macko, R. F. (2009). Aerobic exercise improves cognition and motor function. Neurorehabilitation and Neural Repair, 23, 879-885.

Sunnerghagen KS (2007). Circuit Training in Community-Living “Younger” Men After Stroke. Journal of Stroke and Cerebrovascular Diseases, 16, 122-129.

Assistive Devices

Evidence Reviewed as of before: 10-12-2009
Author(s)*: Wing Chung Chan, BSc OT; Catherine Cusson, BSc OT; Andréane Lalumière Saindon, BSc OT; Nicol Korner-Bitensky, Ph. D OT
Patient/Family Information Table of contents

Introduction

Assistive Technology Devices (ATDs) include aids to locomotion such as canes, walkers and wheelchairs, as well as a wide variety of other technologies for accommodating the functional limitations that result from a disabling condition like stroke. They have the potential to reduce residual disability, slow functional declines, lower health care costs and decrease burden of care. Seniors with stroke living at home own a large number of assistive devices (almost 16 devices per person on average; Mann et al., 1995).

The most commonly adopted ATDs following stroke are locomotion aids since locomotor disability, as defined by difficulties in activities of daily living related to lower limb function, is among the first basic components of daily activities to be trained in the early stages of physical rehabilitation (Isaacs, 1985) and is a common consequence of stroke.

Devices such as canes and walkers are frequently used by stroke survivors. The principal reason is that, for those who reside at home following completion of a hospital rehabilitation program, tolerance for walking tends to be significantly reduced (Chiou & Burnett, 1985; McMurdo & Johnstone, 1995; Myers et al., 1996; Overstall et al., 1977).

Patients who suffer a stroke, particularly when associated with hemiplegia, often require the use of an assistive device such as a wheelchair, walking aids or robotics. The major functions of walking aids post-stroke are to increase stability, to improve muscle action. Aids such as canes serve to increase the base of support and improve ambulation for those with impaired balance. Canes and walkers appear to be effective in compensating for their decreased postural sway and for enhancing their participation in activities of daily living (Fernie et al., 1982), especially if they have hemiplegia (Maeda et al., 2001).

The main advantages for early use of wheelchairs post-stroke are related to support for the hemiplegic sides and greater limited functional improvement and independence. The use of robotics to aid stroke rehabilitation of the upper extremities has gained recent attention. Robotic devices for gait training are modeled by evidence that body-weight support locomotion training improves gait.

Patient/Family Information

Authors: Wing Chung Chan, BSc OT; Catherine Cusson, BSc OT; Andréane Lalumière Saindon, BSc OT, Nicol Korner-Bitensky, Ph. D OT; Geoffroy Hubert, BSc. Lic. K.

What are assistive devices?

An assistive device is any piece of equipment that you can use to help make your daily activities easier to perform. Examples of assistive devices include wheelchairs or bath benches, as well as talking, hearing and vision aids. They can assist you with:

  • walking,
  • bathing,
  • dressing,
  • eating,
  • communicating with family/friends.

Many devices are commercially available (e.g. bath bench) or home-made by family or health care professionals.



Which assistive devices can help with walking?

One study looked at the effects of walking with a cane after a stroke. In this study, some patients walked with a cane while others walked without one. The authors reported that those who used the cane improved on most aspects of walking. While the results of this study were promising, the study itself was not of good quality. We therefore cannot make any firm recommendations about the use of assistive devices.

Which assistive devices can help with bathing?

Studies show that assistive devices often help people to be more independent. Everyone has their own bathing/showering habits and needs. Usually a combination of the following equipments is helpful.

Grab bars: Grab bars can be installed in the shower and/or next to the bathtub. Holding onto a grab bar will provide support when you:

  • Stand up and sit down
  • Go in and out of the shower or bathtub

The number and type of grab bars depends on your needs. Some people only need one, others need more. This diagram shows some of the grab bars that are available. It is very important to install the grab bars firmly and at the right height or place to ensure your safety. You should talk to your occupational therapist or another health care professional for suggestions on the best way to install the bars. Grab bars can be installed onto the wall or clamped directly on the bathtub. Some bars may not be safe for you if you have a weak arm or leg caused by the stroke. Again, make sure to ask a health professional for help or advice before you purchase or install bars.

Bath chair/bench: A bath chair or bench allows you to sit during your bath or shower, which will save your personal energy levels. Sitting in the bath or shower is also a good idea if you are experiencing problems with balance.

Transfer bath bench: A transfer bath bench can make it easier for you to get in and out of the bathtub. Once you are securely seated on the bench, you can lift your legs over the edge into the bathtub. Most people find this easier than lifting their leg over the edge of the bathtub while standing up. Again, it is important that a therapist or nurse show you the safest way to use this device before you try it on your own or with your family.

Anti-slip rubber mats: Anti-slip rubber mats placed inside and outside of the shower/bathtub help prevent falls by providing a surface that is not slippery when it is wet.

Tap turners: By adding leverage, tap turners make it easier for you to open and close taps.

Long handle brushes and sponges: These devices provide assistance in washing parts of your body that require bending and stretching.


Bath mitt: If you cannot use both hands it is often difficult to hold the soap, lather a washcloth, and wring it out. A possible solution: You can put a bar of soap inside a bath mitt so you do not have to hold it. This site does not show all the available assistive devices for bathing. There may be additional devices that could be helpful to you. Further information can be found by asking your health care professional or searching on the Internet by typing key words such as “assistive devices” or “assistive technology”.

Which assistive devices can help with toileting?

Toileting is a task involving many steps:

  • entering the bathroom
  • getting on/off the toilet
  • managing clothing
  • cleaning yourself


Each of these steps can represent a challenge for an individual who has had a stroke. The use of assistive devices can help you to perform these tasks more easily and more safely.

Bathroom accessibility: If you need to adapt your bathroom because it is not accessible for you, here are some guidelines to follow:

  • The doorframe should be large enough for you to enter the bathroom easily, especially if you have a wheelchair or walker.
  • The space available within the bathroom should be large enough to allow you to circulate easily with a walker or a wheelchair if you have one.
  • To reduce the risk of falling, make sure the floor is free from unstable carpets and other objects that may cause you to slip.

If you can not access the bathroom, there are other solutions available for you. You can use a urinal and/or a commode in another room.

  • Getting on/off the toilet:Many assistive devices can help if you have difficulty getting on/off the toilet.
  • Fixed grab bars:

    These are recommended for someone who can walk into the bathroom and who can sit on the toilet while using only one hand for support. The grab bar has to be installed on a wall close to the toilet. The types of grab bars needed may differ from one person to another. The height of the grab bars is also variable depending on your needs. Consult an occupational therapist to ensure that the type of grab bar and the place where you will install the grab bar fit your needs.
  • Fixed toilet frame:

    If there is no wall close to the toilet, or if the person needs two hands to hold on to something to get on/off the toilet, a toilet frame can be fixed to the floor around the toilet.
  • Raised toilet seat:
    A raised toilet seat increases the height of the toilet pan. It makes it easier for you to sit down on the toilet and stand up. Raised toilet seats of different heights are available commercially. The adequate height should allow the user to place his/her foot flat on the floor while seated on the toilet. If you live with other people who use the same bathroom, they will need to know how to remove the raised toilet seat. NOTE: It is important to make sure that it is securely attached to the toilet each time you use it. Incorrect fitting of the raised toilet seat increases risks of falls since it can move. It can also damage the seat if it is placed incorrectly.
  • Toilet frame with seat /Toilet seat with handles:

    This device has both a toilet frame that allows you to hold onto something with two hands as well as a raised toilet seat. All the assistive devices listed above should have non-slippery surfaces to maximize safety when using them. Managing clothing: Refer to “Which assistive devices can help with dressing?” section to learn safe techniques to undress/dress the lower body. Do not rush the task and keep the bathroom floor dry at all times to reduce risks of falling.
  • Cleaning yourself:
  • Sheets of toilet paper or wet wipe sheets: If you have difficulty separating the sheets off a roll of toilet paper, you can try to use already separated sheets or wet wipe sheets, as they are easier to manipulate with one hand.
  • Portable bidet/bidet-toilets:
    If using toilet paper is hard for you because you have difficulty moving one arm, you can also try to use a bidet, which is similar in appearance to a toilet bowl, however it projects water for personal cleaning. In addition to being expensive, bidets are not recommended if you have difficulty standing safely.

Other assistive devices:

  • Urinals

If it is difficult for you to get into the bathroom or to transfer to the toilet, you can try using a urinal, which can be used in the lying or sitting positions. They may be convenient for day and/or night time use. Two types of urinals are available: male urinals (bottles) and female urinals. Urinals should not be used for bowel movements.

  • Bed pans:

    A bed pan can be used if you have difficulty getting up from your bed safely to go to the bathroom. Bed pans are designed to be used for bowel movements or urinating.Bed pans and urinals should be washed regularly for cleanliness and to prevent odours.
  • Bedside commode:

A bedside commode can be used in the bedroom when it is difficult for you to access the bathroom or if you have difficulty reaching the bathroom on time. It is possible to adjust the height of a commode. It is important that your feet touch the ground (preferably flat) when you sit on the commode. Make sure that the brakes are on when transferring onto your commode. This will ensure safety and reduce the risk of injury. The bathroom is the most frequent site of falls for people who have had a stroke. Hence, it is important to identify the potential dangers and to correct them. Also, try to make sure that you do not hurry to the bathroom and that the floor is dry to reduce the risks of falls. This site does not show all the available assistive devices for toileting. There may be additional devices that could be helpful to you. Further information can be found by asking your health care professional or searching on the Internet by typing key words such as “assistive devices” or “assistive technology”.

Which assistive devices can help with grooming?

Individuals who have had a stroke may find it difficult to groom. This section will give you ideas about what assistive devices can be used to make it easier to:

  • Cut your nails:

    If you have difficulty cutting your nails, you can try to soak them in warm water before doing so. This will make them softer and easier to cut. Clippers can be easier to use than scissors as their design makes them easier to manipulate. If you have difficulty using a regular clipper because you lack strength in your hand, the clipper on the left may help you. It is designed to help you cut your nails using a minimal amount of force. Also, its shape makes it easier for you to grasp.
  • Shaving:If you feel that the sensation on your face is not the same as it was before you had your stroke or that your hand is less coordinated, it may be safer for you to use an electric shaver instead of a manual stick razor as they decrease the risks of cutting yourself. Also, it is recommended that you shave in front of a mirror so that you can see what you are doing.
  • Cleaning your teeth:
    If you have difficulty squeezing the toothpaste out of the tube, you can use a tube dispenser that will allow you to put toothpaste on your toothbrush while using only one hand.While brushing your teeth, you may find that using your strong hand to hold the toothbrush is easier. However, it is sometimes recommended that you still try to use your weak hand in daily tasks if regaining function is one of your rehabilitation goals. If you have dentures, you can use a one-handed technique to soak them. For example, you can open the container and put them in water or in a denture cleansing liquid using only your strong hand.
  • Applying makeup: Applying makeup can boost your morale. Try to continue wearing makeup as you would normally. If you have difficulty grasping the brush, a padded handle may help.
  • Brushing and combing your hair:

    Brushing your hair can be difficult after having a stroke, especially if you have lost strength in your arms and hands.Using a brush with a padded handle or adding a universal cuff will make it easier to hold. A long-handle comb can help you to reach the hair at the back of your head and does not require as much lifting and stretching of the arm as does the use of a regular comb. If you feel that these tasks are too difficult to do by yourself, ask the help of your friends or family members.This site does not show all the available assistive devices for grooming. There may be additional devices that could be helpful to you. Further information can be found by asking your health care professional or searching on the Internet by typing key words such as “assistive devices” or “assistive technology”.

Which assistive devices can help with dressing?

There are many reasons why people who have had a stroke have problems getting dressed and undressed. Assistive devices can help them to maintain their independence.

  • General Rule:Dressing techniques: dress the weaker side first.Undressing techniques: techniques are always reversed for undressing.

Click here to see videos showing techniques as to how to dress after a stroke

General advice:

  • Dressing and undressing should be done in a warm, comfortable environment. This will help you to focus on the task.
  • It is recommended to sit on a chair while dressing.
  • Contribute as much as you can to the task.Do not rush, and rest as needed.
  • Avoid tight-fitting clothes.
  • Reduce the amount of clothes worn.
  • Choose clothes made from cotton and natural fibres. This is especially important for someone who spends much of their time sitting. These fabrics are also easier to launder.

Putting on a Sweater/Shirt Dressing techniques:

  • Lay the garment on your lap or in front of you on a bed, with the back facing upwards.
  • Put in your weaker arm first. Pull the sleeve of the sweater or shirt over your elbow. It will prevent the sleeve from falling.
  • When the weaker arm is in, place the other arm into the other sleeve.
  • Use the strong hand to grip the back of the sweater or shirt and pull it over your head.

Undressing techniques: Remove clothing from your stronger arm first and then from the weaker one. Dressing aids:

  • Button hook:

  If you have difficulty buttoning and unbuttoning, a button hook can be of help.  

  • Velcro:Velcro fastening, which can be found at local fabric stores can replace buttons on clothing.
  • Long-handled reacher:

    It can help you:

  – if you have difficulty reaching clothes that are placed too high, too low, or too far from you – if you use a wheelchair, since it may help you to take clothes out of the closet or pick up objects that are on the floor.    

  • Putting on Pants:Dressing techniques:
    • While seated, place the weaker leg in the garment as far down as possible.
    • Next, place the strong leg in.
    • Bring your pants up to mid-thigh and stand to pull the top of the garment up.

    Extra-care is needed for people who have difficulty with balance when standing. A therapist can show you how to dress without standing up if this is safer for you. For example, put pants on while lying on the bed. Undressing techniques:

    • Stand only to pull down lower garments.
    • Sit to remove them from you legs.

    Dressing aids:

    • Dressing stick:

      If you have difficulty getting your leg into the pant, a dressing stick may help you.  

    • Footstool:If you have difficulty bending and reaching, a footstool may be of help, as it will raise your feet and legs off the floor.- you may need the help of another individual in getting dressed. Speak with a health professional who knows how to make dressing easier after a stroke. This person is usually an occupational therapist,- to prevent falls when bringing pants up, the individuals who has had a stroke should never stand in socks or barefoot.

    Other garments:

    • Sock aids:

      A sock aid can be of help if you have difficulty bending forward to put on socks or holding your sock with one hand.    

    • Long-handled shoe horn:

      A long-handled shoe horn can help you if you have difficulty bending and putting on your shoes.  

    • Elastic shoe laces:

      Elastic shoelaces make lacing up shoes easier.  

    • Bras: Fastening a bra at the front around your waist, then turning it around, followed by placing your arms in can make it easier to put on a bra. Alternatively, you can buy a front fastening bra.
    • Neckties:

      If you have difficulty putting on a necktie: – Do not loosen the tie completely after wearing it so that you can re-use the knot by just slipping it over your head with one hand. – You can purchase a clip that is put on the tie that saves you from having to tie a knot.

    Which assistive devices can help with preparing meals?

    Individuals who have had a stroke may find it difficult to prepare meals. This next section will give you ideas about what assistive devices can be used to make it easier to:

    • Transport Objects:

    A kitchen trolley can be used to transport objects from the kitchen to the dining room table. This is a good product to use to make it safer to carry heavy objects. If you choose to use a trolley on wheels, remember that it is not as stable as your walking aid. Make sure that you do not lean on it. Home-made or specialized bags can be attached to your kitchen trolley or walking aid and are useful for carrying items. If you choose to attach bags to your walking aid, make sure that it is not too heavy as carrying a lot of weight in your bag could make your walking aid tip over.

    • Use of utensils:

    Adapted utensils can be useful if you find that you are having more difficulty in using your hands after the stroke. Try combined utensils such as a spoon combined with a fork or a fork with a serrated edge. A rocker knife can help you to cut your food with one hand. The rocking motion of the knife makes it easier to cut without stabilizing the food with the other hand. You can also try a cutting board with spikes to stabilize the food while cutting.




    • Making toast:

    You can use a buttering board to make it easier to spread butter on your toast. The raised edges will keep the bread in place while you are buttering it.

    • Making hot beverages:

    To maximize safety, try using a kettle that turns itself off automatically. You can also try to use a kettle tipper which makes it easier to pour hot liquid into a cup with one hand. In the beginning, pouring hot liquid with one hand can be difficult. It is recommended that you practice using the kettle tipper a few times with a kettle filled with cold water before using it with hot liquids.

    • Other assistive devices:Many other assistive devices are available to help you prepare meals. For example, you can use a bowl holder to transfer food from one bowl to another. A can opener that is mounted on the wall makes it easier to open a can with one hand. Finally, you can try a grater with suction feet if you want to prepare cheese with one hand.


    If you get tired while preparing meals, a perching stool with a back support can help you, since it allows you to sit when you are tired. Using a stool with back support makes preparing meals safer and requires less energy. This site does not show all the available assistive devices for preparing meals. There may be additional devices that could be helpful to you. Further information can be found by asking your health care professional or searching on the Internet by typing key words such as “assistive devices” or “assistive technology”.

    Which assistive devices can help with eating/feeding?

    First, it is important for you to maintain a good position when eating. Sit in a chair that provides good support. If your trunk is weak and you need extra support, you can use pillows, an arm trough for your weaker arm, or a lap board. Good positioning will make it easier for you to swallow your food safely.

    • Use cutlery:If it is difficult for you to use cutlery because one of your arms is weak, you can use adapted utensils which require the use of one hand.
      • Combined utensils (fork and knife, spoon and fork): Using these makes it so that you don’t need to switch from one utensil to another. These utensils have been created for people who have one strong hand.
      • Rocking knives: The rocking action prevents you from having to hold the food in place with the other hand allowing you to cut your food with only one hand.
      • Adhesive placemats: These hold the plate in place. People who have had a stroke often use only one hand when eating. Because they do not have the other hand to hold things down, the plate often moves during cutting or eating. By using a mat like the one in the picture, your plate will stay in one place.
      • Plate guards:
        These can help you use utensils without pushing food off of your plate. This is helpful for people who cannot use their second hand to hold the knife.

        http://www.handiplat.fr/
    • Grasp objects: If it is difficult for you to grasp objects, you can try:
      • Utensils with built-in or longer handles: If your hand is weak, these are easier to grasp.
      • Cups with T-shaped handles: These are easy to hold if you have trouble gripping, since you can simply put your fingers around the handle without closing your hand around it.
      • Attachable handle to add on a glass or soft drink can: These can help you to hold a glass or a can without having to grasp it. They can be attached to any glass or can.
      • Universal cuff: These are to hold a utensil in place, making it easier for some individuals who have difficulty grasping utensils. It is possible to make the cuff tighter around your hand so that the utensil will not move.
      • Drink from a glass or cup:The muscles that you use for drinking and swallowing may be weaker since your stroke. This can cause you to have difficulty drinking. If liquid is leaking out of your mouth when you drink, a straw might help you. You should talk to your health professional if you are having difficulty drinking. There are assessments that he or she will do to see if you are having problems with the muscles that are used for swallowing.A straw-holder may also make drinking easier for you as the straw is fixed into the glass and cannot fall out or move.

      This site does not show all the available assistive devices for eating/feeding. There may be additional devices that could be helpful to you. Further information can be found by asking your health care professional or searching on the Internet by typing key words such as “assistive devices” or “assistive technology.

    Which assistive devices can help with using a computer?
    Individuals who have had a stroke may find it difficult to use a computer. This next section will give you ideas about what assistive devices can be used for this task. First, it is important that you consult an occupational therapist if you think that some devices would help you to use your computer more easily. She or he will evaluate your physical and mental capacities as well as your environment, needs, and goals. Based on this evaluation, devices that best fit your needs will be chosen.

    • Accessibility features on your computer’s operating system ( i.e. Windows): These features are free and are already installed on your computer if you are using more recent versions of your operating system. Here are the main ones:
      • Sticky keys: This feature was designed for people who have difficulty holding down more than one key at a time i.e. if you can only use one hand to type. Once this function is activated pressing one key only can activate the SHIFT, CTRL, ALT, or Windows logo keys.
      • Filter keys: This function can help you if you have difficulty controlling the movements of your hands and fingers. It adjusts the keyboard response so that inadvertently repeated keystrokes are ignored. If you activate it, brief or repeated keystrokes will not be taken into consideration. You can also slow the rate at which a key repeats when you hold it down.
      • Toggle keys: When this feature is turned on, you will hear tones when pressing on the locking keys (CAPS LOCK, NUM LOCK, and SCROLL LOCK). A high sound is played when the keys are switched on and a low sound is played when they are switched off. This feature is helpful to someone with visual impairments.
      • An on-screen keyboard is also available: This may be helpful for you if typing on a regular keyboard is too difficult. It is a virtual keyboard displayed on the computer screen. It allows you to type by using a pointing device.
      • A magnifier: This can be used if you have difficulty reading small characters because of decreased vision. A second assistive device for people with low vision is a narrator which can read out load what is displayed on the computer screen. It is designed to work with many programs including: Notepad, WordPad, Control Panel programs, Internet Explorer, the Windows desktop, and some parts of Windows Setup.Click on www.microsoft.com for more information on free accessibility features available to users.Speak to your rehabilitation therapist for additional programs and technologies for using the computer.
    • Ergonomic equipment: Ergonomic equipment includes accessories that you can use to help you to maintain a good posture and to be more comfortable while using a computer. Here are a few examples of ergonomic equipment that can be helpful to you:
      • Foot rest:

      A foot rest may be useful if your feet are not in contact with the floor when using your computer. This will help you to maintain a better seating position when working at your computer.

      • Good chair:

      If you are using your computer often, it might be important to buy a quality chair with arm rests, adjustable height, and a back rest. It is recommended that you get a chair without wheels to decrease the risk of falls. Many other types of ergonomic supports are available on the market. You can ask your health care professional or search on the Internet for more information.

    • Keyboard:

    A contracted keyboard can help you if your weaker arm has limited movement. This keyboard is small enough to be used easily with only one hand. There are also many different on-screen keyboards that are available and that can help you to type more efficiently. They consist of virtual representations of keyboards displayed on the computer screen. They can also be useful if you are not able to use a regular mouse, since they can be used with other pointing devices, such as a joystick. Many other types of keyboards are available on the market. You can ask your health care professional or search on the Internet for more information.

    • Mouse and other pointing devices: If the stroke has led to weakness in your dominant hand, you can use the computer mouse with your non-dominant one. Place the mouse on the other side of the keyboard and buttons by going into the control panel of your computer to change the mouse options.

    Other types of pointing devices such as trackballs, joysticks, and head pointers are available commercially. You can ask your health care professional or search on the Internet for more information.

    Which assistive devices can help you communicate?

    Individuals who have had a stroke may find it difficult to communicate if their symptoms include aphasia (Partial or complete loss of the ability to speak, or to understand spoken language). If this is your case, the use of assistive devices for communication can help you to communicate and interact socially. This next section will give you ideas about what assistive devices can be used to help you communicate. First, it is important that you consult an expert, such as a Speech-Language Pathologist or an Occupational Therapist, in order to choose the right device for you. She or he will evaluate your physical and mental capacities, as well as your environment, needs, and goals. Based on this evaluation, devices that best fit your needs will be chosen. There are two types of assistive devices that can help you communicate:

    • Alternative communication devices are used for people who cannot speak. They utilize other ways of communication such as gestures and writing.
    • Augmentative communication devices are used for people who are able to speak, but with some limitations in this type of communication. These devices utilize other ways to communicate to support speech.

    Some of the many techniques and assistive devices that help with communication are:

    • Gestures: You can use gestures and simple signing to make yourself more easily understood by your family members and friends.
    • Communication boards and books:


    These may contain pictures, drawings, letters, words, sentences, and/or symbols that represent objects. If you cannot speak, you can communicate your needs to others more easily with these devices by pointing to a specific symbol.

    • Electronic devices:

      These produce speech when you activate the device, either by using a keyboard, switches, or other methods.

    There may be additional devices that could be helpful to you. Further information can be found by asking your health care professional or searching on the Internet by typing key words such as “communication” or “augmentative communication”.

    Which assistive devices can help with leisure activities (cards, golf,fishing, etc.)?

    • Cards:

    Card shuffling is easier with an automatic card shuffler.

    With a cardholder, you can give your hand a break when it feels tired. The cardholder is a useful way of playing cards with only one hand.

    • Gardening:

    You can sit on a stool instead of kneeling. If you purchase a garden hopper (see picture) you can push with your feet to move around. A specially designed garden tool may also be helpful if your arm is weaker after your stroke. For example, the extra support offered by an arm cuff on garden tools makes gardening less strenuous. Look for a handle that is comfortable and easy for you to grasp.

    • Embroidery:

    If you enjoy embroidery, don’t stop just because you have limited use of one hand. An embroidery hood holds the fabric and twists to a convenient angle.

    • Fishing:

    A fishing rod holder straps the fishing rod to your body so you can troll and cast with one strong arm. The fishing rod can also be attached to a wheelchair.

    • Golf:

    You can tee a golf ball standing with a tee tool. A claw is useful to pick up a ball so you do not have to bend down as much. With a specialized golf glove, your golf club is attached firmly with Velcro fastening and allows a controlled swing even if you now have a weak grip.

    Who can teach me how to use assistive devices?

    Different health care professionals focus on assistive devices in their field:

    • Hearing specialists (audiologists): For hearing aids such as sound magnifiers.
    • Low vision specialists: For visual aids such as glasses, magnifiers, etc.
    • Speech-language pathologists: For communication aids.
    • Physical therapists: For mobility aids such as canes and walkers.
    • Occupational therapists: For wheelchair fittings, devices to help things you do everyday activities such as feeding, dressing, toileting, grooming, cooking, and adaptations to help you continue with your hobbies.

    You can always ask any health care professional with whom you are in contact and they will refer you to the right health professional.

    Where can I find assistive devices?

    Before you decide to buy an assistive device (especially an expensive one) it is usually better to ask the advice of a health professional. They can guide you in choosing an appropriate model, help to make sure the device will be useful to you, and most importantly, to minimize risk of injury. You might be able to buy some simple assistive devices, such as a dressing aid, in the hospital or rehabilitation center where you are receiving treatment. Usually, the occupational therapist will have a list of companies supplying assistive devices in your area. There are many private companies who sell different kinds of assistive devices. In addition to your healthcare provider, the Internet is a valuable source of information.

    How much do assistive devices cost?

    It is difficult to put a price range on assistive devices because there are many different kinds, and the cost varies from country to country. A long-handle sponge might cost less than 15$, while a powered wheelchair can cost more than 3000$ Canadian.

    • Are they covered by my insurance company or other governmental programs?If you have private insurance, contact your insurance company to find out your personal coverage information as different plans vary.Governmental programs also provide some coverage on assistive devices. Ask your healthcare professional for details. Note: In Canada, programs vary by province.

    Which assistive devices can help with going back to work?

    It is possible to go back to work after you have had your stroke. Depending on the type of work you want to do, there are many assistive devices that may help you. Assistive devices for driving, walking and communication can help make the transition back to work more successful. Your healthcare provider can assess your needs and can help you choose the proper assistive devices.


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  • Fatigue

    Evidence Reviewed as of before: 28-08-2019
    Author(s)*: Tatiana Ogourtsova, PhD OT; Annabel McDermott, OT
    Content consistency: Gabriel Plumier
    Patient/Family Information Table of contents

    Introduction

    Fatigue is a multidimensional, motor-perceptive, cognitive and emotional experience. It is described as “a feeling of early exhaustion with weariness, lack of energy and aversion to effort that develops during physical or mental activity and is usually not ameliorated by rest” (Staub & Bogousslavsky, 2001). Post-stroke fatigue can be distinguished into three types:

    1) Physical fatigue (i.e. inability to perform activities at physical lengths and intensities);
    2) Cognitive fatigue (i.e. inability to perform activities at concentration, multitasking and/or cognitive load stressors lengths and intensities); and
    3) Emotional fatigue (i.e. getting tired when facing demanding interactions or relationships) (Terrill, Schwartz & Belagaje, 2018).

    Post-stroke fatigue is a prevalent stroke consequence, affecting more than 50% of stroke survivors (Cumming et al. 2016). Prevalence cannot be explained by type of stroke, side of stroke or lesion location. Prevalence is also not associated to stroke severity, meaning that prevalence is the same in mild stroke as compared to severe stroke (Acciarresi et al., 2014). Fatigue is associated with depressive symptoms but can be present without depression. Its association to cognitive deficits and gender remains unclear. However, higher levels of fatigue are found to be associated with female sex, depression, longer post-stroke time period and greater disability (Cumming et al., 2018).

    A documentary (lasting 40 minutes) presenting how fatigue impacts daily life of five individuals and what strategies they use to effectively cope with fatigue was produced in March 2019. The documentary (in French) can be viewed by clicking here.

    Patient/Family Information

    Author: Tatiana Ogourtsova, PhD OT; Annabel McDermott, OT

    Since my stroke I feel tired. Am I normal?

    Fatigue is common in patients with stroke. Approximately 50% of stroke survivors will experience fatigue after having a stroke, no matter what the severity of the stroke is.

    What is fatigue after stroke?

    Fatigue is a feeling of early tiredness, lack of energy and aversion to effort. Fatigue occurs during or after activity that is physically demanding, mentally demanding (i.e. requiring attention and concentration) or emotionally demanding (e.g. conflict with another person). The main difference with regular fatigue is that post-stroke fatigue usually does not get better as fast with rest.

    Are there different types of fatigue?

    Fatigue after stroke is usually distinguished into three types: 1) physical, 2) mental or cognitive, and 3) emotional.

    Physical fatigue is when a person is unusually tired after physical activity, or is unable to perform a physical activity that requires more effort or strength (e.g. walking, going up the stairs) or for a long period of time.

    Mental or cognitive fatigue is when a person is unusually tired after or unable to perform an activity that requires attention, concentration or multitasking (e.g. reading, following a movie).

    Emotional fatigue is when a person is unusually tired after difficult interactions or conflicts with close ones (e.g. marital conflict, being uncomfortable with someone, difficulty managing emotions).

    When would fatigue appear after a stroke?

    Fatigue after stroke can appear at different times. Some people experience fatigue shortly after the stroke. Others experience fatigue much later after stroke, even 1 year after stroke.

    Is fatigue caused by my stroke?

    It is possible that the fatigue you are experiencing is an effect of your stroke. Here is one possible explanation:

    Injury to your brain

    There are debates on whether the site of the lesion (stroke location) is related to symptoms of fatigue. Some research shows that people who have a stroke in specific parts of the brain (basal ganglia, internal capsule, brain stem, thalamus) are more likely to experience post-stroke fatigue. Other research argues that it is the number of strokes that matter, where fatigue is more common in people who have had several strokes rather than in those who had a stroke for the first time.

    How do I know if I have post-stroke fatigue? What are the common signs of fatigue after a stroke?

    People who have fatigue after stroke share some common traits such as:

    • Low energy
    • Feeling weary soon after starting a physical activity (e.g. walking, exercise), an activity that is mentally demanding (e.g. reading, social event) or an activity that is emotionally demanding (e.g. conflict with another person).
    • Feeling a loss of self-control
    • Feeling emotional instability
    • Feeling of tiredness that becomes greater during physical exercise, during activities that require concentration and/or with stress.

    Is it easy to detect fatigue after a stroke?

    It is often easy to detect fatigue in a person that has had a stroke. However, it can be difficult to identify the type of fatigue you are experiencing and what causes you to feel tired. Your rehabilitation therapist may often ask about your level of fatigue. However, sometimes people who had a stroke have problems speaking or understanding words; this makes it more difficult to share information about fatigue symptoms.

    How is the diagnosis of fatigue after a stroke made?

    Your therapist may ask you a series of questions or have you or your caregiver fill out a questionnaire. This will help to identify presence of fatigue.

    Are there different kinds of therapies for fatigue?

    There are many different therapies available for fatigue after stroke. This module includes the following interventions:

    • Mindfulness-based stress reduction (MBSR): a program that helps you to calm you mind and body to help cope with illness, pain, and stress.
    • Inspiratory muscle training (IMT): breathing exercises using a breathing device.
    • Game-based team therapy: playing games in groups that are competitive in nature (e.g. playing ball with scores).
    • Multimodal interventions: rehabilitation that combines physical exercises and cognitive exercises together.
    • Psychoeducation: education, advice, recommendations, and strategies to help change your thoughts and behavior.

    There is no known ‘cure’ for post-stroke fatigue. However, when we asked individuals who have had a stroke for their key strategies to cope with fatigue post-stroke, they told us:

    • To accept that you may need to reduce the frequency or intensity of an activity;
    • To plan rest periods into your daily routine;
    • To organise your environment and routine;
    • To conserve your energy when doing everyday activities by making a task simpler;
    • To identify the type of fatigue you are prone to and the activities that trigger your fatigue;
    • To prioritise activities that are meaningful to you and your well-being;
    • To communicate with your close-ones about your level of fatigue;
    • To engage in planned exercise such as aerobics to increase endurance;
    • To practice good sleep patterns.

    What fatigue therapies work for stroke?

    Fatigue therapies have been examined using high and fair quality research studies. Some therapies were shown to improve mental fatigue and other important domains such as independence in self-care activities, depression, sleep, endurance and respiratory function in some patients after stroke.

    In particular, for patients with chronic stroke (more than 6 months after stroke), mindfulness-based stress reduction therapy has been shown to be useful to improve mental fatigue, depression, anxiety, and cognitive abilities (e.g. attention).

    For patients with stroke across the recovery continuum (acute, subacute and/or chronic), inspiratory muscle training, game-based team therapy, and multimodal interventions have been shown to be useful to improve fatigue, independence in everyday activities (e.g. dressing, walking), respiratory function (e.g. inspiration and expiration lung capacities), depression, and sleep.

    What can I expect in terms of therapy for fatigue?

    Your therapist will discuss with you what fatigue therapy is most suitable for you. How often and for how long the therapy is provided for depends on the nature of therapy.

    Who provides the treatment?

    Different health-care providers can administer fatigue therapies: occupational therapists, physiotherapists, psychologists, neuropsychologists and nurses.

    Are there any side effects or risks?

    Fatigue therapies are usually administered by a trained health professional at a rehabilitation clinic or at home. Your therapist will monitor your reactions to the therapy closely. It is important to report to your therapist any changes in your state (e.g. more or less fatigue, sleep quality, independence for daily tasks). Your therapist will adjust the nature, intensity and the duration of therapy according to your ability, endurance and progress.

    Is it possible to speak to someone who had a stroke?

    Support groups are available in some regions for people who have had a stroke. You can also find stories about people who have had problems similar to yours. Consult your National Stroke Association.

    How does my fatigue impact on my recovery?

    Fatigue after stroke may make you feel less motivated, more tired, and also may cause you to have trouble concentrating. All these symptoms of fatigue will slow down your recovery. Studies have shown that people who have fatigue after stroke do not get better as quickly as people who do not have fatigue.

    I would like to know more about fatigue and stroke?

    Understanding how fatigue and stroke happen can reassure you. There are many resources online. Your health care provider can help answer your specific questions.

    A documentary (lasting 40 minutes) presenting how fatigue impacts daily life of five individuals and what strategies they use to effectively cope with fatigue was produced in March 2019. The documentary (in French) can be viewed by clicking here.

    Please click here to access a video on fatigue posted by Canadian Partnership for stroke recovery.

    Clinician Information

    Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

    The current module includes studies examining interventions specific for post-stroke fatigue. Studies were excluded based on the following exclusion criteria: i) fatigue is a secondary outcome and intervention is not fatigue-specific; and ii) the type of intervention is represented by an existing Stroke Engine module. Please see the following Stroke Engine modules for more information on the effects of these intervention on fatigue: Cognitive Rehabilitation, Robotics, Aerobic Exercise, Transcranial Direct Current Stimulation/Transcranial Magnetic Stimulation, Task-Oriented Upper Extremity, Video Games, Balance Training, and Task-Oriented Lower Extremities. The current module includes eight studies: two high quality RCTs, three fair quality RCTs and three non-RCTs design studies. Of these, seven studies included patients with stroke not defined to one specific post-stroke time period (e.g. participants in the subacute or chronic stage of stroke recovery). The following five types of interventions for post-stroke fatigue emerged and are included in the present module: Mindfulness-based stress reduction, Inspiratory muscle training, Group sports, Multimodal intervention (cognitive and physical training), and Fatigue management psychoeducation.

    No studies on interventions for post-stroke fatigue were found for patients specifically in the acute and subacute phase of stroke recovery.

    Outcomes

    Chronic phase - Mindfulness

    Anxiety
    Not effective
    2a

    One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on anxiety in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Anxiety was measured by the Comprehensive Psychopathological Rating Scale (CPRS: Anxiety) at post-treatment (8 weeks). No significant between-group difference was found.

    Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in reducing anxiety in patients with chronic stroke.

    Depression
    Not effective
    2a

    One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on depression in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Depression was measured by the Comprehensive Psychopathological Rating Scale (CPRS: Depression) at post-treatment (8 weeks). No significant between-group difference was found.

    Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in reducing depression in patients with chronic stroke.

    Executive function
    Not effective
    2a

    One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on executive functions in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Executive function was measured by the Trail Making Test (TMT: A, B, C, D) and the Wechsler Adult Intelligence Scale-III: Digit Symbol-Coding Test at post-treatment (8 weeks). A significant between-group difference was found on only one measure of executive function (TMT – A) in favour of MBSR treatment vs. no treatment.

    Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in improving executive function in patients with chronic stroke.
    Note: Significant between-group differences in TMT-A were also found at baseline, favoring MBSR vs. no treatment. Significant between-group differences in TMT-B and TMT-C scores were found at post-treatment, but differences did not remain significant when adjusted with TMT-A scores.

    Mental fatigue
    Effective
    2a

    One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on mental fatigue in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Mental fatigue was measured by the Self-Evaluation Questionnaire for Mental Fatigue at post-treatment (8 weeks). A significant between-group difference was found in favour of MBSR treatment vs. no treatment.

    Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is more effective than no treatment in reducing mental fatigue in patients with chronic stroke.

    Reading speed
    Not effective
    2a

    One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on reading speed in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Reading speed was measured by a Reading Speed Dyslexia Screening test at post-treatment (8 weeks). No significant between-group difference was found.

    Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in improving reading speed in patients with chronic stroke.

    Verbal fluency
    Not effective
    2a

    One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on verbal fluency in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Verbal fluency was measured by the FAS Verbal Fluency Test at post-treatment (8 weeks). No significant between-group difference was found.

    Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in improving verbal fluency in patients with chronic stroke.

    Working memory
    Not effective
    2a

    One fair quality RCT (Johansson, Bjuhr & Ronnback, 2012) investigated the effect of mindfulness-based stress reduction (MBSR) treatment on working memory in patients with chronic acquired brain injury (62% of participants with stroke). This fair quality RCT randomized patients to receive MBSR treatment or delayed MBSR treatment (no treatment). Working memory was measured by the Wechsler Adult Intelligence Scale-III: Digit Span Test at post-treatment (8 weeks). No significant between-group difference was found.

    Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mindfulness-based stress reduction treatment is not more effective than no treatment in improving working memory in patients with chronic stroke.

    Phase not specific to one period - Fatigue management education

    Activities of daily living
    Not effective
    2a

    One fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) investigated the effect of fatigue management education on activities of daily living (ADLs) in patients with stroke. This fair quality RCT randomized patients with subacute/chronic stroke to receive post-stroke fatigue management psychoeducation or general stroke psychoeducation. ADLs were measured by the Barthel Index and the modified Rankin Scale at post-treatment (6 weeks) and follow-up (3 months). No significant between-group differences were found on any measure at either time point.

    Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that post-stroke fatigue management education is not more effective than a comparison intervention (general stroke education) in improving activities of daily living in patients with stroke.

    Anxiety
    Not effective
    2a

    One fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) investigated the effect of fatigue management education on anxiety in patients with stroke. This fair quality RCT randomized patients with subacute/chronic stroke to receive post-stroke fatigue management psychoeducation or general stroke psychoeducation. Anxiety was measured by the Hospital Anxiety and Depression Scale (HADS: Anxiety) at post-treatment (6 weeks) and follow-up (3 months). No significant between-group difference was found at either time point.

    Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that post-stroke fatigue management education is not more effective than a comparison intervention (general stroke education) in reducing anxiety in patients with stroke.

    Depression
    Not effective
    2a

    One fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) and one non-randomized study (Wu et al., 2017) investigated the effect of fatigue management education on anxiety in patients with stroke.

    The fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) randomized patients with subacute/chronic stroke to receive post-stroke fatigue management psychoeducation or general stroke psychoeducation. Depression was measured by the Hospital Anxiety and Depression Scale (HADS: Depression) at post-treatment (6 weeks) and follow-up (3 months). No significant between-group difference was found at either time point.

    The non-randomized pre-post design study (Wu et al., 2017) allocated patients with subacute/chronic stroke to receive psychoeducation for post-stroke fatigue. Depression was measured by the Patient Health Questionnaire (PHQ-9) at post-treatment (6 sessions) and follow-up (1 month, 3 months). A significant improvement was found at one follow-up time point only (1 month).

    Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that post-stroke fatigue management education is not more effective than a comparison intervention (general stroke education) in reducing depression in patients with stroke. Similarly, a pre-post design study found no significant immediate or long-term benefits from a psychoeducation program.

    Fatigue
    Not effective
    2a

    One fair quality RCT (Clarke, Baker-Collo & Feigin, 2012), and two non-randomized studies (Wu et al., 2017; Boehm, Muehlberg & Stube, 2015) investigated the effect aof fatigue management education on fatigue in patients with stroke.

    The fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) randomized patients with subacute/chronic stroke to receive post-stroke fatigue management psychoeducation or general stroke psychoeducation. Fatigue was measured by the Fatigue Severity Scale, a Visual Analogue Scale for Fatigue (Fatigue, Vigor), and the Checklist of Individual Strength at post-treatment (6 weeks) and follow-up (3 months). No significant between-group differences were found on any measure at either time point.

    A non-randomized pre-post design study (Wu et al., 2017) allocated patients with subacute/chronic stroke to receive psychoeducation for post-stroke fatigue. Fatigue was measured by the Fatigue Assessment Scale at post-treatment (6 sessions) and follow-up (1 month, 3 months). A significant improvement was found at one follow-up time point only (3 months).

    A case report (Boehm, Muehlberg & Stube, 2015) allocated one patient with stroke and post-stroke fatigue (time since stroke not specified) to receive a fatigue management course. Fatigue was measured by the Fatigue Impact Scale (FIS: Physical Fatigue, Cognitive Fatigue, Social Fatigue) at post-treatment (5 weeks). Improvements were noted on all measures of fatigue, however no statistical results were provided. This study is not used in the conclusion below.

    Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that post-stroke fatigue management education is not more effective than a comparison intervention (general stroke education) in reducing fatigue in patients with stroke. A non-randomized also reported no significant improvements in fatigue immediately following a psychoeducation program.

    Health-related quality of life
    Not effective
    2a

    One fair quality RCT (Clarke, Baker-Collo & Feigin, 2012) investigated the effect of fatigue management education on health-related quality of life in patients with stroke. This fair quality RCT randomized patients with subacute/chronic stroke to receive post-stroke fatigue management psychoeducation or general stroke psychoeducation. Health-related quality of life was measured by the Short Form-36 (SF-36: Physical functioning, Role physical, Role emotional, Energy/Fatigue, Emotional wellbeing, Social functioning, Pain, General Health) at post-treatment (6 weeks) and follow-up (3 months). No significant between-group differences were found at either time point.

    Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that post-stroke fatigue management education is not more effective than a comparison intervention (general stroke education) in improving health-related quality of life in patients with stroke.

    Instrumental activities of daily living
    Insufficient evidence
    5

    One non-randomized study (Wu et al., 2017) investigated the effect of fatigue management education on instrumental activities of daily living (IADLs) in patients with stroke. This pre-post design study allocated patients with subacute/chronic stroke to receive psychoeducation for post-stroke fatigue. IADLs were measured by the Nottingham Extended Activities of Daily Living at post-treatment (6 sessions) and follow-up (1 month, 3 months). No significant improvements were found at any time point.

    Conclusion: There is insufficient evidence (Level 5) regarding the effect of post-stroke fatigue management education on instrumental activities of daily living in patients with stroke. However, one pre-post design study found no significant improvements in instrumental activities of daily living following an psychoeducation program.

    Occupational performance
    Insufficient evidence
    5

    One case-report (Boehm, Muehlberg & Stube, 2015) investigated the effect of fatigue management education on occupational performance in a patient with stroke. This case-reported allocated one patient with stroke and post-stroke fatigue (time since stroke not specified) to receive a fatigue management course. Occupational performance was measured by the Canadian Occupational Performance Measure (COPM: Perceived performance, Satisfaction) at post-treatment (5 weeks). No improvements were noted and no statistical results were provided.

    Conclusion: There is insufficient evidence (Level 5) regarding the effect of post-stroke fatigue management education on occupational performance in patients with stroke. However, one case report found no improvement in occupational performance following a fatigue management course.

    Stroke outcomes
    Insufficient evidence
    5

    One non-randomized study (Wu et al., 2017) investigated the effect of fatigue management education on stroke outcomes in patients with stroke. This pre-post design study allocated patients with subacute/chronic stroke to receive psychoeducation for post-stroke fatigue. Stroke outcomes were measured by the Stroke Impact Scale (SIS: General recovery, Physical strength, Memory and thinking, Emotion, Communication, Daily activities, Mobility, Hand function, Social activity) at post-treatment (6 sessions) and follow-up (1 month, 3 months). Significant improvements were noted in some stroke outcomes at post-treatment (SIS: Mobility, Social activity), 1-month follow-up (SIS: Mobility, Social activity), and 3-month follow-up (SIS: General recovery, Memory and thinking, Emotion, Mobility, Social activity).

    Conclusion: There is insufficient evidence (Level 5) regarding the effect of post-stroke fatigue management education on stroke outcomes in patients with stroke. However, one pre-post design study found significant improvements in some stroke outcomes following a psychoeducation program.

    Phase not specific to one period - Group sports

    Depression
    Effective
    2b

    One quasi-experimental design study (Kim, 2012) investigated the effect of group sports on depression in patients with stroke. This quasi-experimental design study allocated patients with acute/subacute/chronic stroke to engage in group sports (ball games) or no treatment; both groups received conventional rehabilitation. Depression was measured by the Korean version of the State Depression Scale at post-treatment (2 weeks). A significant between-group differences was found, favoring group sports vs. no treatment.

    Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that group sports are more effective than no treatment in reducing depression in patients with stroke.

    Fatigue
    Effective
    2b

    One quasi-experimental design study (Kim, 2012) investigated the effect of group sports on fatigue in patients with stroke. This quasi-experimental design study allocated patients with acute/subacute/chronic stroke to engage in group sports (ball games) or no treatment; both groups received conventional rehabilitation. Fatigue was measured by the Brief Fatigue Inventory at post-treatment (2 weeks). A significant between-group difference was found, favoring group sports vs. no treatment.

    Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that group sports are more effective than no treatment in reducing fatigue in patients with stroke.

    Functional independence
    Effective
    2b

    One quasi-experimental design study (Kim, 2012) investigated the effect of group sports on functional independence in patients with stroke. This quasi-experimental design study allocated patients with acute/subacute/chronic stroke to engage in group sports (ball games) or no treatment; both groups received conventional rehabilitation. Functional independence was measured by the Functional Independence Measure (FIM: Motor, Cognition, Total scores) at post-treatment (2 weeks). Significant between-group differences were found in two measures of functional independence (FIM: Motor, Total scores), favoring group sports vs. no treatment.

    Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that group sports are more effective than no treatment in improving functional independence in patients with stroke.

    Sleep quality
    Effective
    2b

    One quasi-experimental design study (Kim, 2012) investigated the effect of group sports on sleep quality in patients with stroke. This quasi-experimental design study allocated patients with acute/subacute/chronic stroke to engage in group sports (ball games) or no treatment; both groups received conventional rehabilitation. Sleep quality was measured by the Pittsburgh Sleep Quality Index at post-treatment (2 weeks). A significant between-group difference was found, favoring group sports vs. no treatment.

    Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that group sports are more effective than no treatment in improving sleep quality in patients with stroke.

    Phase not specific to one period - Inspiratory muscle training

    Activities of daily living
    Effective
    2a

    One fair quality RCT (Chen et al., 2016) investigated the effect of inspiratory muscle training (IMT) on activities of daily living (ADLs) in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive IMT or no treatment; both groups received conventional rehabilitation. ADLs were measured by the Barthel Index at post-treatment (10 weeks). A significant between-group difference was found, favoring IMT vs. no treatment. Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that inspiratory muscle training is more effective than no treatment in improving activities of daily living in patients with stroke.

    Fatigue
    Not effective
    1b

    One high quality RCT (Cho et al., 2018) and one fair quality RCT (Chen et al., 2016) investigated the effect of inspiratory muscle training (IMT) on fatigue in patients with stroke.

    The high quality RCT (Cho et al., 2018) randomized patients with subacute/chronic stroke to receive IMT or no treatment; both groups received conventional physical therapy. Fatigue was measured by the Fatigue Severity Scale at post-treatment (6 weeks). No significant between-group difference was found.

    The fair quality RCT (Chen et al., 2016) randomized patients with acute/subacute stroke to receive IMT or no treatment; both groups received conventional rehabilitation. Fatigue was measured by the Fatigue Assessment Scale at post-treatment (10 weeks). No significant between-group difference was found. Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that inspiratory muscle training is not more effective than no treatment in reducing fatigue in patients with stroke.

    Perceived exertion
    Not effective
    2a

    One fair quality RCT (Chen et al., 2016) investigated the effect of inspiratory muscle training (IMT) on perceived exertion in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive IMT or no treatment; both groups received conventional rehabilitation. Perceived exertion was measured by the modified Borg Scale at post-treatment (10 weeks). No significant between-group difference was found.

    Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that inspiratory muscle training is not more effective than no treatment in improving perceived exertion in patients with stroke.

    Respiratory function
    Effective
    1b

    One high quality RCT (Cho et al., 2018) and one fair quality RCT (Chen et al., 2016) investigated the effect of inspiratory muscle training (IMT) on respiratory function in patients with stroke.

    The high quality RCT (Cho et al., 2018) randomized patients with subacute/chronic stroke to receive IMT or no treatment; both groups received conventional physical therapy. Respiratory function (MIP, IME, affected/non-affected DT at rest/contraction, affected/non-affected DT thickness ratio) was measured by the inspiratory muscle training device PowerBreath K5 (2010, HaB International LtD, UK) at post-treatment (6 weeks). Significant between-group differences were found in some measures of respiratory function (MIP, IME, affected DT at contraction, affected DT thickness ratio), favoring IMT vs. no treatment.

    The fair quality RCT (Chen et al., 2016) randomized patients with acute/subacute stroke to receive IMT or no treatment; both groups received conventional rehabilitation. Respiratory function (FVC, FEV1, ratio FEV1/FVC, MIP, MEP, MMEF, SpO2) was measured by standard spirometer and a finger pulse oximeter at post-treatment (10 weeks). A significant between-group difference was found in one measure of respiratory function (MIP), favoring IMT vs. no treatment.

    Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that inspiratory muscle training is more effective than no treatment in improving respiratory function in patients with stroke. In addition, one fair quality RCT found a significant between-group difference in one measure of respiratory function, favoring inspiratory muscle training compared to no treatment.
    DT: Diaphragm thickness IME: Inspiratory muscle endurance FVC: Forced Vital Capacity FEV1: Forced Expiratory Volume in 1 sec MIP: Maximal inspiratory pressure MEP: Maximal expiratory pressure MMEF: Maximal mid-expiratory flow SpO2: Resting oxyhemoglobin saturation.

    Walking endurance
    Not effective
    1b

    One high quality RCT (Cho et al., 2018) investigated the effect of inspiratory muscle training (IMT) on endurance in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive IMT or no treatment; both groups received conventional physical therapy. Walking endurance was measured by the 6-Minute Walk Test at post-treatment (6 weeks). No significant between-group difference was found.

    Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that inspiratory muscle training is not more effective than no treatment in improving walking endurance in patients with stroke.

    Phase not specific to one period - Multimodal intervention

    Fatigue
    Not effective
    1b

    One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on fatigue in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. Fatigue was measured by the Checklist Individual Strength (CIS: Fatigue) and the Fatigue Self-Observation List at post-treatment (3 months) and follow-up (6 months). There were no significant between-group differences on either measure at either time point.
    Note: The authors noted a significant clinically relevant improvement in CIS: Fatigue scores at follow-up, for the cognitive therapy group with graded activity training.

    Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is not more effective than a comparison intervention (cognitive therapy alone) in reducing fatigue in patients with stroke.

    Health-related quality of life
    Not effective
    1b

    One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on health-related quality of life (HRQoL) in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. HRQoL was measured by the Stroke-Adapted Sickness Impact Profile at post-treatment (3 months) and follow-up (6 months). No significant between-group difference was found at either time point.

    Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is not more effective than a comparison intervention (cognitive therapy alone) in improving health-related quality of life in patients with stroke.

    Mood and affect
    Not effective
    1b

    One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on mood and affect in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. Mood and affect were measured by the Hospital Anxiety and Depression Scale (HADS: Anxiety, Depression) at post-treatment (3 months) and follow-up (6 months). No significant between-group differences were found at either time point.

    Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is not more effective than a comparison intervention (cognitive therapy alone) in improving mood and affect in patients with stroke.

    Pain
    Not effective
    1b

    One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on pain in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. Pain was measured by the Pain Self-Observation List at post-treatment (3 months) and follow-up (6 months). No significant between-group difference found at either time point.

    Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is not more effective than a comparison intervention (cognitive therapy alone) in reducing pain in patients with stroke.

    Sleep quality
    Not effective
    1b

    One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on sleep quality in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. Sleep quality was measured by the Sleep Quality Self-Observation List at post-treatment (3 months) and follow-up (6 months). No significant between-group difference was found at either time point.

    Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is not more effective than a comparison intervention (cognitive therapy alone) in improving sleep quality in patients with stroke.

    Walking endurance
    Effective
    1b

    One high quality RCT (Zedlitz et al., 2012) investigated the effect of a multimodal intervention on walking endurance in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive cognitive therapy with graded activity training or cognitive therapy alone. Walking endurance was measured by the 6 Minute Walk Test at post-treatment (3 months) and follow-up (6 months). A significant between-group difference was found at post-treatment, favoring cognitive therapy with graded activity vs. cognitive therapy alone. This between-group difference remained significant at follow-up.

    Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention of cognitive therapy with graded activity training is more effective than a comparison intervention (cognitive therapy alone) in improving walking endurance in patients with stroke.

    References

    Acciarresi, M., Bogousslavsky, J., & Paciaroni. M. (2014). Post-