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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Depression

Evidence Reviewed as of before: 04-01-2018
Author(s)*: Tatiana Ogourtsova PhD OT; Annabel McDermott OT; Chelsea Hellings BA; Katherine Salter BA; Sanjit Bhogal MSc; Robert Teasell MD; Norine Foley BASc; Mark Speechley PhD; Elissa Sitcoff BSC, BA; Anita Menon, MSc
Patient/Family Information Table of contents

Introduction

A variety of emotional and behavioural disorders may develop following stroke. Depression, the most common emotional disorder, may affect up to 40% of all patients with stroke. Depression affects every aspect of a person’s life, such as their body, emotions, thoughts and mood. It is much more complex than simply “feeling blue” and is characterized by a persistent and pervasive feeling of sadness or hopelessness. Depression can also be associated with a combination of the following symptoms: poor appetite and weight loss (or conversely weight gain), sleep disturbances (insomnia or hypersomnia), constipation, psychomotor retardation (or conversely agitation), difficulties with concentration and thinking, withdrawal from interpersonal contact, feelings of guilt or self-blame, diminished interest or pleasure in most or all activities, and recurrent thoughts of death or suicidal ideation. Depression can occur early after stroke or in the years following. Detection of post-stroke Depression is often overlooked so it is important to use reliable measures when evaluating the patient after stroke.

Various interventions exist for post-stroke Depression and are reviewed in this module. These include psychosocial support programs (individual, group or community), cognitive-behavioral therapy, multimodal interventions (exercise + psychoeducation), neuro-linguistic programming therapy, speech therapy, patient-centered counselling, art therapy and wellness therapies (e.g. relaxation therapy, forest therapy, Yoga, Tai Chi, meditation, enriched environments therapy).

Note: Extensive research has investigated the benefits of various drugs such as heterocyclic antidepressants, psychostimulants, and selective serotonin reuptake inhibitors (SSRIs) to treat post-stroke DepressionDrug studies are not covered in this module.

Patient/Family Information

Authors: Ying Ying Kan, BSc OT; Chantal Barakat, BSc OT; Martine Sourdif, BSc OT

Since my stroke, I feel sad and depressed. Am I normal?

Mood swings and depression are very common in patients with stroke. In fact, at least 1 person out of 4 will feel depressed or moody after a stroke. Some studies have shown that the rate of depression is even higher, as high as 1 person out of 2.

What is depression after a stroke (post-stroke depression)?

Anyone who has experienced a stroke would agree that it is a big life change. Suddenly daily activities like washing and dressing become a challenge. It is a very difficult experience that can affect your emotions.

What are mood swings?

After a stroke, you may experience rapid changes in mood. For example, you may feel happy, and then suddenly very sad. You may feel that your emotions are like a roller coaster. Some people might cry and laugh at inappropriate times.

Just like depression, these mood swings can appear when there is an injury to a specific area of your brain.

When would depression appear after a stroke?

The time after stroke that depression can appear varies. Some people become depressed shortly after the stroke, in the hours or days later. Others will experience depression much later after stroke, after as long as 3 years.

Are my mood swings/depression caused by my stroke?

It is possible that your mood swings or depression are effects of your stroke. There are two possible explanations of depression post-stroke.

  • Injury to your brain
    Indeed, some areas of your brain control your mood and emotions. If one of these areas is affected by the stroke, it can lead to mood swings or depression.There are debates on whether the site of the lesion is related to depression. Some research indicates that individuals who have a stroke in a specific lobe (frontal) are more likely to experience depression. Other research argues that it is the side of the brain (left or right) where the stroke happened that matters.
  • Changes in your life skills and abilities
    Changes in your physical abilities after a stroke can be very difficult to accept. You may find rehabilitation overwhelming. Everyday tasks now require extra efforts. These feelings of sadness can lead to depression.The real cause of depression is probably a combination of these two theories. That is, depression is due in part to the damages in the brain area and also due to the changes in your life skills and abilities caused by the stroke.

How do I know if I am depressed? What are the common signs of depression after a stroke?

People who are depressed share some common traits such as:

  • getting angry easily or crying easily.
  • sleeping too much or too little.
  • feeling down.
  • being slow mentally.
  • feeling guilty.
  • feeling less hopeful about the future.
  • not wanting to see friends.
  • thinking about ending one’s life.

Is it easy to detect depression after a stroke?

It is often difficult to detect depression in a person that has had a stroke. After a stroke, most people will have physical and cognitive problems. Often the treatment will focus more on those two aspects and will forget to include the person’s feelings. Sometimes, people who had a stroke have problems speaking or understanding words; this makes sharing feelings very hard. Thus, it is hard to detect depression as well. Family and close friends are often the first ones to detect signs of depression in their loved one. This is because they know the person better than any health care workers.

How is the diagnosis of depression after a stroke made?

Your clinician may ask you a series of questions or have you fill out a questionnaire. This will help to identify any signs of depression.

Are there different kinds of therapies for depression?

There are many different therapies available for depression after stroke. Those include:

  • Art therapy activities to stimulate cognition, physical state, emotion, communication, social relation and spiritual dimensions (e.g. meditation with music, singing activity, group-healing circle, positive thinking, story sharing).
  • Coordinated discharge care – regular follow-up with a stroke nurse following discharge.
  • Counselling / stroke counselling and education support program –recommendations, education, and advice.
  • Enriched environment inpatient program – equipment and organization of a stimulating environment as well as activities in the medical ward: computers with internet connection, Skype access, Gaming Therapy, library with reading material, music station, life-size mirrors, simulated shopping corner with groceries, electronic payment machine, automatic back teller machine, board games, puzzles, chess, painting, and wood workshop.
  • Exercise – physical exercises (e.g. walking, stationary bicycle, weight lifting).
  • Forest therapy – taking long walks in the forest/nature, meditate in the forest.
  • Multimodal interventions –physical exercises and education together.
  • Neurolinguistic programming therapy – techniques aimed at shifting negative thoughts or beliefs/bad moods, increasing mental energy, releasing pressure and relaxation
  • Psychotherapy/Cognitive Behavioral Therapy – teaches people how to change their thinking in order to change their behavior.
  • Relaxation – listening to soothing music and practice meditation.
  • Speech therapy – training to help people with speech/language problems and depression to speak more clearly or express themselves in different ways that are more comprehensible.
  • Supportive home rehabilitation programs – home exercises and education.
  • Tai Chi – slow movement exercises and meditation.
  • Yoga – breath control, simple meditation, and adoption of specific bodily postures.

What depression therapies work for stroke?

depression therapies have been examined using high quality research studies and were shown to improve depression (and other important domains such as cognitive function, anxiety, quality of life) in some patients after stroke.

In particular, for patients with acute stroke (up to 1 month after stroke): counselling, , multimodal interventions (exercises + education), neurolinguistic programming therapy and supportive home rehabilitation programs have been shown to be useful to improve depression, and other abilities/domains.

For patients with subacute stroke (from 1 to 6 months after stroke), exercise has been shown to be useful to improve depression.

For patients with chronic stroke (more than 6 months after stroke), forest therapy and relaxation have been shown to be useful to improve anxiety and depression.

For patients with stroke across the recovery continuum (acute, subacute and/or chronic), art therapy, cognitive behavioral therapy, and enriched environment inpatient program have been shown to be useful to improve depression/mood/anxiety.

What can I expect?

Your therapist will discuss with you what depression 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 depression therapies: neuropsychologist, nurse, occupational therapists, physical therapists, psychologist and speech language pathologist.

Are there any side effects or risks?

depression therapies are usually administered by a trained health professional at a rehabilitation clinic or at home (in cases of home programs). Your therapist will monitor your reactions to the therapy closely. It is important to report to your therapist any changes in your feelings or thoughts. Your therapist will adjust the nature, intensity and the duration of therapy according to your ability, endurance and progress.

Can sleeping and eating well help?

Sure! Having proper meals and good sleep will give you more energy during your recovery. You may feel you are not hungry or you have difficulty sleeping. This is common with people who are depressed.

Should I exercise?

Yes. It is important, however, to know your own abilities and limitations when you are exercising.

If your doctor agrees, you may start an exercise class. Exercising releases an hormone (endorphin) that will make you feel good.

For information about exercise after a stroke, see Aerobic Exercise Late After Stroke or Aerobic Exercise Early After Stroke.

Should I continue my rehabilitation program if I do not feel like doing it?

Yes. It is possible that you may not feel motivated to go to your rehabilitation sessions. It is hard and demands a lot of energy. However, rehabilitation sessions will teach you many things that will help you feel independent (dressing, walking). You will be proud of yourself and feel more motivated.

Why should I bother seeing people?

Having a social life has been shown to have a positive impact on helping depression. It is very important that you continue having hobbies, such as playing cards, doing cross-words, or going outside. Your occupational therapist can show you possible ways to adapt your hobby, since certain activities may need to be modified after a stroke.

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:

Canada: Heart and Stroke Foundation

How does my depression impact on my recovery?

Indeed, being depressed may slow down your recovery. depression may make you feel less motivated and more tired, and also may cause you to have trouble concentrating. All these symptoms of depression will slow down your recovery capacities. Many studies have shown that people with depression after a stroke do not get better as quickly as people who are not depressed. The extent to which depression can affect recovery is not really known. It seems that both physical loss and depression can act on recovery.

Will depression ever get better?

Some studies show that people who are depressed can get better. On average, the duration of major depression in people who have had a stroke is under a year. However, sometimes depression can return, so it is important to watch for the signs.

How long does it take to recover from depression after a stroke?

Recovery from depression after a stroke takes time. It can vary a lot from one person to another. For example, medication can take a few weeks to work. With treatment, people who are depressed usually get better. As mentioned above, the average duration of major depression for people who have had a stroke is a year.

Does depression lead to stroke?

Not everybody who is depressed will experience a stroke. However, some studies have shown that being depressed may increase the chances of having a stroke. When heart disease, hypertension, diabetes, and tobacco use are all ruled out, depressed people are 2.6 times more likely to report a stroke.

If I was depressed before my stroke, am I more likely to be depressed after my stroke?

Yes, if you were depressed before your stroke, you have more chances to be depressed after. This is one of the risk factors linked with depression after the stroke.

As a care provider, what can I do to avoid being depressed too?

The care provider is the one who takes care of the person who has had a stroke. Usually this person is a family member, a spouse, or a close friend. Often, the care provider will be so devoted to their loved one that they will forget to take care of their own needs.

When your loved one is depressed after a stroke, it is more difficult for both of you to stay positive, so it is especially important that you both receive support. Thus, it is very important that you, as a care provider, take time for yourself everyday. Find a moment during the day to do an activity you like such as reading or shopping. Moreover, you should continue to see your friends to share your feelings and refresh your mind.

I would like to know more about depression and stroke

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

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 present module reviews 28 RCTs including 22 high quality and six fair quality studies. Studies were included in the module only if depression and/or mood/affect were the primary outcomes. Secondary outcomes have also been included in this module.

Other StrokEngine modules also include depression as an outcome of the intervention: Acupuncture, Aerobic Exercise, Music-based Interventions, Transcranial Magnetic Stimulation and Virtual Reality-Upper Extremity. Please refer to those modules for more details.

Extensive research has investigated the benefits of various drugs such as heterocyclic antidepressants, psychostimulants, and selective serotonin reuptake inhibitors (SSRIs) to treat post-stroke depression. Drug studies are not covered in this module; other types of rehabilitative interventions to treat post-stroke depression will be explored.

Results Table

View results table

Outcomes

Acute phase - Counseling

Depression
Effective
1b

One high quality RCT (Watkins et al., 2007; 2011) investigated the effect of counseling on depression in patients with acute stroke. This high quality RCT randomized patients to receive patient-centred counseling or no treatment for 4 weeks; both groups received usual stroke care. depression was measured by the Yale Single Question at follow-up (3 months and 12 months post-stroke). Significant between-group difference was found at 3 months post-stroke, favoring counseling vs. no treatment. This difference did not remain significant at 12 months.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that counseling is more effective than no treatment in improving depression in patients with acute stroke, in the short term.

Functional independence
Not effective
1b

One high quality RCT (Watkins et al., 2007; 2011) investigated the effect of counseling on functional independence in patients with acute stroke. This high quality RCT randomized patients to receive patient-centred counseling or no treatment for 4 weeks; both groups received usual stroke care. Functional independence was measured by the Barthel Index at follow-up (3 months and 12 months post-stroke). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that counseling is not more effective than no treatment in improving functional independence in patients with acute stroke.

Instrumental activities of daily living
Not effective
1b

One high quality RCT (Watkins et al., 2011) investigated the effect of counseling on instrumental activities of daily living (IADLs) in patients with acute stroke. This high quality RCT randomized patients to receive patient-centred counseling or no treatment for 4 weeks; both groups received usual stroke care. IADLs were measured by the Nottingham Extended activities of Daily Living at follow-up (12 months post-stroke). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that counseling is not more effective than no treatment in improving instrumental activities of daily living in patients with acute stroke.

Mood and affect
Effective
1b

One high quality RCT (Watkins et al., 2007; 2011) investigated the effect of counseling on mood and affect in patients with acute stroke. This high quality RCT randomized patients to receive patient-centred counseling or no treatment for 4 weeks; both groups received usual stroke care. Mood and affect was measured by the General Health Questionnaire-28 at follow-up (3 months and 12 months post-stroke). Significant between-group difference was found at both follow-up points, favoring counseling vs. no treatment.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that counseling is more effective than no treatment in improving mood and affect in patients with acute stroke.

Recovery beliefs and expectations
Not effective
1b

One high quality RCT (Watkins et al., 2007; 2011) investigated the effect of counseling on recovery beliefs and expectations in patients with acute stroke. This high quality RCT randomized patients to receive patient-centred counseling or no treatment for 4 weeks; both groups received usual strokecare. Recovery beliefs and expectations were measured by the stroke Expectations Questionnaire (Beliefs, Expectations, Differences between beliefs and expectations) at follow-up (3 months and 12 months post-stroke). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that counseling is not more effective than no treatment in improving recovery beliefs and expectations in patients with acute stroke.

Acute phase – Individual multimodal home intervention

Cognitve function
Not effective
1b

One high quality RCT (Chaiyawat, Kulkantrakorn & Sritipsukho, 2009) and one follow-up analysis (Chaiyawat & Kulkantrakorn, 2012) investigated the effect of an individual multimodal home intervention on cognitive function in patients with acute stroke. This high quality RCT randomized patients to receive an individual multimodal home intervention or standard care. Cognitive function was measured by the Thai Mental State Examination at post-treatment (3 months) and at follow-up (24 months post-discharge from hospital). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one follow-up report that an individual multimodal home intervention is not more effective than a comparison intervention (standard care) in improving cognitive function in patients with acute stroke.

Depression
Effective
1b

One high quality RCT (Chaiyawat, Kulkantrakorn & Sritipsukho, 2009) and one follow-up analysis (Chaiyawat & Kulkantrakorn, 2012) investigated the effect of an individual multimodal home intervention on depression in patients with acute stroke. This high quality RCT randomized patients to receive an individual multimodal home intervention or standard care. depression was measured by the Hospital Anxiety and depression Scale (HADS: depression) at post-treatment (3 months) and at follow-up (24 months post-discharge from hospital). Significant between-group difference was found at both time points, favoring individual multimodal home rehabilitation vs. standard care.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one follow-up report that an individual multimodal home intervention is more effective than a comparison intervention (standard care) in improving depression in patients with acute stroke.

Functional independence
Effective
1b

One high quality RCT (Chaiyawat, Kulkantrakorn & Sritipsukho, 2009) and one follow-up analysis (Chaiyawat & Kulkantrakorn, 2012) investigated the effect of an individual multimodal home intervention on functional independence in patients with acute stroke. This high quality RCT randomized patients to receive an individual multimodal home intervention or standard care. Functional independence was measured by the Barthel Index (BI) and the Modified Rankin Scale (MRS) at post-treatment (3 months) and at follow-up (24 months post-discharge from hospital, BI only). Significant between-group differences were found at post-treatment (BI, MRS) and at follow-up (BI), favoring individual multimodal home intervention vs. standard care.
Note: The Modified Rankin Scale measure was not used at the time of the follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one follow-up repot that an individual multimodal home intervention is more effective than a comparison intervention (standard care) in improving functional independence in patients with acute stroke.

Health related quality of life
Effective
1b

One high quality RCT (Chaiyawat, Kulkantrakorn & Sritipsukho, 2009) investigated the effect of an individual multimodal home intervention on health-related quality of life in patients with acute stroke. This high quality RCT randomized patients to receive an individual multimodal home intervention or standard care. Health-related quality of life was measured by the EQ-5D at post-treatment (3 months). Significant between-group difference was found, favoring individual multimodal home intervention vs. standard care.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that an individual multimodal home intervention is more effective than a comparison intervention (standard care) in improving health-related quality of life in patients with acute stroke.

Acute phase - Multimodal intervention

Anxiety
Not effective
1a

Two high quality RCTs (Ihle-Hansen et al., 2014; Faulkner et al., 2015) investigated the effect of a multimodal intervention on anxiety in patients with acute stroke.

The first high quality RCT (Ihle-Hansen et al., 2014) randomized patients to receive a healthy lifestyle promotion program or standard care. Anxiety was measured by the Hospital Anxiety and Depression Scale (HADS – Anxiety subscale) at 1-year post-stroke (follow-up). No significant between-group difference was found.

The second high quality RCT (Faulkner et al., 2015) randomized patients to receive an exercise + education program or standard care. Anxiety was measured by the HADS (Anxiety subscale) at post-treatment (8 weeks) and at follow-up (12 months). No significant between-group difference was found at either time point.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that multimodal interventions are not more effective than a comparison intervention (standard care) in reducing anxiety in patients with acute stroke.

Depression
Not effective
1a

Two high quality RCTs (Ihle-Hansen et al., 2014; Faulkner et al., 2015) investigated the effect of a multimodal intervention on depression in patients with acute stroke.

The first high quality RCT (Ihle-Hansen et al., 2014) randomized patients to receive a healthy lifestyle promotion program or standard care. depression was measured by the Hospital Anxiety and depression Scale (HADS – depression subscale) at 1-year post-stroke follow-up. No significant between-group difference was found.

The second high quality RCT (Faulkner et al., 2015) randomized patients to receive an exercise + education program or standard care. depression was measured by the HADS (depression subscale) and the Profile of Mood States (PMS – depression subscale) at post-treatment (8 weeks) and follow-up (12 months). There were no significant between-group difference at either time point.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that multimodal interventions are not more effective than a comparison intervention (standard care) in improving depression in patients with acute stroke.

Functional independence
Effective
2a

One fair quality RCT (Wu et al., 2012) investigated the effect of a multimodal intervention on functional independence in patients with acute stroke. This fair quality RCT randomized patients to receive psychology + physical rehabilitation or no treatment. Functional independence was measured by the Barthel Index at 90 days (follow-up). Significant between-group difference was found, favoring multimodal intervention vs. no treatment.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that multimodal intervention is more effective than no treatment in improving functional independence in patients with acute stroke.

Health related quality of life
Effective
1b

One high quality RCT (Faulkner et al., 2015) investigated the effect of a multimodal intervention on health-related quality of life in patients with acute stroke. This high quality RCT randomized patients to receive an exercise + education program or standard care. Change in health-related quality of life was measured by the Short-Form 36 (SF-36 – Physical component, Mental component, Mental health, Social functioning, Global health, Role physical, Role emotional, Vitality, Bodily pain, Physical functioning subscales) from baseline to post-treatment (8 weeks) and to follow-up (12 months). Significant between-group difference was found on some aspects of health-related quality of life from baseline to post-treatment (SF-36 – Physical component, Global health, Role physical, Vitality, Physical functioning) favoring multimodal intervention vs. standard care. This difference was not maintained at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention is more effective than a comparison intervention (standard care) in improving some aspects of health-related quality of life in patients with acute stroke, in the short term.

Impairments
Effective
2a

One fair quality RCT (Wu et al., 2012) investigated the effect of a multimodal intervention on impairments in patients with acute stroke. This fair quality RCT randomized patients to receive psychology + physical rehabilitation or no treatment. Impairments were measured by the European stroke Scale at day 3 and day 21 of treatment. While there were no significant difference between groups at day 3 of treatment, significant between-group difference was found at day 21, favoring multimodal intervention vs. no treatment.

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

Mood and affect
Not effective
1a

Two high quality RCTs (Ihle-Hansen et al., 2014; Faulkner et al., 2015) and one fair quality RCT (Wu et al., 2012) investigated the effect of a multimodal intervention on mood and affect in patients with acute stroke.

The first high quality RCT (Ihle-Hansen et al., 2014) randomized patients to receive a healthy lifestyle promotion program or standard care. Overall mood was measured by the Hospital Anxiety and Depression Scale (HADS) Total score at 1-year post-stroke follow-up. No significant between-group difference was found.

The second high quality RCT (Faulkner et al., 2015) randomized patients to receive an exercise + education program or standard care. Mood and affect were measured by the Profile of Mood States (PMS – Vigor, Confusion, Tension, Anger, Fatigue, Depression) at post-treatment (8 weeks) and follow-up (12 months). A significant between-group difference in change scores from post-treatment to follow-up of one measure of mood and affect (PMS – Fatigue) was found, favoring multimodal intervention vs. standard care.

The fair quality RCT (Wu et al., 2012) randomized patients to receive psychology + physical rehabilitation or no treatment. Mood and affect were measured by the Taita Symptom Checklist (TSCL-90 – Somatization, Obsession, Interpersonal sensitivity, Depression, Anxiety, Hostility, Fear, Paranoia, Mental disease subscores) at day 3 and day 21 of treatment. While there were no significant between-group difference at day 3 of treatment, significant between-group difference was found for most measures of mood and affect (TSCL-90 – Somatization, Obsession, Depression, Anxiety, Hostility, Fear, Mental disease) at day 21, favouring multimodal intervention vs. no treatment.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that a multimodal intervention is not more effective than a comparison intervention (standard care) in improving mood and affect in patients with acute stroke. However, one fair quality RCT found that a multimodal intervention in the form of psychological + comprehensive rehabilitation training is more effective than no treatment in improving some measures of mood and affect in patients with acute stroke.

Physical activity/inactivity
Not effective
1b

One high quality RCT (Faulkner et al., 2015) investigate the effect of a multimodal intervention on physical activity and inactivity in patients with acute stroke. This high quality RCT randomized patients to receive an exercise + education program or standard care. Physical activity/inactivity was measured by the International Physical Activity Questionnaire at post-treatment (8 weeks) and at follow-up (12 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 is not more effective than a comparison intervention (standard care) in improving physical activity/inactivity in patients with acute stroke.

Stroke awareness
Effective
1b

One high quality RCT (Faulkner et al., 2015) investigated the effect of a multimodal intervention on stroke awareness in patients with acute stroke. This high quality RCT randomized patients to receive an exercise + education program or standard care. stroke awareness was measured by the stroke Awareness Questionnaire at baseline, post-treatment (8 weeks) and at follow-up (12 months). Significant between-group difference in stroke awareness scores was found from baseline to post-treatment, favoring multimodal intervention vs. usual care. Differences did not remain significant at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a multimodal intervention is more effective than a comparison intervention (standard care) in improving stroke awareness in patients with acute stroke, in the short term.

Acute phase - Neuro-linguistic programming therapy and education

Anxiety
Effective
1b

One high quality RCT (Peng et al., 2015) investigated the effect of neuro-linguistic programming (NLP) therapy on anxiety in patients with acute stroke. This high quality RCT randomized patients to receive NLP therapy + health education or no treatment; both groups received standard care. Anxiety was measured by the Hamilton Anxiety Scale at post-treatment (2 weeks) and at follow-up (6 months). Significant between-group difference was found at post-treatment, favoring NLP therapy + health education vs. no treatment. Difference did not remain significant at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that neuro-linguistic programming therapy + health education is more effective than no treatment in reducing anxiety in patients with acute stroke, in the short term.

Depression
Effective
1b

One high quality RCT (Peng et al., 2015) investigated the effect of neuro-linguistic programming (NLP) therapy on depression in patients with acute stroke. This high quality RCT randomized patients to receive NLP therapy + health education or no treatment; both groups received standard care. depression was measured by the Hamilton-17 depression Scale at post-treatment (2 weeks) and at follow-up (6 months). Significant between-group difference was found at post-treatment, favoring NLP therapy + health education vs. no treatment. Difference did not remain significant at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that neuro-linguistic programming therapy + health education is more effective than no treatment in improving depression in patients with acute stroke, in the short term.

Functional independence
Effective
1b

One high quality RCT (Peng et al., 2015) investigated the effect of neuro-linguistic programming (NLP) therapy on functional independence in patients with acute stroke. This high quality RCT randomized patients to receive NLP therapy + health education or no treatment; both groups received standard care. Functional independence was measured by the Barthel Index at post-treatment (2 weeks) and at follow-up (6 months). Significant between-group difference was found at both time points, favoring NLP therapy + health education vs. no treatment.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that neuro-linguistic programming therapy + health education is more effective than no treatment in improving functional independence in patients with acute stroke.

Health related quality of life
Effective
1b

One high quality RCT (Peng et al., 2015) investigated the effect of neuro-linguistic programming (NLP) therapy on health-related quality of life in patients with acute stroke. This high quality RCT randomized patients to receive NLP therapy + health education or no treatment; both groups received standard care. Health-related quality of life was measured by the Quality of Life Index at post-treatment (2 weeks) and at follow-up (6 months). Significant between-group difference was found at both time points, favoring NLP therapy + health education vs. no treatment.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that neuro-linguistic programming therapy + health education is more effective than no treatment in improving health-related quality of life in patients with acute stroke.

Stroke awareness
Effective
1b

One high quality RCT (Peng et al., 2015) investigated the effect of neuro-linguistic programming (NLP) therapy on stroke awareness in patients with acute stroke. This high quality RCT randomized patients to receive NLP therapy + health education or no treatment; both groups received standard care. stroke awareness was measured by the stroke Knowledge Questionnaire at post-treatment (2 weeks). Significant between-group difference was found favoring NLP therapy + health education vs. no treatment.
Note: The stroke Knowledge Questionnaire was not used at the time of the follow-up.

Conclusion: There is moderate evidence (Level 1b) from one fair quality RCT that neuro-linguistic programming therapy + health education is more effective than no treatment in improving stroke awareness in patients with acute stroke.

Subacute phase - Exercise training

Depression
Conflicting
4

Two high quality RCTs (Lai et al., 2006; Holmgren et al., 2010) investigated the effect of exercise training on depression in patients with subacute stroke.

The first high quality RCT (Lai et al., 2006) randomized patients to receive exercise training or standard care. depression was measured by the Geriatric depression Scale 15 (GDS-15 – mean score, score ≥ 6) at post-treatment (3 months) and at follow-up (9 months). Significant between-group difference was found at post-treatment (GDS-15 mean score, score ≥ 6), and at follow-up (GDS-15 score ≥ 6), favoring exercises training vs. standard care.

The second high quality RCT (Holmgren et al., 2010) randomized patients to receive high-intensity functional exercises + group discussions or group discussions alone. depression was measured by the GDS-15 at post-treatment (5 weeks) and follow-up (3, 6 months). No significant between-group difference was found at any time point.

Conclusion: There is conflicting evidence regarding the effect of exercise training on depression in patients with subacute stroke. While one high quality RCT found that exercise training is more effective than standard care, another high quality RCT found that high-intensity functional exercises + group discussions is not more effective than group discussions alone in improving depression in patients with subacute stroke.
Note:
The differences in the treatment duration (3 months vs. 5 weeks) might justify the differences in findings across these two studies.

Mood and affect
Effective
1b

One high quality RCT (Lai et al., 2006) investigated the effect of exercise training on mood and affect in patients with subacute stroke. This high quality RCT randomized patients to receive exercise training or standard care. Mood and affect were measured by the stroke Impact Scale (SIS – Emotion score) and the Short-Form-36 (SF-36 – Emotion score) at post-treatment (3 months) and at follow-up (9 months). Significant between-group differences in both measures were found at post-treatment, favoring exercises training vs. standard care. Between-group differences were not maintained at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that exercise training is more effective than a comparison intervention (standard care) in improving mood and affect in patients with subacute stroke, in the short term.

Physical comorbidity
Not effective
1b

One high quality RCT (Lai et al., 2006) investigated the effect of exercise training on physical comorbidity in patients with subacute stroke. This high quality RCT randomized patients to receive exercise training or standard care. Physical comorbidity was measured by the Duke Comorbidity Scale at post-treatment (3 months) and at follow-up (9 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 exercise training is not more effective than a comparison intervention (standard care) in reducing physical comorbidity in patients with subacute stroke.

Quality of life
Not effective
1b

One high quality RCT (Holmgren et al., 2010) investigated the effects of exercise training on quality of life in patients with subacute stroke. This high quality RCT randomized patients to receive high-intensity functional exercises + group discussions or group discussion alone. Quality of life was measured by the Short-Form-36 (SF-36 – Physical Component Scale, Mental Component Scale, Physical functioning, Role functioning physical/emotional, Bodily pain, General health, Vitality, Social functioning, Mental health subscores) at post-treatment (5 weeks) and follow-up (3, 6 months). There were no significant difference at post-treatment. Significant between-group difference was found in two measures of quality of life at 3-month follow-up (SF-36 – Mental Component Scale, Mental health subscore), favoring group discussion alone vs. high-intensity functional exercises + group discussions. Difference did not remain significant at 6-month follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that high-intensity functional exercises + group discussions is not more effective than a comparison intervention (group discussions alone) in improving quality of life in patients with subacute stroke. In fact, high-intensity functional exercises + group discussions was found to be less effective than group discussion alone in improving 2 components of quality of life in patients with subacute stroke.

Social support
Not effective
1b

One high quality RCT (Lai et al., 2006) investigated the effect of exercise training on social support in patients with subacute stroke. This high quality RCT randomized patients to receive exercise training or standard care. Social support was measured by the Pearlin Expressive Social Support Scale at post-treatment (3 months) and at follow-up (9 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 exercise training is not more effective than a comparison intervention (standard care) in improving social support in patients with subacute stroke.

Subacute phase - Speech therapy

Mood and affect
Not effective
2a

One fair quality RCT (Lincoln, Jones & Mulley, 1985) investigated the effect of speech therapy on mood and affect in patients with subacute stroke. This fair quality RCT randomized patients to received speech therapy or no speech therapy; both groups received conventional rehabilitation. Mood and affect were measured by the Mood Rating Scale (Angry-calm, Sad-happy, Afraid-secure, Anxious-relaxed, Depressed-cheerful, Frustrated-contented items) and the Multiple Adjective Checklist (Anxiety, Depression, Hostility subscores) at mid-treatment (12 weeks) and at post-treatment (24 weeks). No significant between-group differences were found on both outcome measures at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that speech therapy is not more effective than no treatment in improving mood and affect in patients with subacute stroke.

Spousal depression
Not effective
2a

One fair quality RCT (Lincoln, Jones & Mulley, 1985) investigated the effect of speech therapy on depression among spouses of patients with subacute stroke. This fair quality RCT randomized patients to received speech therapy or no speech therapy; both groups received conventional rehabilitation. Spousal depression was measured by the Wakefield depression Inventory at mid-treatment (12 weeks) and at post-treatment (24 weeks). No significant between-group difference was found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that speech therapy is not more effective than no treatment in improving depression among spouses of patients with subacute stroke.

Spousal mental health
Not effective
2a

One fair quality RCT (Lincoln, Jones & Mulley, 1985) investigated the effect of speech therapy on mental health of spouses of patients with subacute stroke. This fair quality RCT randomized patients to received speech therapy or no speech therapy; both groups received conventional rehabilitation. Spousal mental health was measured by the Goldberg General Health Questionnaire at mid-treatment (12 weeks) and at post-treatment (24 weeks). No significant between-group difference was found at either time point.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that speech therapy is not more effective than no treatment in improving mental health of spouses of patients with subacute stroke.

Chronic phase - Autogenic relaxation

Anxiety
Effective
1b

One high quality RCT (Golding et al., 2016) and a follow-up report (Golding et al., 2017a) investigated the effect of an autogenic relaxation program on anxiety in patients with chronic stroke. This high quality RCT randomized patients to receive an autogenic relaxation program or no treatment (waiting list). Anxiety was measured by the Hospital Anxiety and Depression Scale (HADS – Anxiety subscale) at baseline, at post-treatment (1 month), and follow-up (2 and 3 months, and 12 months). Significant between-group difference was found at post-treatment and follow-up (2 and 3 months), favoring the autogenic relaxation program vs. no treatment. Between-group analyses were not conducted at 12-month follow-up. However, both groups demonstrated significantly reduced anxiety from baseline to 12-month follow-up, at which timepoint all participants had received the intervention.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that an autogenic relaxation program is more effective than no treatment in reducing anxiety in patients with chronic stroke.

Depression
Not effective
1b

One high quality RCT (Golding et al., 2017b) investigated the effect of an autogenic relaxation program on anxiety in patients with chronic stroke. This high quality RCT randomized patients to receive an autogenic relaxation program or no treatment (waiting list). Depression was measured by the Hospital Anxiety and Depression Scale (HADS – Depression subscale) at post-treatment (1 month) and follow-up (2 and 3 months, and 12 months). No significant between-group difference was found at any time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that an autogenic relaxation program is not more effective than no treatment in improving Depression in patients with chronic stroke.

Chronic phase - Forest therapy

Anxiety
Effective
2a

One fair quality RCT (Chun et al., 2017) investigated the effect of forest therapy on anxiety in patients with chronic stroke. This fair quality RCT randomized patients to receive forest therapy or urban therapy in group format. Anxiety was measured by the Spielberger State-Trait Anxiety Inventory at post-treatment (4 days). Significant between-group difference was found favoring forest therapy vs. urban therapy.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that forest therapy is more effective than a comparison intervention (urban therapy) in reducing anxiety in patients with chronic stroke.

Depression
Effective
2a

One fair quality RCT (Chun et al., 2017) investigated the effect of forest therapy on depression in patients with chronic stroke. This fair quality RCT randomized patients to receive forest therapy or urban therapy in group format. depression was measured by the Beck depression Inventory and the Hamilton depression Rating Scale at post-treatment (4 days). Significant between-group differences were found at post-treatment on both outcome measures of depression, favoring forest therapy vs. urban therapy.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that forest therapy is more effective than a comparison intervention (urban therapy) in improving depression in patients with chronic stroke.

Chronic phase - Yoga

Anxiety
Not effective
1a

Two high quality RCTs (Chan, Immink & Hillier, 2012; Immink et al., 2014) investigated the effect of yoga on anxiety in patients with chronic stroke.

The first high quality RCT (Chan, Immink & Hillier, 2012) randomized patients to receive yoga + exercises or exercises alone. Anxiety was measured by the State-Trait Anxiety Inventory (STAI – State anxiety, Trait anxiety scores) at post-treatment (6 weeks). No significant between-group difference was found.

The second high quality RCT (Immink et al., 2014) randomized patients to receive yoga or no treatment (waiting list). Anxiety was measured by the STAI (State anxiety, Trait anxiety scores) at post-treatment (10 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that yoga is not more effective than comparison intervention (exercises alone, no treatment) in reducing anxiety in patients with chronic stroke.

Balance
Not effective
1b

One high quality RCT (Immink et al., 2014) investigated the effect of yoga on balance in patients with chronic stroke. This high quality RCT randomized patients to receive yoga or no treatment (waiting list). Balance was measured by the Berg Balance 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 that yoga is not more effective than no treatment in improving balance in patients with chronic stroke.

Depression
Not effective
1a

Two high quality RCTs (Chan, Immink & Hillier, 2012; Immink et al., 2014) investigated the effect of yoga on depression in patients with chronic stroke.

The first high quality RCT (Chan, Immink & Hillier, 2012) randomized patients to receive yoga + exercises or exercises alone. depression was measured by the Geriatric depression Scale – Short Form 15 (GDS-15) at post-treatment (6 weeks). No significant between-group difference was found.

The second high quality RCT (Immink et al., 2014) randomized patients to receive yoga or no treatment (waiting list). depression was measured by the GDS-15 at post-treatment (10 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that yoga is not more effective than comparison interventions (exercises alone, no treatment) in improving depression in patients with chronic stroke.

Mobility
Not effective
1b

One high quality RCT (Immink et al., 2014) investigated the effect of yoga on mobility in patients with chronic stroke. This high quality RCT randomized patients to receive yoga or no treatment (waiting list). Mobility was measured by the 2-Minute Walking Distance test at post-treatment (10 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that yoga is not more effective than no treatment in improving mobility in patients with chronic stroke.

Motor function
Not effective
1b

One high quality RCT (Immink et al., 2014) investigated the effect of yoga on motor function in patients with chronic stroke. This high quality RCT randomized patients to receive yoga or no treatment (waiting list). Motor function was measured by the Motor 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 that yoga is not more effective than no treatment in improving motor function in patients with chronic stroke.

Stroke outcomes
Not effective
1b

One high quality RCT (Immink et al., 2014) investigated the effect of yoga on stroke outcomes in patients with chronic stroke. This high quality RCT randomized patients to receive yoga or no treatment (waiting list). stroke outcomes were measured by the stroke Impact Scale (SIS – Physical, Emotion, Memory, Communication, Social participation, stroke recovery subscores) at post-treatment (10 weeks). Significant between-group difference was found for only one stroke outcome (SIS – Memory), favoring yoga vs. no treatment.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that yoga is not more effective than no treatment in improving stroke outcomes in patients with chronic stroke.

Walking speed
Not effective
1b

One high quality RCT (Immink et al., 2014) investigated the effect of yoga on walking speed in patients with chronic stroke. This high quality RCT randomized patients to receive yoga or no treatment (waiting list). Walking speed was measured by the Comfortable Gait Speed test at post-treatment (10 weeks). No significant between-group difference was found.

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

Phase not specific to one period - Art therapy

Anxiety
Not effective
1b

One high quality RCT (Kongkasuwan et al., 2016) investigated the effect of art therapy on anxiety in patients with stroke. This high quality RCT randomized patients with stroke (stage of stroke recovery not specified) to receive art therapy or no art therapy; both groups received physical therapy. Anxiety was measured by the Hospital Anxiety and Depression Scale (HADS – Anxiety score) at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that art therapy is not more effective than no art therapy (physical therapy alone) in reducing anxiety in patients with stroke.

Cognition
Not effective
1b

One high quality RCT (Kongkasuwan et al., 2016) investigated the effect of art therapy on cognition in patients with stroke. This high quality RCT randomized patients with stroke (stage of stroke recovery not specified) to receive art therapy or no art therapy; both groups received physical therapy. Cognition was measured by the Abbreviated Mental Test at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that art therapy is not more effective than no art therapy (physical therapy alone) in improving cognition in patients with stroke.

Depression
Effective
1b

One high quality RCT (Kongkasuwan et al., 2016) investigated the effect of art therapy on depression in patients with stroke. This high quality RCT randomized patients with stroke (stage of stroke recovery not specified) to receive art therapy or no art therapy; both groups received physical therapy. depression was measured by the Hospital Anxiety and depression Scale (HADS – depression score) at post-treatment (4 weeks). Significant between-group difference was found favoring art therapy vs. no art therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that art therapy is more effective than no art therapy (physical therapy alone) in improving depression in patients with stroke.

Functional independence
Effective
1b

One high quality RCT (Kongkasuwan et al., 2016) investigated the effect of art therapy on functional independence in patients with stroke. This high quality RCT randomized patients with stroke (stage of stroke recovery not specified) to receive art therapy or no art therapy; both groups received physical therapy. Functional independence was measured by the Modified Barthel Index at post-treatment (4 weeks). Significant between-group difference was found favoring art therapy vs. no art therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that art therapy is more effective than no art therapy (physical therapy alone) in improving functional independence in patients with stroke.

Health related quality of life
Effective
1b

One high quality RCT (Kongkasuwan et al., 2016) investigated the effect of art therapy on health-related quality of life (HRQoL) in patients with stroke. This high quality RCT randomized patients with stroke (stage of stroke recovery not specified) to receive art therapy or no art therapy; both groups received physical therapy. HRQoL was measured by the Pictorial Thai Quality of Life Questionnaire at post-treatment (4 weeks). Significant between-group difference was found favoring art therapy vs. no art therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that art therapy is more effective than no art therapy (physical therapy alone) in improving health-related quality of life in patients with stroke.

Phase not specific to one period - Cognitive behavioral therapy

Anger
Effective
2a

One fair quality RCT (Chang et al., 2011) investigated the effect of cognitive behavioral therapy (CBT) on anger in patients with stroke. This fair quality RCT randomized patients with acute / subacute / chronic stroke to receive CBT (education and behavioral training) or no CBT; both groups received conventional therapy. Anger was measured by the State-Trait Anger Expression Inventory (STAXI – State anger, Hostility, Anger-in, Anger-out, Anger control items) at baseline and at post-treatment (1 month). Significant between-group difference in anger (STAXI – State anger, Anger-out, Anger control) change scores from baseline to post-treatment was found in favor of CBT vs. no CBT. In contrast, significant between-group difference in anger (STAXI – Anger-in) change scores from baseline to post-treatment was found in favor of no CBT vs. CBT.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that cognitive behavioral therapy is more effective than no CBT in improving some aspects of anger in patients with stroke.

Anxiety
Not effective
1a

Two high quality RCTs (Hoffmann et al., 2015; Kootker et al., 2017) and one fair quality RCT (Chang et al., 2011) investigated the effect of cognitive behavioral therapy (CBT) on anxiety in patients with stroke.

The first high quality RCT (Hoffmann et al., 2015) randomized patients with stroke (stage of stroke recovery not specified) to receive CBT (cognitive and behavioral coping-skills exercises), self-management intervention or no treatment. Anxiety was measured by the Hospital Anxiety and Depression Scale (HADS – Anxiety score) and the State-Trait Anxiety Inventory (STAI – Trait anxiety, State anxiety scores) at post-treatment (8 sessions) and follow-up (3 months). No significant between-group differences were found on both outcome measures at either time point.

The second high quality RCT (Kootker et al., 2017) randomized patients with subacute/chronic stroke to receive CBT (goal-setting, meaningful activities, relaxation/communication strategies) or computerized cognitive therapy. Anxiety was measured by the HADS (Anxiety score) at post-treatment (4 months) and at follow-up (8 and 12 months). No significant between-group difference was found at any time point.

The fair quality RCT (Chang et al., 2011) randomized patients with acute/subacute/chronic stroke to receive CBT (education and behavioral training) or no CBT; both groups received conventional rehabilitation. Anxiety was measured by the Hamilton Anxiety Rating Scale at post-treatment (1 month). No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs and one fair quality RCT that cognitive behavioral therapy is not more effective than a comparison intervention (self-management intervention, computerized cognitive therapy, no treatment) in reducing anxiety in patients with stroke.

Caregiver burden
Not effective
1b

One high quality RCT (Thomas et al., 2012) investigated the effect of cognitive behavioral therapy (CBT) on burden among caregivers of patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke and low mood to receive CBT or no CBT; both groups received usual care. Caregivers’ burden was measured by the Caregiver Strain Index at follow-up (6 months). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive behavioral therapy is not more effective than no CBT in improving caregiver burden following stroke.

Coping
Not effective
1b

One high quality RCT (Kootker et al., 2017) investigated the effect of cognitive behavioral therapy (CBT) on coping in patients with stroke. This high quality RCT randomized patients with subacute / chronic stroke to receive CBT (goal-setting, meaningful activities, relaxation / communication strategies) or computerized cognitive therapy. Coping was measured by the Utrecht Proactive Coping Competence Life Scale at post-treatment (4 months) and at follow-up (8 and 12 months). No significant between-group difference was found at any time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive behavioral therapy is not more effective than a comparison intervention (computerized cognitive training) in improving coping in patients with stroke.

Depression
Not effective
1a

Four high quality RCTs (Lincoln & Flannaghan, 2003; Thomas et al., 2012; Hoffmann et al., 2015; Kootker et al., 2017) and two fair quality RCTs (Chang et al., 2011; Alexopoulos et al., 2012) investigated the effect of cognitive behavioral therapy (CBT) on depression in patients with stroke.

The first high quality RCT (Lincoln & Flannaghan, 2003) randomized patients with subacute / chronic stroke to receive CBT, attention placebo, or no treatment. depression was measured by the Beck depression Inventory and the Wakefield Self-Assessment of depression Inventory at post-treatment (3 months) and follow-up (6 months). No significant between-group differences were found on both outcome measures at either time point.

The second high quality RCT (Thomas et al., 2012) randomized patients with subacute/chronic stroke and low mood to receive CBT or no CBT; both groups received usual care. depression was measured by the stroke Aphasia depression Questionnaire 21-item hospital version at post-treatment (3 months) and follow-up (6 months). No significant between-group difference was found at post-treatment, however a significant between-group difference in depression was found at follow-up, favoring CBT vs. no CBT.

The third high quality RCT (Hoffmann et al., 2015) randomized patients with stroke (stage of stroke recovery not specified) to receive CBT (cognitive and behavioral coping-skills exercises), self-management intervention or no treatment. depression was measured by the Hospital Anxiety and depression Scale (HADS – depression score) and the Montgomery and Asberg depression Rating Scale at post-treatment (8 sessions) and follow-up (3 months). A significant between-group difference in one measure of depression (HADS – depression) was found at post-treatment, favoring CBT vs. no treatment. Differences did not remain significant at follow-up. No other between-group differences were found.

The fourth high quality RCT (Kootker et al., 2017) randomized patients with subacute/chronic stroke to receive CBT (goal-setting, meaningful activities, relaxation/communication strategies) or computerized cognitive therapy. depression was measured by the HADS (depression score) and the Post-Stroke depression Rating Scale at post-treatment (4 months) and at follow-up (8 and 12 months). No significant between-group differences were found on both outcome measures at any time point.

The first fair quality RCT (Chang et al., 2011) randomized patients with acute / subacute / chronic stroke to receive CBT (education and behavioral training) or no CBT; both groups received conventional rehabilitation. depression was measured by the Hamilton depression Rating Scale (HDRS) at baseline and at post-treatment (1 month). Significant between-group difference in depression change scores from baseline to post-treatment was found, favoring CBT vs. no CBT.

The second fair quality RCT (Alexopoulos et al., 2012) randomized patients with stroke (stage of stroke recovery not specified) to receive CBT (Ecosystem Focused Therapy: education and behavioral training, goal setting) or education on stroke and depression. depression was measured by the HDRS at post-treatment (3 months). No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs and one fair quality RCT that cognitive behavioral therapy is not more effective than comparison interventions (attention placebo, no treatment, self-management intervention, computerized cognitive therapy, education on stroke and depression) in improving depression in patients with stroke.
Note:
However, one high quality RCT saw significant between-group differences in one measure of depression immediately following CBT versus no treatment; a fair quality RCT also found differences in depression in favour of CBT vs. no CBT. In addition, one of the high quality RCTs that saw no difference between CBT and no CBT immediately post-treatment found CBT to be more effective than no CBT at 6-month follow-up.

Disability
Not effective
1b

One high quality RCT (Lincoln & Flannaghan, 2003) and one fair quality RCT (Alexopoulos et al., 2012) investigated the effect of cognitive behavioral therapy (CBT) on disability in patients with stroke.

The high quality RCT (Lincoln & Flannaghan, 2003) randomized patients with subacute / chronic stroke to receive CBT, attention placebo, or no treatment. Disability was measured by the London Handicap Scale at post-treatment (3 months) and follow-up (6 months). No significant between-group differences were found at any time point.

The fair quality RCT (Alexopoulos et al., 2012) randomized patients with stroke (stage of stroke recovery not specified) to receive CBT (Ecosystem Focused Therapy: education and behavioral training, goal setting) or education on stroke and depression. Disability was measured by the World Health Organization Disability Assessment Schedule II at post-treatment (3 months). Significant between-group difference was found favoring CBT vs. education.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive behavioral therapy is not more effective than comparison interventions (attention placebo, no treatment) in improving disability in patients with stroke.
Note:
However, one fair quality RCT found that CBT was more effective than a comparison intervention (education on stroke and depression) in improving disability in patients with stroke.

Functional independence
Not effective
1b

One high quality RCT (Hoffmann et al., 2015) and one fair quality RCT (Chang et al., 2011) investigated the effect of cognitive behavioral therapy (CBT) on functional independence in patients with stroke.

The high quality RCT (Hoffmann et al., 2015) randomized patients with stroke (stage of stroke recovery not specified) to receive CBT (cognitive and behavioral coping-skills exercises), self-management intervention or no treatment. Functional independence was measured by the modified Barthel Index (mBI) at post-treatment (8 sessions) and follow-up (3 months). No significant between-group differences were found at either time point.

The fair quality RCT (Chang et al., 2011) randomized patients with acute/subacute/chronic stroke to receive CBT (education and behavioral training) or no CBT; both groups received conventional rehabilitation. Functional independence was measured by the BI at baseline and at post-treatment (1 month). Significant between-group difference in functional independence change scores from baseline to post-treatment was found, favoring CBT vs. no treatment.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive behavioral therapy is not more effective than comparison interventions (self-management intervention, no treatment) in improving functional independence in patients with stroke.
Note:
However, one fair quality RCT found that CBT is more effective than no CBT in improving functional independence in patients with stroke.

Health related quality of life
Not effective
1a

Two high quality RCTs (Hoffmann et al., 2015; Kootker et al., 2017) and one fair quality RCT (Chang et al., 2011) investigated the effect of cognitive behavioral therapy (CBT) on health-related quality of life (HRQoL) in patients with stroke.

The first high quality RCT (Hoffmann et al., 2015) randomized patients with stroke (stage of stroke recovery not specified) to receive CBT (cognitive and behavioral coping-skills exercises), self-management intervention or no treatment. HRQoL was measured by the stroke and Aphasia Quality of Life Scale (SAQoL – General, Psychosocial, Physical, Communication subscores) at post-treatment (8 sessions) and follow-up (3 months). No significant between-group differences were found at either time point.

The second high quality RCT (Kootker et al., 2017) randomized patients with subacute/chronic stroke to receive CBT (goal-setting, meaningful activities, relaxation/communication strategies) or computerized cognitive therapy. HRQoL was measured by the Life Satisfaction Questionnaire and the stroke Specific Quality of Life (SSQoL) Scale at post-treatment (4 months) and at follow-up (8 and 12 months). No significant between-group differences were found on both outcome measures at any time point.

The fair quality RCT (Chang et al., 2011) randomized patients with acute/subacute/chronic stroke to receive CBT (education and behavioral training) or no CBT; both groups received conventional rehabilitation. HRQoL was measured by the SSQoL at baseline and post-treatment (1 month). Significant between-group difference in SSQoL change scores from baseline to post-treatment was found, favoring CBT vs. no treatment.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that cognitive behavioral therapy is not more effective than comparison interventions (self-management intervention, no treatment, computerized cognitive therapy) in improving health-related quality of life in patients with stroke.
Note:
However, one fair quality RCT found that CBT was more effective than no CBT in improving health-related quality of life in patients with stroke.

Instrumental activities of daily living
Not effective
1a

Two high quality RCTs (Lincoln & Flannaghan, 2003; Hoffmann et al., 2015) investigated the effect of cognitive behavioral therapy (CBT) on instrumental activities of daily living (IADLs) in patients with stroke.

The first high quality RCT (Lincoln & Flannaghan, 2003) randomized patients with subacute / chronic stroke to receive CBT, attention placebo, or no treatment. IADLs were measured by the Extended activities of Daily Living Scale at post-treatment (3 months) and follow-up (6 months). No significant between-group differences were found at either time point.

The second high quality RCT (Hoffmann et al., 2015) randomized patients with stroke (stage of stroke recovery not specified) to receive CBT (cognitive and behavioral coping-skills exercises), self-management intervention or no treatment. IADLs were measured by the Nottingham Extended activities of Daily Living Scale at post-treatment (8 sessions) and follow-up (3 months). No significant between-group differences were found at either time point.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that cognitive behavioral therapy is not more effective than comparison interventions (attention placebo, self-management intervention, no treatment) in improving instrumental activities of daily living in patients with stroke.

Leisure
Not effective
1b

One high quality RCT (Thomas et al., 2012) investigated the effect of cognitive behavioral therapy (CBT) on leisure in patients with stroke. This high quality RCT randomized patients with subacute / chronic stroke and low mood to receive CBT or no CBT; both groups received usual care. Leisure was measured by the Nottingham Leisure Questionnaire at post-treatment (3 months) and follow-up (6 months). While no significant between-group difference was found at post-treatment, a significant between-group difference in leisure was found at follow-up, favoring CBT vs. no treatment.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive behavioral therapy is not more effective than no CBT in improving leisure in patients with stroke.

Mood and affect
Effective
1b

One high quality RCT (Thomas et al., 2012) investigated the effect of cognitive behavioral therapy (CBT) on mood and affect in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke and low mood to receive CBT or no CBT; both groups received usual care. Mood and affect was measured by the Visual Analogue Mood Scale (Sad item) at post-treatment (3 months) and follow-up (6 months). A significant between-group difference was found at both time points, favoring CBT vs. no CBT.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive behavioral therapy is more effective than no CBT in improving mood and affect in patients with stroke.

Satisfaction with care
Not effective
1b

One high quality RCT (Thomas et al., 2012) investigated the effect of cognitive behavioral therapy (CBT) on satisfaction with care in patients with stroke and their caregivers. This high quality RCT randomized patients with subacute/chronic stroke and low mood to receive CBT or no CBT; both groups received usual care. Patients’ and carers’ satisfaction with care was measured by the Visual Analogue Satisfaction with Care Rating at follow-up (6 months). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive behavioral therapy is not more effective than no CBT in improving satisfaction with care in patients with stroke.

Self-efficacy
Not effective
1b

One high quality RCT (Hoffmann et al., 2015) investigated the effect of cognitive behavioral therapy (CBT) on self-efficacy in patients with stroke. This high quality RCT randomized patients with stroke (stage of stroke recovery not specified) to receive CBT (cognitive and behavioral coping-skills exercises), self-management intervention or no treatment. Self-efficacy was measured by the stroke Self-Efficacy Questionnaire at post-treatment (8 sessions) and follow-up (3 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 cognitive behavioral therapy is not more effective than comparison interventions (self-management intervention, no treatment) in improving self-efficacy in patients with stroke.

Self-esteem
Effective
1b

One high quality RCT (Thomas et al., 2012) investigated the effect of cognitive behavioral therapy (CBT) on self-esteem in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke and low mood to receive CBT or no CBT; both groups received usual care. Self-esteem was measured by the Visual Analogue Self-Esteem Scale at post-treatment (3 months) and follow-up (6 months). A significant between-group difference in self-esteem was found at both time points, favoring CBT vs. no CBT.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive behavioral therapy is more effective than no CBT in improving self-esteem in patients with stroke.

Social participation
Not effective
1b

One high quality RCT (Kootker et al., 2017) investigated the effect of cognitive behavioral therapy (CBT) on social participation in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive CBT (goal-setting, meaningful activities, relaxation/communication strategies) or computerized cognitive therapy. Social participation was measured by the Utrecht Scale for Evaluation of Rehabilitation (participation subscale) at post-treatment (4 months) and at follow-up (8 and 12 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 cognitive behavioral therapy is not more effective than a comparison intervention (computerized cognitive training) in improving social participation in patients with stroke.

Stroke knowledge
Effective
1b

One high quality RCT (Hoffmann et al., 2015) investigated the effect of cognitive behavioral therapy (CBT) on stroke knowledge in patients with stroke. This high quality RCT randomized patients with stroke (stage of stroke recovery not specified) to receive CBT (cognitive and behavioral coping-skills exercises), self-management intervention or no treatment. stroke knowledge was measured by the stroke Knowledge Questionnaire at post-treatment (8 sessions) and follow-up (3 months). Significant between-group differences were found for stroke knowledge at post-treatment, favoring CBT vs. no treatment. These differences did not remain significant at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive behavioral therapy is more effective than no treatment in improving self-efficacy in patients with stroke.
Note:
CBT was not more effective than a comparison intervention (self-management intervention) in improving stroke knowledge.

Phase not specific to one period - Discharge care coordination

Adherence to self-management practices
Effective
2a

One fair quality RCT (Clairborne, 2006) investigated the effect of discharge care coordination on adherence to self-management practices in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive care coordination at discharge or no treatment; both group received standard follow-up care. Adherence to self-management practices was measured by the number of incidences in which patients did not follow through with self-management practices (medication regimen, medical appointments, dietary requirements, home exercise program, stress reduction, and other individualized recommendations) at follow-up (3 months post-discharge). Significant between-group difference was found favoring care coordination vs. no treatment.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that discharge care coordination is more effective than no treatment in improving adherence to self-management practices in patients with stroke.

Caregiver burden
Effective
1b

One high quality RCT (Burton & Gibbon, 2005) investigated the effect of discharge care coordination on burden among caregivers of individuals with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive discharge support and education from a stroke nurse or usual discharge care. Caregivers’ burden was measured by the Caregiver Strain Index at baseline, at post-treatment (3 months post-stroke), and at follow-up (12 months post-stroke). Significant between-group difference was found at post-treatment, favoring discharge education and support vs. usual care. In addition, there were significant between-group difference in caregiver burden change scores from baseline to follow-up, favoring discharge education and support vs. usual care.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that discharge support and education from a stroke nurse is more effective than a comparison intervention (usual discharge care) in improving caregiver’s burden among caregivers of patient with stroke.

Depression
Conflicting
4

Two high quality RCTs (Burton & Gibbon, 2005; Graven et al., 2016) and one fair quality RCT (Clairborne, 2006) investigated the effect of discharge care coordination on depression among patients with stroke.

The first high quality RCT (Burton & Gibbon, 2005) randomized patients with acute/subacute stroke to receive discharge support and education from a stroke nurse or usual discharge care. depression was measured by the Beck depression Inventory at post-treatment (3 months post-stroke) and at follow-up (12 months post-stroke). No significant between-group difference was found at either time point.

The high quality RCT (Graven et al., 2016) randomized patients with acute/subacute stroke to receive multimodal discharge management (liaison with services, education, follow-up) or standard discharge care. depression was measured by the Geriatric depression Scale (GDS-15) at follow-up (1 year post-stroke). Significant between-group difference was found favoring multimodal discharge management vs. standard discharge care.

The fair quality RCT (Clairborne, 2006) randomized patients with acute/subacute stroke to receive care coordination at discharge or no treatment; both group received standard follow-up care. depression was measured by the GDS-15 at follow-up (3 months post-discharge). Significant between-group difference was found at follow-up, favoring care coordination vs. no treatment.

Conclusion: There is conflicting evidence (Level 4) on the effect of discharge care coordination in improving depression in patients with stroke. While one high quality RCT found that discharge support and education from a stroke nurse is not more effective than usual discharge care; another high quality RCT and a fair quality RCT found that discharge care coordination is more effective than usual discharge care in improving depression in patients with stroke.
Note:
Differences in outcomes measures used could explain the differences in found treatment effects across these studies.

Functional independence
Effective
1b

One high quality RCT (Burton & Gibbon, 2005) investigated the effect of discharge care coordination on functional independence in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive discharge support and education from a stroke nurse or usual discharge care. Functional independence was measured by the Barthel Index at post-treatment (3 months post-stroke) and at follow-up (12 months post-stroke). While no significant between-group difference was found at post-treatment, there was a significant between-group difference in change scores from 3 to 12 months, favoring discharge support vs. usual discharge care.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that discharge support and education from a stroke nurse is more effective than a comparison intervention (usual discharge care) in improving functional independence in patients with stroke.

Health related quality of life
Effective
1b

One high quality RCT (Burton & Gibbon, 2005) and one fair quality RCT (Clairborne, 2006) investigated the effect of discharge care coordination on health-related quality of life (HRQoL) in patients with stroke.

The high quality RCT (Burton & Gibbon, 2005) randomized patients with acute/subacute stroke to receive discharge support and education from a stroke nurse or usual discharge care. HRQoL was measured by the Nottingham Health Profile (NHP – Total score, Energy, Emotional reaction, Physical mobility, Pain, Social isolation, Sleep subscores) at post-treatment (3 months post-stroke) and at follow-up (12 months post-stroke). Significant between-group difference was found at post-treatment (NHP – Emotional reaction, Pain, Social isolation), and at follow-up (NHP – Emotional reaction, Social isolation, Total score), favoring discharge support and education vs. usual care.

The fair quality RCT (Clairborne, 2006) randomized patients with acute/subacute stroke to receive care coordination at discharge or no treatment; both group received standard follow-up care. HRQoL was measured by the Short-Form 36 (SF-36 – Physical Component Summary; SF-36 – Mental Component Summary) at follow-up (3 months post-discharge). Significant between-group difference was found (SF-36 – Mental Component Summary) favoring care coordination vs. no treatment.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that discharge care coordination is more effective than comparison interventions (usual discharge care, no treatment) in improving aspects of health-related quality of life in patients with stroke.

Instrumental activities of daily living
Not effective
1b

One high quality RCT (Burton & Gibbon, 2005) investigated the effect of discharge care coordination on instrumental activities of daily living (IADLs) in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive discharge support and education from a stroke nurse or usual discharge care. IADLs were measured by the Frenchay activities Index at post-treatment (3 months post-stroke) and at follow-up (12 months post-stroke). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that continued discharge support from a stroke nurse is not more effective than a comparison intervention (usual discharge care) in improving instrumental activities of daily living in patients with stroke.

Phase not specific to one period - Environmental enrichment inpatient program

Cognition
Not effective
1b

One high quality RCT (Khan et al., 2016) investigated the effect of environmental enrichment (EE) on cognition in patients with stroke. This high quality RCT randomized patients with neurological conditions (n=53 with acute/subacute/chronic stroke) to receive an EE inpatient program or usual ward activity. Cognition was measured by the Montreal Cognitive Assessment at post-treatment (discharge from the inpatient ward, range of duration: 9-12 days). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that an environmental enrichment inpatient program is not more effective than a comparison intervention (usual ward activity) in improving cognition in patients with stroke.

Emotional state
Effective
1b

One high quality RCT (Khan et al., 2016) investigated the effect of environmental enrichment (EE) on emotional state of patients with stroke. This high quality RCT randomized patients with neurological conditions (n=53 with acute/subacute/chronic stroke) to receive an EE inpatient program or usual ward activity. Emotional state was measured by the Depression Anxiety Stress Scale (DASS – Total, Depression