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 practiced by a trained health professional. For example, in Quebec (Canada) the practice of acupuncture is regulated by a professional Order and only members of the Order can practice it. Different health care professionals such as physicians and physiotherapists may use the trigger point needle technique as part of their 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.

References

Alexander D.N., Cen S., Sullivan K.J., Bhavnani G., Ma X., & Azen S.P. (2004). Effects of acupuncture treatment on poststroke motor recovery and physical function: a pilot study. Neurorehabilitation and Neural Repair, 18(4), 259-267.
https://www.ncbi.nlm.nih.gov/pubmed/15537996

Chen, L., Fang, J., Ma, R., Gu, X., Chen, L., Li, J., & Xu, S. (2016). Additional effects of acupuncture on early comprehensive rehabilitation in patients with mild to moderate acute ischemic stroke: a multicenter randomized controlled trial. BMC complementary and alternative medicine16(1), 226.
https://bmccomplementalternmed.biomedcentral.com/articles/10.1186/s12906-016-1193-y

Fink M., Rollnik J. D., Bijak M., Borstadt C., Dauper J., Guergueltcheva V., Dengler, Reinhard D., & Karst M. (2004). Needle acupuncture in chronic poststroke leg spasticity. Archives of Physical Medicine and Rehabilitation, 85(4), 667-672.
http://www.archives-pmr.org/article/S0003-9993(03)00941-9/abstract

Gosman – Hedstrom G., Claesson L., Klingenstierna U., Carlsson J., Olausson B., Frizell M., Fagerberg B., & Blomstrand C. (1998). Effects of acupuncture treatment on daily life activities and quality of life: a controlled, prospective, and randomized study of acute stroke patients. Stroke, 29, 2100-2108.
https://www.ncbi.nlm.nih.gov/pubmed/9756589

Hegyi, G., & Szigeti, G. P. (2012). Rehabilitation of stroke patients using yamamoto new scalp acupuncture: a pilot study. The Journal of Alternative and Complementary Medicine18(10), 971-977.
http://online.liebertpub.com/doi/abs/10.1089/acm.2011.0047

Hopwood V, Lewith G., Prescott P., & Campbell M.J. (2008). Evaluating the efficacy of acupuncture in defined aspects of stroke recovery: A randomized, placebo controlled single blind study, Journal of Neurology, 255, 858-866.
https://www.ncbi.nlm.nih.gov/pubmed/18465110

Hsieh R.L., Wang L.Y., & Lee W.C. (2007). Additional therapeutic effects of electro-acupuncture in conjunction with conventional rehabilitation for patients with first-ever ischaemic stroke. Journal of Rehabilitation Medicine, 39, 205-211.
https://www.medicaljournals.se/jrm/content/html/10.2340/16501977-0032

Hu H.H., Chung C., Li T.J., Chen R.C., Chen C.H., Chou P., Huang W.S., Lin J.C.T., & Tsuei J.J. (1993). A randomized controlled trial on the treatment for acute partial ischemic stroke with acupuncture. Neuroepidemiology, 12, 106-113.
https://www.ncbi.nlm.nih.gov/pubmed/8232703

Jiang, C., Yang, S., Tao, J., Huang, J., Li, Y., Ye, H., … & Chen, L. (2016). Clinical efficacy of acupuncture treatment in combination with rehacom cognitive training for improving cognitive function in stroke: a 2× 2 factorial design randomized controlled trial. Journal of the American Medical Directors Association17(12), 1114-1122.
http://www.sciencedirect.com/science/article/pii/S1525861016302997

Johansson K., Lindgren I., Widner H., Wiklund I., & Johansson B.B. (1993). Can sensory stimulation improve the functional outcome in stroke patients? Neurology, 43, 2189-2192.
https://www.ncbi.nlm.nih.gov/pubmed/8232927

Johansson B.B., Haker E., von Arbin M., Britton M., Langstrom G., Teréent A, Ursing D., & Asplund K. (2001). Acupuncture and transcutaneous nerve stimulation in stroke rehabilitation: a randomized, controlled trial. Stroke, 32, 707-713.
http://stroke.ahajournals.org/content/strokeaha/32/3/707.full.pdf

Kim Y.S., Lee S.H., Jung W.S., Park S.U., Moon S.K., Ko C.N., Cho K.H., Bae H.S. (2004). Intradermal acupuncture on shen-men and nei-kuan acupoints in patients with insomnia after stroke. American Journal of Chinese Medicine, 32, 771-778.
https://www.ncbi.nlm.nih.gov/pubmed/15633811

Kjendahl A., Sallstrom S., Egil Osten P., & Kvalvik Stanghelle J. (1997). A one year follow-up study on the effects of acupuncture in the treatment of stroke patients in the subacute stage: a randomized, controlled study. Clinical Rehabilitation, 11, 192-200.
https://www.ncbi.nlm.nih.gov/pubmed/9360031

Li, H., Liu, H., Liu, C., Shi, G., Zhou, W., Zhao, C., … & Sun, J. (2014). Effect of “Deqi” during the study of needling “Wang’s Jiaji” acupoints treating spasticity after stroke. Evidence-Based Complementary and Alternative Medicine2014.
https://www.hindawi.com/journals/ecam/2014/715351/abs/

Liu, C. H., Hsieh, Y. T., Tseng, H. P., Lin, H. C., Lin, C. L., Wu, T. Y., … & Zhang, H. (2016). Acupuncture for a first episode of acute ischaemic stroke: an observer-blinded randomised controlled pilot study. Acupuncture in Medicine34(5), 349-355.
http://aim.bmj.com/content/34/5/349

Mao, L. Y., Li, L. L., Mao, Z. N., Han, Y. P., Zhang, X. L., Yao, J. X., & Li, M. (2016). Therapeutic effect of acupuncture combining standard swallowing training for post-stroke dysphagia: A prospective cohort study. Chinese Journal of Integrative Medicine22(7), 525-531.
https://link.springer.com/article/10.1007/s11655-016-2457-6

Min, M., Xin, C., Yuefeng, C., Ping, R., & Jian, L. (2008). Stage-oriented comprehensive acupuncture treatment plus rehabilitation training for apoplectic hemiplegia. Journal of Traditional Chinese Medicine28(2), 90-93.
http://www.sciencedirect.com/science/article/pii/S0254627208600229

Mukherjee M., McPeak L.K., Redford J. B., Sun C., & Liu W. (2007). The effect of electro-acupuncture on spasticity of the wrist joint in chronic stroke survivors. Archives of Physical Medicine and Rehabilitation, 88, 159-166.
https://www.ncbi.nlm.nih.gov/pubmed/17270512

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

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

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

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

Sallstrom S., Kjendahl A., Osten P.E., Stanghelle J.H., & Borchgrevink C.F. (1996). Acupuncture in the treatment of stroke patients in the subacute stage: a randomized, controlled study. Complementary Therapies in Medicine, 4, 193-197.
http://www.sciencedirect.com/science/article/pii/S0965229996800094

Schaechter J.D., Connell B.D., Stason W.B., Kaptchuk T.J., Krebs D.E., Macklin E.A., Schnyer R.N., Stein J., Scarborough D.M., Parker S.W., McGibbon C.A., & Wayne P.M. (2007). Correlated change in upper limb function and motor cortex activation after verum and sham acupuncture in patients with chronic stroke. Journal of Alternative and Complementary Medicine. 13, 527-532.
https://www.ncbi.nlm.nih.gov/pubmed/17604556

Schuler M.S., Durdak C., Hosl N.M., Klink A., Hauer K.A., & Oster P. (2005). Acupuncture treatment of geriatric patients with ischemic stroke: a randomized, double-controlled, single-blind study. Journal of the American Geriatrics Society, 53, 549-550.
https://www.ncbi.nlm.nih.gov/pubmed/15743311

Si Q.C., Wu G.C., & Cao X.D. (1998). Effects of electroacupuncture on acute cerebral infarction. Acupuncture and Electro-therapeutics Research, 23, 117-124.
https://www.ncbi.nlm.nih.gov/pubmed/9789586

Sze F.K., Wong E., Yi X., & Woo J. (2002). Does acupuncture have additional value to standard poststroke motor rehabilitation? Stroke, 33, 186-194.
https://www.ncbi.nlm.nih.gov/pubmed/11779909

Tan, F., Wang, X., Li, H. Q., Lu, L., Li, M., Li, J. H., … & Zheng, G. Q. (2013). A randomized controlled pilot study of the triple stimulation technique in the assessment of electroacupuncture for motor function recovery in patients with acute ischemic stroke. Evidence-Based Complementary and Alternative Medicine2013.
https://www.hindawi.com/journals/ecam/2013/431986/abs/

Wang, C., Wu, Z., Li, N., Zhao, Y., Tian, F., Zhou, X., & Wang, Z. (2014). Clinical curative effect of electric acupuncture on acute cerebral infarction: a randomized controlled multicenter trial. Journal of Traditional Chinese Medicine34(6), 635-640.
http://www.sciencedirect.com/science/article/pii/S0254627215300753

Wayne P. M., Krebs D. E., Macklin E. A., Schnyer R., Kaptchuk T. J., Parker S. W., Scarborough D.M., McGibbon C.A., Schaechter J.D., Stein J., & Stason W.B. (2005). Acupuncture for upper-extremity rehabilitation in chronic stroke: a randomized sham-controlled study. Archive of Physical Medicine Rehabilitation, 86, 2248-2255.
https://www.ncbi.nlm.nih.gov/pubmed/16344019

Wong A.M., Su T.Y., Tang F.T., Cheng P.T., & Liaw M.Y. (1999). Clinical trial of electrical acupuncture on hemiplegic stroke patients. American Journal of Physical Medicine and Rehabilitation, 78, 117-122.
https://www.ncbi.nlm.nih.gov/pubmed/10088585

Xia, W., Zheng, C., Zhu, S., & Tang, Z. (2016). Does the addition of specific acupuncture to standard swallowing training improve outcomes in patients with dysphagia after stroke? a randomized controlled trial. Clinical Rehabilitation30(3), 237-246.
http://journals.sagepub.com/doi/abs/10.1177/0269215515578698

Zhang, S., Wu, B., Liu, M., Li, N., Zeng, X., Liu, H., … & Wang, D. (2015). Acupuncture Efficacy on Ischemic Stroke Recovery. Stroke46(5), 1301-1306.
http://stroke.ahajournals.org/content/46/5/1301.short

Zhu, Y., Zhang, L., Ouyang, G., Meng, D., Qian, K., Ma, J., & Wang, T. (2013). Acupuncture in subacute stroke: no benefits detected. Physical Therapy93(11), 1447-1455.
https://academic.oup.com/ptj/article/93/11/1447/2735273/Acupuncture-in-Subacute-Stroke-No-Benefits

Zhuang, L. X., Xu, S. F., D’Adamo, C. R., Jia, C., He, J., Han, D. X., & Lao, L. X. (2012). An Effectiveness Study Comparing Acupuncture, Physiotherapy, and Their Combination in Poststroke Rehabifitation: A Multicentered, Randomized, Controlled Clinical Trial. Alternative Therapies in Health & Medicine18(3).
https://www.ncbi.nlm.nih.gov/pubmed/22875557

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, Anxiety, Stress subscores) at post-treatment (discharge from the inpatient ward, range 9-12 days) and at follow-up (3 months post-discharge from the inpatient ward). Significant between-group difference was seen for all measures of negative emotional state (DASS – Total, Depression, Anxiety, Stress subscores) at post-treatment, favoring EE inpatient program vs. usual ward activity. Differences did not remain significant at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that an environmental enrichment inpatient program is more effective than a comparison intervention (usual ward activity) in improving negative emotional state of patients with stroke, in the short term.

Functional independence
Effective
1b

One high quality RCT (Khan et al., 2016) investigated the effect of environmental enrichment (EE) on functional independence 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. Functional independence was measured by the Functional Independence Measure (FIM – Motor total, Self-care, Sphincter, Mobility, Locomotion, Cognition total, Communication, Psychosocial, Social cognition subscores) at post-treatment (discharge from the inpatient ward, range of duration: 9-12 days) and at follow-up (3 months post-discharge from the inpatient ward). Significant between-group difference was found for three measures of functional independence (FIM – Motor total, Self-care, Mobility subscores) at post-treatment, favoring EE inpatient program vs. usual ward activity. Difference did not remain significant at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that an environmental enrichment inpatient program is more effective than a comparison intervention (usual ward activity) in improving some aspects of functional independence in patients with stroke, in the short term.

Health related beliefs
Not effective
1b

One high quality RCT (Khan et al., 2016) investigated the effect of environmental enrichment (EE) on health-related beliefs 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. Health-related beliefs were measured by the Multidimensional Health Locus of Control Scale (MHLC – Internal, Chance, Doctors, Other people items) at post-treatment (discharge from the inpatient ward, range 9-12 days) and at follow-up (3 months post-discharge from the inpatient ward). A significant between-group difference in one item (MHLC – Internal) was found at post-treatment, favoring EE inpatient program vs. usual ward activity. Differences did not remain significant at follow-up.

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 health-related beliefs in patients with stroke.

Health related quality of life
Not effective
1b

One high quality RCT (Khan et al., 2016) investigated the effect of environmental enrichment (EE) on health-related quality of life (HRQoL) 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. HRQoL was measured by the EQ-5D (Mobility, Self-care, Daily activity, Pain/discomfort, Anxiety/depression, Index value, Overall health scores) at post-treatment (discharge from the inpatient ward, range 9-12 days) and at follow-up (3 months post-discharge from the inpatient ward). A significant between-group difference in one measure (EQ-5D – Index value) was seen at post-treatment, favoring EE inpatient program vs. usual ward activity. At follow-up there was a significant between-group difference in overall health-related quality of life (EQ-5D – Overall health), favoring EE inpatient program vs. usual ward activity.

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 health-related quality of life in patients with stroke.

Self-esteem
Not effective
1b

One high quality RCT (Khan et al., 2016) investigated the effect of environmental enrichment (EE) on self-esteem 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. Self-esteem was measured by the Rosenberg Self-Esteem Scale at post-treatment (discharge from the inpatient ward, range 9-12 days) and at follow-up (3 months post-discharge from the inpatient ward). No significant between-group difference was found at either time point.

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 self-esteem in patients with stroke.

Phase not specific to one period - Relaxation

Anxiety
Not effective
1b

One high quality RCT (Mead et al., 2007) investigated the effect of relaxation on anxiety in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive relaxation or exercise training. Anxiety was measured by the Hospital Anxiety and Depression Scale (HADS – Anxiety) at post-treatment (3 months) and follow-up (7 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 relaxation is not more effective than a comparison intervention (exercise training) in reducing anxiety in patients with stroke.

Balance
Not effective
1b

One high quality RCT (Mead et al., 2007) investigated the effect of relaxation on balance in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive relaxation or exercise training. Balance was measured by the Functional Reach Test at post-treatment (3 months) and follow-up (7 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 relaxation is not more effective than a comparison intervention (exercise training) in improving balance in patients with stroke.

Depression
Not effective
1b

One high quality RCT (Mead et al., 2007) investigated the effect of relaxation on depression in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive relaxation or exercise training. Depression was measured by the Hospital Anxiety and Depression Scale (HADS – Depression) at post-treatment (3 months) and follow-up (7 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 relaxation is not more effective than a comparison intervention (exercise training) in improving depression in patients with stroke.

Functional independence
Not effective
1b

One high quality RCT (Mead et al., 2007) investigated the effect of relaxation on functional independence in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive relaxation or exercise training. Functional independence was measured by the Functional Independence Measure at post-treatment (3 months) and follow-up (7 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 relaxation is not more effective than a comparison intervention (exercise training) in improving functional independence in patients with stroke.

Instrumental activities of daily living
Not effective
1b

One high quality RCT (Mead et al., 2007) investigated the effect of relaxation on instrumental activities of daily living (IADLs) in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive relaxation or exercise training. IADLs were measured by the Nottingham Extended Activities of Daily Living Scale at post-treatment (3 months) and follow-up (7 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 relaxation is not more effective than a comparison intervention (exercise training) in improving instrumental activities of daily living in patients with stroke.

Health related quality of life
Not effective
1b

One high quality RCT (Mead et al., 2007) investigated the effect of relaxation on health-related quality of life (HRQoL) in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive relaxation or exercise training. HRQoL was measured by the Short-Form 36 (SF-36 – Physical functioning, Role physical, General health, Vitality, Mental health scores) at post-treatment (3 months) and follow-up (7 months). A significant between-group difference in one measure of HRQoL (SF-36 – Role physical) was found at both time points, favoring exercise vs. relaxation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that relaxation is not more effective than a comparison intervention (exercise training) in improving health-related quality of life in patients with stroke.
Note:
In fact, exercise training was found to be more effective than relaxation in improving quality of life relating to physical role function.

Mobility
Not effective
1b

One high quality RCT (Mead et al., 2007) investigated the effect of relaxation on mobility in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive relaxation or exercise training. Mobility was measured by the Rivermead Mobility Index and the Timed Up and Go Test (TUG) at post-treatment (3 months) and follow-up (7 months). A significant between-group difference in one measure of mobility (TUG) was found at post-treatment, favoring exercise vs. relaxation. Differences did not remain significant at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that relaxation is not more effective than a comparison intervention (exercise training) in improving mobility in patients with stroke.
Note:
In fact, exercise training was found to be more effective than relaxation in improving one measure of mobility.

Power/strength (lower extremity)
Not effective
1b

One high quality RCT (Mead et al., 2007) investigated the effect of relaxation on lower extremity power/strength in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive relaxation or exercise training. Lower extremity power was measured by the Nottingham Power Rig (NPR – Affected extensors, Non-affected extensors, W/kg) and lower extremity strength was measured by the Sit-to-Stand timed test at post-treatment (3 months) and follow-up (7 months). No significant between-group differences were found at either time point for either measure.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that relaxation is not more effective than a comparison intervention (exercise training) in improving lower extremity power/strength in patients with stroke.

Walking economy
Not effective
1b

One high quality RCT (Mead et al., 2007) investigated the effect of relaxation on walking economy in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive relaxation or exercise training. Walking economy (oxygen uptake, ml/kg per meter) was measured by a portable breath-by-breath metabolic measurement system at post-treatment (3 months) and follow-up (7 months). A significant between-group difference was found at post-treatment, favoring exercise training vs. relaxation. Differences did not remain significant at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that relaxation is not more effective than a comparison intervention (exercise training) in improving walking economy in patients with stroke.
Note:
In fact, exercise training was found to be more effective than relaxation in improving walking economy.

Walking speed
Not effective
1b

One high quality RCT (Mead et al., 2007) investigated the effect of relaxation on walking speed in patients with stroke. This high quality RCT randomized patients with subacute / chronic stroke to receive relaxation or exercise training. Walking speed (m/s) was measured by walking a 17-m circuit at comfortable speed at post-treatment (3 months) and follow-up (7 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 relaxation is not more effective than a comparison intervention (exercise training) in improving walking speed in patients with stroke.

Phase not specific to one period - Stroke psychosocial education programs

Caregivers' burden
Not effective
1b

One high quality RCT (Ostwald et al., 2014) investigated the effect of a stroke psychosocial education program on burden among caregivers of individuals with stroke. This high quality RCT randomized patients with acute/subacute/chronic stroke and their caregivers to receive home-based psychosocial education + mailed information or mailed information alone. Caregivers’ burden was measured by the Zarit Burden Inventory at post-treatment (6 months) 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 home-based psychosocial education + mailed information is not more effective than a comparison intervention (mailed information alone) in improving caregivers’ burden among caregivers of patients with stroke.

Caregiver's coping
Not effective
1b

One high quality RCT (Ostwald et al., 2014) investigated the effect of a stroke psychosocial education program on coping among caregivers of individuals with stroke. This high quality RCT randomized patients with acute/subacute/chronic stroke and their caregivers to receive home-based psychosocial education + mailed information or mailed information alone. Caregivers’ coping was measured by the Family Crisis Oriented Personal Evaluation Scales (F-COPES – Mobilising family support, Acquiring social support, Reframing, Seeking spiritual support, Passive appraisal subscores) at post-treatment (6 months) and follow-up (12 months). Significant between-group difference in two measures of coping (F-COPES – Mobilising family support, Acquiring social support) was found at follow-up only, favoring home-based psychosocial education + mailed information vs. mailed information alone.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that psychosocial education + mailed information is not more effective than a comparison intervention (mailed information alone) in improving coping among caregivers of individuals who have had a stroke.

Caregivers' preparedness
Not effective
1b

One high quality RCT (Ostwald et al., 2014) investigated the effect of a stroke psychosocial education program on preparedness among caregivers of individuals with stroke. This high quality RCT randomized patients with acute/subacute/chronic stroke and their caregivers to receive home-based psychosocial education + mailed information or mailed information alone. Caregivers’ preparedness was measured by the 4-Item Caregiver Preparedness Scale at post-treatment (6 months) 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 psychosocial education + mailed information is not more effective than a comparison intervention (mailed information alone) in improving preparedness among caregivers of individuals who have had a stroke.

Caregivers' social support
Not effective
1a

Two high quality RCTs (Smith et al., 2012; Ostwald et al., 2014) investigated the effect of a stroke psychosocial education program on social support among caregivers of individuals with stroke.

The first high quality RCT (Smith et al., 2012) randomized patients with stroke (stage of stroke recovery unspecified) and their caregivers to receive a web-based psychoeducation program or no treatment. Caregiver’s social support was measured by the 11-item Medical Outcome Study (MOS) Social Support Survey at post-treatment (9 weeks) and follow-up (1 month). No significant between-group difference was found at either time point.

The second high quality RCT (Ostwald et al., 2014) randomized patients with acute / subacute / chronic stroke and their caregivers to receive home-based psychosocial education + mailed information or mailed information alone. Caregivers’ social support was measured by the MOS Social Support Survey at post-treatment (6 months) 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 a stroke psychosocial education program is not more effective than comparison interventions (no treatment, mailed information alone) in improving social support among caregivers of individuals who have had a stroke.

Depression
Not effective
1a

Three high quality RCTs (Smith et al., 2012; Ostwald et al., 2014; Saal et al., 2015) investigated the effect of a stroke psychosocial education program on depression in patients with stroke.

The first high quality RCT (Smith et al., 2012) randomized patients with stroke (stage of stroke recovery unspecified) and their caregivers to receive a web-based psychoeducation program or no treatment. Depression among patients and caregivers was measured by the Patient Health Questionnaire – 9 (PHQ) and the 20-item Center for Epidemiological Studies Depression (CESD) at post-treatment (9 weeks) and follow-up (1 month). There were no significant differences in depression among patients at either time point. Significant between-group differences in caregivers’ depression (CESD) were found at both time points, favoring the web-based psychoeducation program vs. no program.

The second high quality RCT (Ostwald et al., 2014) randomized patients with acute / subacute / chronic stroke and their caregivers to receive home-based psychosocial education + mailed information or mailed information alone. Depression among patients and caregivers was measured by the Brief Geriatric Depression Scale at post-treatment (6 months) and at follow-up (12 months). No significant between-group difference was found at either time point for patients or caregivers.

The third high quality RCT (Saal et al., 2015) randomized patients with acute/subacute stroke to receive stroke education + support (home visits, mailed information, educational sessions) or mailed information alone (2 brochures). Depression was measured by the Geriatric Depression Scale at post-treatment (1 year). No significant between-group difference was found.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs that a stroke psychosocial education program is not more effective than comparison interventions (no treatment, mailed information alone) in improving depression in patients with stroke.
Note:
Results regarding depression among caregivers was conflicting (level 4). One high quality RCT reported significant differences on one measure of depression (CESD) among caregivers in favour of web-based psychoeducational intervention vs. no treatment, whereas a second high quality RCT found no difference in caregivers’ depression following home-based psychosocial education + mailed information vs. mailed information alone.

Functional independence
Effective
1b

One high quality RCT (Ostwald et al., 2014) investigated the effect of a stroke psychosocial education program on functional independence in patients with stroke. This high quality RCT randomized patients with acute/subacute/chronic stroke and their caregivers to receive home-based psychosocial education + mailed information or mailed information alone. Functional independence was measured by the Functional Independence Measure (FIM – Motor, Cognitive subtotals) at post-treatment (6 months) and at follow-up (12 months). Significant between-group difference was found at post-treatment (FIM – Cognitive), favoring psychosocial education + mailed information vs. mailed information alone. Differences did not remain significant at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that home-based psychosocial education + mailed information is more effective than comparison interventions (mailed information alone) in improving functional independence in patients with stroke.

Health related quality of life
Conflicting
4

Two high quality RCTs (Ostwald et al., 2014; Saal et al., 2015) investigated the effect of a stroke psychosocial education program on health-related quality of life (HRQoL) in patients with stroke.

The first high quality RCT (Ostwald et al., 2014) randomized patients with acute / subacute / chronic stroke and their caregivers to receive home-based psychosocial education + mailed information or mailed information alone. HRQoL of patients and caregivers was measured by the Medical Outcomes Study Short-Form Survey (SF-36) at post-treatment (6 months) and at follow-up (12 months). Significant between-group difference in HRQoL of patients and caregivers was found at post-treatment, favoring psychosocial education + mailed information vs. mailed intervention alone. Difference did not remain significant at follow-up.

The second high quality RCT (Saal et al., 2015) randomized patients with acute/subacute stroke to receive stroke education + support (home-based visits, mailed information, educational sessions) or mailed information alone (2 brochures). HRQoL was measured by the World Health Organization Quality of Life Short Version at post-treatment (1 year). No significant between-group difference was found.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of psychosocial education programs on health-related quality of life following stroke. One high quality RCT reported that psychosocial education + mailed information was more effective than mailed information alone in improving health-related quality of life of patients and carers, whereas a second high quality RCT found no significant difference between stroke education + support vs. mailed information in improving health-related quality of life of patients following stroke. Differences in content, administration and duration of services, and/or outcome measures used to assess health-related quality of life may account for differences in findings.

Health services usage
Not effective
1b

One high quality RCT (Saal et al., 2015) investigated the effect of a stroke psychosocial education program on health services usage in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive stroke education + support (home-based visits, mailed information, educational sessions) or mailed information alone (2 brochures). Health services usage (use frequency of health services) was measured at post-treatment (1 year). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a stroke education + support is not more effective than a comparison intervention (mailed information alone) in improving patients’ use of health services after stroke.

Mastery
Not effective
1b

One high quality RCTs (Smith et al., 2012) investigated the effect of a stroke psychosocial education program on mastery among patients with stroke and their caregivers. This high quality RCT randomized patients with stroke (stage of stroke recovery unspecified) and their caregivers to receive a web-based psychoeducation program or no treatment. Mastery among patients and caregivers was measured by the Pearlin & Schooler Mastery Scale at post-treatment (9 weeks) and follow-up (1 month). 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 web-based psychoeducation intervention is not more effective than a comparison intervention (no treatment) in improving mastery in patients with stroke or their caregivers.

Perceived stress
Not effective
1b

One high quality RCT (Ostwald et al., 2014) investigated the effect of a stroke psychosocial education program on perceived stress among patients with stroke and their caregivers. This high quality RCT randomized patients with acute/subacute/chronic stroke and their caregivers to receive home-based psychosocial education + mailed information or mailed information alone. Perceived stress among patients and caregivers was measured by the 10-item Perceived Stress Scale at post-treatment (6 months) and at follow-up (12 months). No significant between-group difference was found for patients or caregivers at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that psychosocial education + mailed information is not more effective than a comparison intervention (mailed information alone) in reducing perceived stress among patients with stroke and their caregivers.

Psychological symptoms
Not effective
1b

One high quality RCT (Saal et al., 2015) investigated the effect of a stroke psychosocial education program on psychological symptoms in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive stroke education + support (home-based visits, mailed information, educational sessions) or mailed information alone (2 brochures). Psychological symptoms were measured by the Symptom Checklist 90 Revised (Somatization subscale) at post-treatment (1 year). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that stroke education and support is not more effective than a comparison intervention (mailed information) in improving psychological symptoms in patients with stroke.

Quality of caregiving relationship
Not effective
1b

One high quality RCT (Ostwald et al., 2014) investigated the effect of a stroke psychosocial education program on the quality of caregiving relationships between patients with stroke and their caregivers. This high quality RCT randomized patients with acute/subacute/chronic stroke and their caregivers to receive home-based psychosocial education + mailed information or mailed information alone. Quality of caregiving relationships between patients and caregivers was measured by the Mutuality Scale at post-treatment (6 months) and at follow-up (12 months). No significant between-group difference was found at either time point among patients or caregivers.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that psychosocial education + mailed information is not more effective than a comparison intervention (mailed information alone) in improving the quality of caregiving relationship in patients with stroke and their caregivers.

Self-esteem
Not effective
1b

One high quality RCTs (Smith et al., 2012) investigated the effect of a stroke psychosocial education program on self-esteem among patients with stroke and their caregivers. This high quality RCT randomized patients with stroke (stage of stroke recovery unspecified) and their caregivers to receive a web-based psychoeducation program or no treatment. Patients’ and caregivers’ self-esteem was measured by the Rosenberg Self-Esteem Scale at post-treatment (9 weeks) and follow-up (1 month). 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 web-based psychoeducational intervention is not more effective than no treatment in improving self-esteem in patients with stroke and their caregivers.

Stroke outcomes
Not effective
1a

Two high quality RCTs (Ostwald et al., 2014; Saal et al., 2015) investigated the effect of a stroke psychosocial education program on stroke outcomes in patients with stroke.

The first high quality RCT (Ostwald et al., 2014) randomized patients with acute / subacute / chronic stroke and their caregivers to receive home-based psychosocial education + mailed information or mailed information alone. Stroke outcomes were measured by the Stroke Impact Scale (SIS – Physical, Emotion, Memory, Communication, Social participation, Stroke recovery subscores) at post-treatment (6 months) and at follow-up (12 months). No significant between-group difference was found at either time point.

The second high quality RCT (Saal et al., 2015) randomized patients with acute/subacute stroke to receive stroke education + support (home-based visits, mailed information, educational sessions) or mailed information alone (2 brochures). Stroke outcomes were measured by the SIS (Physical domain score) at post-treatment (1 year). Significant between-group difference was found favoring mailed information alone vs. stroke education and support intervention.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that a stroke psychosocial education program is not more effective than a comparison intervention (mailed information alone) in improving stroke outcomes in patients with stroke.
Note:
In fact, one high quality RCT found that stroke education + support was LESS effective than mailed information alone.

Stroke recurrence
Not effective
1b

One high quality RCT (Saal et al., 2015) investigated the effect of a stroke psychosocial education program on the incidence of recurrent stroke(s) in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive stroke education + support (home-based visits, mailed information, educational sessions) or mailed information alone (2 brochures). The incidence of recurrent stroke(s) was measured at post-treatment (1 year). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that stroke education and support is not more effective than a comparison intervention (mailed information alone) in reducing the incidence of recurrent stroke(s) in patients with stroke.

Phase not specific to one period - Tai Chi

Depression
Not effective
1b

One high quality RCT (Taylor-Piliae et al., 2014) investigated the effect of Tai Chi on depression in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive Tai Chi, a time-matched fitness program or standard care. Depression was measured by the Center for Epidemiologic Studies Depression Scale 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 Tai Chi is not more effective than comparison interventions (time-matched fitness program, standard care) in improving depression in patients with stroke.

Endurance
Effective
1b

One high quality RCT (Taylor-Piliae et al., 2014) investigated the effect of Tai Chi on endurance in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive Tai Chi, a time-matched fitness program or standard care. Endurance was measured by the 2-Minute Step Test at post-treatment (12 weeks). Significant between-group differences were found, favoring Tai Chi vs. standard care; and favoring the time-matched fitness program vs. standard care. There were no significant differences between Tai Chi and the time-matched fitness program.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that Tai Chi is more effective than a comparison intervention (standard care) in improving endurance in patients with stroke. It is not more effective than a time-matched fitness program.

Falls
Effective
1b

One high quality RCT (Taylor-Piliae et al., 2014) investigated the effect of Tai Chi on falls rate in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive Tai Chi, a time-matched fitness program or standard care. Falls rate was measured at post-treatment (12 weeks). Significant between-group differences were found, favoring Tai Chi vs. standard care. There were no significant differences between Tai Chi and the time-matched fitness program, or between the time-matched fitness program and standard care.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that Tai Chi is more effective than a comparison intervention (standard care) in reducing the rate of falls in patients with stroke. It is not more effective than a time-matched fitness program.

Health related quality of life
Not effective
1b

One high quality RCT (Taylor-Piliae et al., 2014) investigated the effect of Tai Chi on health-related quality of life (HRQoL) in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive Tai Chi, a time-matched fitness program or standard care. HRQoL was measured by the 36-Item Short-Form Survey (SF-36 – Physical Component Score, Mental Component Score) 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 Tai Chi is not more effective than comparison interventions (time-matched fitness program, standard care) in improving health-related quality of life in patients with stroke.

Mobility
Not effective
1b

One high quality RCT (Taylor-Piliae et al., 2014) investigated the effect of Tai Chi on mobility in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive Tai Chi, a time-matched fitness program or standard care. Mobility was measured by the Short-Form Performance Battery (SFPB – Total, Balance, Strength, Gait subscores) at post-treatment (12 weeks). There were no significant differences in any measure of mobility between Tai Chi and the time-matched fitness program, or Tai Chi and standard care.
Note: A significant between-group difference in one mobility score (SFPB – Strength) was found, favoring the time-matched fitness program vs. standard care.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that Tai Chi is not more effective than comparison interventions (time-matched fitness program, standard care) in improving mobility in patients with stroke.

Sleep quality
Not effective
1b

One high quality RCT (Taylor-Piliae et al., 2014) investigated the effect of Tai Chi on sleep quality in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive Tai Chi, a time-matched fitness program or standard care. Sleep quality was measured by the Pittsburgh Sleep Quality Index at post-treatment (12 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) that Tai Chi is not more effective than comparison interventions (time-matched fitness program, standard care) in improving sleep quality in patients with stroke.

References

Alexopoulos, G. S., Wilkins, V. M., Marino, P., Kanellopoulos, D., Reding, M., Sirey, J. A., … & Kiosses, D. N. (2012). Ecosystem focused therapy in poststroke depression: a preliminary study. International Journal of Geriatric Psychiatry, 27(10), 1053-1060.
https://onlinelibrary.wiley.com/doi/full/10.1002/gps.2822

Burton, C., & Gibbon, B. (2005). Expanding the role of the stroke nurse: a pragmatic clinical trial. Journal of Advanced Nursing, 52(6), 640-650.
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2648.2005.03639.x

Chaiyawat, P., Kulkantrakorn, K., & Sritipsukho, P. (2009). Effectiveness of home rehabilitation for ischemic stroke. Neurology International, 1(1).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093230/

Chaiyawat, P., & Kulkantrakorn, K. (2012). Randomized controlled trial of home rehabilitation for patients with ischemic stroke: impact upon disability and elderly depression. Psychogeriatrics, 12(3), 193-199.
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1479-8301.2012.00412.x

Chan, W., Immink, M. A., & Hillier, S. (2012). Yoga and exercise for symptoms of depression and anxiety in people with poststroke disability: a randomized, controlled pilot trial. Alternative Therapies in Health and Medicine, 18(3), 34.
https://search.proquest.com/openview/627c26ec5587cb9717770a9507388256/1?pq-origsite=gscholar&cbl=32528

Chang, K., Zhang, H., Xia, Y., & Chen, C. (2011). Testing the effectiveness of knowledge and behavior therapy in patients of hemiplegic stroke. Topics in Stroke Rehabilitation, 18(5), 525-535.
https://www.tandfonline.com/doi/abs/10.1310/tsr1805-525

Chun, M. H., Chang, M. C., & Lee, S. J. (2017). The effects of forest therapy on depression and anxiety in patients with chronic stroke. International Journal of Neuroscience, 127(3), 199-203.
https://www.tandfonline.com/doi/abs/10.3109/00207454.2016.1170015

Claiborne, N. (2006). Effectiveness of a care coordination model for stroke survivors: a randomized study. Health & Social Work, 31(2), 87-96.
https://academic.oup.com/hsw/article-abstract/31/2/87/625312

Faulkner, J., McGonigal, G., Woolley, B., Stoner, L., Wong, L., & Lambrick, D. (2015). A randomized controlled trial to assess the psychosocial effects of early exercise engagement in patients diagnosed with transient ischaemic attack and mild, non-disabling stroke. Clinical Rehabilitation, 29(8), 783-794.
http://journals.sagepub.com/doi/abs/10.1177/0269215514555729

Golding, K., Fife-Schaw, C., & Kneebone, I. (2017). A pilot randomized controlled trial of self-help relaxation to reduce post-stroke depression. Clinical Rehabilitation, 0269215517741947.
http://journals.sagepub.com/doi/abs/10.1177/0269215517741947

Golding, K., Kneebone, I., & Fife-Schaw, C. (2016). Self-help relaxation for post-stroke anxiety: A randomised, controlled pilot study. Clinical Rehabilitation, 30(2), 174-180.
http://journals.sagepub.com/doi/abs/10.1177/0269215515575746

Golding, K., Fife-Schaw, C., & Kneebone, I. (2017). Twelve month follow-up on a randomised controlled trial of relaxation training for post-stroke anxiety. Clinical Rehabilitation, 31(9), 1164-1167.
http://journals.sagepub.com/doi/abs/10.1177/0269215516682820?journalCode=crea

Graven, C., Brock, K., Hill, K. D., Cotton, S., & Joubert, L. (2016). First Year After Stroke: An Integrated Approach Focusing on Participation Goals Aiming to Reduce Depressive Symptoms. Stroke, 47(11), 2820-2827.
http://stroke.ahajournals.org/content/47/11/2820.short

Hoffmann, T., Ownsworth, T., Eames, S., & Shum, D. (2015). Evaluation of brief interventions for managing depression and anxiety symptoms during early discharge period after stroke: a pilot randomized controlled trial. Topics in Stroke Rehabilitation, 22(2), 116-126.
https://www.tandfonline.com/doi/abs/10.1179/1074935714Z.0000000030

Holmgren, E., Gosman-Hedström, G., Lindström, B., & Wester, P. (2010). What is the benefit of a high-intensive exercise program on health-related quality of life and depression after stroke? A randomized controlled trial. Advances in Physiotherapy, 12(3), 125-133.
https://www.tandfonline.com/doi/abs/10.3109/14038196.2010.488272

Immink, M. A., Hillier, S., & Petkov, J. (2014). Randomized controlled trial of yoga for chronic poststroke hemiparesis: motor function, mental health, and quality of life outcomes. Topics in Stroke Rehabilitation, 21(3), 256-271.
https://www.tandfonline.com/doi/abs/10.1310/tsr2103-256

Ihle-Hansen, H., Thommessen, B., Fagerland, M. W., Øksengård, A. R., Wyller, T. B., Engedal, K., & Fure, B. (2014). Effect on anxiety and depression of a multifactorial risk factor intervention program after stroke and TIA: a randomized controlled trial. Aging & Mental Health, 18(5), 540-546.
https://www.tandfonline.com/doi/abs/10.1080/13607863.2013.824406

Khan, F., Amatya, B., Elmalik, A., Lowe, M., Ng, L., Reid, I., & Galea, M. P. (2016). An enriched environmental programme during inpatient neuro-rehabilitation: A randomized controlled trial. Journal of Rehabilitation Medicine, 48(5), 417-425.
http://www.ingentaconnect.com/content/mjl/sreh/2016/00000048/00000005/art00002

Kootker, J. A., Rasquin, S. M., Lem, F. C., van Heugten, C. M., Fasotti, L., & Geurts, A. C. (2017). Augmented cognitive behavioral therapy for poststroke depressive symptoms: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 98(4), 687-694.
http://www.archives-pmr.org/article/S0003-9993(16)31234-5/abstract

Kongkasuwan, R., Voraakhom, K., Pisolayabutra, P., Maneechai, P., Boonin, J., & Kuptniratsaikul, V. (2016). Creative art therapy to enhance rehabilitation for stroke patients: a randomized controlled trial. Clinical Rehabilitation, 30(10), 1016-1023.
http://journals.sagepub.com/doi/abs/10.1177/0269215515607072

Lai, S. M., Studenski, S., Richards, L., Perera, S., Reker, D., Rigler, S., & Duncan, P. W. (2006). Therapeutic exercise and depressive symptoms after stroke. Journal of the American Geriatrics Society, 54(2), 240-247.
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1532-5415.2006.00573.x

Lincoln, N. B., & Flannaghan, T. (2003). Cognitive behavioral psychotherapy for depression following stroke: a randomized controlled trial. Stroke, 34(1), 111-115.
http://stroke.ahajournals.org/content/34/1/111.short

Lincoln, N. B., Jones, A. C., & Mulley, G. P. (1985). Psychological effects of speech therapy. Journal of Psychosomatic Research, 29(5), 467-474.
http://www.jpsychores.com/article/0022-3999(85)90080-7/fulltext

Mead, G. E., Greig, C. A., Cunningham, I., Lewis, S. J., Dinan, S., Saunders, D. H., … & Young, A. (2007). Stroke: a randomized trial of exercise or relaxation. Journal of the American Geriatrics Society, 55(6), 892-899.
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1532-5415.2007.01185.x

Ostwald, S. K., Godwin, K. M., Cron, S. G., Kelley, C. P., Hersch, G., & Davis, S. (2014). Home-based psychoeducational and mailed information programs for stroke-caregiving dyads post-discharge: a randomized trial. Disability and Rehabilitation, 36(1), 55-62.
https://www.tandfonline.com/doi/abs/10.3109/09638288.2013.777806

Peng, Y., Lu, Y., Wei, W., Yu, J., Wang, D., Xiao, Y., … & Wang, Z. (2015). The effect of a brief intervention for patients with ischemic stroke: A randomized controlled trial. Journal of Stroke and Cerebrovascular Diseases, 24(8), 1793-1802.
https://www.ncbi.nlm.nih.gov/pubmed/26117212

Saal, S., Becker, C., Lorenz, S., Schubert, M., Kuss, O., Stang, A., … & Behrens, J. (2015). Effect of a stroke support service in Germany: a randomized trial. Topics in Stroke Rehabilitation, 22(6), 429-436.
https://www.ncbi.nlm.nih.gov/pubmed/25920942

Shiflett, S. C., Nayak, S., Bid, C., Miles, P., & Agostinelli, S. (2002). Effect of Reiki treatments on functional recovery in patients in poststroke rehabilitation: a pilot study. The Journal of Alternative & Complementary Medicine, 8(6), 755-763.
https://www.liebertpub.com/doi/abs/10.1089/10755530260511766

Smith, G. C., Egbert, N., Dellman-Jenkins, M., Nanna, K., & Palmieri, P. A. (2012). Reducing depression in stroke survivors and their informal caregivers: a randomized clinical trial of a Web-based intervention. Rehabilitation Psychology, 57(3), 196.
http://psycnet.apa.org/record/2012-23562-002

Taylor-Piliae, R. E., Hoke, T. M., Hepworth, J. T., Latt, L. D., Najafi, B., & Coull, B. M. (2014). Effect of Tai Chi on physical function, fall rates and quality of life among older stroke survivors. Archives of Physical Medicine and Rehabilitation, 95(5), 816-824.
http://www.archives-pmr.org/article/S0003-9993(14)00010-0/abstract

Thomas, S. A., Walker, M. F., Macniven, J. A., Haworth, H., & Lincoln, N. B. (2013). Communication and Low Mood (CALM): a randomized controlled trial of behavioural therapy for stroke patients with aphasia. Clinical Rehabilitation, 27(5), 398-408.
http://journals.sagepub.com/doi/abs/10.1177/0269215512462227

Watkins, C. L., Auton, M. F., Deans, C. F., Dickinson, H. A., Jack, C. I., Lightbody, C. E., … & Leathley, M. J. (2007). Motivational interviewing early after acute stroke: a randomized, controlled trial. Stroke, 38(3), 1004-1009.
http://stroke.ahajournals.org/content/38/3/1004.short

Watkins, C. L., Wathan, J. V., Leathley, M. J., Auton, M. F., Deans, C. F., Dickinson, H. A., … & Lightbody, C. E. (2011). The 12-month effects of early motivational interviewing after acute stroke: a randomized controlled trial. Stroke, 42(7), 1956-1961.
http://stroke.ahajournals.org/content/42/7/1956.short

Wu, D. Y., Guo, M., Gao, Y. S., Kang, Y. H., Guo, J. C., Jiang, X. L., … & Liu, T. (2012). Clinical effects of comprehensive therapy of early psychological intervention and rehabilitation training on neurological rehabilitation of patients with acute stroke. Asian Pacific Journal of Tropical Medicine, 5(11), 914-916.
https://www.sciencedirect.com/science/article/pii/S1995764512601710

Excluded Studies

Aben, L., Heijenbrok-Kal, M. H., Ponds, R. W., Busschbach, J. J., & Ribbers, G. M. (2014). Long-lasting effects of a new memory self-efficacy training for stroke patients: a randomized controlled trial. Neurorehabilitation and Neural Repair, 28(3), 199-206.
Reason for exclusion: Study part of COGNITIVE REHABILITATION module.

Aben, L., Heijenbrok-Kal, M. H., van Loon, E. M., Groet, E., Ponds, R. W., Busschbach, J. J., & Ribbers, G. M. (2013). Training memory self-efficacy in the chronic stage after stroke: a randomized controlled trial. Neurorehabilitation and Neural Repair, 27(2), 110-117.
Reason for exclusion: Study part of COGNITIVE REHABILITATION module.

Byl, N. N., Abrams, G. M., Pitsch, E., Fedulow, I., Kim, H., Simkins, M., … & Rosen, J. (2013). Chronic stroke survivors achieve comparable outcomes following virtual task specific repetitive training guided by a wearable robotic orthosis (UL-EXO7) and actual task specific repetitive training guided by a physical therapist. Journal of Hand Therapy, 26(4), 343-352.
Reason for exclusion: Study part of ROBOTICS module.

Damush, T. M., Kroenke, K., Bair, M. J., Wu, J., Tu, W., Krebs, E. E., & Poleshuck, E. (2016). Pain self‐management training increases self‐efficacy, self‐management behaviours and pain and depression outcomes. European Journal of Pain, 20(7), 1070-1078.
Reason for exclusion: No population of interest.

Fary, K. H. A. N., & FAFRM, M. (2017). Effectiveness of a structured sexual rehabilitation programme following stroke: A randomized controlled trial. Journal of Rehabilitation Medicine, 49, 333-340.
Reason for exclusion: Study part of SEXUALITY module.

Hackett, M. L., Carter, G., Crimmins, D., Clarke, T., Arblaster, L., Billot, L., … & Sturm, J. (2013). ImProving Outcomes after STroke (POST): results from the randomized clinical pilot trial. International Journal of Stroke, 8(8), 707-710.
Reason for exclusion: Intervention consisted of sending a post-card to patients with stroke and not provided directly by rehabilitation professionals (OT/PT/SLP, etc.).

Johansson, B., Bjuhr, H., & Rönnbäck, L. (2012). Mindfulness-based stress reduction (MBSR) improves long-term mental fatigue after stroke or traumatic brain injury. Brain Injury, 26(13-14), 1621-1628.
Reason for exclusion: Intervention not performed within a rehabilitation context; not specified whether a rehabilitation professional delivered the intervention.

Joubert, J., Reid, C., Joubert, L., Barton, D., Ruth, D., Jackson, D., & Davis, S. M. (2006). Risk factor management and depression post-stroke: the value of an integrated model of care. Journal of Clinical Neuroscience, 13(1), 84-90.
Reason for exclusion: Intervention provided by MDs, not rehabilitation professionals (OT/PT/SLP, etc.).

Jun, E. M., Roh, Y. H., & Kim, M. J. (2013). The effect of music‐movement therapy on physical and psychological states of stroke patients. Journal of Clinical Nursing, 22(1-2), 22-31.
Reason for exclusion: Study part of MUSIC-BASED INTERVENTIONS module.

Khedr, E. M., Abo El-Fetoh, N., Ali, A. M., El-Hammady, D. H., Khalifa, H., Atta, H., & Karim, A. A. (2014). Dual-hemisphere repetitive transcranial magnetic stimulation for rehabilitation of poststroke aphasia: a randomized, double-blind clinical trial. Neurorehabilitation and Neural Repair, 28(8), 740-750.
Reason for exclusion: Study part of rTMS module.

Kim, D. S., Park, Y. G., Choi, J. H., Im, S. H., Jung, K. J., Cha, Y. A., … & Yoon, Y. H. (2011). Effects of music therapy on mood in stroke patients. Yonsei Medical Journal, 52(6), 977-981.
Reason for exclusion: Study part of MUSIC-BASED INTERVENTIONS module.

Kirk, H., Kersten, P., Crawford, P., Keens, A., Ashburn, A., & Conway, J. (2014). The cardiac model of rehabilitation for reducing cardiovascular risk factors post transient ischaemic attack and stroke: a randomized controlled trial. Clinical Rehabilitation, 28(4), 339-349.
Reason for exclusion: Depression as secondary outcome.

Lempka, S. F., Malone, D. A., Hu, B., Baker, K. B., Wyant, A., Ozinga, J. G., … & Machado, A. G. (2017). Randomized clinical trial of deep brain stimulation for poststroke pain. Annals of Neurology, 81(5), 653-663.
Reason for exclusion: Study part of rTMS/BRAIN STIMULATION module.

Linder, S. M., Rosenfeldt, A. B., Bay, R. C., Sahu, K., Wolf, S. L., & Alberts, J. L. (2015). Improving quality of life and depression after stroke through telerehabilitation. American Journal of Occupational Therapy, 69(2), 6902290020p1-6902290020p10.
Reason for exclusion: Study part of ROBOTICS module.

Man, S. C., Hung, B. H., Ng, R. M., Yu, X. C., Cheung, H., Fung, M. P., … & Ziea, E. (2014). A pilot controlled trial of a combination of dense cranial electroacupuncture stimulation and body acupuncture for post-stroke depression. BMC Complementary and Alternative Medicine, 14(1), 255.
Reason for exclusion: Study part of ACUPUNCTURE module.

Mayo, N. E., Anderson, S., Barclay, R., Cameron, J. I., Desrosiers, J., Eng, J. J., … & Richards, C. L. (2015). Getting on with the rest of your life following stroke: a randomized trial of a complex intervention aimed at enhancing life participation post stroke. Clinical Rehabilitation, 29(12), 1198-1211.
Reason for exclusion: Study part of LEISURE/PARTICIPATION module.

Qian, X., Zhou, X., You, Y., Shu, S., Fang, F., Huang, S., & Zhou, S. (2015). Traditional chinese acupuncture for poststroke depression: A single-blind double-simulated randomized controlled trial. The Journal of Alternative and Complementary Medicine, 21(12), 748-753.
Reason for exclusion: Study part of ACUPUNCTURE module (excluded as both groups received a form of acupuncture treatment).

Renner, C. I., Outermans, J., Ludwig, R., Brendel, C., Kwakkel, G., & Hummelsheim, H. (2016). Group therapy task training versus individual task training during inpatient stroke rehabilitation: A randomised controlled trial. Clinical Rehabilitation, 30(7), 637-648.
Reason for exclusion: Study part of LOWER EXTREMITIES TASK-ORIENTED module.

Rochette, A., Korner-Bitensky, N., Bishop, D., Teasell, R., White, C. L., Bravo, G., … & Kapral, M. (2013). The YOU CALL–WE CALL Randomized Clinical Trial: Impact of a Multimodal Support Intervention After a Mild Stroke. Circulation: Cardiovascular Quality and Outcomes, 6(6), 674-679.
Reason for exclusion: Depression as a secondary outcome.

Sackley, C. M., Walker, M. F., Burton, C. R., Watkins, C. L., Mant, J., Roalfe, A. K., … & Fletcher-Smith, J. (2015). An occupational therapy intervention for residents with stroke related disabilities in UK care homes (OTCH): cluster randomised controlled trial. BMJ, 350, h468.
Reason for exclusion: Depression as secondary outcome.

Taricco, M., Dallolio, L., Calugi, S., Rucci, P., Fugazzaro, S., Stuart, M., … & EFG [Esercizio Fisico di Gruppo]/2009 Investigators. (2014). Impact of adapted physical activity and therapeutic patient education on functioning and quality of life in patients with postacute strokes. Neurorehabilitation and Neural Repair, 28(8), 719-728.
Reason for exclusion: Depression as a secondary outcome; not a RCT.

Thanakiatpinyo, T., Suwannatrai, S., Suwannatrai, U., Khumkaew, P., Wiwattamongkol, D., Vannabhum, M., … & Kuptniratsaikul, V. (2014). The efficacy of traditional Thai massage in decreasing spasticity in elderly stroke patients. Clinical Interventions in Aging, 9, 1311.
Reason for exclusion: Depression as a secondary outcome.

Visser, M. M., Heijenbrok-Kal, M. H., van‘t Spijker, A., Lannoo, E., Busschbach, J. J., & Ribbers, G. M. (2016). Problem-solving therapy during outpatient stroke rehabilitation improves coping and health-related quality of life: randomized controlled trial. Stroke, 47(1), 135-142.
Reason for exclusion: Depression as a secondary outcome.

Music Therapy

Evidence Reviewed as of before: 19-07-2017
Author(s)*: Tatiana Ogourtsova, PhD Candidate MSc BSc OT; Elissa Sitcoff, BA BSc; Sandy Landry, BSc OT; Virginie Bissonnette, BSc OT; Anne-Julie Laforest, BSc OT; Jolyann Lavoi, BSc OT; Valérie Parenteau, BSc OT; Annabel McDermott, OT; Nicol Korner-Bitensky, PhD OT
Patient/Family Information Table of contents

Introduction

Music interventions are used to optimize an individual’s emotional well-being, physical health, social functioning, communication abilities, and cognitive skills. This module reviews studies that incorporate music as the primary type of intervention.

Patient/Family Information

Authors*: Erica Kader; Elissa Sitcoff, BA BSc; Sandy Landry, BSc OT; Virginie Bissonnette, BSc OT; Anne-Julie Laforest, BSc OT; Jolyann Lavoi, BSc OT; Valérie Parenteau, BSc OT; Nicol Korner-Bitensky, PhD OT

What is music therapy?

Music therapy is a specific form of rehabilitation that is typically facilitated by an accredited music therapist and uses music in a variety of ways to help achieve therapeutic goals. Music therapy has been found to be helpful for people who have had a stroke. Since music is emotionally and intellectually stimulating, this form of therapy can help to maintain or improve one’s physical and mental health, quality of life, and well-being.

Are there different kinds of music therapy?

Music therapy can be provided in different forms, depending on your needs and preferences. Various ways of conducting music therapy and its benefits include:

  • Active listening – develops attention, memory, and awareness to your environment.
  • Composing/songwriting – can be a way of sharing your feelings and being able to express yourself.
  • Improvising movements to music – a creative, non-verbal way of expressing feelings. Since improvisation does not require any previous musical training anyone can participate.
  • Rhythmic movements and dancing – improves movement, speed, balance, breathing, stamina, relaxation of muscles, and walking.
  • Playing instruments – increases coordination, balance, and strength. As an example, hitting a tambourine with a stick is a good exercise to improve your hand-eye coordination and develop strength in your arms and hands. This is a great activity whether or not you have previous experience playing instruments.
  • Singing – improves communication, speech, language skills, articulation, and breathing control. Singing is particularly useful after a stroke for those who are unable to speak, because sometimes even though speech is affected, the individual is still able to sing. This happens because the speech center located in the brain is in a different location than the brain area used for singing. So, someone may have damage to the brain area responsible for speech, but no damage to the area responsible for singing.
With permission of the Music Therapy Association of British Columbia

Is music therapy offered individually or in a group?

Music therapy can be offered either way, so it is your choice. You and your music therapist can plan your music therapy sessions together. Benefits to participating in a group includes improving communication and social skills, making new friends, and the opportunity to share feelings and experiences. Playing instruments in a group can help develop cooperation and attention, as well as improve self-esteem and well-being. Composing and songwriting is another activity that works well in a group, as it allows you to communicate and work along with others. If you are not comfortable working in a group, music therapy sessions can also be offered on an individual basis. Individual sessions may lead to group sessions later on in the rehabilitation process, or the treatment plan may involve a combination of both. For people who are restricted to bed, music therapy can even be offered at their bedside with portable instruments.

Why use music therapy after a stroke?

Music therapy has the ability to help in the rehabilitation of individuals who have had a stroke. The research on the effects of this intervention is still quite new. There is some limited evidence suggesting that music therapy can help improve the movement of the arms, walking, pain perception, mood, and behaviour after stroke.

Courtesy of the Institute for Music and Neurologic Function

Do music-based treatments work in post-stroke rehabilitation?

Researchers have studied how different music-based treatments can help patients with stroke:

In individuals with ACUTE stroke (up to 1 month after stroke), studies found that:

  • Listening to music is MORE helpful than comparison treatment(s) in improving attention, memory, mood and affect. It is AS helpful as comparison treatment(s) in improving executive functions (cognitive processes that assist in managing oneself and one’s resources in order to achieve a goal), language, music cognition, quality of life, and the ability to identify visual and spatial relationships among objects.
  • Music-movement therapy is MORE helpful than comparison treatment(s) in improving mood and affect, and range of motion. It is AS helpful as comparison treatment(s) in improving functional independence in self-care activities (e.g. dressing, feeding), and muscle strength.
  • Rhythmic music interventions are MORE helpful than comparison treatment(s) in improving walking ability.

In individuals with SUBACUTE stroke (1 month to 6 months after stroke), studies found that:

  • Music training is MORE helpful than a comparison treatment in improving hand and arm function.

In individuals with CHRONIC stroke (more than 6 months after stroke), studies found that:

  • Music therapy + occupational therapy is MORE helpful than comparison treatment(s) in improving functional independence in self-care activities (e.g. dressing, feeding), quality of life, sensation, and arm function. It is AS helpful as comparison treatment(s) in improving consequences of stroke, and arm movement quality.
  • Melodic intonation therapy is AS helpful as a comparison treatment in improving language.
  • Rhythmic music interventions are MORE helpful than comparison treatment(s) in improving balance, behavior, walking ability, grip strength, interpersonal relationships, quality of life, legs range of movement, consequences of stroke, and mood and affect. They are AS helpful as comparison treatment(s) in improving cognitive functions (e.g. attention), dexterity, language, musical behavior, occupational performance, arm function, memory, and walking endurance.

In individuals with stroke (acute, subacute and/or chronic), studies found that:

  • Melodic intonation therapy is MORE helpful than a comparison treatment in improving language.
  • Music performance is AS helpful as comparison treatment(s) in improving dexterity and arm range of motion and function.
  • Rhythmic music interventions are MORE helpful than comparison treatment(s) in improving balance, and walking ability. They are AS helpful as comparison treatment(s) in improving dexterity, sensation, strength, stroke consequences, arm function and activity.

Who provides the treatment?

Many hospitals and rehabilitation centers have music therapy programs that are conducted by accredited music therapists. The music therapist will meet with you to assess your needs and discuss preferences, so that he or she can design a program specific to your needs. In some centers it may be a recreational therapist or leisure therapist who provides music therapy. Ask your health professional or family members to help you find out more about the music therapy services offered in your hospital, rehabilitation center or community.

Are there any side effects or risks?

You do not face any risks when participating in music therapy after a stroke, as long as activities are practiced in a manner that fits your abilities. Consult your physician or rehabilitation healthcare professional for the best advice on how to participate safely. This is especially important if you are going to incorporate dancing or rhythmic movements into your music sessions and have some balance difficulties. *Family members/friends: it is important to help the person who has had a stroke seek out new activities such as music therapy that may be both pleasant and therapeutic.

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.

This module reviews 24 studies that use music as a primary means of rehabilitation; of these, 12 are high quality RCTs, seven are fair quality RCTs, one is a poor quality RCT and four are non-randomized studies.

This module reviews the following types of music-based interventions:

Listening to music: Participants listening to music.

Music therapy + occupational therapy: Participants playing instruments (e.g. drums, bells, shakers, mallets, chimes, piano, harp) with the affected upper limb to encourage proximal and distal upper limb movements, with attention to positioning and movement quality.

Melodic intonation therapy: Participants singing phrases and tap to the rhythm of the phrases; this intervention has been shown to improve outcomes related to language/aphasia.

Music-movement therapy: Participants performing movements of lower and upper extremities while listening to music.

Music performance: Participants playing acoustic musical instruments and/or iPads with touchscreen musical instruments as part of fine/distal exercise.

Music training: Participants are taught to play a musical instrument.

Rhythmic music interventions: Participants performing matching upper and/or lower extremity movements or gait patters to musical rhythm.

Results Table

View results table

Outcomes

Acute phase - Listening to music

Attention
Effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on attention in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Measures of attention were taken at 3 and 6 months post-stroke, and outcomes included: (1) attention, measured by the CogniSpeed reaction time software; (2) focused attention, measured by the mental subtraction and Stroop subtests (number correct and reaction time); and (3) sustained attention, measured by the vigilance (number correct, reaction time) and simple reaction time subtests. Significant between-group differences in focused attention were found at 3 months post-stroke, favoring the music group vs. the control group. Significant between-group differences in focused attention were found at 6 months post-stroke, favoring the music group vs. the audio book group, and favoring the music group vs. the control group. There were no significant between-group differences in other measures of attention at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is more effective than comparison interventions (listening to audio books, no training) in improving focused attention in patients with acute stroke. However, no between-group differences were found on measures of attention or sustained attention.

Auditory sensory memory
Not effective
1b

One high quality RCT (Sarkamo et al., 2010) investigated the effect of music interventions on auditory sensory memory in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Auditory sensory memory was evaluated by the magnetically-measured mismatch negativity (MMNm) responses to change in sound frequency and duration from baseline to 3 and 6 months post-stroke. There were no significant differences between groups at 3 months post-stroke. At 6 months post-stroke, there were significant between-group differences in auditory sensory memory (frequency MMNm only), favoring the music group vs. the control group.
Note: Comparison of the audio book group vs. the control group revealed significant differences favoring the audio book group in frequency MMNm (left and right lesions) and duration MMNm (right lesions only) at 6 months post-stroke.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving auditory sensory memory among patients with acute stroke in the short term.
Note:
However, this high quality RCT showed that patients who listened to music demonstrated significantly better auditory sensory memory several months following treatment than patients who received conventional rehabilitation alone.

Executive function
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on executive function in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Executive function was measured by the Frontal Assessment Battery at 3 and 6 months post-stroke. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving executive function in patients with acute stroke.

Language
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on language in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Language was measured by the Finnish version of the Boston Diagnostic Aphasia Examination (word repetition, sentencing repetition, reading subtests), the CERAD battery (verbal fluency, naming subtests) and the Token Test at 3 and 6 months post-stroke. No significant between-group differences were found at either time point on any of the measures.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving language in patients with acute stroke.

Memory
Effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on memory in patients with acute stroke. This high quality RCT randomized patients to a music group that listened to music for a minimum 1 hour/day, a language group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Measures of memory were taken at 3 and 6 months post-stroke and outcomes included: (1) verbal memory, measured by the Rivermead Behavioral Memory Test (story recall subtests) and an auditory list learning task; and (2) short-term working memory, measured by the Wechsler Memory Scale – Revised (digit span subtest) and a memory interference task. Significant between-group differences in verbal memory were found at 3 months post-stroke, favoring the music group vs. the audio book group, and favoring the music group vs. the control group. Similarly, significant between-group differences in verbal memory were found at 6 months post-stroke, favoring the music group vs. the audio book group. There were no significant between-group differences in short-term working memory at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is more effective than comparison interventions (listening to audio books, no training) in improving verbal memory in patients with acute stroke. However, no between-group differences were found on measures of short-term working memory.

Mood
Effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on mood in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Mood was measured by a shortened Finnish Version of the Profile of Mood States at 3 and 6 months post-stroke. Significant between-group differences in mood (depression score only) were found at 3 months post-stroke favoring the music group vs. the control group.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is more effective than comparison interventions (listening to audio books, no training) in improving mood in patients with acute stroke.

Music cognition
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on music cognition in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Music cognition was measured by the Montreal Battery of Evaluation of Amusia (scale and rhythm subtests) at 3 months post-stroke. No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving music cognition in patients with acute stroke.

Quality of life
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on quality of life in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Quality of life was measured by the Stroke and Aphasia Quality of Life Scale – 39 (self-rated, proxy rated) at 3 and 6 months post-stroke. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (audio therapy, no training) in improving quality of life in patients with acute stroke.

Visuospatial skills
Not effective
1b

One high quality RCT (Sarkamo et al., 2008) investigated the effect of music interventions on visuospatial skills in patients with acute stroke. This high quality RCT randomized patients to a group that listened to music for a minimum 1 hour/day, a group that listened to audio books for a minimum 1 hour/day, or a control group that received no training; all groups received conventional rehabilitation for the duration of the 2-month study. Visuospatial skills were measured by the Clock Drawing Test, Figure Copying Test, Benton Visual Retention Test (short version), and Balloons Test (subtest B) at 3 and 6 months post-stroke. No significant between-group differences were found at either time point on any of the measures.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that listening to music is not more effective than comparison interventions (listening to audio books, no training) in improving visuospatial skills in patients with acute stroke.

Acute phase - Music-movement therapy

Behavioral outcomes
Effective
2b

One poor quality RCT (Jun et al., 2012) investigated the effect of music interventions on mood and affect in patients with acute stroke. This poor quality RCT randomized patients to receive music-movement therapy or no training; both groups received standard care. Behavioral outcomes were assessed according to: 1) mood measured by the Korean version of the Profile of Mood States Brief Instrument; and 2) depression, measured by the Center for Epidemiologic Studies Depression Scale at post-treatment (8 weeks). Significant between-group differences were found for mood favoring music-movement therapy vs. no training.  

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that music-movement therapy is more effective than no training in improving behavioral outcomes (mood) in patients with acute stroke.

Functional independence
Not effective
2b

One poor quality RCT (Jun et al., 2012) investigated the effect of music interventions on functional independence in patients with acute stroke. This poor quality RCT randomized patients to receive music-movement therapy or no training; both groups received standard care. Functional independence was measured by the Korean modified Barthel Index at post-treatment (8 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that music-movement therapy is not more effective than no training in improving functional independence in patients with acute stroke.

Muscle strength
Not effective
2b

One poor quality RCT (Jun et al., 2012) investigated the effect of music interventions on muscle strength in patients with acute stroke. This poor quality RCT randomized patients to receive music-movement therapy or no training; both groups received standard care. Muscle strength of the affected upper and lower extremities was measured by the Medical Research Council Scale at post-treatment (8 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that music-movement therapy is not more effective than no training in improving muscle strength in patients with acute stroke.

Range of motion
Effective
2b

One poor quality RCT (Jun et al., 2012) investigated the effect of music interventions on range of motion (ROM) in patients with acute stroke. This poor quality RCT randomized patients to receive music-movement therapy or no training; both groups received standard care. ROM of the affected side (shoulder/elbow/wrist flexion, hip/knee flexion) was measured by goniometer at post-treatment (8 weeks). Significant between-group differences in ROM were found (shoulder/elbow flexion, hip flexion), favoring music-movement therapy vs. no training.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that music-movement therapy is more effective than no training in improving range of motion of the proximal joints of patients with acute stroke.

Acute phase - Rhythmic music interventions

Gait parameters
Effective
2a

One fair quality RCT (Schneider et al., 2007) investigated the effect of music interventions on dexterity in patients with subacute stroke. This fair quality RCT randomized patients to receive music training (drum and/or piano) + conventional rehabilitation or conventional rehabilitation alone. Dexterity was measured by the Box and Block Test and the Nine Hole Peg Test at post-treatment (3 weeks). Significant between-group differences were found on both measures of dexterity, favoring music training + conventional rehabilitation vs. conventional rehabilitation alone.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that music training + conventional rehabilitation is more effective than conventional rehabilitation alone in improving dexterity in patients with subacute stroke.

Subacute phase - Music training

Dexterity
Effective
2a

One fair quality RCT (Schneider et al., 2007) investigated the effect of music interventions on dexterity in patients with subacute stroke. This fair quality RCT randomized patients to receive music training (drum and/or piano) + conventional rehabilitation or conventional rehabilitation alone. Dexterity was measured by the Box and Block Test and the Nine Hole Peg Test at post-treatment (3 weeks). Significant between-group differences were found on both measures of dexterity, favoring music training + conventional rehabilitation vs. conventional rehabilitation alone.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that music training + conventional rehabilitation is more effective than conventional rehabilitation alone in improving dexterity in patients with subacute stroke.

Upper extremity motor function
Effective
2a

One fair quality RCT (Schneider et al., 2007) investigated the effect of music interventions on upper extremity motor function in patients with subacute stroke. This fair quality RCT randomized patients to receive music training (drum and/or piano) + conventional rehabilitation or conventional rehabilitation alone.  Upper extremity motor function was measured by the Action Research Arm Test, Arm Paresis Score, and computerized hand/fingers movement analysis (velocity and frequency profile) at post-treatment (3 weeks). Significant between-group differences were found on all measures of upper extremity motor function, favoring music training + conventional rehabilitation vs. conventional rehabilitation alone.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that music training + conventional rehabilitation is more effective than conventional rehabilitation alone in improving upper extremity motor function in patients with subacute stroke.

Chronic phase - Melodic intonation therapy

Language
Not effective
1b

One high quality RCT (van Der Meulen et al., 2016), investigated the effect of music interventions on language in patients with chronic stroke. This high quality cross-over design RCT randomized patients to receive melodic intonation therapy (MIT) or no treatment. Language was measured by the Sabadel story retell task, Amsterdam-Nijmegen Everyday Language Test, Aachen Aphasia Test (naming, repetition, auditory comprehension), and MIT task (trained/untrained items) at post-treatment (6 weeks) and at follow-up (12 weeks). Significant between-group differences were found on only one measure of language (MIT task – trained items) at post-treatment favoring MIT vs. no treatment. These differences were not maintained at follow-up.
Note: When the control group crossed-over to receive the MIT treatment, no significant between-group differences were found.

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

Chronic phase - Music therapy and occupational therapy

Functional independence
Effective
2b

One quasi-experimental design study (Raghavan et al., 2016) investigated the effect of music interventions on functional independence in patients with chronic stroke. This quasi-experimental design study assigned patients to receive music therapy + occupational therapy integrated upper limb training. Functional independence was measured by the Modified Rankin Scale at baseline, post-treatment (6 weeks) and follow-up (1 year). Significant improvements were found at both time points.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that music therapy + occupational therapy integrated upper limb training is effective in improving functional independence in patients with chronic stroke.

Quality of life
Effective
2b

One quasi-experimental design study (Raghavan et al., 2016) investigated the effect of music interventions on quality of life in patients with chronic stroke. This quasi-experimental design study assigned patients to receive music therapy + occupational therapy integrated upper limb training. Quality of life was measured by the World Health Organization Well-Being Index at baseline, post-treatment (6 weeks) and follow-up (1 year). Significant improvements were found at both time points.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that music therapy + occupational therapy integrated upper limb training is effective in improving quality of life in patients with chronic stroke.

Sensation
Effective
2b

One quasi-experimental design study (Raghavan et al., 2016) investigated the effect of music interventions on sensation in patients with chronic stroke. This quasi-experimental design study assigned patients to receive music therapy + occupational therapy integrated upper limb training. Sensation was measured by the Two-Point Discrimination Test at baseline, post-treatment (6 weeks) and follow-up (1 year). Significant improvements were found at both time points.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that music therapy + occupational therapy integrated upper limb training is effective in improving sensation in patients with chronic stroke.

Stroke outcomes
Not effective
2b

One quasi-experimental design study (Raghavan et al., 2016) investigated the effect of music interventions on stroke outcomes in patients with chronic stroke. This quasi-experimental design study assigned patients to receive music therapy + occupational therapy integrated upper limb training. Stroke outcomes were measured by the Stroke Impact Scale (SIS activities of daily living, participation subscales) at baseline, post-treatment (6 weeks) and follow-up (1 year). There were no significant changes in stroke outcomes from baseline to post-treatment. There was a significant improvement on one measure (SIS – activities of daily living) from post-treatment to follow-up.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that music therapy + occupational therapy integrated upper limb training is not effective in improving stroke outcomes in patients with chronic stroke in the short term.
Note
: However, the quasi-experimental design study showed significant improvements in one measure of stroke outcomes (activities of daily living) in the long term.

Upper extremity kinematics
Not effective
2b

One quasi-experimental design studies (Raghavan et al., 2016) investigated the effect of music interventions on upper extremity kinematics in patients with chronic stroke. This quasi-experimental design study assigned patients to receive music therapy + occupational therapy integrated upper-limb training. Kinematic analysis of wrist flexion/extension was performed at baseline and at post-treatment (6 weeks). No significant changes were found.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that music therapy + occupational therapy integrated upper limb training is not effective in improving upper extremity kinematics in patients with chronic stroke.

Upper extremity motor function
Effective
2b

One quasi-experimental design studies (Raghavan et al., 2016) investigated the effect of music interventions on upper extremity motor function in patients with chronic stroke. This quasi-experimental design study assigned patients to receive music therapy + occupational therapy integrated upper-limb training. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity subscale at baseline, post-treatment (6 weeks) and 1-year follow-up. Significant improvements were found at both time points.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that music therapy + occupational therapy integrated upper limb training is effective in improving upper extremity motor function in patients with chronic stroke.

Chronic phase - Rhythmic music interventions

Balance
Effective
1a

Two high quality RCTs (Cha et al., 2014; Bunketorp-Kall et al., 2017) investigated the effect of music interventions on balance in patients with chronic stroke.

The first high quality RCT (Cha et al., 2014) randomized patients to receive rhythmic auditory stimulation (RAS) gait training or time-matched standard gait training. Balance was measured by the Berg Balance Scale (BBS) at post-treatment (6 weeks). Significant between-group differences were found, favoring RAS gait training vs. time-matched standard gait training.

The second high quality RCTs (Bunketorp-Kall et al., 2017) randomized patients to receive rhythm-and-music therapy (listening to music while performing rhythmic movements of the hands and feet), horse-riding therapy or no treatment. Balance was measured by the BBS and the Backstrand, Dahlberg and Liljenas Balance Scale (BDL-BS) at post-treatment (12 weeks) and follow-up (6 months). Significant between-group differences (BDL-BS only) were found at post-treatment and follow-up, favoring rhythm-and-music therapy vs. no treatment. There were no significant differences between rhythm-and-music therapy and horse-riding therapy at either time point on any of the measures.
Note: There was also a significant between-group difference (BBS, BDL-BS) at post-treatment, favoring horse-riding therapy vs. no treatment. These differences did not remain significant at follow-up.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that rhythmic music interventions are more effective than comparison interventions (time-matched standard gait training, no treatment) in improving balance in patients with chronic stroke.

Behavior
Effective
2b

One fair quality RCT (Raglio et al., 2016) and one quasi-experimental design study (Purdie et al., 1997) investigated the effect of music interventions on behavior in patients with chronic stroke.

The fair quality RCT (Raglio et al., 2016) randomized patients to receive music therapy (using rhythmic melodic instruments and singing) + speech language therapy or speech language therapy alone. Behavior was measured by the Big Five Observer (energy/extroversion, friendship, diligence, emotional stability, open mindedness) at post-treatment (15 weeks). Neither group demonstrated significant changes in behaviour at post-treatment.
Note: This study did not report between-group analyses so is not used to determine the level of evidence in the conclusion below.

The quasi-experimental design study (Purdie et al., 1997) randomized patients to receive music therapy (using percussion/synthesizers and singing) or no music therapy. Behavior was measured by the Behavior Rating Scale (BRS) at post-treatment (12 weeks). Significant between-group differences were found (BRS emotional stability, spontaneous interaction subscales), favoring music therapy vs. no music therapy.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that rhythmic music intervention is more effective than no music therapy in improving some aspects of behavior in patients with chronic stroke.
Note
: However, one fair quality RCT reported no significant change in behavior following rhythmic music therapy + speech language therapy.

Cognitive function
Not effective
1b

One high quality RCT (Bunketorp-Kall et al., 2017) investigated the effect of music interventions on cognitive function in patients with chronic stroke. This high quality RCT randomized patients to receive rhythm-and-music therapy (listening to music while performing rhythmic movements of the hands and feet), horse-riding therapy or no treatment. Cognitive function was measured by the Barrow Neurological Institute Screen for Higher Cerebral Functions at post-treatment (12 weeks) and follow-up (6 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that rhythmic music intervention is not more effective than comparison interventions (horse-riding therapy, no treatment) in improving cognitive function in patients with chronic stroke.

Dexterity
Not effective
2b

Two quasi-experimental design studies (Hill et al., 2011; Villeneuve et al., 2014) investigated the effect of music interventions on dexterity in patients with chronic stroke.

The first quasi-experimental design study (Hill et al., 2011) assigned patients to receive rhythm and timing training (interactive metronome training) + occupational therapy or occupational therapy alone. Dexterity was measured by the Box and Block Test at post-treatment (10 weeks). No significant between-group differences were found

The second quasi-experimental AABA design study (Villeneuve et al., 2014) assigned patients to receive music-supported therapy (using piano training). Dexterity was measured by the Box and Block Test and the Nine Hole Peg Test at post-treatment (3 weeks) and follow-up (6 weeks). Significant improvements in both measures of dexterity were found at post-treatment. No significant changes in scores were observed from post-treatment to follow-up.
Note: This study did not report between-group analyses so is not used to determine level of evidence in the conclusion below.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that rhythmic music intervention is not more effective than a comparison intervention (occupational therapy alone) in improving dexterity in patients with chronic stroke.
Note
: One quasi-experimental design study found improvements in dexterity immediately following music-supported therapy using piano training.

Gait parameters
Effective
1b

One high quality RCT (Cha et al., 2014) investigated the effect of music interventions on gait parameters in patients with chronic stroke. This high quality RCT randomized patients to receive rhythmic auditory stimulation (RAS) gait training or time-matched standard gait training. Gait parameters (gait velocity, cadence, stride length of the affected/less-affected legs, double stance period of the affected/less-affected legs) were measured by the GAITRite system at post-treatment (6 weeks). Significant between-group differences were found for all gait parameters of the affected leg and most gait parameters of the less affected leg (excluding stride length, double stance period), favoring RAS gait training vs. time-matched standard gait training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that rhythmic auditory stimulation gait training is more effective than a comparison intervention (time-matched standard gait training) in improving gait parameters in patients with chronic stroke.

Grip strength
Effective
1b

One high quality RCT (Bunketorp-Kall et al., 2017) investigated the effect of music interventions on grip strength in patients with chronic stroke. This high quality RCT randomized patients to receive rhythm-and-music therapy (listening to music while performing rhythmic movements of the hands and feet), horse-riding therapy or no treatment. Grip strength was measured by the GRIPPIT (right/left hands – max, mean and final scores) at post-treatment (12 weeks) and follow-up (6 months). Significant between-group differences were found at post-treatment (right hand max score, left hand final score), and at follow-up (left hand final score only), favoring rhythm-and-music therapy vs. no treatment. There were no significant differences between rhythm-and-music therapy and horse-riding therapy at either time point on any of the measures.
Note: There were no significant differences between horse-riding therapy and no treatment at either time point on any of the measures.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that rhythm-and-music therapy is more effective than no treatment in improving grip strength in patients with chronic stroke.

Interpersonal relationships
Effective
2a

One fair quality RCT (Jeong et al., 2007) investigated the effect of music interventions on interpersonal relationships of patients with chronic stroke. This fair quality RCT randomized patients to receive rhythmic auditory stimulation (RAS) music-movement training (using dynamic rhythmic movement and rhythm tools) or no treatment. Perception of interpersonal relationships was measured by the Relationship Change Scale at post-treatment (8 weeks). Significant between-group differences were found, favoring RAS music-movement training vs. no treatment.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that rhythmic music interventions are more effective than no treatment in improving interpersonal relationships in patients with chronic stroke.

Language
Not effective
2b

One fair quality RCT (Raglio et al., 2016) and one quasi-experimental design study (Purdie et al., 1997) investigated the effect of music interventions on language in patients with chronic stroke.

The fair quality RCT (Raglio et al., 2016) randomized patients to receive music therapy (using rhythmic melodic instruments and singing) + speech language therapy or speech language therapy alone. Language was measured by the Token Test, Boston Naming Test and Aachener Aphasie Test (picture description, spontaneous speech) at post-treatment (15 weeks). Neither group demonstrated a significant change on any measure of language at post-treatment.
Note: This study did not report between-group analyses so is not used to determine level of evidence in the conclusion below.

The quasi-experimental design study (Purdie et al., 1997) randomized patients to receive music therapy training (using percussion/synthesizers and singing) or no music therapy. Language was measured by the Frenchay Aphasia Screening Test at post-treatment (12 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that rhythmic music intervention is not more effective than no music therapy in improving language in patients with chronic stroke.
Note
: Further, one fair quality RCT reported no significant improvement in language following music therapy + speech language therapy.

Mood and affect
Effective
2a

Two fair quality RCTs (Jeong et al., 2007; Raglio et al., 2016) and one quasi-experimental design study (Purdie et al., 1997) investigated the effect of music interventions on mood and affect in patients with chronic stroke.

The first fair quality RCT (Jeong et al., 2007) randomized patients to receive rhythmic auditory stimulation (RAS) music-movement training (using dynamic rhythmic movement and rhythm tools) or no treatment. Mood and affect were measured by the Profile of Mood States at post-treatment (8 weeks). Significant between-group differences were found, favoring RAS music-movement training vs. no treatment.

The second fair quality RCT (Raglio et al., 2016) randomized patients to receive music therapy (using rhythmic melodic instruments and singing) + speech language therapy or speech language therapy alone. Mood and affect were measured by the Beck Depression Inventory at post-treatment (15 weeks). Neither group demonstrated a significant change in mood.
Note: This study did not report between-group analyses so is not used to determine level of evidence