Acupuncture

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

Introduction

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

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

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

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

Patient/Family Information

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

What is acupuncture?

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

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

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

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

Are there different kinds of acupuncture?

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

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

Why use acupuncture after a stroke?

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

Does it work for stroke?

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

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

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

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

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

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

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

What can I expect?

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

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

Side effects/risks?

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

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

Who provides the treatment?

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

How many treatments?

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

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

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

Is acupuncture for me?

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

Clinician Information

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

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

Results Table

View results table

Outcomes

Acute Phase

Balance
Not effective
1b

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

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

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

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

Cognitive function
Not effective
1a

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

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

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

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

Depression
Not effective
1b

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

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

Dexterity
Not effective
1a

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

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

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

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

Dysphagia
Effective
1b

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

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

Functional independence
Not effective
1a

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Language function
Not effective
1b

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

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

Memory
Not effective
1b

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

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

Mobility
Not effective
1b

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

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

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

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

Motor function
Conflicting
4

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

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

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

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

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

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

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

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

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

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

Motor function (lower extremity)
Not effective
1a

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

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

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

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

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

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

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

Motor function (upper extremity)
Not effective
1a

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

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

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

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

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

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

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

Range of motion
No effective
1b

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

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

Sensation
Not effective
1b

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

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

Spasticity
Conflicting
4

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

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

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

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

Strength
Not effective
1a

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

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

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

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

Stroke outcomes
Not effective
1a

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

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

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

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

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

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

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

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

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

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

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

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

Swallowing function
Effective
1a

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

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

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

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

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

Swallowing-related quality of life
Effective
1b

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

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

Unilateral spatial neglect
Not effective
1b

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

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

Walking speed
Not effective
1b

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

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

Subacute phase

Range of motion
Not effective
1b

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

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

Chronic phase

Depression
Not effective
1a

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

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

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

Functional independence
Not effective
1b

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

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

Gait parameters
Not effective
1b

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

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

Grip strength
Not effective
1b

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

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

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

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

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

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

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

Impression of improvement
Not effective
1b

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

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

Mobility
Not effective
1b

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

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

Motor function
Not effective
1a

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

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

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

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

Pain
Not effective
1b

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

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

Range of motion (upper extremity)
Not effective
1a

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

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

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

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

Spasticity (lower extermity)
Not effective
1b

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

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

Spasticity (upper extermity)
Not effective
1a

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

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

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

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

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

Walking endurance
Not effective
1b

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

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

Phase not specific to one period

Balance
Not effective
1b

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

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

Cognitive function
Effective
1b

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

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

Functional independence
Not effective
1a

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

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

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

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

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

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

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

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

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

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

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

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

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

Insomnia
Effective
1b

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

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

Joint pain
Not effective
1b

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

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

Mobility
Effective
2a

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

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

Motor function
Not effective
1a

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

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

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

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

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

Motor function (lower extremity)
Effective
1b

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

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

Motor function (upper extremity)
Not effective
1b

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

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

Range of motion
Not effective
1b

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

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

Sensation
Not effective
1b

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

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

Stroke outcomes
Not effective
1a

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

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

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

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

Swallowing function
Effective
2b

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

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

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

Aerobic Exercise – Chronic

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

Introduction

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

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

Patient/Family Information

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

What is aerobic exercise?

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

Why is exercise important after I have had a stroke?

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

Can exercise still be useful in the chronic phase?

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

How do I begin to exercise after a stroke?

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

What kind of activities should I do?

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

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




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

Can I participate in the same exercise as before?

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

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

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

Who can help me resume my exercise activities?

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

How much exercise should I do?

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

Here is a link to an online Stroke Class.

Is it effective after stroke?

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

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

Are there any side effects or risks?

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

Clinician Information

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

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

Outcomes

Activity and participation
Not effective
1b

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

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

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

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

Ambulation and transfers
Effective
1b

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

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

Attention
Insufficient evidence
5

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

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

Balance
Not effective
1a

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

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

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

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

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

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

Blood lipid profile
Effective
2b

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

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

Blood pressure
Effective
2a

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

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

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

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

Body composition
Effective
2a

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

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

Bone mineral density
Effective
1b

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

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

Carbon dioxide production
Effective
2a

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

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

Depression
Insufficient evidence
5

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

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

Disability related to mobility
Not effective
2a

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

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

Endurance
Effective
2a

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

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

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

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

Executive function
Not effective
1b

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

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

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

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

Flexibility
Effective
2a

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

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

Gait speed
Conflicting
4

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

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

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

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

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

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

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

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

Memory
Insufficient evidence
5

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

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

Mobility
Insufficient evidence
5

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

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

Motor learning
Effective
1b

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

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

Peak heart rate
Not effective
1b

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

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

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

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

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

Peak VO2
Effective
1a

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Peak volume of total exhalation
Effective
2a

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

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

Peak workload
Effective
1a

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

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

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

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

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

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

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

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

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

Perceived self-efficacy in functional mobility
Not effective
1b

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

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

Quality of life
Not effective
1b

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

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

Respiratory exchange ratio
Not effective
1b

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

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

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

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

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

Resting heart rate
Not effective
2a

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

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

Sensorimotor function
Not effective
1b

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

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

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

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

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

Stair climbing
Not effective
2a

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

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

Strength (Lower extremity)
Conflicting
4

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

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

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

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

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

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

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

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

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

Strength (Upper extremity)
Effective
2a

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

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

Submaximal VO2
Not effective
2b

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

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

Walking distance
Conflicting
4

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

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

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

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

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

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

Walking economy
Effective
2b

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

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

Walking endurance
Insufficient evidence
5

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aerobic Exercise – Subacute

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

Introduction

It has been shown that patients with stroke have been shown to have low endurance during exercise, likely due to both the event and also as a secondary reaction to forced inactivity. It is also known that there is a positive connection between aerobic capacity and functional performance (Katz-Leurer et al. 2003). This module focuses on aerobic exercise as an intervention for people who are in the sub-acute phase (1-6 months post stroke) of recovery.

Click here to view the AEROBICS 2019 Update Best Practice Recommendations.

Click here to access the CPSR 2013 Clinicians’ guide.

Click here to access the CPSR 2013 Patients’ guide.

Patient/Family Information

Authors*: Erica Kader; Adam Kagan, B.Sc.; Nathalie Serrat, BSC PT; Amanda Ischayek BSc PT; Sabrina Ianni, BSc, PT; Caroline Labelle, BSc PT; Sukhdeep Johal, Bsc PT; Monica Trozzo BSc. PT; Elissa Sitcoff, BA BSc; Nicol Korner-Bitensky, PhD OT NOTE: *The authors have no direct financial interest in any tools, tests or interventions presented in StrokEngine.

What is aerobic exercise?

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

Why is exercise important after I have had a stroke?

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

How do I begin to exercise after a stroke?

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

What kind of activities should I do?

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

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

Gardening and housework are also great forms of aerobic exercise. Try adding exercise to your daily routine, for example, parking your car further away from your destination. Any form of physical activity can be beneficial as long as it is done regularly and consistently.

When it comes to bicycling, many people find it difficult or are afraid to fall. This problem can be solved by using a stationary bicycle. Stationary bicycles are a safe and effective means of low-impact, or light, aerobic exercise, so they are a good choice for people who have had a stroke. They can also be altered to fit your individual needs.

Treadmills are also helpful for walking, providing that there is a bar to hold on to, and a way to modify speed and intensity. A treadmill is especially useful to retrain people who have had a stroke to walk again.

Can I participate in the same exercise as before?

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

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

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

Who can help me resume my exercise activities?

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

How much exercise should I do?

According to the American Heart Association, the recommended frequency of training is 3 to 7 days a week, with a duration of 20 to 60 minutes per day, depending on the patient’s level of fitness. ** Once again, however, it is very important that you seek medical advice before beginning an exercise program and get advice on how often and for how long you should be doing the activities.

Where can I participate in exercise?

While in the hospital or rehabilitation centre, you will participate in exercise programs developed and assisted by your rehabilitation team. When you are ready to go home, the team may show you how to continue with this exercise on your own, may recommend that you join an exercise program, or a combination of the two. Day centers, local community centers, and gyms in your area may be able to provide appropriate programs and support that you need.

Is it effective after stroke?

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

Are there any side effects or risks?

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

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.
Note: It is often difficult to say with absolute certainty whether a particular exercise intervention is “aerobic” in nature. In this module we include only those studies that had a clear aerobic exercise intervention. Specifically only those that included an outcome examining the effect of exercise on aerobic capacity (peak VO2, peak workload and peak heart rate during some sort of maximal aerobic test) were considered. Many of these studies also examined functional, physical and emotional outcomes and these results are included. As well, all studies to date that have examined the effect of aerobic exercise on sub-acute stroke featured a “cocktail” of different types of treatment (e.g. strength training, flexibility training as well as a strong aerobic training component) so it is important to note that the effects of these interventions may be due in part to the combination of different treatments and not the aerobic component specifically.

The studies that meet the inclusion criteria (three fair quality RCTs, one quasi-experimental study and one pilot study) suggest that a sustained exercise program containing an aerobic component provided over a period of at least 8 weeks, 3 times per week, may improve aspects of physiological function, physical function, and emotional well-being in patients with sub-acute stroke.

Outcomes

Anaerobic threshold VO2
Insufficient Evidence
5

One pre-post pilot study (Yang et al., 2007) investigated the effect of aerobic exercise on anaerobic threshold VO2 in patients with sub-acute stroke who also had a history of carotid artery disease (CAD) and remaining mild to moderate hemiparetic gait. The patients followed a program of moderate intensity treadmill training for 12 weeks. A significant pre-post improvement in anaerobic threshold VO2 was found.

Conclusion: There is insufficient evidence (level 5) that aerobic exercise has an effect on anaerobic threshold VO2 in patients with subacute stroke. However one pre-post pilot study found that aerobic exercise significantly improves anaerobic threshold VO2 in patients with sub-acute stroke.

Balance
Effective
1b

One high quality RCT (Duncan et al., 2003) studied the effect of aerobic exercise on balance in patients with sub-acute stroke. A significant improvement in balance, as measured by the Berg Balance Scale, was found in favour of the treatment group immediately following a 12-to-14 week endurance, strength, balance and upper extremity exercise program when compared to the control group who received usual care only. However no between group difference was found on functional reach.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that aerobic exercise improves some aspects of balance (but not functional reach) compared to usual care in individuals with subacute stroke. It is of note that the exercise program contained a balance component.

Blood lipid profile
Insufficient Evidence
5

One pre-post pilot study (Yang et al., 2007), investigated the effect of aerobic exercise on blood lipid profile in patients with sub-acute stroke who also had a history of carotid artery disease (CAD) and remaining mild to moderate hemiparetic gait. The patients followed a program of moderate intensity treadmill training for 12 weeks. A significant pre-post improvement in blood lipid profile was found, as indicated by a decrease in total cholesterol (TC), low density lipoprotein cholesterol (LDL), triglyceride and TC/high density lipoprotein cholesterol (HDL). As well, an increase in total HDL was found, however the increase was not significant.

Conclusion: There is insufficient evidence (level 5) that aerobic exercise has an effect on the blood lipid profile of patients with subacute stroke. However, one pre-post pilot study found that aerobic exercise improves the blood lipid profile of patients with sub-acute stroke.

Blood pressure
Not Effective
1B

One high quality RCT (Katz-Leurer et al., 2003a) studied the effect of aerobic exercise on blood pressure in patients who were in the sub-acute phase after a first stroke. No significant effect on resting or sub maximal blood pressure was found for the treatment group following an 8-week aerobic training program using a leg cycle ergometer when compared to the control group who received regular therapy only.

One pre-post pilot study (Yang et al., 2007), studied the effect of aerobic exercise on blood pressure in patients with sub-acute stroke who also had a history of carotid artery disease (CAD) and remaining mild to moderate hemiparetic gait. The patients followed a program of moderate intensity treadmill training for 12 weeks. A significant pre-post improvement in blood pressure was found, as indicated by a significant decrease in resting blood pressure and a significant increase in peak systolic blood pressure; however peak diastolic blood pressure did not change significantly.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that aerobic exercise does not improve resting or sub maximal blood pressure compared to usual care in patients with sub-acute stroke. However, one pre-post pilot study found that aerobic exercise does improve resting blood pressure as well as peak systolic (but not diastolic) blood pressure in patients with subacute stroke.

Depression
Effective*
1B

One high quality RCT (Lai et al., 2006, based on the patient group studied by Duncan et al., 2003) studied the effect of aerobic exercise on depression in patients with sub-acute stroke. A significantly better outcome in depressive symptoms, as indicated by a lower mean score on the Geriatric Depression Scale and higher mean scores on the emotional subscales of both the Medical Outcome Short Form-36 and the Stroke Impact Scale, was found in favour of the intervention group immediately following a 12-to-14 week endurance, strength, balance and upper extremity exercise program when compared to the control group who received usual care only. However, when measured at 6 months post treatment, the between group differences were no longer significant. Significantly fewer patients in the intervention group, compared to the control group, scored in the “depressed range” of the GDS (GDS score ≥ 6) at both assessment times when compared to baseline. No significant difference in antidepressant medication use was reported between groups immediately post intervention or at 6 month follow up.

Note: It should be noted that no relation was found between depressive symptoms at baseline and effect of aerobic exercise on gains in physical function, however it was found that only patients in the intervention group with depressive symptoms at baseline showed improvements in measures of quality of life (measured by the Stroke Impact Scale and Medical Outcome Short Form-36).

Conclusion: There is moderate evidence (level 1b) from one* high quality RCT that aerobic exercise improves depressive symptoms in the short term, but not the long term (6-month follow up), and also results in significantly fewer scoring in the “depressed range” on the Geriatric Depression Scale (score ≥ 6) in both the short term and the long term (6-month follow up), compared to usual care for individuals with subacute stroke.

*It is important to note that along with finding an improvement for depressive symptoms, this study also found an improvement for aerobic capacity (as per Duncan et al., 2003 ).

Endurance
Effective
1A

Three high quality RCTs (Letombe et al., 2010, Katz-Leurer et al., 2003a, Duncan et al., 2003) studied the effect of aerobic exercise on endurance in patients with subacute stroke.

The first high quality RCT (Letombe et al., 2010) found an improvement at 4 weeks (post-treatment) in exercise duration in favour of aerobic exercise + conventional therapy compared to conventional therapy alone.

The second high quality RCT (Katz-Leurer et al., 2003a) found an improvement in endurance, as indicated by a significantly longer exercise time (higher stage reached during a multi-stage test on a leg cycle ergometer), in favour of the treatment group following an 8-week aerobic training program using a leg cycle ergometer, when compared to the control group who received regular therapy only.

The third high quality RCT (Duncan et al., 2003) found an improvement in endurance, as indicated by a significant increase in exercise duration, in favour of the treatment group immediately following a 12-to-14 week endurance, strength, balance and upper extremity exercise program when compared to the control group who received usual care only.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs that aerobic exercise improves endurance compared to usual care in individuals with subacute stroke.

Functional independence
Not Effective
1B

One high quality RCT (Katz-Leurer et al., 2003a) and one fair quality RCT (Katz-Leurer & Shochina, 2007) investigated the effect of aerobic exercise on functional independence in patients with subacute stroke.

In the high quality RCT (Katz-Leurer et al., 2003a), patients were randomly assigned to one of two groups; the intervention group received regular rehabilitation therapy combined with an 8-week supervised aerobic exercise program, while the control group received regular therapy alone. No overall effect of aerobic exercise on level of functional independence was found, as indicated by a lack of significant between group difference on the Functional Independence Measure (FIM), measured at baseline and immediately post intervention.

The fair quality RCT (Katz-Leurer & Shochina, 2007) found no significant difference in Functional Independence Measure scores between a group of patients who received 8 weeks of aerobic exercise on a cycle ergometer (with a target of 30 minutes per session at 60% of HR reserve) combined with usual care and a group who received usual care only (control).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one fair quality RCT that aerobic exercise does not improve functional independence compared to usual care in patients with subacute stroke.

Independence in daily and social activities
Not Effective
1B

One high quality RCT (Letombe et al., 2010) and one fair quality RCT (Katz-Leurer et al., 2003b) investigated the effect of aerobic exercise on independence in daily and social activities for patients with subacute stroke.

The first high quality RCT (Letombe et al., 2010) randomized patients with subacute stroke to receive aerobic exercise + conventional therapy or conventional therapy alone. At 4 weeks (post-treatment), no significant differences were observed between groups on independence in daily activities as measured with the Barthel Index and the Katz ADL Scale.

In the fair fair quality RCT (Katz-Leurer et al., 2003b using the group studied in Katz-Leurer et al., 2003a) patients were randomly assigned to one of two groups; the intervention group received regular rehabilitation therapy combined with an 8-week supervised aerobic exercise program, and the control group received regular therapy alone. No overall effect of aerobic exercise on level of independence in daily and social activities was found, as indicated by a lack of significant between group difference on the Frenchay Activities Index (FAI), measured at baseline (to assess pre-stroke levels) and at 6 months post stroke. However, a significant effect was found for a subgroup of patients who had higher severity of stroke (Stroke Severity Scale [SSS] > 30 at baseline), as indicated by significantly less decline in scores on the FAI for the intervention group compared to the control group.

Conclusion: There is moderate evidence (level 1b) from one* high quality RCT and one* fair quality RCT that aerobic exercise does not improve independence in daily and social activities compared to usual care in patients with acute/subacute stroke.

*It is important to note that along with finding an effect of aerobic exercise on independence in patients with severe stroke, these studies also found an improvement in aerobic capacity (please see Katz-Leurer et al., 2003a).

Lactic acid
Insufficient Evidence
5

One pre-post pilot study (Yang et al., 2007), studied the effect of aerobic exercise on resting and peak lactic acid levels in patients with subacute stroke who also had a history of carotid artery disease (CAD) and remaining mild to moderate hemiparetic gait. The patients followed a program of moderate intensity treadmill training for 12 weeks. A significant pre-post increase in peak lactate (indicating an improvement) was found while no significant pre-post difference was noted for resting lactate.

Conclusion: There is insufficient evidence (level 5) that aerobic exercise has an effect on lactic acid in patients with sub-acute stroke. However, one pre-post pilot study found that aerobic exercise improves peak lactate but does not improve resting lactate, in patients with subacute stroke who have CAD.

Motor control (Upper and lower extremity)
Not Effective
1B

One high quality RCT (Duncan et al., 2003) studied the effect of aerobic exercise on upper and lower extremity motor control in patients with subacute stroke. No significant difference in motor control for the upper and lower extremities, as measured by the Fugl-Meyer Motor Score, was found between the treatment group immediately following a 12- to-14 week endurance, strength, balance and upper extremity exercise program and the control group who received usual care only.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that aerobic exercise does not improve upper and lower extremity motor control compared to usual care in patients with subacute stroke.

Peak heart rate
Not Effective
1B

One high quality RCT (Katz-Leurer et al., 2003a), one quasi-experimental study (Tang et al., 2008) and one pre-post pilot study (Yang et al., 2007), investigated the effect of aerobic exercise on peak heart rate in patients with subacute stroke.

One high quality RCT (Katz-Leurer et al., 2003a) studied the effect of aerobic exercise on peak heart rate in patients who had a first stroke and were in the sub-acute phase. The treatment group received regular therapy combined with an 8-week aerobic training program using a leg cycle ergometer and the control group received regular therapy only. No significant between group difference was found for peak heart rate.

The quasi-experimental study (Tang et al., 2008) found no significant difference in peak heart rate between a group of patients who received cycle ergometry sessions until discharge combined with standard rehabilitation, compared to the control group who received standard rehabilitation only.

One pre-post pilot study (Yang et al., 2007), investigated the effect of aerobic exercise on aerobic capacity in patients with sub-acute stroke who also had a history of carotid artery disease (CAD) and remaining mild to moderate hemiparetic gait. The patients followed a program of moderate intensity treadmill training for 12 weeks. A significant pre-post increase in peak heart rate during a treadmill stress test was found, indicating an improvement in aerobic capacity.

Conclusion: There is moderate evidence (level 1b) from one highquality RCTand one quasi-experimental study that aerobic exercise does not significantly increase peak heart rate compared to usual care in patients with subacute stroke. It is of note, however, that one pre-post pilot study found that aerobic exercise does significantly increase peak heart rate – indicating an improvement in aerobic capacity – in patients with subacute stroke.

Peak VO2
Effective
1A

Two high quality RCTs (Letombe et al., 2010, Duncan et al., 2003), one quasi-experimental study (Tang et al., 2008) and one pre-post pilot study (Yang et al., 2007) studied the effect of aerobic exercise on peak VO2 in patients with subacute stroke.

The first high quality RCT (Letombe et al., 2010) found a significant difference in peak VO2 during a stationary bike stress test, at 4 weeks (immediately post-treatment) in favour of aerobic focused exercise + conventional rehabilitation compared to conventional rehabilitation alone.

The second high quality RCT (Duncan et al., 2003) found a significant increase in peak VO2 during a bicycle stress test, indicating an improvement in aerobic capacity, in favour of the treatment group immediately following a 12-to-14 week endurance, strength, balance and upper extremity exercise program when compared to the control group who received usual care only.

The quasi-experimental study (Tang et al., 2008) found a trend toward improvement for peak VO2 in favour of the exercise group, who received cycle ergometry sessions until discharge combined with standard rehabilitation, compared to the control group who received standard rehabilitation only. However no significant between group differences were found.

One pre-post pilot study (Yang et al., 2007) investigated the effect of aerobic exercise on peak VO2 in patients with sub-acute stroke who also had a history of carotid artery disease (CAD) and remaining mild to moderate hemiparetic gait. The patients followed a program of moderate intensity treadmill training for 12 weeks. A significant pre-post improvement in peak VO2 during a treadmill stress test was found indicating an improvement in aerobic capacity.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that aerobic exercise significantly increases peak VO2 compared to usual care in patients with subacute stroke. In addition, one pre-post pilot study found an improvement following treatment. While one quasi-experimental study found a trend toward improvement in peak VO2 following aerobic exercise compared to the non-exercise control, no significant between-group differences were found.

Peak workload
Effective
1A

Two high quality RCTs (Letombe et al., 2010, Katz-Leurer et al., 2003a), one fair quality RCT (Katz-Leurer & Shochina, 2007) and one quasi-experimental study (Tang et al., 2008) studied the effect of aerobic exercise on peak workload in patients with subacute stroke.

The first high quality RCT (Letombe et al., 2010) found a significant increase in peak workload (Watts), at 4 weeks (immediately post-treatment), in favour of aerobic exercise combined with conventional therapy compared to conventional therapy alone.

The second high quality RCT (Katz-Leurer et al., 2003a), the treatment group received regular therapy combined with an 8-week aerobic training program using a leg cycle ergometer and the control group received regular therapy only. A significant increase in peak workload during a test on a leg cycle ergometer, indicating an improvement in aerobic capacity, was found in favour of the treatment group compared to the control group immediately following intervention.

The fair quality study by Katz-Leurer & Shochina (2007) found a significant increase in peak workload following 8 weeks of aerobic exercise on a cycle ergometer (with a target of 30 minutes per session at 60% of HR reserve) combined with usual care compared to usual care only (control).

The quasi-experimental study (Tang et al., 2008) found no significant difference in peak work rate (Watts) between a group of patients who received cycle ergometry sessions until discharge combined with standard rehabilitation, compared to the control group who received standard rehabilitation only.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs and one fair quality RCT that aerobic exercise significantly increases peak workload compared to usual care in patients with subacute stroke. However, it should be noted that one quasi-experimental study found no improvement.

Quality of life
Effective*
1B

One high quality RCT (Lai et al., 2006, using the patient population indicated in Duncan et al., 2003) studied the effect of aerobic exercise on quality of life in patients with subacute stroke. No significant difference for quality of life as measured by the Stroke Impact Scale (SIS) and the Medical Outcome Short Form-36 (SF-36) was found between the intervention group who followed a 12-to-14 week endurance, strength, balance and upper extremity exercise program, and the control group who received usual care. It was found, however, that patients in the intervention group with significant depressive symptoms at baseline showed significantly greater improvement in most of the subscales of the SIS and SF-36 when compared to the control group.

Conclusion: There is moderate evidence (level 1b) from one* high quality RCT that patients with sub-acute stroke who also have significant depressive symptoms may improve their quality of life, compared to usual care, by performing aerobic exercise.

*It is important to note that along with finding an improvement for quality of life in patients with baseline depressive symptoms, this study (based on Duncan et al., 2003) also found an improvement for aerobic capacity.

Resting heart rate
Effective
1B

One high quality RCT (Katz-Leurer et al., 2003a), one fair quality RCT (Katz-Leurer & Shochina, 2007) and one pre-post pilot study (Yang et al., 2007) studied the effect of aerobic exercise on resting heart rate in patients with subacute stroke.

The one high quality RCT (Katz-Leurer et al., 2003a) found a significant decrease in resting heart rate (indicating an improvement) in favour of the treatment group, who received regular therapy combined with an 8-week aerobic training program using a leg cycle ergometer, compared to the control group, who received regular therapy, immediately following intervention.

The fair quality RCT (Katz-Leurer & Shochina, 2007) found no significant difference in resting heart rate post intervention between a group of patients who received 8 weeks of aerobic exercise on a cycle ergometer (with a target of 30 minutes per session at 60% of HR reserve) combined with usual care and a group who received usual care only (control).

One pre-post pilot study (Yang et al., 2007) investigated the effect of aerobic exercise on resting heart rate in patients with sub-acute stroke who also had a history of carotid artery disease (CAD) and remaining mild to moderate hemiparetic gait. The patients followed a program of moderate intensity treadmill training for 12 weeks. A significant pre-post reduction in resting heart rate was found, indicating an improvement.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one pre-post pilot study that aerobic exercise improves resting heart rate compared to usual care in patients with subacute stroke. However one fair quality RCT found no improvement compared to usual care.

Stair climbing
Effective
1B

One high quality RCT (Katz-Leurer et al., 2003a) and one fair quality RCT (Katz-Leurer & Shochina, 2007) looked at the effect of aerobic exercise on stair climbing in patients with subacute stroke.

The high quality RCT (Katz-Leurer et al., 2003a) found a significant improvement in the number of stairs climbed was found for the intervention group, immediately following an 8-week aerobic training program using a leg cycle ergometer, compared to the control group who did not receive aerobic training.

The fair quality RCT by Katz-Leurer & Shochina (2007) found a significant improvement in number of stairs climbed in favour of a group of patients who received 8 weeks of aerobic exercise on a cycle ergometer (with a target of 30 minutes per session at 60% of HR reserve) combined with usual care and a group who received usual care only (control).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one fair quality RCT that aerobic exercise improves stair climbing, specifically the number of stairs climbed, compared to usual care, in patients with subacute stroke.

Strength
Not Effective
1B

One high quality RCT (Duncan et al., 2003) studied the effect of aerobic exercise on strength in patients with subacute stroke. No significant improvement in grip strength, as measured by a JAMAR dynamometer, or in ankle dorsiflexion and knee extension isometric strength, as measured by a Cybex dynamometer, was found for the treatment group who received a 12 to 14-week endurance, strength, balance and upper extremity exercise program, compared to the control group who received usual care only.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that aerobic exercise does not improve strength compared to usual care in patients with subacute stoke.

Upper extremity function
Not Effective
1B

One high quality RCT (Duncan et al., 2003) studied the effect of aerobic exercise on upper extremity function in patients with sub-acute stroke. No significant difference in upper extremity function, as measured by the Wolf Motor Function Test, was found between the treatment group immediately following a 12-to-14 week endurance, strength, balance and upper extremity exercise program and the control group who received usual care only.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that aerobic exercise does not improve upper extremity function compared to usual care in patients with subacute stroke.

Walking distance
Conflicting
4

Two high quality RCTs (Duncan et al., 2003, Katz-Leurer et al., 2003a), one fair quality RCT (Katz-Leurer & Shochina, 2007) and one quasi-experimental study (Tang et al., 2008) investigated the effect of aerobic exercise on walking distance in patients with subacute stroke.

The high quality RCT (Duncan et al., 2003) found a significant increase in 6-minute walking distance in favour of the treatment group immediately following a 12- to-14 week endurance, strength, balance and upper extremity exercise program compared to the control group who received usual care only. In contrast, a second high quality RCT (Katz-Leurer et al., 2003a) found no significant between-group difference in distance (measured by a subjective test of walking distance) immediately following an 8-week aerobic training program using a leg cycle ergometer, when compared to the control group who did not receive aerobic training.

The fair quality RCT (Katz-Leurer & Shochina, 2007) found no significant difference in walking distance post intervention between a group of patients who received 8 weeks of aerobic exercise on a cycle ergometer (with a target of 30 minutes per session at 60% of HR reserve) combined with usual care and a group who received usual care only (control).

The quasi-experimental study (Tang et al., 2008) found a trend toward improvement for patients who received 30 minutes on a cycle ergometer, 3 times per week, until discharge, compared to the control group who received standard rehabilitation only. However, no significant between group differences were found.

Conclusion: There is conflicting evidence (level 4) as to whether aerobic exercise improves walking distance, with one high quality RCT showing that aerobic exercise does improve walking distance compared to usual care, and one high quality RCT along with one fair quality RCT reporting that aerobic exercise does not improve walking distance compared to usual care. However, it is to be noted that the high quality RCT that found an improvement (Duncan et al., 2003) had a longer treatment period and included a more varied treatment intervention.

Walking speed
Conflicting
4

Two high quality RCTs (Duncan et al., 2003, Katz-Leurer et al., 2003a) and one quasi-experimental study (Tang et al., 2008) investigated the effect of aerobic exercise on walking speed in patients with subacute stroke.

The high quality RCT (Duncan et al., 2003) found a significant increase in 10-meter walking velocity in favour of the treatment group who received a 12-to-14 week endurance, strength, balance and upper extremity exercise program when compared to the control group who received usual care only. In contrast, a second high quality RCT (Katz-Leurer et al., 2003a) found no significant between-group difference in 10-m walking velocity, immediately following an 8-week aerobic training program using a leg cycle ergometer, when compared to the control group who did not receive aerobic training.

The quasi-experimental study (Tang et al., 2008) found no improvement in walking speed following 30 minutes on a cycle ergometer, 3 times per week, until discharge, compared to the control group who received standard rehabilitation only.

Conclusion: There is conflicting evidence (level 4) as to whether aerobic exercise improves walking speed, with one high quality RCT showing that aerobic exercise does improve walking speed compared to usual care, and one high quality RCT reporting that aerobic exercise does not improve walking speed compared to usual care. However, it is to be noted that the high quality RCT that found an improvement (Duncan et al., 2003) had a longer treatment period and included a more varied treatment intervention.

References

Cooke, E. V., Mares, K., Clark, A., Tallis, R. C. & Pomeroy, V. M. (2010). The effects of increased dose of exercise-based therapies to enhance motor recovery after stroke: a systematic review and meta-analysis. BMC Medicine, 8:60. Doi:10.1186/1741-7015-8-60.

Duncan P., Studenski S., Richards L., Gollub S., Lai S.M., Reker D., Perera S., Yates J., Koch V., Rigler S., & Johnson D. (2003). Randomized clinical trial of therapeutic exercise in sub-acute stroke. Stroke, 34, 2173-2180.

Katz-Leurer M., Shochina M., Carmeli E., & Friedlander Y. (2003a). The influence of early aerobic training on the functional capacity in patients with cerebrovascular accident at the subacute stage. Archives of American Journal of Physical Medicine & Rehabilitation, 84, 1609-1614.

Katz-Leurer M., Carmeli E., & Shochina M. (2003b). The effect of early aerobic training on independence six months post stroke. Journal of Clinical Rehabilitation, 17, 735-741.

Katz-Leurer M. & Shochina M. (2007). The influence of autonomic impairment on aerobic exercise outcome in stroke patients. NeuroRehabilitation, 22, 267-72.

Lai S.M., Studenski S., Richards L., Pereram S., Reker D., Rigler S., & Duncan P.W. (2006). Therapeutic exercise and depressive symptoms after stroke. Journal of the American Geriatrics Society, 54, 240-247.

Letombe, A., Cornille, C., Delahaye, H., Khaled, A., Morice, O., Tomaszewski, A., & Olivier, N. (2010). Early post-stroke physical conditioning in hemiplegic patients: A preliminary study. Annals of Physical and Rehabilitation Medicine, 53, 632–642.

Tang A, Sibley K, Thomas S, Bayley M, Richardson D, McIlroy W & Brooks D. (2008). Effects of an aerobic exercise program on aerobic capacity, spatiotemporal gait parameters, and functional capacity in subacute stroke. Neurorehabilitation & Neural Repair OnlineFirst, DOI:10.1177/1545968308326426

Yang A.L., Lee S.D., Su C.T., Wang J.L., & Lin K.L. (2007). Effects of exercise intervention on patients with stroke with prior coronary artery disease: aerobic capacity, functional ability and lipid profile: a pilot study. Journal of Rehabilitation Medicine, 39, 88-90.

Balance Training

Evidence Reviewed as of before: 09-06-2012
Author(s)*: Annabel McDermott, OT; Nicol Korner-Bitensky, PhD OT; Norine Foley, BASc; Mark Speechley, PhD; Nancy M. Salbach, PhD, PT; Maxim Ben Yakov, BSc. PT; Robert Teasell, MD
Patient/Family Information Table of contents

Introduction

Balance problems are caused by motor, sensory and cognitive impairments and are one of the most common issues after stroke. Impaired postural control contributes to difficulties with recovery of mobility and functional independence among patients with stroke. Most rehabilitation therapies aim for the restoration of balance in sitting, as well as in standing, reaching, and rising to stand.

Additional support from undergraduate students, School of Physical and Occupational Therapy, McGill University: Natasha Alloul, Julie Parent -Taillon, Nadia Boule-Laghzali, Genevieve Larivee, Ang Li, Zahra Adl-Zarabi, Michael Dyck

Patient/Family Information

Author: Maxim Ben Yakov, BSc. PT

What is balance training?

To sit and to walk safely you need to have good balance. Balance training focuses on practicing and improving the body’s ability to perform coordinated movement (of arms and legs) while maintaining a balanced posture, i.e. without falling, stumbling, or feeling wobbly. This is usually achieved through rehearsal of tasks, such as reaching for objects while holding the body straight. Training in sitting and standing should be initiated as soon as possible after a stroke, as these are basic, necessary tasks in daily life.

Why train balance after a stroke?

Balance is a basic requirement for active, independent, and safe movement of our bodies in daily life. Before your stroke, you probably balanced your body when sitting and standing automatically, without thinking about it. After a stroke, you may have balance problems that require you to concentrate a great deal to do simple things, such as putting on your socks, or standing at a sink to brush your teeth. Even people who experience only small problems with balance may have difficulty when walking outside on uneven ground or when crossing the street.

Are there different kinds of balance training?

Yes, there are different ways to retrain balance after a stroke.

  • Functional balance training: Recently, balance training has been focusing more on functional, task-specific training. In functional training, the individual who has had a stroke works on typical tasks that people perform in their daily lives, such as reaching into a cupboard for a cup or plate, or trying to carry a grocery bag.
  • Body weight support: After a stroke, some individuals are too weak and have difficulty sitting, standing, or walking in therapy. If this is the case, your body weight may be supported while you stand or walk either  by your therapist or by a body harness.
  • Hydrotherapy: Sometimes, balance training is done in a therapeutic pool, using a technique called Hydrotherapy. Water makes your limbs lighter, since you are not moving against gravity. Water also provides support and stimulation so that you can work on your balance in a safe environment. Your therapist will usually work in the water with you to make sure that you are well supported and safe.
  • Proprioception training: Balance training can also include something called proprioception training, which can help you to be aware of where your arms and legs are in space. For example, after a stroke some people have difficulty knowing where their hand is when their eyes are closed. Proprioception is important to achieve proper balance, and the good news is that as we work on improving balance, we are training proprioception as well.Other types of balance training you might hear about are:“Bobath approach”: Bobath was a physiotherapist who developed a treatment approach that analyzes and interprets how you move after your stroke. After a stroke, many people move in a way that is different from before. Your therapist will work on training and modifying your movements to help you accomplish daily tasks. Usually a therapist will guide your arms, legs or trunk through the correct movements so that you can re-learn to do the activities correctly.“Visual feedback” or “Biofeedback for trunk control”: This technique uses a mirror in front of you or a video camera system to track your body, arms, or legs while doing activities like catching a ball or placing objects on a shelf. This allows you to see how you are moving so that you can try to correct your movements.

    “Vision-deprived training”: With your eyes covered, your therapist will help you do activities like standing on one or both legs, trying to sit on a pillow, or simply getting up from a chair and sitting down. This challenges your balance more than when your eyes are open. This is an activity you should try doing as you get better.

    “Independent practice”: You can work on your balance on your own. For example, during your independent exercise, you could have as a goal to stand on both legs with equal weight, or to try and sit on both buttocks with equal pressure.

    NOTE: You should only try this once your therapist tells you that it is safe for you to do so.

    “Balance biofeedback:”

    After a stroke, it is typical to put more weight on your “good” leg when you are standing. However, it is important that you also put weight on your weaker leg. While you are standing, your therapist will use a computer screen with a special mat that will sense how much pressure goes through each foot. The amount of weight put through your weaker leg will then be recorded and will show up on the computer screen. Training in this way gives you immediate feedback about how well you are doing. At first, the goal may be to increase the amount of weight you put on your weaker leg. Next, it may be to put an equal amount of weight on both legs while standing. Eventually, you may try to put more weight on your weaker leg. This is important because as we walk, we need to put our body weight through one leg at a time.

    “Perceptual training”:

    This technique focuses on training the awareness of your arms, legs, and trunk in space. For example you might be asked to touch your knee and then your forehead while your eyes are closed.

    “Multisensorial Training”:

    Following a stroke, you may become overly reliant on visual cues to help maintain your balance. Multisensorial training is a form of rehabilitation conducted while restricting the amount that you see. It focuses on the amount and intensity of your movements and exercise without placing emphasis on how well you perform them.

Does balance training work after a stroke?

Researchers have done experiments to see if balance training helps people who have had a stroke.

  • Task-oriented interventions: One high quality study looked at task-oriented interventions for walking. The results showed that this treatment can improve a person’s confidence in balance.
  • Perceptual exercises: After a stroke, it is common to have more body sway, and this makes you more unsteady on your feet. In one high quality study, results showed that perceptual exercises reduced the amount of body sway. NOTE: Even without a stroke, everyone has a certain normal amount of body sway that we are not aware of.
  • Bobath Therapy Approach: One high quality study showed that the Bobath approach did not improve independence in normal daily living, sitting balance, standing balance, or the amount of weight put on the weaker leg.
  • Task-specific reaching training: One high quality study found that task-specific reaching does not improve how evenly you distribute your body weight through both buttocks when sitting. The same study results showed that such training does not improve how equally you put your body weight through both feet while standing.
  • Independent-practice training: There is limited research from one fair quality study that showed that when independent-practice training is combined with therapy based on the Bobath approach it does not improve balance after a stroke.
  • Visual feedback training: There is limited research based on two fair quality studies suggesting that visual feedback training does not result in improvements in balance. It is worth noting that one study did find important gains in the ability to perform self-care activities (such as washing, toileting, dressing, and grooming).
  • Balance biofeedback training: There are conflicting findings in this area. Three fair quality studies found no real gains in balance after using this training method. In contrast, two high quality studies on balance biofeedback training found that balance did improve after a stroke. Another high quality study demonstrated that biofeedback for trunk control training can improve significantly standing balance (not when walking or reaching).
  • Multisensorial Training: One high quality study found that multisensorial training (a form of therapy conducted while restricting what you see and focusing on the amount and intensity of movement and exercise) is not more effective than neurodevelopmental therapy (a form of therapy which focuses on quality of movement and exercise) in improving standing balance. However, it is more effective at improving your balance when walking and moving around, as well as increasing independence in functional activities and improving quality of life.

Side effects/risks?

Balance is important to prevent you from falling. During balance training, you should always be supervised by an individual who knows about practicing balance training safely. Eventually, you will probably begin practicing balance exercises with your family or friends. Before you do so, your therapist should show them safe ways of working with you.

Who provides the treatment?

Balance training should be performed or supervised by a trained health professional. A variety of health professionals provide balance training as part of their treatment, including occupational therapists, physical therapists, and exercise therapists.

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.

Of the 42 studies included in this module that have investigated interventions to improve balance post-stroke, 25 are high quality randomized controlled trials. Interventions reviewed in this module include aquatic therapy, Bobath therapy, force platform or mechanical balance training devices, multisensory training, perceptual exercises, task-specific exercises, trunk exercises, vibration therapy and virtual reality. Although a majority of the studies demonstrated a positive benefit of balance training, the heterogeneity of intervention and outcomes measures does not allow us to make definite conclusions regarding any one most efficacious intervention method for balance re-training post-stroke.

Lubetzky-Vilnai & Kartin (2010) conducted a systematic review of recent studies on balance training interventions that comprised 22 RCTs, pilot studies and case series from January 2006 to February 2010. Comparison among studies was limited by diversity in balance training interventions (type, duration, intensity and progression), control interventions (conventional physiotherapy, standard interdisciplinary care, conventional gait training, patient-initiated training, body-weight supported training, standard rehabilitation and neurodevelopmental treatment) and outcomes measured. Most studies reported that balance training programs were not more effective than control therapies as both experimental and control groups demonstrated improved balance following intervention.

An & Shaughnessy (2011) conducted a systematic review of exercise interventions used to improve balance and/or gait following stroke. The authors reviewed 17 English-language RCTs published from 2001 to January 2010, 10 of which included balance as an outcome (5 of these were also included in the 2010 systematic review by Lubetzky-Vilnai & Kartin). This systematic review concluded that multisensory programs do not seem to be effective in improving balance following stroke. However, early initiation of exercise after stroke was reported to be effective in improving balance, and aerobic exercise was positively associated with improved balance in subacute and chronic stroke. The systematic review concluded that exercise performed for at least 20-60 minutes, 3-4 times a week for 6-12 weeks can improve balance following stroke.

Results Table

View results table

Outcomes

Aquatic therapy
Effective
2A

One fair quality RCT (Noh et al., 2008) has investigated the effectiveness of aquatic therapy in improving balance in patients with stroke.

The fair quality RCT (Noh et al., 2008) randomized patients with chronic stroke and unilateral limb weakness to an aquatic therapy program or a conventional gym exercise program. At one month post-treatment there were significant between-group differences, with those in the aquatic group having better balance (Berg Balance Scale) and weight-bearing ability on the affected side (vertical ground reaction force during forward and backward weight-shift). There was no significant group difference in weight-bearing ability during sit-to-stand or lateral weight-shift.

Conclusion: There is limited evidence (level 2a) from 1 fair quality RCT that aquatic therapy is more effective than a gym exercise program for improving balance, forward/backward weight shift and knee flexor strength of the affected limb in patients with stroke.

Note: however, the fair quality RCT found no significant difference between groups in weight shift during lateral movements and when rising from a chair, or strength of knee extensor and trunk muscles.

Bobath therapy
Effective
2a

One fair quality RCT (Mudie et al., 2002) has investigated the use of the Bobath approach in improving balance following stroke.

The fair quality study (Mudie et al., 2002) randomly assigned patients with acute stroke to one of four treatment groups: (1) task-specific reaching; (2) Bobath therapy interventions; (3) BPM biofeedback interventions; or (4) conventional physiotherapy and occupational therapy (control). The Bobath group demonstrated a significant improvement in seated symmetry of weight distribution at post-treatment (2 weeks), although results did not remain significant at follow-up time point (12 weeks). At 12 weeks post-study 29% of the Bobath group were able to distribute weight to both sides, in comparison to the BPM group (83%), task-specific group (38%) and the control group (0%).

Conclusion: There is limited evidence (level 2a) from 1 fair quality RCT that Bobath therapy is effective for improving balance (seated weight distribution) following stroke. However, between-group differences were not reported.

Cycling training
Effective
1B

One high quality RCT (Katz-Leurer et al., 2006) has investigated the effectiveness of cycling training in improving balance in patients with stroke.

The high quality RCT (Katz-Leurer et al., 2006) randomized patients with subacute stroke to receive cycling training and conventional rehabilitation or conventional rehabilitation training alone. At post-treatment (6 weeks) there were significant group-time interactions in favour of the cycling group compared to the control group for balance on the Postural Assessment Scale for Stroke Patients total, static and dynamic scores. However, no significant between-group differences were seen for standing balance as measured using the Standing Balance Test.

Conclusion: There is moderate evidence (level 1b) from 1 high quality RCT that cycling training is more effective than conventional rehabilitation alone for improving balance in patients with stroke.

Note: However, the high quality RCT showed no significant between-group differences on the Standing Balance test.

Force platform training
Effective
1a

Two high quality RCTs (Sackley & Lincoln, 1997; Cheng et al., 2001), 6 fair quality RCTs (Shumway-Cook et al., 1988;Wong et al., 1997; Grant et al., 1997; Walker et al., 2000; Chen et al., 2002; Mudie et al., 2002) and 1 poor quality RCT (Geiger et al., 2001) have investigated the effect of force platform biofeedback training on balance following stroke.

The first high quality RCT (Sackley & Lincoln, 1997) randomized patients with subacute or chronic stroke to receive balance training using the Nottingham Balance Platform with visual feedback regarding weight distribution and weight shift activity, or a placebo balance intervention. Balance measures were taken at baseline, 4 weeks (post-treatment) and 12 weeks (follow-up) using assessment of stance symmetry and sway. Significant between-group differences were seen in favour of the treatment group compared to the placebo group for stance symmetry at post-treatment, but these differences did not remain significant at follow-up. There were no significant differences in sway.

The second high quality RCT (Cheng et al., 2001) assigned patients with hemiplegia following stroke to balance training using a dual force platform standing biofeedback trainer with visual and auditory feedback, or conventional physical therapy. Significant between-group differences were noted in favour of the force platform group compared to the control group on balance measures of mediolateral sway, rate of rise in force when rising from a chair, and frequency of falls post-stroke. There were no significant between-group differences in sit-to-stand or stand-to-sit performance at post-treatment, but at 6-month follow-up a significant difference in sit-to-stand performance was reported in favour of the force platform group compared to the control group.

The first fair quality RCT (Shumway-Cook et al., 1988) randomly assigned individuals with subacute stroke to standing balance retraining using a static force platform biofeedback device, or standing balance training without biofeedback. A significant between-group difference in lateral sway displacement was reported in favour of the force platform group compared to the control group. There was no significant difference in total sway area between groups.

The second fair quality RCT (Wong et al., 1997) randomised patients with acute stroke to training using a Standing Biofeedback Training (SBT) device that provides real-time visual and auditory weight bearing biofeedback, or a Standing Training Table (STT) worktable. Significant between-group differences in postural symmetry were seen at week 1, week 2 and week 4, in favour of the SBT group compared to the STT group. Note: significant between-group differences in postural symmetry were not seen at day 1 or week 3.

The third fair quality RCT (Grant et al., 1997) reported preliminary findings from a study by Walker et al., 2000 (see below), whereby 16 patients with stroke were randomly assigned to visual biofeedback balance training and physiotherapy, or standard balance training and physiotherapy. No significant differences were noted on measures of balance (Berg Balance Scale, postural sway, standing symmetry).

The fourth fair quality RCT (Walker et al., 2000) randomly assigned 54 patients with stroke to one of three treatment groups: (1) balance training using the dual force platform Balance Master with visual feedback and conventional physiotherapy and occupational therapy; (2) ‘standard’ balance training and conventional physiotherapy and occupational therapy; or (3) conventional physiotherapy and occupational therapy alone. There were no significant differences on measures of balance (Berg Balance Scale, postural sway) when comparing either intervention group with the control group.

The fifth fair quality RCT (Chen et al., 2002) randomly assigned patients with stroke to balance training using the Smart Balance Master with visual feedback in combination with conventional physical and occupational therapy, or physical and occupational therapy alone. Significant differences were observed between groups on one of three measures of static balance (absence of sway but not maximum stability or center of gravity alignment) and all three measures of dynamic balance (axis velocity, directional control, end-point excursion).

The sixth fair quality RCT (Mudie et al., 2002) randomly assigned individuals with recent stroke to one of four treatment groups: (1) task-specific reaching; (2) Bobath therapy interventions; (3) Balance Performance Monitor (BPM) weight-distribution training in sitting and standing with visual feedback; or (4) conventional physiotherapy and occupational therapy (control). The BPM group demonstrated a significant improvement in seated symmetry of weight distribution at post-treatment (2 weeks) but these results did not remain significant at follow-up time points (4 weeks, 12 weeks). At 12 weeks post-study 83% of the BPM group was distributing weight to both sides, as compared to 38% of the task-specific reaching group, 29% of the Bobath group and 0% of the control group. The BPM group also demonstrated some generalization of symmetry training in sitting to standing.

The poor quality study (Geiger et al., 2001) assigned patients with stroke to balance training using the forceplate Neurocom Balance Master with visual feedback, or regular balance training. There were no significant differences in balance (Berg Balance Scale) at post-treatment (4 weeks).

Conclusion: There is strong evidence (level 1a) from 2 high quality RCTs and 3 fair quality RCTs that force platform biofeedback training is more effective than control therapies for improving balance (e.g. symmetry, mediolateral sway, dynamic balance, frequency of falls) following stroke.

Note: However, numerous studies reported that force platform biofeedback training was not more effective than control therapies for improving other measures of balance (e.g. Berg Balance Scale, postural sway, seated weight-distribution).

Independent practice
Not Effective
2A

One fair quality RCT (Pollock et al. 2002) has investigated the efficacy of independent-practice training for improving balance post-stroke.

The fair quality RCT (Pollock et al. 2002) randomly assigned patient with stroke to 1 of 2 treatment groups: (1) Independent practice with balance-focused exercise in combination with conventional therapy; or (2) conventional therapy alone (control). No significant difference was found between groups. It was concluded that performance of postural control and weight distribution did not increase for individuals in either group post-stroke.

Conclusion: There is limited evidence (level 2a) from 1 fair quality study that independent-practice training with conventional therapy is not more effective than conventional therapy alone for improving balance post-stroke.

Mechanical balance training devices
Not Effective
1b

One high quality RCT (Goljar et al., 2010) and one controlled clinical trial (Byun et al., 2011) have investigated the effect of a mechanical balance training device on balance in patients with stroke.

The high quality RCT (Goljar et al., 2010) randomized patients with subacute or chronic stroke to receive physiotherapy and balance training using a mechanical device, or physiotherapy and conventional balance training. There was no significant between-group difference in balance (Berg Balance Scale; one-leg standing) at post-treatment.

The controlled clinical trial (non-randomized crossover design) (Byun et al., 2011) divided patients with chronic stroke into two groups to receive conventional rehabilitation in addition to balance training using a sliding rehabilitation machine for 2 weeks (experimental period), preceded (group B) or followed (group A) by 2 weeks of conventional rehabilitation alone (control period). There was a significant difference in favour of the experimental period as compared to the control period in improving balance (Berg Balance Scale).

Conclusion: There is moderate evidence (level 1b) from 1 high quality RCT that a mechanical balance training device is not more effective than physiotherapy and conventional training for improving balance among patients with subacute and chronic stroke.

Note: However, 1 controlled clinical trial found that a balance trainer (sliding rehabilitation machine) is more effective than conventional rehabilitation alone in improving balance among patients with chronic stroke. Variations in the type of mechanical balance training devices used may account for differences in results between studies.

Multisensory training
Effective
1B

Two high quality RCTs (Yelnik et al., 2008; Gok et al., 2008), one fair quality RCT (Bayouk et al., 2006) and one poor quality RCT(Onigbinde et al., 2009) have investigated the use of multisensorial training on balance in patients with stroke.

The first high quality RCT (Yelnik et al., 2008) randomised patients with subacute and chronic stroke to receive multisensorial therapy or neurodevelopmental therapy (control group). No significant between-group differences in balance (Berg Balance Scale*; self reported perception of security) were seen at post treatment (30 days) or follow-up (60 days). However, a significant between-group difference in dynamic balance (percentage of double-limb stance time) was seen at follow-up, in favour of the multisensorial group compared to the control group.

*Note: Differences in standing balance may not have been detected due to the ceiling effect of the Berg Balance Scale. The authors also questioned the clinical meaning of the improvements to the patients due to the small values.

The second high quality RCT (Gok et al., 2008) randomized patients with chronic stroke to receive balance training using a kinaesthetic ability training (KAT) device and conventional rehabilitation, or conventional rehabilitation alone. The KAT device held a centrally-pivoted balance platform with a pressure bladder that allowed adjustments in weight shift in response to visual feedback. At 4 weeks (post-treatment) the KAT group showed significantly greater improvement in balance (Fugl-Meyer Stroke Assessment [FMA] balance subscore; KAT static and dynamic balance indices) than the control group.

The fair quality RCT (Bayouk et al., 2006) randomised hemiparetic patients with chronic stroke to a task-oriented exercise program with manipulation of sensory input (eyes open/closed; soft/firm surface) or a task-oriented program under normal conditions. Outcomes were taken as a measure of the center of pressure (COP) displacement during double-legged stance and sit-to-stand with eyes open or closed and on normal or soft surfaces, as well as the 10-m walking test. Although between-group differences were not reported*, a significant difference in pre- and post-test balance (COP displacement during double-leg stance with eyes open on normal and soft surfaces) was seen for the experimental group but not the control group. Both groups demonstrated a significant difference in pre- and post-test results in other balance measures (COP displacement during sit-to-stand with eyes open on a soft surface) and walking speed (10-m walking test).

*Note: as between-group differences are not reported, this study is not used to determine level of evidence regarding the effectiveness of multisensorial training in the conclusion below.

The poor quality RCT (Onigbinde et al., 2009) randomised patients with stroke (time since stroke not specified) to perform wobble board exercises with visual feedback and conventional physiotherapy, or conventional physiotherapy alone. At post-treatment (6 weeks) there were significant between-group differences in static balance (eyes closed) and dynamic balance (Four Square Step Test time), in favour of the experimental group compared to the control group. There were no significant between-group differences in static balance (eyes open) at post-treatment.

Conclusion: There is moderate evidence (level 1b) from 1 high quality RCT and 1 poor quality RCT that multisensorial training is more effective than conventional rehabilitation for improving balance following stroke. One fair quality RCT also reported a significant improvement in balance following multisensory training.

Note: One high quality RCT reported no significant difference in balance between multisensory training and conventional rehabilitation, although noted a potential ceiling effect of the instrument used to measure balance (Berg Balance Scale). The same RCT saw a significant between-group difference in dynamic balance at follow-up (but not at post-treatment), in favour of the multisensorial training group.

Perceptual exercises
Effective
1B

One high quality RCT (Morioka et al. 2003) has investigated the use of perceptual training for balance retraining post-stroke.

The high quality RCT (Morioka et al., 2003) randomly assigned patients with stroke to receive rehabilitation including perceptual learning exercises or standard rehabilitation (control). Significant improvements were reported in the length, the enveloped area and the rectangular area of the parameter of postural sway in the group receiving the perceptual exercises compared to the control group.

Conclusion: There is moderate evidence (level 1b) from 1 high quality RCT that perceptual exercises are more effective than standard rehabilitation for improving balance measures post-stroke.

Speed-dependent treadmill training
Not Effective
1B

One high quality RCT (Lau et al., 2011) has investigated the use of speed-dependent treadmill training for improving balance following stroke.

The high quality RCT (Lau et al., 2011) randomised patients with subacute stroke to a speed-dependent treadmill training group or a steady-speed treadmill training group. At post-treatment (10 x 30-minute sessions) there was no significant between-group difference in balance (Berg Balance Scale).

Conclusion: There is moderate evidence (level 1b) from 1 high quality RCT that speed-dependent treadmill training is not more effective than steady-speed treadmill training for improving balance following stroke.

Standing practice
Not Effective
1b

One high quality RCT (Allison & Dennett, 2007) has investigated the effectiveness of standing practice to improve balance among patients with stroke.

The high quality RCT (Allison & Dennett, 2007) randomized patients with acute or subacute stroke to receive standing practice and conventional physiotherapy or physiotherapy alone. There were no significant between-group differences in balance or trunk control (Berg Balance Scale; Trunk Control Test; Rivermead Motor Assessment – Gross Functional Tool Section) at weeks 1, 2 or 12.

Note: However, a significant difference in change in Berg Balance Scale scores from week 1 to week 12 was seen in favour of the standing practice group compared to the control group.

Conclusion: There is moderate evidence (level 1b) from 1 high quality RCT that standing practice is not more effective than conventional physiotherapy alone for improving balance and trunk control in patients with acute or subacute stroke.

Tai chi
Effective
1B

One high quality RCT (Au-Yeung et al., 2009) has investigated the effect of tai chi on balance in patients with stroke.

The high quality RCT (Au-Yeung et al., 2009) randomized patients with chronic stroke to a tai chi group or a control group that performed general exercises for breathing, stretching, mobilization, memory and reasoning. Dynamic standing balance was measured by center of gravity (COG) excursion during self-initiated body leaning forward, backward and towards the affected and non-affected sides using the Limit of Stability test; and standing equilibrium was measured by the Sensory Organization test. A significant between-group difference was seen in COG excursion amplitude when leaning forward, backward and toward the nonaffected side from week 6 (mid-treatment), and also toward the affected side from week 12 (post-treatment), in favour of the tai chi group compared to the control group. These results were maintained at 18 weeks (follow-up). A significant between-group difference in reaction time during voluntary weight shift towards the non-affected side was seen at 12 weeks and 18 weeks in favour of the tai chi group compared to the control group. There was a significant difference in standing equilibrium with vestibular input at 12 weeks (post-treatment), in favour of the tai chi group compared to the control group.

Conclusion: There is moderate evidence (level 1b) from 1 high quality RCT that tai chi is more effective than regular exercises for improving balance in patients with chronic stroke.

Task-oriented walking
Not Effective
1A

Five high quality RCTs (Richards et al., 1993; McClellan & Ada, 2004; Salbach et al., 2004 and Salbach et al., 2005; Marigold et al., 2005; Outermans et al., 2010), 1 fair quality RCT (Dean et al., 2000) and 1 quasi-experimental study (Rose et al., 2011) have investigated the use of task-oriented interventions targeting walking for balance retraining post-stroke.

The first high quality RCT (Richards et al., 1993) randomised patients with acute stroke to receive intensive gait-focused task-oriented physical therapy, or one of two control groups that received different intensities of standard physical therapy. No significant difference in balance (Berg Balance Scale, Fugl Meyer Assessment balance subscale) was seen between groups at 6 weeks (post-treatment) or 3 months (follow-up).

The second high quality RCT (McClellan & Ada, 2004) randomised patients with chronic stroke to receive home-based task-oriented mobility training or home-based task-oriented upper extremity training exercises. There was a significant between-group difference in standing balance (Functional Reach Test) at 6 weeks (post-treatment) and at 2-month follow-up, in favour of the task-oriented mobility group compared to the task-oriented upper extremity group.

The third high quality RCT (Salbach et al., 2004; Salbach et al., 2005) randomised patients with subacute or chronic stroke to receive task-oriented mobility training or task-oriented upper extremity training. There was a significant between-group difference in balance confidence (Activities-specific Balance Confidence scale), but not balance (Berg Balance Scale) at 6 weeks (post-treatment), in favour of the task-oriented mobility group compared to the task-oriented upper extremity group.

The fourth high quality RCT (Marigold et al., 2005) randomised patients with chronic stroke to receive a task-oriented mobility training program or a program that emphasized slow stretching and weight-shift. No significant differences in balance (Berg Balance Scale), balance confidence (Activities-specific Balance Confidence Scale) or falls (unforced falls during reaching transferring; induced falls during platform translation) were seen at 10 weeks (post-treatment) or 1-month follow-up.

The fifth high quality RCT (Outermans et al., 2010) randomised patients with subacute stroke to receive high intensity task-oriented mobility training or low intensity standard therapy. No significant between-group differences in balance (Berg Balance Test; Functional Reach Test) were seen at 4 weeks (post-treatment).

The fair quality RCT (Dean et al., 2000) randomised patients with chronic stroke and residual hemiplegia to receive task-oriented mobility training or task-oriented upper extremity training. A significant between-group difference in balance during stepping (Step Test) was seen in favour of the task-oriented mobility group compared to the upper extremity group at 4 weeks (post-treatment) and 2 months (follow-up).

The quasi-experimental study (Rose et al., 2011) assigned patients with acute stroke to receive task-oriented mobility training or conventional rehabilitation. No significant between-group difference in balance (Berg Balance Scale) was seen at hospital discharge (post-treatment).

Conclusion 1 (balance): There is strong evidence (level 1a) from 4 high quality RCTs and 1 quasi-experimental study that task-oriented mobility training is not more effective than control therapies (conventional rehabilitation, physiotherapy) for improving balance following stroke.

Note: however, 1 high quality RCT found a significant difference in standing balance, and 1 fair quality RCT found a significant difference in stepping balance, in favour of task-oriented mobility training compared to control therapies.

Conclusion 2 (balance confidence): There is conflicting evidence (level 4) between 2 high quality RCTs regarding the effectiveness of task-oriented mobility training for improving balance confidence following stroke.

One fair quality RCT (Mudie et al. 2002) has investigated the use of task-specific reaching for balance retraining post-stroke.

The fair quality RCT (Mudie et al., 2002) randomly assigned patients with recent stroke to one of four treatment groups: (1) task-specific reaching; (2) Bobath therapy interventions; (3) BPM biofeedback interventions; or (4) conventional physiotherapy and occupational therapy (control). The task-specific reaching group did not demonstrate a significant improvement in seated weight distribution at post-treatment (2 weeks) or follow-up time points (4 weeks, 12 weeks), whereas all other groups demonstrated significantly improved sitting symmetry at post-treatment. At 12 weeks post-study, 38% of the task-specific reaching group were distributing weight to both sides, as compared to 83% of the BPM group, 29% of the Bobath group and 0% of the conventional therapy group.

Conclusion: There is limited evidence (level 2a) from 1 fair quality RCT that task specific reaching is not effective for improving balance post-stroke. However, between-group differences were not reported.

Task-specific reaching
Not Effective
2A

One fair quality RCT (Mudie et al. 2002) has investigated the use of task-specific reaching for balance retraining post-stroke.

The fair quality RCT (Mudie et al., 2002) randomly assigned patients with recent stroke to one of four treatment groups: (1) task-specific reaching; (2) Bobath therapy interventions; (3) BPM biofeedback interventions; or (4) conventional physiotherapy and occupational therapy (control). The task-specific reaching group did not demonstrate a significant improvement in seated weight distribution at post-treatment (2 weeks) or follow-up time points (4 weeks, 12 weeks), whereas all other groups demonstrated significantly improved sitting symmetry at post-treatment. At 12 weeks post-study, 38% of the task-specific reaching group were distributing weight to both sides, as compared to 83% of the BPM group, 29% of the Bobath group and 0% of the conventional therapy group.

Conclusion: There is limited evidence (level 2a) from 1 fair quality RCT that task specific reaching is not effective for improving balance post-stroke. However, between-group differences were not reported.

Thermal therapy
Not Effective
1B

One high quality RCT