Circuit Training

Evidence Reviewed as of before: 08-07-2020
Author(s)*: Annabel McDermott, OT; Nicol Korner-Bitensky, PhD OT; Shawn Aitken, OT
Content consistency: Gabriel Plumier
Patient/Family Information Table of contents

Introduction

Circuit training, also referred to as circuit therapy and circuit class therapy, comprises repetitive practice of task-specific exercises and activities. Participants typically perform progressive functional exercises as a series of workstations or individualized exercises. Circuit training commonly addresses goals relating to improved mobility and/or use of the affected upper extremity. Circuit training can be performed individually or in a group setting (at least 2 participants per therapist). The group format is believed to be advantageous as it allows participants to observe others completing similar movements or exercises, and the social element may also aide compliance (English & Hillier, 2010).

Patient/Family Information

What is circuit training?

Circuit training is a form of training that uses repetitive exercises based on real-life activities. Exercises are performed in a ‘circuit’ of workstations or as a series of individual movements. Circuit training exercises are used to improve physical abilities such as balance, strength, mobility or coordination. Circuit training can be done in small groups or one-to-one.

Why use circuit training after a stroke?

It is common to need rehabilitation after a stroke. Circuit training can be used as well as, or instead of, traditional rehabilitation to improve physical abilities. Circuit training can be used at all stages of stroke recovery – from the acute phase (approximately 1 month after the stroke) through to the chronic phase (6 or more months post-stroke). Your rehabilitation specialist can choose activities that suit your stage of recovery and rehabilitation goals. activities can be made more or less difficult, depending on your ability. Furthermore, circuit training can be done in groups, which can benefit motivation and social interactions.

Is circuit training effective after a stroke?

Current research shows that circuit training is at least as effective as traditional rehabilitation for improving most physical abilities. In fact, many studies show that circuit training is more effective than regular rehabilitation for some outcomes. Circuit training is also shown to be as effective as traditional rehabilitation methods for improving emotional wellbeing, quality of life and cognitive function.

Are there different kinds of circuit training?

Circuit training can be used to improve different physical skills such as mobility, balance, and function (i.e. use) of the arms and legs. Different exercises can be chosen by the rehabilitation clinician to suit the patient’s rehabilitation needs. Circuit training can be done individually or in a small group. The format of circuit training will be determined by the rehabilitation centre.

Are there risks or side effects?

If you are medically cleared to participate in physical rehabilitation after your stroke, there are no specific risks or side effects associated with circuit training. It is very important that the circuit training program be developed by a qualified professional to suit the person’s rehabilitation goals and level of ability. High quality studies have shown that circuit training is not associated with a higher risk of falls than other forms of rehabilitation.

Who provides circuit training?

Circuit training is often provided by physiotherapists, but can also be provided by occupational therapists, kinesiologists, or other qualified professionals. Group circuit training programs may have more than one therapist or therapy assistant, according to the number of participants. Circuit training can be provided in inpatient or outpatient settings such as acute care hospitals and rehabilitation centers.

How much does it cost?

The cost of circuit training depends on public health or insurance policies. In Canada, costs are covered if you are receiving care in a rehabilitation setting that offers this form of treatment. If you are receiving private rehabilitation, it is important to verify that your insurance covers circuit training.

How long does it take?

In the studies reviewed, circuit training was provided for 3 to 6 weeks (most commonly 4 weeks duration). Circuit training was provided for approximately 30-60 minutes per session, and sessions were provided 3 to 5 times per week. In real life rehabilitation settings, the frequency and duration of circuit training may vary from these timeframes. Sessions are often shorter and more frequent in the early stages of stroke recovery (i.e. 1-6 months post-stroke). Sessions can be affected by the individual’s wellness, and their ability to tolerate exercise. Circuit training may end when the person reaches their rehabilitation goals (e.g. being able to return home safely). Other factors such as organisation of care or individual medical restrictions can also affect the duration of treatment.

Is circuit training for me?

Circuit training is a feasible form of rehabilitation to help recover and improve physical ability after a stroke. Speak with your rehabilitation specialists to decide if circuit training is suitable for you.

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.

A total of 25 studies (15 high quality RCTs, five fair quality RCTs, two poor quality RCTs and three non-randomized studies) that investigate the use of circuit training in post-stroke rehabilitation were reviewed in this StrokEngine module. Circuit training programs were typically oriented towards lower limb impairment and included functional tasks relating to mobility such as balance, transfers, walking, stepping and using stairs. Frequency of circuit training intervention programs varied from 30 to 180 minutes/day, 3 to 7 days/week, for 2 to 52 weeks duration. Control groups included standard care, upper extremity circuit training, non-task-specific upper or lower extremity rehabilitation, gait training, individual task-oriented exercise, neurodevelopmental treatment, individual physiotherapy, cognition training, stretching/weight-shifting exercises, social and educational classes, stretching or no rehabilitation.

A recent Cochrane review on circuit class therapy (English, Hillier & Lynch, 2017) that comprised 17 RCTs or controlled clinical trials reported statistically significant differences in favour of circuit training compared to control interventions for walking endurance, gait speed, gait cadence, mobility, balance confidence, physical stroke outcomes, fitness and daily physical activity. The review concluded that circuit training is effective for improving walking after stroke regardless of time since stroke, and that it may be effective for improving cardiorespiratory fitness and increasing daily physical activity. All but three of the 17 RCTs from the Cochrane review met criteria for inclusion in this StrokEngine module. A subsequent meta-analysis by Bonini-Rocha et al. (2018) conducted a quantitative analysis of eight RCTs (seven of the studies were considered suitable for inclusion in this StrokEngine module; six of the studies were included in the 2017 Cochrane review by English, Hillier & Lynch). This meta-analysis reported that circuit-based exercises focusing on balance and mobility showed statistically significant differences in gait speed (but not balance and functional mobility) compared to control groups.

This StrokEngine module includes studies in which circuit training was provided to individuals or groups. Some circuit training programs included upper extremity activities, whereas other studies used upper extremity circuit training as a control group. Accordingly, effort has been made to draw comparisons between (i) circuit training and control interventions, and (ii) lower extremity circuit training and upper extremity circuit training.

Overall, circuit training was found to be more effective than control treatments for improving upper extremity motor activity and walking speed in the acute phase of stroke recovery; gait impairment, gait parameters and walking independence in the subacute phase of stroke recovery; and balance/falls, cognitive function, gait parameters, lower extremity muscle strength and walking endurance in the chronic phase of stroke recovery. While circuit training was not more effective than control treatments for other outcomes, it was in most instances as effective as them. This indicates that circuit training can be considered as a potentially cost-effective option that results in comparable outcomes to conventional interventions.

Comparison of upper extremity (UE) circuit training and lower extremity (LE) circuit training in the subacute phase of stroke recovery showed that UE circuit training was more effective than LE circuit training for improving dexterity, whereas LE/mobility circuit training was more effective than UE circuit training for improving balance, mobility and walking endurance. Similarly, in the chronic phase of stroke recovery LE circuit training was more effective than UE circuit training for improving balance, transfers, walking endurance and walking speed.

Results Table

View results table

Outcomes

Acute Phase

Balance
Not effective
2B

One non-randomized study (Rose et al., 2011) investigated the effect of circuit training on balance in patients the acute phase of stroke recovery. This non-randomized feasibility study assigned patients to receive individual lower extremity circuit training or conventional physiotherapy during hospital stay. Balance was measured by the Berg Balance Scale at discharge (average length of stay 19 days). No significant between-group difference was found.

Conclusion: There is limited evidence (level 2b) from one non-randomized study that circuit training is not more effective than a comparison intervention (conventional physiotherapy) for improving balance in patients in the acute phase of stroke recovery.

Functional independence
Not effective
2B

One non-randomized study (Rose et al., 2011) investigated the effect of circuit training on functional independence in patients in the acute phase of stroke recovery. This non-randomized feasibility study assigned patients to receive individual lower extremity circuit training or conventional physiotherapy during hospital stay (average length of stay 19 days). Functional independence was measured by a phone version of the Functional Independence Measure (FONE-FIM) at follow-up (90 days post-stroke). No significant between-group difference was found.

Conclusion: There is limited evidence (level 2b) from one non-randomized study that circuit training is not more effective, in long term, than a comparison intervention (conventional physiotherapy) for improving functional independence in patients in the acute phase of stroke recovery.

Mobility
Not effective
2B

One non-randomized study (Rose et al., 2011) investigated the effect of circuit training on mobility in patients in the acute phase of stroke recovery. This non-randomized feasibility study assigned patients to receive individual lower extremity circuit training or conventional physiotherapy during hospital stay. Mobility was measured by the Transfers and Locomotion subscales of the Functional Independence Measure (FIM – Mobility score) at discharge (average length of stay 19 days). No significant between-group difference was found.

Conclusion: There is limited evidence (level 2b) from one non-randomized study that circuit training is not more effective than a comparison intervention (conventional physiotherapy) for improving mobility in patients in the acute phase of stroke recovery.

Motor activity - upper extremity
Effective
2a

One fair quality RCT (Moon et al., 2018) investigated the effect of circuit training on upper extremity motor activity in patients in the acute phase of stroke recovery. This fair quality RCT randomized patients to receive upper extremity circuit training or neurodevelopmental treatment (NDT). Upper extremity motor activity was measured by the Motor Activity Log – Amount of Use (MAL-AOU) and – Quality of Movement (MAL-QOM) scores at post-treatment (4 weeks). A significant between-group difference was found on one measure (MAL-AOU) of the affected upper extremity in favour of circuit training vs. NDT.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that circuit training is more effective than a comparison intervention (neurodevelopmental treatment) for improving one measure of the upper extremity motor activity in patients in the acute phase of stroke recovery.

Motor function - lower extremity
Not effective
2B

One non-randomized study (Rose et al., 2011) investigated the effect of circuit training on lower extremity motor function in patients in the acute phase of stroke recovery. This non-randomized feasibility study assigned patients to receive individual lower extremity circuit training or conventional physiotherapy during hospital stay. Lower extremity motor function was measured by the Fugl-Meyer Assessment – Lower Extremity (FMA-LE motor score) at discharge (average length of stay 19 days). No significant between-group difference was found.

Conclusion: There is limited evidence (level 2b) from one non-randomized study that circuit training is not more effective than a comparison intervention (conventional physiotherapy) for improving lower extremity motor function in patients in the acute phase of stroke recovery.

Motor function - upper extremity
Not effective
2a

One fair quality RCT (Moon et al., 2018) investigated the effect of circuit training on upper extremity motor function in patients in the acute phase of stroke recovery. This fair quality RCT randomized patients to receive upper extremity circuit training or neurodevelopmental treatment. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity (FMA-UE – Shoulder/elbow/forearm, Wrist, Hand, Coordination and speed subtests) at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that circuit training is not more effective than a comparison intervention (neurodevelopmental treatment) for improving upper extremity motor function in patients in the acute phase of stroke recovery.

Sensory function - lower extremity
Not effective
2B

One non-randomized study (Rose et al., 2011) investigated the effect of circuit training on lower extremity sensory function in patients in the acute phase of stroke recovery. This non-randomized feasibility study assigned patients to receive individual lower extremity circuit training or conventional physiotherapy during hospital stay. Lower extremity sensory function was measured by the Fugl-Meyer Assessment – Lower Extremity (FMA-LE sensory score) at discharge (average length of stay 19 days). No significant between-group difference was found.

Conclusion: There is limited evidence (level 2b) from one non-randomized study that circuit training is not more effective than a comparison intervention (conventional physiotherapy) for improving lower extremity sensory function in patients in the acute phase of stroke recovery.

Stroke outcomes
Not Effective
2a

One fair quality RCT (Moon et al., 2018) and one non-randomized study (Rose et al., 2011) investigated the effect of circuit training on stroke outcomes in patients in the acute phase of stroke recovery.

The fair quality RCT (Moon et al., 2018) randomized patients to receive upper extremity circuit training or neurodevelopmental treatment (NDT). stroke outcomes were measured by the stroke Impact Scale (SIS – Strength, Hand function, ADLs, stroke recovery, Total scores) at post-treatment (4 weeks). A significant between-group difference was found on one measure (SIS – Strength), in favour of circuit training vs. NDT.

The non-randomized feasibility study (Rose et al., 2011) assigned patients to receive individual lower extremity circuit training or conventional physiotherapy during hospital stay (average length of stay 19 days). stroke outcomes were measured by the SIS at follow-up (90 days post-stroke). No significant between-group difference was found.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT and one non-randomized study that circuit training is not more effective than comparison interventions (neurodevelopmental treatment, conventional physiotherapy) for improving stroke outcomes in patients in the acute phase of stroke recovery.
Note:
However, the fair quality RCT found a significant between-group difference in strength, in favour of circuit training vs. neurodevelopmental treatment.

Walking speed
Effective
2B

One non-randomized study (Rose et al., 2011) investigated the effect of circuit training on walking speed in patients in the acute phase of stroke recovery. This non-randomized feasibility study assigned patients to receive individual lower extremity circuit training or conventional physiotherapy during hospital stay. Walking speed was measured by a 5-meter walk test at discharge (average length of stay 19 days). A significant between-group difference was found in favour of circuit training vs. conventional physiotherapy.

Conclusion: There is limited evidence (level 2b) from one non-randomized study that circuit training is more effective than a comparison intervention (conventional physiotherapy) for improving walking speed in patients in the acute phase of stroke recovery.

Subacute Phase

Activities of daily living
Conflicting
4

Three high quality RCTs (Verma et al., 2011; van de Port et al., 2012; Kim et al., 2016) investigated the effect of circuit training on Activities of Daily Living (ADLs) in patients in the subacute phase of stroke recovery.

The first high quality RCT (Verma et al., 2011) randomized patients to receive group mobility circuit training + motor imagery or dose-matched conventional lower extremity rehabilitation using the Bobath approach for 2 weeks. ADLs were measured by the Barthel Index (BI –Toilet transfer, Transfer chair and bed, Ambulation, Stair climbing, Total scores) at follow-up only (6 weeks). Significant between-group differences were found (BI –Toilet transfer, Ambulation, Stair climbing, Total scores), in favour of circuit training vs. conventional lower extremity rehabilitation.

The second high quality RCT (van de Port et al., 2012) randomized patients to receive group mobility circuit training or conventional physiotherapy. ADLs were measured by the Nottingham Extended Activities of Daily Living (NEADL – Mobility, Kitchen, Domestic, Leisure scores) at post-treatment (12 weeks) and follow-up (24 weeks). A significant between-group difference was found on one score (NEADL – Leisure) at post-treatment, in favour of conventional physiotherapy vs. circuit training. No significant between-group differences were found at follow-up.

The third high quality RCT (Kim et al., 2016) randomized patients to receive group mobility and fitness circuit training or conventional physiotherapy. ADLs were measured by the modified Barthel Index (Korean version) at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is conflicting evidence (level 4) regarding the effect of circuit training on Activities of Daily Living (ADLs) in patients in the subacute phase of stroke recovery). While one high quality RCT found that circuit training + motor imagery was more effective than a comparison intervention (conventional lower extremity rehabilitation) on several measures of ADLs; another high quality RCT that used the same outcome measure found no significant difference between circuit training vs. conventional physiotherapy (in fact, this high quality RCT found that conventional physiotherapy was more effective than the circuit training). Furthermore, another high quality RCT found that circuit training was more effective than conventional physiotherapy on only one measure of ADLs.

Ambulation
Not effective
1a

Four high quality RCTs (Verma et al., 2011; van de Port et al., 2012; English et al., 2015; Renner et al., 2016) and one fair quality RCT (Kim, Jung & Lee, 2017) investigated the effect of circuit training on ambulation in patients in the subacute phase of stroke recovery.

The first high quality RCT (Verma et al., 2011) randomized patients to receive group mobility circuit training + motor imagery or dose-matched conventional lower extremity rehabilitation using the Bobath approach. Ambulation was measured by the Functional Ambulation Categories (FAC) at post-treatment (2 weeks) and follow-up (6 weeks). A significant between-group difference was found at both time points, in favour of circuit training + motor imagery vs. conventional lower extremity rehabilitation.

The second high quality RCT (van de Port et al., 2012) randomized patients to receive group mobility circuit training or conventional physiotherapy. Ambulation was measured using the FAC at post-treatment (12 weeks) and follow-up (24 weeks). No significant between-group difference was found at either time point.

The third high quality RCT (English et al., 2015) randomized patients to receive group circuit training, time-matched physiotherapy (5 days/week), or intensive physiotherapy (7 days/week). Ambulation was measured by the FAC at post-treatment (4 weeks). No significant between-group differences were found.

The fourth high quality RCT (Renner et al., 2016), randomized patients to receive group mobility circuit training or individual progressive task training. Ambulation was measured by the FAC at post-treatment (6 weeks). No significant between-group difference was found.

The fair quality RCT (Kim, Jung & Lee, 2017) randomized patients receive group balance and gait circuit training or individual task-oriented lower extremity rehabilitation; both groups also received neurodevelopmental treatment. Ambulation was measured by the FAC at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs and one fair quality RCT that circuit training is not more effective than comparison interventions (conventional physiotherapy, intensive physiotherapy, progressive task training, task-oriented lower extremity rehabilitation) for improving ambulation in patients in the subacute phase of stroke recovery.
Note:
However, one high quality RCT found that circuit training with motor imagery was more effective than conventional lower extremity rehabilitation.

Balance
Not Effective
1a

Three high quality RCTs (van de Port et al., 2012; Kim et al., 2016; Renner et al., 2016), one fair quality RCT (Kim, Jung & Lee, 2017) and one non-randomized study (English et al., 2007) investigated the effect of circuit training on balance in patients in the subacute phase of stroke recovery.

The first high quality RCT (van de Port et al., 2012) randomized patients to receive group mobility circuit training or conventional physiotherapy. Balance was measured by the Timed Balance Test at post-treatment (12 weeks) and follow-up (24 weeks). No significant between-group difference was found at either time point.

The second high quality RCT (Kim et al., 2016) randomized patients to receive group mobility and fitness circuit training or conventional physiotherapy. Balance was measured by the Berg Balance Scale (BBS) at post-treatment (4 weeks). No significant between-group difference was found.

The third high quality RCT (Renner et al., 2016) randomized patients to receive group mobility circuit training or individual progressive task training. Balance was measured by the Timed Balance Test at post-treatment (6 weeks). No significant between-group difference was found.

The fair quality RCT (Kim, Jung & Lee, 2017) randomized patients to receive group balance and gait circuit training or individual task-oriented lower extremity rehabilitation; both groups also received neurodevelopmental treatment. Balance was measured by the BBS at post-treatment (4 weeks). No significant between-group difference was found.

The non-randomized study (English et al., 2007) assigned patients to receive group mobility and upper extremity circuit training or individual physiotherapy during inpatient rehabilitation (average length of stay 56 and 71 days, respectively). Balance was measured by the BBS at week 4 of rehabilitation, discharge from rehabilitation and 6 months post-stroke. No significant between-group difference was seen at any time point.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs, one fair quality RCT and one non-randomized study that circuit training is not more effective than comparison interventions (conventional physiotherapy, progressive task training, task-oriented lower extremity rehabilitation) for improving balance in patients in the subacute phase of stroke recovery.

Emotional wellbeing
Not Effective
1a

Two high quality RCTs (van de Port et al., 2012; Renner et al., 2016) investigated the effect of circuit training on emotional wellbeing in patients in the subacute phase of stroke recovery.

The first high quality RCT (van de Port et al., 2012) randomized patients to receive group mobility circuit training or conventional physiotherapy. Emotional wellbeing was measured by the Hospital Anxiety and Depression Scale (HADS) at post-treatment (12 weeks) and follow-up (24 weeks). No significant between-group difference was found at either time point.

The second high quality RCT (Renner et al., 2016) randomized patients with subacute stroke to receive group mobility circuit training or individual progressive task training. Emotional wellbeing was measured by the HADS (Anxiety, Depression scales) at baseline and at post-treatment (6 weeks). A significant between-group difference in change scores from baseline to post-treatment was found on one measure of emotional wellbeing (HADS – Anxiety), in favour of progressive task training vs. circuit training.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that circuit training is not more effective than comparison interventions (physiotherapy, progressive task training) for improving emotional wellbeing in patients in the subacute phase of stroke recovery.
Note:
In fact, one high quality RCT found a significant between-group difference in reduced anxiety, in favour of progressive task training vs. circuit training.

Falls
Not Effective
1a

Two high quality RCTs (van de Port et al., 2012; Renner et al., 2016) investigated the effect of circuit training on falls and fear of falling in patients in the subacute phase of stroke recovery.

The first high quality RCT (van de Port et al., 2012) randomized patients to receive group mobility circuit training or conventional physiotherapy. Number of falls was measured during the treatment period and fear of falling was measured by the Falls Efficacy Scale (FES) at post-treatment (12 weeks) and follow-up (24 weeks). No significant between-group differences were found at either time point.

The second high quality RCT (Renner et al., 2016) randomized patients to receive group mobility circuit therapy or individual progressive task training. Fear of falling was measured by the FES at post-treatment (6 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that circuit training is not more effective than comparison interventions (physiotherapy, progressive task training) for reducing falls or improving fear of falling in patients in the subacute phase of stroke recovery.

Fatigue
Not effective
1a

Two high quality RCTs (van de Port et al., 2012; Renner et al., 2016) investigated the effect of circuit training on fatigue in patients in the subacute phase of stroke recovery.

The first high quality RCT (van de Port et al., 2012) randomized patients to receive group mobility circuit training or conventional physiotherapy. Fatigue was measured by the Fatigue Severity Scale at post-treatment (12 weeks) and follow-up (24 weeks). No significant between-group difference was found at either time point.

The second high quality RCT (Renner et al., 2016) randomized patients to receive group mobility circuit training or individual progressive task training. Fatigue was measured by the Fatigue Severity Scale at post-treatment (6 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that circuit training is not more effective than comparison interventions (conventional physiotherapy, progressive task training) for improving fatigue in patients in the subacute phase of stroke recovery.

Functional independence
Not effective
1b

One high quality RCT (English et al., 2015) investigated the effect of circuit training on functional independence in patients in the subacute phase of stroke recovery. This high quality RCT randomized patients to receive group circuit training, time-matched physiotherapy (5 days/week), or intensive physiotherapy (7 days/week). Functional independence was measured by the Functional Independence Measure (FIM) at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is not more effective than comparison interventions (time-matched physiotherapy, intensive physiotherapy) for improving functional independence in patients in the subacute phase of stroke recovery.

Gait impairment
Effective
1b

One high quality RCT (Verma et al., 2011) investigated the effect of circuit training on gait impairment in patients in the subacute phase of stroke recovery. This high quality RCT randomized patients to receive group mobility circuit training + motor imagery or dose-matched conventional lower extremity rehabilitation using the Bobath approach. gait impairment was measured by the Rivermead Visual gait Assessment at post-treatment (2 weeks) and follow-up (6 weeks). A significant between-group difference was found at both time points, in favour of circuit training vs. conventional lower extremity rehabilitation.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training + motor imagery is more effective than comparison intervention (conventional lower extremity rehabilitation) for reducing gait impairment in patients in the subacute phase of stroke recovery.

Gait parameters
Effective
1b

One high quality RCT (Verma et al., 2011) investigated the effect of circuit training on gait parameters in patients in the subacute phase of stroke recovery. This high quality RCT randomized patients to receive group mobility circuit training + motor imagery or dose-matched conventional lower extremity rehabilitation using the Bobath approach. gait parameters (cadence, step length asymmetry, stride length asymmetry) were measured at post-treatment (2 weeks) and follow-up (6 weeks). A significant between-group difference in one measure only (cadence) was found at both time points, in favour of circuit training vs. conventional lower extremity rehabilitation.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training + motor imagery is more effective than a comparison intervention (conventional lower extremity rehabilitation) for improving one gait parameter (cadence) in patients in the subacute phase of stroke recovery.
Note:
There was no between-group difference in other gait parameters (step/stride length asymmetry).

Health-related quality of life
Not effective
1b

One high quality RCT (English et al., 2015) investigated the effect of circuit training on health related quality of life in patients in the subacute phase of stroke recovery. This high quality RCT randomized patients to receive group circuit training, time-matched physiotherapy (5 days/week), or intensive physiotherapy (7 days/week). Health-related quality of life was measured by the Australian Quality of Life scale (AQoL) at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is not more effective than comparison interventions (conventional physiotherapy, intensive physiotherapy) for improving health-related quality of life in patients in the subacute phase of stroke recovery.

Mobility
Not effective
1a

Two high quality RCTs (van de Port et al., 2012; Renner et al., 2016) and one fair quality RCT (Kim, Jung & Lee, 2017) investigated the effect of circuit training on mobility in patients in the subacute phase of stroke recovery.

The first high quality RCT (van de Port et al., 2012) randomized patients to receive group mobility circuit training or conventional physiotherapy. Mobility was measured by the Rivermead Mobility Index (RMI) and the Timed Up and Go Test (TUG) at post-treatment (12 weeks) and follow-up (24 weeks). No significant between-group difference was found at either time point.

The second high quality RCT (Renner et al., 2016) randomized patients to receive group mobility circuit training or individual progressive task training. Mobility was measured by the RMI, TUG and Chair Stand-up test at post-treatment (6 weeks). No significant between-group differences were found.

The fair quality RCT (Kim, Jung & Lee, 2017) randomized patients to receive group balance and gait circuit training or individual task-oriented lower extremity rehabilitation; both groups also received neurodevelopmental treatment. Mobility was measured by the TUG at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs and one fair quality RCT that circuit training is not more effective than comparison interventions (conventional physiotherapy, progressive task training, task-oriented lower extremity rehabilitation) for improving mobility in patients in the subacute phase of stroke recovery.

Motor function - lower extremity
Not Effective
1a

Three high quality RCTs (van de Port et al., 2012; Kim et al., 2016; Renner et al., 2016) investigated the effect of circuit training on lower extremity motor function in patients in the subacute phase of stroke recovery.

The first high quality RCT (van de Port et al., 2012) randomized patients to receive group mobility circuit training or conventional physiotherapy. Lower extremity motor function was measured by the Motricity Index (MI – Leg score) at post-treatment (12 weeks) and follow-up (24 weeks). No significant between-group difference was found at either time point.

The second high quality RCT (Kim et al., 2016) randomized patients to receive group mobility and fitness circuit training or conventional physiotherapy. Lower extremity motor function was measured by the Fugl-Meyer Assessment (FMA – Lower Extremity) at post-treatment (4 weeks). No significant between-group difference was found.

The third high quality RCT (Renner et al., 2016) randomized patients to receive group mobility circuit training or individual progressive task training. Lower extremity motor function was measured by the Motricity Index (MI – Leg score) at post-treatment (6 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs that circuit training is not more effective than comparison interventions (conventional physiotherapy, progressive task training) for improving lower extremity motor function in patients in the subacute phase of stroke recovery.

Motor function - upper extremity
Not Effective
1a

Three high quality RCTs (van de Port et al.,2012; English et al., 2015; Renner et al., 2016) and one non-randomized study (English et al., 2007) investigated the effect of circuit training on upper extremity motor function in patients in the subacute phase of stroke recovery.

The first high quality RCT (van de Port et al., 2012) randomized patients to receive group mobility circuit training or conventional physiotherapy. Upper extremity motor function was measured by the Motricity Index (MI – Arm score) at post-treatment (12 weeks) and follow-up (24 weeks). No significant between-group difference was found at either time point.

The second high quality RCT (English et al., 2015) randomized patients to receive group circuit training, time-matched physiotherapy (5 days/week), or intensive physiotherapy (7 days/week). Upper extremity motor function was measured by the Wolf Motor Function Test (WMFT) at post-treatment (4 weeks). No significant between-group difference was found.

The third high quality RCT (Renner et al., 2016) randomized patients to receive group mobility circuit training or individual progressive task training. Upper extremity motor function was measured by the Motricity Index (MI – Arm score) at post-treatment (6 weeks). No significant between-group difference was found.

The non-randomized study (English et al., 2007) assigned patients to receive group mobility and upper extremity circuit training or individual physiotherapy during inpatient rehabilitation (average length of stay 56 and 71 days, respectively). Upper extremity motor function was measured by the Motor Assessment Scale (MAS – Upper limb subscore) at week 4 of rehabilitation, discharge from rehabilitation and 6 months post-stroke. No significant between-group difference was found at any time point.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs and one non-randomized study that circuit training is not more effective than comparison interventions (conventional physiotherapy, intensive physiotherapy, progressive task training) for improving upper extremity motor function in patients in the subacute phase of stroke recovery.

Satisfaction
Not effective
2B

One non-randomized study (English et al., 2007) investigated the effect of circuit training on satisfaction in patients in the subacute phase of stroke recovery. This non-randomized study assigned patients to receive group mobility and upper extremity circuit training or individual physiotherapy during inpatient rehabilitation. Patient satisfaction was measured by an adapted version of the Pound Scale at week 4 of rehabilitation, on discharge from rehabilitation and at follow-up (6 months post-stroke). A significant between-group difference in patients’ satisfaction with the amount of therapy received was found at 6-month follow-up only, in favour of circuit training vs. physiotherapy.

Conclusion: There is limited evidence (level 2b) from one non-randomized study that circuit training is not more effective than a comparison intervention (conventional physiotherapy) for improving patient satisfaction in patients in the subacute phase of stroke recovery.
Note:
However, this non-randomized study found a significant between-group difference in patient satisfaction with amount of physiotherapy received at 6 months post-stroke, in favour of circuit training.

Shoulder pain
Not effective
2b

One non-randomized study (English, Hillier & Stiller, 2008) investigated the effect of circuit training on shoulder pain in patients in the subacute phase of stroke recovery. This non-randomized study assigned patients to receive group mobility and upper extremity circuit training or individual physiotherapy during inpatient rehabilitation. Shoulder pain was measured according to incidence (yes/no response) and severity (visual analogue scale) at week 4 of rehabilitation and on discharge from rehabilitation. No significant between-group differences in incidence or severity of shoulder pain were found at either time point.

Conclusion: There is limited evidence (level 2b) from one non-randomized study that circuit training is not more effective than a comparison intervention (conventional physiotherapy) for reducing incidence or severity of shoulder pain in patients in the subacute phase of stroke recovery.

Stair competence
Conflicting
4

Two high quality RCTs (van de Port et al., 2012; Renner et al., 2016) investigated the effect of circuit training on stair competence in patients in the subacute phase of stroke recovery.

The first high quality RCT (van de Port et al., 2012) randomized patients to receive group mobility circuit training or conventional physiotherapy. Stair competence was measured by the Modified Stairs Test at post-treatment (12 weeks) and follow-up (24 weeks). A significant between-group difference was found at post-treatment, in favour of circuit training vs. conventional physiotherapy. Differences did not remain significant at follow-up.

The second high quality RCT (Renner et al., 2016) randomized patients to receive group mobility circuit training or individual progressive task training. Stairs competence was measured by the Modified Stairs Test at the baseline and at post-treatment (6 weeks). A significant between-group difference in change scores from baseline to post-treatment was found, in favour of progressive task training vs. circuit training.

Conclusion: There is conflicting evidence (level 4) regarding the effect of circuit training on stair competence in patients in the subacute phase of stroke recovery. While one high quality RCT found that circuit training was more effective than conventional physiotherapy, another high quality RCT found that progressive task training was more effective than circuit training.

Stroke Outcomes
Not Effective
1a

Three high quality RCTs (van de Port et al., 2012; English et al., 2015; Renner et al., 2016) investigated the effect of circuit training on stroke outcomes in patients in the subacute phase of stroke recovery.

The first high quality RCT (van de Port et al., 2012) randomized patients to receive group mobility circuit training or conventional physiotherapy. stroke outcomes were measured using the stroke Impact Scale (SIS – Mobility, Strength, Memory and thinking, Mood/Emotion, Communication, ADL/IADLs, Hand function, Participation, stroke recovery scores) at post-treatment (12 weeks) and follow-up (24 weeks). A significant between-group difference in one measure (SIS – Memory and thinking) was found at post-treatment, in favour of conventional physiotherapy vs. circuit training. Differences did not remain significant at follow-up.

The second high quality RCT (English et al., 2015) randomized patients with subacute stroke to receive group circuit training, time-matched physiotherapy (5 days/week), or intensive physiotherapy (7 days/week). stroke outcomes were measured using the SIS (Physical subscale) at post-treatment (4 weeks). No significant between-group differences were found.

The third high quality RCT (Renner et al., 2016) randomized patients to receive group mobility circuit training or individual progressive task training. stroke outcomes were measured using the SIS (Mobility, Strength, Memory and thinking, Mood/Emotion, Communication, ADL/IADLs, Hand function, Participation, stroke recovery scores) at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs that circuit training is not more effective than comparison interventions (conventional physiotherapy, intensive physiotherapy, progressive task training) for improving stroke outcomes in patients in the subacute phase of stroke recovery.
Note:
In fact, one high quality RCT found that conventional physiotherapy was more effective than circuit training on one measure (SIS – Memory and thinking).

Unilateral spatial neglect
Not Effective
1a

Two high quality RCTs (van de Port et al., 2012; Renner et al., 2016) investigated the effect of circuit training on unilateral spatial neglect in patients in the subacute phase of stroke recovery.

The first high quality RCT (van de Port et al., 2012) randomized patients to receive group mobility circuit training or conventional physiotherapy. Unilateral spatial neglect was measured by the Letter Cancellation Task at post-treatment (12 weeks) and follow-up (24 weeks). No significant between-group difference was found at either time point.

The second high quality RCT (Renner et al., 2016) randomized patients to receive group mobility circuit training or individual progressive task training. Unilateral spatial neglect was measured by the Letter Cancellation Task at post-treatment (6 weeks). No significant between-group difference was found.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that circuit training is not more effective than comparison interventions (conventional physiotherapy, progressive task training) for improving unilateral spatial neglect in patients in the subacute phase of stroke recovery.

Walking endurance
Conflicting
4

Five high quality RCTs (Verma et al., 2011; van de Port et al., 2012; English et al., 2015; Kim et al., 2016; Renner et al., 2016), one fair quality RCT (Kim, Jung & Lee, 2017) and one non-randomized study (English et al., 2007) investigated the effect of circuit training on walking endurance in patients in the subacute phase of stroke recovery.

The first high quality RCT (Verma et al., 2011) randomized patients to receive group mobility circuit training + motor imagery or dose-matched conventional lower extremity rehabilitation using the Bobath approach. Walking endurance was measured by the 6 Minute Walk Test (6MWT) at post-treatment (2 weeks) and follow-up (6 weeks). A significant between-group difference was found at both time points, in favour of circuit training vs. conventional lower extremity rehabilitation.

The second high quality RCT (van de Port et al., 2012) randomized patients to receive group mobility circuit training or conventional physiotherapy. Walking endurance was measured by the 6MWT at post-treatment (12 weeks) and follow-up (24 weeks). A significant between-group difference was found at post-treatment, in favour of circuit training vs. conventional physiotherapy. Differences did not remain significant at follow-up.

The third high quality RCT (English et al., 2015) randomized patients to receive group circuit training, time-matched physiotherapy (5 days/week), or intensive physiotherapy (7 days/week). Walking endurance was measured by the 6MWT at post-treatment (4 weeks). No significant between-group differences were found.

The fourth high quality RCT (Kim et al., 2016) randomized patients to receive group mobility and fitness circuit training or conventional physiotherapy. Walking endurance was measured by the 6MWT at post-treatment (4 weeks). No significant between-group difference was found.

The fifth high quality RCT (Renner et al., 2016) randomized patients to receive group mobility circuit training or individual progressive task training. Walking endurance was measured by the 6MWT at post-treatment (6 weeks). There was a significant between-group difference in the proportion of participants who showed a clinically relevant improvement (i.e. 6MWT change score ≥ 54), in favour of circuit training vs. progressive task training.

The fair quality RCT (Kim, Jung & Lee, 2017) randomized patients to receive group balance and gait circuit training or individual task-oriented lower extremity rehabilitation; both groups also received neuro-developmental treatment. Walking endurance was measured by the 6MWT at post-treatment (4 weeks). A significant between-group difference was found in favour of circuit training vs. task-oriented lower extremity rehabilitation.

The non-randomized study (English et al., 2007) assigned patients to receive group mobility and upper extremity circuit training or individual physiotherapy during inpatient rehabilitation. Functional walking capacity was measured by the Two Minute Walk Test at week 4 of rehabilitation, on discharge from rehabilitation, and at follow-up (6 months post-stroke). A significant between-group difference was seen at follow-up only, in favour of group mobility and upper extremity circuit training vs. individual physiotherapy.

Conclusion: There is conflicting evidence (level 4) regarding the effect of circuit training on walking endurance in patients in the subacute phase of stroke recovery. While three high quality RCTs and one fair quality RCT found that circuit training was more effective than comparison interventions (conventional lower extremity rehabilitation, conventional physiotherapy, progressive task training, task-oriented lower extremity rehabilitation), two high quality RCTs and one non-randomized study found that circuit training was not more effective than comparison interventions (intensive physiotherapy, conventional physiotherapy).
Note: The non-randomized study found a significant difference in walking endurance in favour of circuit training vs. individual physiotherapy at follow-up only.

Walking independence
Effective
2b

One non-randomized study (English et al., 2007) investigated the effect of circuit training on walking independence in patients in the subacute phase of stroke recovery. This non-randomized study assigned patients to receive group mobility and upper extremity circuit training or individual physiotherapy during inpatient rehabilitation. Walking independence was measured by the Iowa Level of Assistance Scale at week 4 of rehabilitation, on discharge from rehabilitation, and at follow-up (6 months post-stroke). A significant between-group difference in the proportion of patients who were able to walk independently was seen at discharge from rehabilitation, in favour of circuit training vs. physiotherapy.

Conclusion: There is limited evidence (level 2b) from one non-randomized study that circuit training is more effective than a comparison intervention (conventional physiotherapy) for improving walking independence in patients in the subacute phase of stroke recovery.

Walking speed
Conflicting
4

Four high quality RCTs (Verma et al., 2011; van de Port et al., 2012; English et al., 2015; Renner et al., 2016) and one non-randomized study (English et al., 2007) investigated the effect of circuit training on walking speed in patients in the subacute phase of stroke recovery.

The first high quality RCT (Verma et al., 2011) randomized patients to receive group mobility circuit training + motor imagery or dose-matched conventional lower extremity rehabilitation using the Bobath approach. Walking speed was measured by the 10-meter walk test (comfortable walking speed, maximal effort) at post-treatment (2 weeks) and follow-up (6 weeks). A significant between-group difference in one measure (comfortable walking speed) was seen at both time points, in favour of circuit training vs. conventional lower extremity rehabilitation.

The second high quality RCT (van de Port et al., 2012) randomized patients to receive group mobility circuit training or conventional physiotherapy. Walking speed was measured using the 5-meter walk test (comfortable walking speed) at post-treatment (12 weeks) and follow-up (24 weeks). A significant between-group difference was found at both time points, in favour of circuit training vs. conventional physiotherapy.

The third high quality RCT (English et al., 2015) randomized patients to receive group circuit training, time-matched physiotherapy (5 days/week), or intensive physiotherapy (7 days/week). Walking speed was measured by the 5-meter walk test at post-treatment (4 weeks). No significant between-group differences were found.

The fourth high quality RCT (Renner et al., 2016) randomized patients to receive group mobility circuit training or individual progressive task training. Walking speed was measured by the 10-meter walk test (comfortable walking speed) at post-treatment (6 weeks). A significant between-group difference in the proportion of participants who showed a clinically relevant improvement (i.e. increase in comfortable walking speed ≥ 0.16m/s) was found at post-treatment, in favour of circuit training vs. progressive task training.

The non-randomized study (English et al., 2007) assigned patients to receive group mobility and upper extremity circuit training or individual physiotherapy during inpatient rehabilitation. Walking speed was measured by a 5 meter walk test at week 4 of rehabilitation, discharge from rehabilitation and follow-up (6 months post-stroke). No significant between-group difference was found at any time point.

Conclusion: There is conflicting evidence (level 4) regarding the effect of circuit training on walking speed in patients in the subacute phase of stroke recovery. While three high quality RCTs found that circuit training was more effective than comparison interventions (conventional lower extremity rehabilitation, conventional physiotherapy, progressive task training), one high quality RCT and one non-randomized study found that circuit training was not more effective than comparison interventions (time-matched or intensive physiotherapy).

Subacute Phase: lower extremity vs. upper extremity circuit training

Balance
Effective
1B

One high quality RCT (Blennerhassett & Dite, 2004) investigated the effect of circuit training on balance in patients in the subacute phase of stroke recovery. This high quality RCT randomized patients to receive group mobility circuit training or group upper extremity circuit training. Balance was measured by the Step Test at post-treatment (4 weeks) and follow-up (6 months); between-group differences were measured as treatment effect sizes using the effect size d. A moderate treatment effect size was found at post-treatment, in favour of mobility circuit training vs. upper extremity circuit training. Differences did not remain significant at follow-up.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that mobility circuit training is more effective than upper extremity circuit training for improving balance in patients in the subacute phase of stroke recovery.

Dexterity
Effective
1B

One high quality RCT (Blennerhassett & Dite, 2004) investigated the effect of circuit training on dexterity in patients in the subacute phase of stroke recovery. This high quality RCT randomized patients to receive group mobility circuit training or group upper extremity circuit training. Dexterity was measured by the Jebsen Taylor Hand Function Test at post-treatment (4 weeks) and follow-up (6 months); between-group differences were measured as treatment effect sizes using the effect size d. A moderate treatment effect size was found at post-treatment, in favour of upper extremity circuit training vs. mobility circuit training. Differences did not remain significant at follow-up.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that upper extremity circuit training is more effective than mobility circuit training for improving dexterity in patients in the subacute phase of stroke recovery.

Mobility
Effective
1B

Un ECR de haute qualité (Blennerhassett & Dite, 2004) a examiné l’effet de l’entraînement en circuit sur l’équilibre de patients en phase subaiguë de récupération post-AVC. Cet ECR de haute qualité a assigné aléatoirement les patients pour recevoir un entraînement en circuit de la mobilité en groupe ou un entraînement en circuit du membre supérieur en groupe. La mobilité des patients a été mesurée à 4 semaines (après l’intervention) et à 6 mois (au moment d’un suivi) par le Timed Up and Go Test ; les différences entre les groupes ont été mesurées en calculant l’ampleur de l’effet d du traitement. Après l’intervention, une ampleur de l’effet modérée du traitement a été relevée en faveur de l’entraînement en circuit de la mobilité comparé à l’entraînement en circuit du membre supérieur. Cette différence ne s’est pas maintenue au moment du suivi.

Conclusion : Des données probantes modérées (niveau 1b), provenant d’un ECR de haute qualité, indiquent qu’un entraînement en circuit de la mobilité est plus efficace qu’un entraînement en circuit du membre supérieur pour améliorer la mobilité de patients en phase subaiguë de récupération post-AVC.

Motor function - upper extremity
Not Effective
1B

One high quality RCT (Blennerhassett & Dite, 2004) investigated the effect of circuit training on upper extremity motor function in the subacute phase of stroke recovery. This high quality RCT randomized patients to receive group mobility circuit training or group upper extremity circuit training. Upper extremity motor function was measured by the Motor Assessment Scale at post-treatment (4 weeks) and follow-up (6 months); between-group differences were not reported. The upper extremity circuit training group demonstrated significant improvements at either time point, whereas change scores for the mobility circuit training group were not significant at either time point.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that mobility circuit training is not more effective than upper extremity circuit training for improving upper extremity motor function in patients in the subacute phase of stroke recovery.

Walking endurance
Effective
1B

One high quality RCT (Blennerhassett & Dite, 2004) investigated the effect of circuit training on walking endurance in patients in the subacute phase of stroke recovery. This high quality RCT randomized patients to receive group mobility circuit training or group upper extremity circuit training. Walking endurance was measured by the 6 Minute Walk Test at post-treatment (4 weeks) and follow-up (6 months); between-group differences were measured as treatment effect sizes using the effect size d. A large treatment effect size was found at post-treatment, in favour of mobility circuit training vs. upper extremity circuit training. Differences did not remain significant at follow-up.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that mobility circuit training is more effective than upper extremity circuit training for improving walking endurance in patients in the subacute phase of stroke recovery.raining for improving walking endurance of patients with subacute stroke.

Chronic Phase

Activity participation
Not Effective
1B

One high quality RCT (Pang et al., 2005) investigated the effect of circuit training on activity participation in patients in the chronic phase of stroke recovery. This high quality RCT randomized patients to receive the Fitness and Mobility Exercise (FAME) group circuit training program or a seated upper extremity exercise program. Activity participation was measured by the Physical Activity Scale for Individuals with Physical Disability at post-treatment (19 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is not more effective than a comparison intervention (seated upper extremity exercise) for improving activity participation in patients in the chronic phase of stroke recovery.

Balance
Conflicting
4

Four high quality RCTs (Pang et al., 2005; Marigold et al., 2005; Yang et al., 2006; Moore et al., 2015) and one fair quality RCT (Park & Kim, 2016) investigated the effect of circuit training on balance in patients in patients in the chronic phase of stroke recovery.

The first high quality RCT (Pang et al., 2005) randomized patients to receive the Fitness and Mobility Exercise (FAME) group circuit training program or a seated upper extremity exercise program. Balance was measured by the Berg Balance Scale (BBS) at post-treatment (19 weeks). No significant between-group difference was found.

The second high quality RCT (Marigold et al., 2005) randomized patients to receive group agility circuit training or a stretching and weight-shifting exercise program. Balance was measured by the BBS at post-treatment (10 weeks) and follow-up (1 month post-treatment). No significant between-group difference was found at either time point.

The third high quality RCT (Yang et al., 2006) randomized patients to receive individual strength circuit training or no rehabilitation. Standing balance was measured by the Step Test at post-treatment (4 weeks). A significant between-group difference was found, in favour of circuit training vs. no rehabilitation.

The fourth high quality RCT (Moore et al., 2015) randomized patients to receive group circuit training based on the FAME program or a time-matched home stretching program. Balance was measured using the BBS at post-treatment (19 weeks). A significant between-group difference was found in favour of circuit training vs. stretching.

The fair quality RCT (Park & Kim, 2016) randomized patients to receive individual gait circuit training or walking rehabilitation on a firm indoor surface. Balance was measured by the BBS at post-treatment (3 weeks). A significant between-group difference was found, in favour of circuit training vs. walking rehabilitation.

Conclusion: There is conflicting evidence (level 4) regarding the effect of circuit training on balance in patients in the chronic phase of stroke recovery. While two high quality RCTs and one fair quality RCT found that circuit training was more effective than comparison groups (no rehabilitation, home stretching, walking rehabilitation), two high quality RCTs found that circuit training was not more effective than comparison interventions (seated upper extremity exercise program, stretching/weight-shifting exercise program).

Balance confidence
Not Effective
1A

Two high quality RCTs (Marigold et al., 2005; Mudge, Barber & Stott, 2009) investigated the effect of circuit training on balance confidence in patients in the chronic phase of stroke recovery.

The first high quality RCT (Marigold et al., 2005) randomized patients to receive group agility circuit training or a stretching and weight-shifting exercise program. Balance confidence was measured by the Activity-specific Balance Confidence (ABC) Scale at post-treatment (10 weeks) and follow-up (1 month post-treatment). No significant between-group difference was found at either time point.

The second high quality RCT (Mudge, Barber & Stott, 2009) randomized patients to receive group lower extremity circuit training or time-matched social/educational classes. Balance confidence was measured by the ABC Scale at post-treatment (4 weeks) and follow-up (3 months). No significant between-group difference was found at either time point.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that circuit training is not more effective than comparison interventions (stretching and weight-shifting exercises, social/educational classes) for improving balance confidence in patients in the chronic phase of stroke recovery.

Balance - falls
Effective
1b

One high quality RCT (Marigold et al., 2005) investigated the effect of circuit training on falls in patients in the chronic phase of stroke recovery. This high quality RCT randomized patients to receive group agility circuit training or a stretching and weight-shifting exercise program. Falls were measured (a) by the number of falls during platform translations, and (b) using a falls diary to record the number of self-reported community-based falls at post-treatment (10 weeks) and follow-up (1 month post-treatment). A significant between-group difference in one measure of falls (number of falls during platform translations) was found at post-treatment only, in favour of circuit training vs. stretching/weight-shifting exercises.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is more effective than a comparison intervention (stretching/weight-shifting exercises) for reducing falls in patients in the chronic phase of stroke recovery.
Note:
No significant differences in community-based falls were found.

Cognitive function
Effective
1b

One high quality RCT (Moore et al., 2015) investigated the effect of circuit training on cognitive function in patients in the chronic phase of stroke recovery. This high quality RCT randomized patients to receive group fitness and mobility circuit training based on the Fitness and Mobility Exercise (FAME) program or a time-matched home stretching program. Cognitive function was measured by Addenbrooke’s Cognitive Examination – Revised at post-treatment (19 weeks). A significant between-group difference was found, in favour of circuit training vs. home stretching.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is more effective than a comparison intervention (home stretching) for improving cognitive function in patients in the chronic phase of stroke recovery.

Gait parameters
Effective
1a

Two high quality RCTs (Marigold et al., 2005; Yang et al., 2006), one fair quality RCT (Park & Kim, 2016) and one poor quality RCT (Song, Kim & Park, 2015) investigated the effect of circuit training on gait parameters in patients in the chronic phase of stroke recovery.

The first high quality RCT (Marigold et al., 2005) randomized patients to receive group agility circuit training or a stretching and weight-shifting exercise program. gait parameters (step reaction time) were measured at post-treatment (10 weeks) and follow-up (1 month post-treatment). A significant between-group difference was seen at post-treatment, in favour of circuit training vs. stretching/weight-shifting exercises. Differences did not remain significant at follow-up.
Note: There was a significant between-group difference in step reaction time at baseline, which was entered as a covariate for statistical analysis.

The second high quality RCT (Yang et al., 2006) randomized patients to receive individual strength circuit training or no rehabilitation. gait parameters (gait velocity, cadence, stride length) were measured using the GAITRite system at post-treatment (4 weeks). Significant between-group differences were found for all gait parameters, in favour of circuit training vs. no rehabilitation.

The fair quality RCT (Park & Kim, 2016) randomized patients to receive individual gait circuit training or walking rehabilitation on a firm indoor surface. gait parameters (plantar prints percentage, hindfoot percentage, forefoot percentage, cadence) were measured by the Smart Step test at post-treatment (3 weeks). No significant between-group differences were found.

The poor quality RCT (Song, Kim & Park, 2015) randomized patients to receive individual upper extremity and mobility circuit training, group upper extremity and mobility circuit training, or no circuit training; all groups received conventional physiotherapy. gait parameters (velocity, cadence, stance phase symmetry profile, swing phase symmetry profile, step length symmetry profile) were measured by the GAITRite system at post-treatment (4 weeks). Significant between-group differences in two measures (velocity, cadence) were found, in favour of group circuit training vs. no training. A significant between-group difference in one measure (velocity) was seen in favour of individual circuit training vs. no training. There were no significant differences between group circuit training vs. individual circuit training.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs and one poor quality RCT that circuit training is more effective than comparison groups (stretching/weight-shifting exercises, no rehabilitation, conventional physiotherapy) for improving gait parameters in patients in the chronic phase of stroke recovery.
Note:
However, one fair quality RCT found no significant difference between circuit training and indoors walking rehabilitation, using a difference outcome measure of gait parameters.

Health-related quality of life - carers
Not Effective
1b

One high quality RCT (Marsden et al., 2010) investigated the effect of circuit training on health-related quality of life in carers in the chronic phase of stroke recovery. This high quality cross-over RCT randomized patients and their carers to receive the Community Living After stroke for Survivors and Carers (CLASSiC*) programme or no intervention. Carers’ health-related quality of life was measured using the Health Impact Scale (Communication, Emotion, ADL/IADL, Hand function, Memory, Mobility, Participation, Strength, Composite Physical scores) at post-treatment (7 weeks) and follow-up (21 weeks). No significant between-group differences were found at either time point.
* The CLASSiC program comprised group lower extremity and balance circuit training, social discussion and stroke education sessions.
Note: This pilot study was not adequately powered to detect significant between-group differences.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is not more effective than no specific intervention for improving health-related quality of life in carers of patients in the chronic phase of stroke recovery.

Health-related quality of life - patients
Not Effective
1B

One high quality RCT (Marigold et al., 2005) investigated the effect of circuit training on health-related quality of life in patients in the chronic phase of stroke recovery. This high quality RCT randomized patients to receive group agility circuit training or a stretching and weight-shifting exercise program. Health-related quality of life was measured by the Nottingham Health Profile at post-treatment (10 weeks) and follow-up (1 month post-treatment). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is not more effective than a comparison intervention (stretching/weight-shifting exercises) for improving health-related quality of life in patients in the chronic phase of stroke recovery.

Mobility - carers
Not Effective
1b

One high quality RCT (Marsden et al., 2010) investigated the effect of circuit training on mobility among carers of chronic stroke patients. This high quality cross-over RCT randomized patients and their carers to receive the Community Living After stroke for Survivors and Carers (CLASSiC*) programme or no intervention. Carer mobility was measured by the Timed Up and Go Test at post-treatment (7 weeks) and follow-up (21 weeks). No significant between-group difference was found at either time point.
* The CLASSiC program comprised group lower extremity and balance circuit training, social discussion and stroke education sessions.
Note: This pilot study was not adequately powered to detect significant between-group differences.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is not more effective than no specific intervention for improving carers’ mobility of patients in the chronic phase of stroke recovery.

Mobility - patients
Conflicting
4

Four high quality RCTs (Marigold et al., 2005; Yang et al., 2006; Mudge, Barber & Stott, 2009; Marsden et al., 2010) and one fair quality RCT (Park & Kim, 2016) investigated the effect of circuit training on mobility in patients in the chronic phase of stroke recovery.

The first high quality RCT (Marigold et al., 2005) randomized patients to receive group agility circuit training or a stretching and weight-shifting exercise program. Mobility was measured by the Timed Up and Go Test (TUG) at post-treatment (10 weeks) and follow-up (1 month post-treatment). No significant between-group difference was found at either time point.

The second high quality RCT (Yang et al., 2006) randomized patients to receive individual strength circuit training or no rehabilitation. Mobility was measured by the TUG at post-treatment (4 weeks). A significant between-group difference was found, in favour of circuit training vs. no rehabilitation.
The third high quality RCT (Mudge, Barber & Stott, 2009) randomized patients to receive group lower extremity circuit training or time-matched social/educational classes. Mobility was measured by the Rivermead Mobility Index (RMI) and a StepWatch Activity Monitor (mean number of steps/day, steps/min, percentage of time inactive) at post-treatment (4 weeks) and follow-up (3 months). A significant between-group difference in self-reported mobility (RMI) was found at follow-up only, in favour of circuit training vs. social/educational classes.

The fourth high quality cross-over RCT (Marsden et al., 2010) randomized patients and their carers to receive the Community Living After stroke for Survivors and Carers (CLASSiC*) programme or no intervention. Mobility was measured by the TUG at post-treatment (7 weeks) and follow-up (21 weeks). No significant between-group difference was found at either time point.
* The CLASSiC program comprised group lower extremity and balance circuit training, social discussion and stroke education sessions.
Note: This pilot study was not adequately powered to detect significant between-group differences.

The fair quality RCT (Park & Kim, 2016) randomized patients to receive individual gait circuit training or walking rehabilitation on a firm indoor surface. Mobility was measured by the TUG at post-treatment (3 weeks). A significant between-group difference was found, in favour of circuit training vs. indoors walking rehabilitation.

Conclusion: There is conflicting evidence (level 4) regarding the effect of circuit training on mobility in patients in the chronic phase of stroke recovery. While three* high quality RCTs found that circuit training was not more effective than comparison interventions (stretching/weight-shifting exercises, social/educational classes, no specific intervention), one high quality RCT and one fair quality RCT found that circuit training was more effective than comparison groups (no rehabilitation, indoor walking rehabilitation) for improving mobility.
* Note:
One of these studies found that circuit training was more effective, in long term, than social/educational classes for improving self-reported mobility.

Muscle strength - lower extremity
Effective
1A

Two high quality RCTs (Pang et al., 2005; Yang et al., 2006) investigated the effect of circuit training on lower extremity muscle strength in patients in the chronic phase of stroke recovery.

The first high quality RCT (Pang et al., 2005) randomized patients to receive the Fitness and Mobility Exercise (FAME) group circuit training program or a seated upper extremity exercise program. Lower extremity muscle strength was measured using a handheld dynamometer (isometric knee extension – paretic/nonparetic leg) at post-treatment (19 weeks). A significant between-group difference in muscle strength of the paretic limb was found, in favour of circuit training vs. seated upper extremity exercises.

The second high quality RCT (Yang et al., 2006) randomized patients to receive individual strength circuit training or no rehabilitation. Lower extremity muscle strength was measured by handheld dynamometer (hip flexors/extensors, knee flexors/extensors, ankle dorsi/plantarflexors – paretic/nonparetic leg) at post-treatment (4 weeks). Significant between-group differences in all measures of lower extremity muscle strength (paretic and nonparetic legs) were found, in favour of circuit training vs. no rehabilitation.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that circuit training is more effective than comparison groups (seated upper extremity exercises, no rehabilitation) for improving lower extremity muscle strength in patients in the chronic phase of stroke recovery.
Note:
One high quality RCT found significant between-group differences in muscle strength of the paretic lower extremity only.

Reflexes
Not Effective
1B

One high quality RCT (Marigold et al., 2005) investigated the effect of circuit training on reflexes in patients in the chronic phase of stroke recovery. This high quality RCT randomized patients to receive group agility circuit training or a stretching and weight-shifting exercise program. Reflexes were measured by postural reflex onset latency (tibialis anterior, rectus femoris, medial head of gastrocnemius, biceps femoris) at post-treatment (10 weeks) and follow-up (1 month post-treatment). A significant between-group difference was found in only one measure (paretic rectus femoris) at post-treatment, in favour of circuit training vs. stretching/weight-shifting exercise. Results did not remain significant at follow-up.
Note: There were significant between-group differences in paretic rectus femoris onset latency at baseline, which were entered as a covariate for statistical analysis.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is not more effective than a comparison intervention (stretching/weight-shifting exercises) for improving reflexes in patients in the chronic phase of stroke recovery.

Self-reported physical activity
Not Effective
1B

One high quality RCT (Mudge, Barber & Stott, 2009) investigated the effect of circuit training on self-reported physical activity in patients in the chronic phase of stroke recovery. This high quality RCT randomized patients to receive group lower extremity circuit training or time-matched social/educational classes. Physical activity was measured by the Physical Activity and Disability Scale at post-treatment (4 weeks) and follow-up (3 months). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is not more effective than a comparison intervention (social/educational classes) for improving self-reported physical activity in patients in the chronic phase of stroke recovery.

Stroke outcomes
Not effective
1b

Two high quality RCTs (Marsden et al., 2010; Moore et al., 2015) investigated the effect of circuit training on stroke outcomes in patients in the chronic phase of stroke recovery.

The first high quality cross-over RCT (Marsden et al., 2010) randomized patients and their carers to receive the Community Living After stroke for Survivors and Carers (CLASSiC*) programme or no intervention. Patients’ stroke outcomes were measured using the stroke Impact Scale (SIS – Communication, Mood/Emotion, ADL/IADL, Hand function, Memory, Mobility, Participation, Strength, Composite Physical, Recovery scores) at post-treatment (7 weeks) and follow-up (21 weeks). No significant between-group differences were found at either time point.
* The CLASSiC program comprised group lower extremity and balance circuit training, social discussion and stroke education sessions.
Note: This pilot study was not adequately powered to detect significant between-group differences.

The second high quality RCT (Moore et al., 2015) randomized patients to receive group fitness and mobility circuit training based on the Fitness and Mobility Exercise (FAME) program or a time-matched home stretching program. stroke outcomes were measured by the SIS (Communication, Mood/Emotion, ADL/IADL, Hand function, Memory, Mobility, Participation, Strength, Composite Physical, Recovery scores) at post-treatment (19 weeks). A significant between-group difference was seen on only two measures (SIS – Mood/Emotion, Recovery), in favour of circuit training vs. home stretching.

Conclusion: There is moderate evidence (level 1b) from two high quality RCT that circuit training is not more effective than no specific intervention or a comparison intervention (home stretching) for improving stroke outcomes in patients in the chronic phase of stroke recovery.
Note: One high quality RCT found differences in recovery and mood/emotion in favour of circuit training vs. home stretching.

Walking endurance - carers
Not effective
1b

One high quality RCT (Marsden et al., 2010) investigated the effect of circuit training on walking endurance among carers of chronic stroke patients. This high quality cross-over RCT randomized patients and their carers to receive the Community Living After stroke for Survivors and Carers (CLASSIC*) programme or no intervention. Carers’ walking endurance was measured by the 6 Minute Walk Test at post-treatment (7 weeks) and follow-up (21 weeks). No significant between-group difference was found at either time point.
* The CLASSiC program comprised group lower extremity and balance circuit training, social discussion and stroke education sessions.
Note: This pilot study was not adequately powered to detect significant between-group differences.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is not more effective than no specific intervention for improving carers’ walking endurance of patients in the chronic phase of stroke recovery.

Walking endurance - patients
Effective
1A

Five high quality RCTs (Pang et al., 2005; Yang et al., 2006; Mudge, Barber & Stott, 2009; Marsden et al., 2010; Moore et al., 2015) and one poor quality RCT (Song, Kim & Park, 2015) investigated the effect of circuit training on walking endurance in patients in the chronic phase of stroke recovery.

The first high quality RCT (Pang et al., 2005) randomized patients to receive the Fitness and Mobility Exercise (FAME) group circuit training program or a seated upper extremity exercise program. Walking endurance was measured by the 6 Minute Walk Test (6MWT) at post-treatment (19 weeks). A significant between-group difference was found, in favour of circuit training vs. seated upper extremity exercises.

The second high quality RCT (Yang et al., 2006) randomized patients to receive individual strength circuit training or no rehabilitation. Walking endurance was measured by the 6MWT at post-treatment (4 weeks). A significant between-group difference was found, in favour of circuit training vs. no rehabilitation.

The third high quality RCT (Mudge, Barber & Stott, 2009) randomized patients to receive group lower extremity circuit training or time-matched social/educational classes. Walking endurance was measured by the 6MWT at post-treatment (4 weeks) and follow-up (3 months). A significant between-group difference was found at post-treatment, in favour of circuit training vs. social/educational classes. Differences did not remain significant at follow-up (3 months).

The fourth high quality cross-over RCT (Marsden et al., 2010) randomized patients and their carers to receive the Community Living After stroke for Survivors and Carers (CLASSIC*) programme or no intervention. Walking endurance was measured by the 6MWT at post-treatment (7 weeks) and follow-up (21 weeks). No significant between-group difference was found at either time point.
* The CLASSiC program comprised group lower extremity and balance circuit training, social discussion and stroke education sessions.
Note: This pilot study was not adequately powered to detect significant between-group differences; results will not be used to contribute to the conclusion below.

The fifth high quality RCT (Moore et al., 2015) randomized patients to receive group fitness and mobility circuit training based on the FAME program or a time-matched home stretching program. Walking endurance was measured by the 6MWT at post-treatment (19 weeks). A significant between-group difference was found, in favour of circuit training vs. home stretching.

The poor quality RCT (Song, Kim & Park, 2015) randomized patients to receive individual upper extremity and mobility circuit training, group upper extremity and mobility circuit training, or no circuit training; all groups received conventional physiotherapy. Walking endurance was measured by the 2 Minute Walk Test at post-treatment (4 weeks). Significant between-group differences were found, in favour of individual circuit training vs. no training, and in favour of group circuit training vs. no training. There was no significant difference between individual vs. group circuit training.

Conclusion: There is strong evidence (level 1a) from four high quality RCTs and one poor quality RCT that circuit training is more effective than comparison groups (seated upper extremity exercise, no rehabilitation, social/educational classes, home stretching, conventional physiotherapy) for improving walking endurance in patients in the chronic phase of stroke recovery.

Walking speed
Conflicting
4

Two high quality RCTs (Mudge, Barber & Stott, 2009; Moore et al., 2015) and one fair quality RCT (Park & Kim, 2016) investigated the effect of circuit training on walking speed in patients in the chronic phase of stroke recovery.

The first high quality RCT (Mudge, Barber & Stott, 2009) randomized patients to receive group lower extremity circuit training or time-matched social/educational classes. Walking speed was measured by the 10-meter walk test at post-treatment (4 weeks) and follow-up (3 months). A significant between-group difference was seen at follow-up only, in favour of circuit training vs. social/educational classes.

The second high quality RCT (Moore et al., 2015) randomized patients to receive group fitness and mobility circuit training based on the based on the Fitness and Mobility Exercise (FAME) program or a time-matched home stretching program. Walking speed was measured by the 10-meter walk test at post-treatment (19 weeks). A significant between-group difference was found, in favour of circuit training vs. home stretching.

The fair quality RCT (Park & Kim, 2016) randomized patients to receive individual gait circuit training or walking rehabilitation on a firm indoor surface. Walking speed was measured by the 10-meter walk test at post-treatment (3 weeks). A significant between-group difference was found, in favour of circuit training vs. indoors walking rehabilitation.

Conclusion: There is conflicting evidence (level 4) regarding the effect of circuit training on walking speed in patients in the chronic phase of stroke recovery. While one high quality RCT and one fair quality RCT found that circuit training was more effective than comparison interventions (home stretching, indoor walking rehabilitation) immediately post-treatment, a second high quality RCT found that circuit training was more effective than a comparison intervention (social/educational classes) only at 3-month follow-up.

Well-being - carers
Not effective
1b

One high quality RCT (Marsden et al., 2010) investigated the effect of circuit training on wellbeing among carers of chronic stroke patients. This high quality cross-over RCT randomized patients and their carers to receive the Community Living After stroke for Survivors and Carers (CLASSiC*) programme or no intervention. Carers’ wellbeing was measured by the Carer Strain Index at post-treatment (7 weeks) and follow-up (21 weeks). No significant between-group difference was found at either time point.
* The CLASSiC program comprised group lower extremity and balance circuit training, social discussion and stroke education sessions.
Note: This pilot study was not adequately powered to detect significant between-group differences.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is not more effective than no specific intervention for improving carers’ wellbeing of patients in the chronic phase of stroke recovery.

Chronic Phase: lower extremity vs. upper extremity circuit training

Balance
Effective
2a

One fair quality RCT (Dean et al., 2000) investigated the effect of circuit training on balance in the chronic phase of stroke recovery. This fair quality RCT randomized patients to receive group lower extremity circuit training or group upper extremity circuit training. Balance was measured by the Step Test at post-treatment (4 weeks) and follow-up (2 months later). A significant between-group difference was found at both time points, in favour of lower extremity circuit training vs. upper extremity circuit training.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that lower extremity circuit training is more effective than upper extremity circuit training for improving balance in the chronic phase of stroke recovery.

Dexterity
Not Effective
2a

One fair quality RCT (Dean et al., 2000) investigated the effect of circuit training on dexterity in patients in the chronic phase of stroke recovery. This fair quality RCT randomized patients to receive group lower extremity circuit training or group upper extremity circuit training. Dexterity was measured by the Purdue Pegboard Test at post-treatment (4 weeks) and follow-up (2 months post-treatment). No significant between-group difference was found at either time point.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that upper extremity circuit training is not more effective than lower extremity circuit training for improving dexterity in patients in the chronic phase of stroke recovery.

Grip strength
Not Effective
2A

One fair quality RCT (Dean et al., 2000) investigated the effect of circuit training on grip strength in patients in the chronic phase of stroke recovery. This fair quality RCT randomized patients to receive group lower extremity circuit training or group upper extremity circuit training. Grip strength was measured by Jamar dynamometer at post-treatment (4 weeks) and follow-up (2 months post-treatment). No significant between-group difference was found at either time point.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that upper extremity circuit training is not more effective than lower extremity circuit training for improving grip strength in patients in the chronic phase of stroke recovery.

Mobility
Not Effective
2a

One fair quality RCT (Dean et al., 2000) investigated the effect of circuit training on mobility in patients in the chronic phase of stroke recovery. This fair quality RCT randomized patients to receive group lower extremity circuit training or group upper extremity circuit training. Mobility was measured by the Timed Up and Go Test at post-treatment (4 weeks) and follow-up (2 months post-treatment). No significant between-group difference was found at either time point.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that lower extremity circuit training is not more effective than upper extremity circuit training for improving mobility in patients in the chronic phase of stroke recovery.

Transfers
Effective
2a

One fair quality RCT (Dean et al., 2000) investigated the effect of circuit training on transfers in patients in the chronic phase of stroke recovery. This fair quality RCT randomized patients to receive group lower extremity circuit training or group upper extremity circuit training. Force production through the affected foot during sit-to-stand (measured by mean peak vertical ground reaction force) was measured at post-treatment (4 weeks) and follow-up (2 months post-treatment). A significant between-group difference was found at both time points, in favour of lower extremity circuit training vs. upper extremity circuit training.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that lower extremity circuit training is more effective than upper extremity circuit training for improving transfers in patients in the chronic phase of stroke recovery.

Walking endurance
Effective
2a

One fair quality RCT (Dean et al., 2000) investigated the effect of circuit training on walking endurance in patients in the chronic phase of stroke recovery. This fair quality RCT randomized patients to receive group lower extremity circuit training or group upper extremity circuit training. Walking endurance was measured by the 6 Minute Walk Test at post-treatment (4 weeks) and follow-up (2 months post-treatment). A significant between-group difference was found at both time points, in favour of lower extremity circuit training vs. upper extremity circuit training.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that lower extremity circuit training is more effective than upper extremity circuit training for improving walking endurance in patients in the chronic phase of stroke recovery.

Walking speed
Effective
2a

One fair quality RCT (Dean et al., 2000) investigated the effect of circuit training on walking speed in patients in the chronic phase of stroke recovery. This fair quality RCT randomized patients to receive group lower extremity circuit training or group upper extremity circuit training. Walking speed was measured by a 10-meter walk test (with assistive device, without assistive device) at post-treatment (4 weeks) and follow-up (2 months post-treatment). A significant between-group difference in walking speed (without an assistive device) was found at both time points, in favour of lower extremity circuit training vs. upper extremity circuit training.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that lower extremity circuit training is more effective than upper extremity circuit training for improving walking speed (when participants are not reliant on an assistive device) in patients in the chronic phase of stroke recovery.

Phase of stroke recovery not specific to one period

Balance
Not effective
1a

Two high quality RCTs (Harrington et al., 2010; Dean et al., 2012) and one poor quality RCT (Ain, Malik & Amjad, 2018b) investigated the effect of circuit training on balance following stroke.

The first high quality RCT (Harrington et al., 2010) randomized patients with subacute/chronic stroke to receive group circuit training + education or standard care. Balance was measured by the Functional Reach test at post-treatment (9 weeks) and follow-up (6 months, 12 months). No significant between-group difference was found at any time point.

The second high quality RCT (Dean et al., 2012) randomized patients with subacute/chronic stroke to receive group mobility circuit training or exercise classes to improve upper extremity function and cognition. Balance was measured using the Step Test (paretic, non-paretic lower extremity), the coordinated stability task and according to maximum balance range (mm), and single-leg stance (paretic, non-paretic lower extremity) at post-treatment (12 months). No significant between-group differences were found.

The poor quality RCT (Ain, Malik & Amjad, 2018b) randomized patients with stroke (time since stroke not specified) to receive group balance + gait circuit training or conventional gait exercise. Balance was measured by the Berg Balance Scale at post-treatment (6 weeks). A significant improvement in balance was found following group balance + gait circuit training.
Note: Between-group differences were not reported; results will not be used to contribute to the conclusion below.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that circuit training is not more effective than comparison interventions (standard care, upper extremity + cognition exercise classes) for improving balance following stroke.

Community participation
Not effective
1b

One high quality RCT (Dean et al., 2012) investigated the effect of circuit training on community participation following stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive group mobility circuit training or exercise classes to improve upper extremity function and cognition. Community participation was measured using the Adelaide Activities Profile (AAP – Domestic chores, Household maintenance, Service to others, Social Activities scores) at post-treatment (12 months). A significant between-group difference was found on one measure of community participation (AAP – Service to others), in favour of circuit training vs. upper extremity + cognition exercise classes. However, there was a significant between-group difference in another aspect of community participation (AAP – Social Activities), in favour of upper extremity + cognition exercise classes vs. circuit training.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is not more effective than a comparison intervention (upper extremity + cognition exercise classes) for improving community participation following stroke.
Note:
The high quality RCT found that circuit training participants engaged more in service to others, whereas upper extremity + cognition exercise class participants engaged in more social Activities.

Emotional well-being
Not effective
1b

One high quality RCT (Harrington et al., 2010) investigated the effect of circuit training on the emotional wellbeing following stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive group circuit training + education or standard care. Emotional wellbeing was measured using the Hospital Anxiety and Depression Scale (Anxiety, Depression, Total scores) at post-treatment (9 weeks) and follow-up (6 months, 12 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 circuit training + education is not more effective than a comparison intervention (standard care) for improving emotional wellbeing following stroke.

Falls
Not effective
1b

One high quality RCT (Dean et al., 2012) and one poor quality RCT (Ain, Malik & Amjad, 2018b) investigated the effect of circuit training on falls following stroke.

The high quality RCT (Dean et al., 2012) randomized patients with subacute/chronic stroke to receive group mobility circuit training or exercise classes to improve upper extremity function and cognition. Falls were measured according to the number of falls over 12 months and fall rates, and falls risk was measured by the Short Form Physiological Profile Assessment and by choice stepping reaction time at post-treatment (12 months). A significant between-group difference was found on only one measure (choice stepping reaction time), in favour of circuit training vs. upper extremity + cognition exercise classes.

The poor quality RCT (Ain, Malik & Amjad, 2018b) randomized patients with stroke (time since stroke not specified) to receive group balance + gait circuit training or conventional gait exercise. Falls efficacy was measured by the Falls Efficacy Scale at post-treatment (6 weeks). A significant improvement in falls efficacy was found following group balance and gait circuit training.
Note: Between-group differences were not reported; results will not be used to contribute to the conclusion below.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is not more effective than a comparison intervention (upper extremity + cognition exercise classes) for reducing falls following stroke.

Gait parameters
Effective
2a

One fair quality RCT (Ain et al., 2018a) investigated the effect of circuit training on walking parameters following stroke. This fair quality RCT randomized patients with stroke (time since stroke not specified) to receive group balance + gait circuit training or traditional gait training. gait parameters (cadence, step length, step width) were measured at post-treatment (6 weeks). Significant between-group differences were found on all measures, in favour of circuit training vs. traditional gait training.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that circuit training is more effective than a comparison intervention (traditional gait training) for improving gait parameters following stroke.

Health-related quality of life
Not effective
1b

One high quality RCT (Harrington et al., 2010) investigated the effect of circuit training on the health-related quality of life following stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive group circuit training + education or standard care. Health-related quality of life was measured by the WHOQoL-Bref (Physical, Psychological, Social, Environmental scores) at post-treatment (9 weeks) and follow-up (6 months, 12 months). There was a significant between-group difference in one measure of health-related quality of life (WHOQoL-Bref – Psychological score) at 6-month follow-up only, in favour of circuit training + education vs. standard care.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training + education is not more effective than a comparison intervention (standard care) for improving health-related quality of life following stroke.

Instrumental Activities of Daily Living
Not effective
1b

One high quality RCT (Harrington et al., 2010) investigated the effect of circuit training on instrumental activities of daily living (IADLs) following stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive group circuit training + education or standard care. IADLs were measured using the Frenchay activities Index at post-treatment (9 weeks) and follow-up (6 months, 12 months). No significant between-group difference was seen at any time point.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training + education is not more effective than a comparison intervention (standard care) for improving instrumental activities of daily living following stroke.

Knee strength
Not effective
1b

One high quality RCT (Dean et al., 2012) investigated the effect of circuit training on knee strength following stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive group mobility circuit training or exercise classes to improve upper extremity function and cognition. Isometric muscle strength of the paretic and non-paretic knee was measured at post-treatment (12 months). A significant between-group difference in knee strength (non-paretic leg only) was found, in favour of circuit training vs. upper extremity + cognition exercise classes.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is not more effective than a comparison intervention (upper extremity + cognition exercise classes) for improving paretic knee strength following stroke.

Mobility
Not effective
1a

Two high quality RCTs (Harrington et al., 2010; Dean et al., 2012) and one fair quality RCT (Ain et al., 2018a) investigated the effect of circuit training on mobility following stroke.

The first high quality RCT (Harrington et al., 2010) randomized patients with subacute/chronic stroke to receive group circuit training + education or standard care. Mobility was measured using the Rivermead Mobility Index and the Timed Up and Go Test (TUG) at post-treatment (9 weeks) and follow-up (6 months, 12 months). No significant between-group difference was seen at any time point.

The second high quality RCT (Dean et al., 2012) randomized patients with subacute/chronic stroke to receive group mobility circuit training or exercise classes to improve upper extremity function and cognition. Mobility was measured using the TUG at post-treatment (12 months). No significant between-group difference was found.

The fair quality RCT (Ain et al., 2018a) randomized patients with stroke (time since stroke not specified) to receive group balance + gait circuit training or traditional gait training. Mobility was measured by the TUG at post-treatment (6 weeks). A significant between-group difference was found, in favour of circuit training vs. traditional gait training.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that circuit training is not more effective than a comparison intervention (standard care, upper extremity function and cognition exercise classes) for improving mobility following stroke.
Note:
However, one fair quality RCT found a significant difference in mobility in favour of circuit training vs. traditional gait training.

Physical activity
Not effective
1b

One high quality RCT (Dean et al., 2012) investigated the effect of circuit training on physical activity following stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive group mobility circuit training or exercise classes to improve upper extremity function + cognition. Physical activity was measured according to steps/day (7-day pedometer count) at post-treatment (12 months). No significant between-group difference was found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is not more effective than a comparison intervention (upper extremity + cognition exercise classes) for improving physical activity following stroke.

Quality of life
Not effective
1b

One high quality RCT (Dean et al., 2012) and one poor quality RCT (Ain, Malik & Amjad, 2018b) investigated the effect of circuit training on quality of life following stroke.

The high quality RCT (Dean et al., 2012) randomized patients with subacute/chronic stroke to receive group mobility circuit training or exercise classes to improve upper extremity function and cognition. Quality of life was measured by the Short Form-12 version 2 (Physical Composite score, Mental Composite score) at post-treatment (12 months). No significant between-group differences were found.

The poor quality RCT (Ain, Malik & Amjad, 2018b) randomized patients with stroke (time since stroke not specified) to receive group balance and gait circuit training or conventional gait exercise. Quality of life was measured by the Stroke-Specific Quality of Life Scale at post-treatment (6 weeks). No significant changes in quality of life were found.
Note: Between-group differences were not reported; results will not be used to contribute to the conclusion below.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is not more effective than a comparison intervention (upper extremity + cognition exercise classes) for improving quality of life following stroke.

Stroke outcomes
Effective
1b

One high quality RCT (Harrington et al., 2010) investigated the effect of circuit training on stroke outcomes following stroke.This high quality RCT randomized patients with subacute/chronic stroke to receive group circuit training + education or standard care. stroke outcomes were measured using the Subjective Index of Physical and Social Outcome (SIPSO – Physical, Social, Total scores) at post-treatment (9 weeks) and follow-up (6 months, 12 months). There was a significant between-group difference in one measure of stroke outcomes (SIPSO – Physical) at post-treatment and again at 12-month follow-up, in favour of circuit training vs. standard care.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is more effective than a comparison intervention (standard care) for improving physical stroke outcomes following stroke.

Transfers
Not effective
1b

One high quality RCT (Dean et al., 2012) investigated the effect of circuit training on transfers following stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive group mobility circuit training or exercise classes to improve upper extremity function and cognition. Transfers were measured using the Five Times Sit-to-Stand Test at post-treatment (12 months). No significant between-group difference was found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is not more effective than a comparison intervention (upper extremity + cognition exercise classes) for improving transfers following stroke.

Walking endurance
Effective
1b

One high quality RCT (Dean et al., 2012) investigated the effect of circuit training on walking endurance following stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive group mobility circuit training or exercise classes to improve upper extremity function and cognition. Walking endurance was measured by the 6 Minute Walk Test at post-treatment (12 months). A significant between-group difference was found, in favour of circuit training vs. upper extremity + cognition exercise classes.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is more effective than a comparison intervention (upper extremity + cognition exercise classes) for improving walking endurance following stroke.

Walking speed
Effective
1b

One high quality RCT (Dean et al., 2012) investigated the effect of circuit training on walking speed following stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive group mobility circuit training or exercise classes to improve upper extremity function and cognition. Walking speed was measured by a 10-meter walk test (comfortable walking speed, fast walking speed) at post-treatment (12 months). A significant between-group difference was found (fast walking speed only), in favour of circuit training vs. upper extremity + cognition exercise classes.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is more effective than a comparison intervention (upper extremity + cognition exercise classes) for improving walking speed following stroke.

Well-being - carers
Not effective
1b

One high quality RCT (Harrington et al., 2010) investigated the effect of circuit training on wellbeing among carers of stroke patients. This high quality RCT randomized patients with subacute/chronic stroke to receive group circuit training + education or standard care. Carer wellbeing was measured by the Carer Strain Index at post-treatment (9 weeks) and follow-up (6 months, 12 months). No significant between-group difference was seen at any time point.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that circuit training is not more effective than a comparison intervention (standard care) for improving wellbeing among carers of patients with subacute or chronic stroke.

Phase of stroke recovery not specific to one period: lower extremity vs upper extremity circuit training

Balance
Not effective
1b

One high quality RCT (Salbach et al., 2004) investigated the effect of circuit training on balance following stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive group mobility circuit training or group upper extremity circuit training. Balance was measured by the Berg Balance Scale at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that mobility circuit training is not more effective than upper extremity circuit training for improving balance following stroke.

Mobility
Not effective
1b

One high quality RCT (Salbach et al., 2004) investigated the effect of circuit training on mobility following stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive group mobility circuit training or group upper extremity circuit training. Mobility was measured by the Timed Up and Go Test at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that mobility circuit training is not more effective than upper extremity circuit training for improving mobility following stroke.

Walking endurance
Effective
1b

One high quality RCT (Salbach et al., 2004) investigated the effect of circuit training on walking endurance following stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive group mobility circuit training or group upper extremity circuit training. Walking endurance was measured by the 6 Minute Walk Test at post-treatment (4 weeks). A significant between-group difference was found, in favour of mobility circuit training vs. upper extremity circuit training.
Note: Between-group differences in walking endurance were largest in a subgroup of people with moderate walking deficit (0.3-0.7m/s), and smallest in a subgroup of people with a severe walking deficit (<0.3m/s).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that mobility circuit training is more effective than upper extremity circuit training for improving walking endurance following stroke.

Walking speed
Effective
1b

One high quality RCT (Salbach et al., 2004) investigated the effect of circuit training on walking speed following stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive group mobility circuit training or group upper extremity circuit training. Walking speed was measured by a 5-meter walk test (comfortable walking speed, maximum walking speed) at post-treatment (4 weeks). Significant between-group differences in comfortable and maximum walking speeds were found, in favour of mobility circuit training vs. upper extremity circuit training.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that mobility circuit training is more effective than upper extremity circuit training for improving walking speed following stroke.

References

Ain, Q., Malik, A. N., & Amjad, I. (2018a). Effect of circuit gait training vs traditional gait training on mobility performance in stroke. Journal of the Pakistan Medical Association, 68, 455-8. https://www.ncbi.nlm.nih.gov/pubmed/29540885

Ain, Q., Malik, A. N., Haq, U., & Ali, S. (2018b). Effect of task specific circuit training on gait parameters and mobility in stroke survivors. Pakistan Journal of Medical Sciences, 34, 1300-3. https://www.ncbi.nlm.nih.gov/pubmed/30344596

Blennerhassett, J. & Dite, W. (2004). Additional task-related practice improves mobility and upper limb function early after stroke: a randomised controlled trial. Australian Journal of Physiotherapy, 50, 219-24. https://www.ncbi.nlm.nih.gov/pubmed/15574110

Bonini-Rocha, A. C., de Andrade, A. L. S., Moraes, A. M., Matheus, L. B. G., Diniz, L. R., & Martins, W. R. (2018). Effectiveness of circuit-based exercises on gait speed, balance, and functional mobility in people affected by stroke: a meta-analysis. Physical Medicine & Rehabilitation, 10, 398-409. https://www.ncbi.nlm.nih.gov/pubmed/29111465

Dean, C.M., Richards, C.L., & Malouin, F. (2000). Task-related circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial. Archives of Physical Medicine and Rehabilitation, 81, 409-17. https://www.ncbi.nlm.nih.gov/pubmed/10768528

Dean, C. M., Rissel, C., Sherrington, C., Sharkey, M., Cumming, R. G., Lord, S. R., … & O’Rourke, S. (2012). Exercise to enhance mobility and prevent falls after stroke: the community stroke club randomized trial. Neurorehabilitation and Neural Repair, 26, 1046-57. https://www.ncbi.nlm.nih.gov/pubmed/22544817

English, C. & Hillier, S.L. (2010). Circuit class therapy for improving mobility after stroke. Cochrane Database of Systematic Reviews, Issue 7. Art. No.: CD007513. DOI: 10.1002/14651858.CD007513.pub2. https://www.ncbi.nlm.nih.gov/pubmed/20614460

English, C.K., Hillier, S.L., Stiller, K.R., & Warden-Flood, A. (2007). Circuit class therapy versus individual physiotherapy sessions during inpatient stroke rehabilitation: a controlled trial. Archives of Physical Medicine and Rehabilitation, 88, 955-63. https://www.ncbi.nlm.nih.gov/pubmed/17678655

English, C., Hillier, S., & Stiller, K. (2008). Incidence and severity of shoulder pain does not increase with the use of circuit class therapy during inpatient stroke rehabilitation: a controlled trial. Australian Journal of Physiotherapy, 54, 41-6. https://www.ncbi.nlm.nih.gov/pubmed/18298358

English, C., Bernhardt, J., Crotty, M., Esterman, A., Segal, L., & Hillier, S. (2015). Circuit class therapy or seven‐day week therapy for increasing rehabilitation intensity of therapy after stroke (CIRCIT): a randomized controlled trial. International Journal of Stroke, 10, 594-602. https://www.ncbi.nlm.nih.gov/pubmed/25790018

English, C., Hillier, S. L., & Lynch, E. A. (2017). Circuit class therapy for improving mobility after stroke. Cochrane Database of Systematic Reviews, Issue 6. Art. No.:CD007513. DOI: 10.1002/14651858.CD007513.pub3. https://www.ncbi.nlm.nih.gov/pubmed/28573757

Harrington, R., Taylor, G., Hollinghurst, S., Reed, M., Kay, H., & Wood, V. A. (2010). A community-based exercise and education scheme for stroke survivors: a randomized controlled trial and economic evaluation. Clinical Rehabilitation, 24, 3-15. https://www.ncbi.nlm.nih.gov/pubmed/20026571

Kim, S. M., Han, E. Y., Kim, B. R., & Hyun, C. W. (2016). Clinical application of circuit training for subacute stroke patients: a preliminary study. Journal of Physical Therapy Science, 28, 169-74. https://www.ncbi.nlm.nih.gov/pubmed/26957751

Kim, K., Jung, S. I., & Lee, D. K. (2017). Effects of task-oriented circuit training on balance and gait ability in subacute stroke patients: a randomized controlled trial. Journal of Physical Therapy Science, 29, 989-92. https://www.ncbi.nlm.nih.gov/pubmed/28626306

Marigold, D.S., Eng, J.J., Dawson, A.S., Inglis, J.T., Harris, J.E., & Gylfadottir, S. (2005). Exercise leads to faster postural reflexes, improved balance and mobility, and fewer falls in older persons with chronic stroke. Journal of the American Geriatrics Society, 53, 416-23. https://www.ncbi.nlm.nih.gov/pubmed/15743283

Marsden, D., Quinn, R., Pond, N., Golledge, R., Neilson, C., White, J., … & Pollack, M. (2010). A multidisciplinary group programme in rural settings for community-dwelling chronic stroke survivors and their carers: a pilot randomized controlled trial. Clinical Rehabilitation, 24, 328-41. https://www.ncbi.nlm.nih.gov/pubmed/20176772

Moon, J. H., Park, K. Y., Kim, H. J., & Na, C. H. (2018). The Effects of Task-Oriented Circuit Training Using Rehabilitation Tools on the Upper-Extremity Functions and Daily Activities of Patients with Acute Stroke: A Randomized Controlled Pilot Trial. Osong Public Health and Research Perspectives, 9, 225-30. https://www.ncbi.nlm.nih.gov/pubmed/30402377

Moore, S. A., Hallsworth, K., Jakovljevic, D. G., Blamire, A. M., He, J., Ford, G. A., … & Trenell, M. I. (2015). Effects of community exercise therapy on metabolic, brain, physical, and cognitive function following stroke: a randomized controlled pilot trial. Neurorehabilitation and Neural Repair, 29, 623-35. https://www.ncbi.nlm.nih.gov/pubmed/25538152

Mudge, S., Barber, P.A., & Stott, S. (2009). Circuit-based rehabilitation improves gait endurance but not usual walking activity in chronic stroke: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 90, 1989-96. https://www.ncbi.nlm.nih.gov/pubmed/19969159

Pang, M.Y.C., Eng, J.J., Dawson, A.S., McKay, H.A., & Harris, J.E. (2005). A community-based fitness and mobility exercise program for older adults with chronic stroke: a randomized, controlled trial. Journal of the American Geriatric Society, 53, 1667-74. https://www.ncbi.nlm.nih.gov/pubmed/16181164

Park, K. T., & Kim, H. J. (2016). Effect of the a circuit training program using obstacles on the walking and balance abilities of stroke patients. Journal of Physical Therapy Science, 28, 1194-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4868212/

Renner, C. I., Outermans, J., Ludwig, R., Brendel, C., Kwakkel, G., & Hummelsheim, H. (2016). Group therapy task training versus individual task training during inpatient stroke rehabilitation: A randomised controlled trial. Clinical Rehabilitation, 30, 637-48. https://www.ncbi.nlm.nih.gov/pubmed/26316552

Rose, D., Paris, T., Crews, E., Wu, S.S., Sun, A., Behrman, A.L., & Duncan, P. (2011). Feasibility and effectiveness of circuit training in acute stroke rehabilitation. Neurorehabilitation and Neural Repair, 25(2), 140-8. https://www.ncbi.nlm.nih.gov/pubmed/21051764

Salbach, N.M., Mayo, N.E., Wood-Dauphinee, S., Hanley, J.A., Richards, C.L., & Cote, R. (2004). A task-oriented intervention enhances walking distance and speed in the first year post-stroke: a randomized controlled trial.  Clinical Rehabilitation, 18, 509-19. https://www.ncbi.nlm.nih.gov/pubmed/15293485

Song, H. S., Kim, J. Y., & Park, S. D. (2015). Effect of the class and individual applications of task-oriented circuit training on gait ability in patients with chronic stroke. Journal of Physical Therapy Science, 27, 187-9. https://www.ncbi.nlm.nih.gov/pubmed/25642070

van de Port, I.G.L., Wevers, L.E.G., Lindeman, E., & Kwakkel, G. (2012). Effects of circuit training as alternative to usual physiotherapy after stroke: randomised controlled trial. British Medical Journal, 344, e2672. https://www.ncbi.nlm.nih.gov/pubmed/22577186

Verma, R., Arya, K.N., Garg, R.K., & Singh, T. (2011). Task-oriented circuit class training program with motor imagery for gait rehabilitation in poststroke patients: a randomized controlled trial. Topics in Stroke Rehabilitation, 18(Suppl 1), 620-32. https://www.ncbi.nlm.nih.gov/pubmed/22120031

Wevers, L., van de Port, I., Vermue, M., Mead, G., & Kwakkel, G. (2009). Effects of task-oriented circuit class training on walking competency after stroke: a systematic review. Stroke, 40, 2450-9. DOI: 10.1161/STROKEAHA.108.541946. https://www.ncbi.nlm.nih.gov/pubmed/19461035

Yang, Y-R., Wang, R-Y., in, K-H., Chu, M-Y., & Chan, R-C. (2006). Task-oriented progressive resistance strength training improves muscle strength and functional performance in individuals with stroke. Clinical Rehabilitation, 20, 860-70. https://www.ncbi.nlm.nih.gov/pubmed/17008338

 

Excluded Studies:

Holmgren, E., Gosman-Hedström, G., Lindström, B., & Wester, P. (2010). What is the benefit of a high-intensive exercise program on health-related quality of life and depression after stroke? A randomized controlled trial. Advances in Physiotherapy12, 125-33. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2956448/

Reason for exclusion: This paper insufficiently detailed their intervention and it is unclear whether circuit training was used.

Kim, B., Park, Y., Seo, Y., Park, S., Cho, H., Moon, H., … & Yu, J. (2016). Effects of individualized versus group task-oriented circuit training on balance ability and gait endurance in chronic stroke inpatients. Journal of Physical Therapy Science, 28, 1872-5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4932078/

Reason for exclusion: Both groups received circuit training in different formats.

Mead, G.E., Greig, C.A., Cunningham, I., Lewis, S.J., Dinan, S., Saunders, D.H., Fitzsimons, C., & Young, A. (2007). Stroke: a randomized trial of exercise or relaxation. Journal of the American Geriatrics Society, 55, 892-9. https://pubmed.ncbi.nlm.nih.gov/17537090/

Reason for exclusion: This paper compared exercise circuit training (intervention) to relaxation (attention-matched control). Exercises were performed in a circuit format but were not task-specific, focusing instead on improving physical ability (e.g. bicycle ergonometry).

Outermans, J.C., van Peppen, R.P.S., Wittink, H., Takken, T., & Kwakkel, G. (2010). Effects of a high-intensity task-oriented training on gait performance early after stroke: a pilot study. Clinical Rehabilitation, 24, 979-87. https://pubmed.ncbi.nlm.nih.gov/20719820/

Reason for exclusion: This paper compared high intensity task-oriented training with low-intensity physiotherapy, where both groups were performed as circuit training. The focus of the study was intervention intensity.

Tang, A., Eng, J. J., Krassioukov, A. V., Madden, K. M., Mohammadi, A., Tsang, M. Y., & Tsang, T. S. (2014). Exercise-induced changes in cardiovascular function after stroke: a randomized controlled trial. International Journal of Stroke, 9, 883-9. https://www.ncbi.nlm.nih.gov/pubmed/24148695

Reason for exclusion: This paper insufficiently detailed their intervention and it is unclear whether circuit training was used.

Critical Care Pathways

Evidence Reviewed as of before: 22-11-2011
Author(s)*: Robert Teasell, MD; Norine Foley, BASc; Sanjit Bhogal, MSc; Mark Speechley, MD; Chelsea Hellings
Patient/Family Information Table of contents

Introduction

A care pathway is a goal-oriented, high-quality plan of care based on evidence/best practice guidelines. Care pathways were introduced in an attempt to improve the quality and consistency of stroke rehabilitation.

Care pathways should, intuitively, improve the quality of stroke care; however, surprisingly, evidence does not support this conclusion. It is not clear why this occurs. Care pathways may simply reinforce rather than change practice. This suggests that imposing a blueprint of care, rather than individualizing treatment, does not improve outcomes. Therefore, although organized interdisciplinary stroke rehabilitation units have been shown to improve outcomes, Care pathways do not appear to be contributing to this success.

Patient/Family Information

Author: Marc-André Roy, MSc

What is a critical care pathway?

Critical care pathways are designed to offer organized and efficient care based on research. The goal is to make sure each person with a stroke receives important tests and treatments.

Spoiler title

Critical care pathways differ from “normal” stroke care by following a written care plan. This plan is designed especially for persons with stroke. In most cases, checklists are created for each healthcare professional (doctors, nurses and therapists). These checklists are used to improve communication between these professionals and to make sure specific tests and treatments are done. They also help the healthcare professionals make decisions about the best treatment for an individual.

Is it better to receive treatment from a critical care pathway?

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. If you have or suspect you have a medical problem, promptly contact your professional 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.

Seven studies were included in this review of critical care pathway for stroke. Of the seven studies, one was a Cochrane Systematic Review, three were fair quality RCTs and one was a cohort study.

Care pathways are often investigated using a comparison to a conventional, multidisciplinary mode of care. Outcomes compared and results are summarized below.

Results Table

View results table

Outcomes

Frequency of stroke-related assessment
Effective
1b

One high quality RCT (Sulch et al. 2002b) and one non-randomized study (Kwan et al. 2004b) investigated the effect of care pathways on the frequency of stroke-related assessments (i.e. nutritional assessments, tests of inattention and CT brain scans). An increased frequency of assessment was reported for those who had received care pathway interventions post-stroke.

Conclusion: There is moderate (Level 1b) evidence from one high quality RCT that care pathways increase the frequency of stroke-related assessments post-stroke.

Functional ability
Not effective
1B

One high quality randomized control trial (RCT) (Sulch et al. 2000), and one non-randomized study (Hamrin et al. 1990), have investigated the efficacy of care pathways for improving functional ability post-stroke. No significant differences were found between groups.

Conclusion: There is moderate (Level 1b) evidence from one high quality RCT, that care pathways do not improve functional ability post-stroke.

Hospital costs
Not effective
2a

One fair quality RCT (Falconer et al. 1993) examined cost for usual care versus care in a care pathway. Care pathways did not reduce hospital costs.

Conclusion: There is limited (Level 2a) evidence from one fair quality RCT that Care pathways do not reduce hospital costs in comparison to conventional care for stroke patients.

Independence at discharge
Not effective
2A

One fair quality RCT (Falconer et al. 1993) investigated the use of care pathways for improving functional independence at discharge compared to regular therapy. There was no significant difference between groups as measured using the FIM.

Conclusion: There is limited (Level 2a) evidence from one fair quality RCT that care pathways do not increase patient independence at discharge.

Institutionalization
Not effective
1B

One high quality RCT (Sulch et al. 2000) and two non-randomized studies (Kwan et al. 2004b; Hamrin et al. 1990) investigated the use of care pathways on frequency of institutionalization compared to regular therapy. There were no significant differences in institutionalization between groups in the three studies.

Conclusion: There is moderate (Level 1b) evidence from one high quality RCT that care pathways do not reduce frequency of institutionalization post-stroke.

Length of hospital stay (LOS)
Not effective
1B

Two RCTs, one of high quality (Sulch et al. 2000) and one of fair quality (Falconer et al. 1993), and one non-randomized study (Kwan et al. 2004b) have investigated the effectiveness of care pathways in decreasing length of hospital stay (LOS) post-stroke. None of the three studies demonstrated shortened length of stay with the use of care pathways.

Conclusion: There is moderate (Level 1b) evidence from one high quality RCT and one fair quality RCT that care pathways do not decrease the length of stay in hospital post-stroke.

Mortality
Not effective
1B

One high quality RCT (Sulch et al. 2000) and two non-randomized studies (Hamrin et al. 1990; Kwan et al. 2004b) investigated the relationship between care pathways and mortality rates. No significant difference in mortality was observed between the group receiving care through a care pathway and the group receiving regular therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that care pathways do not reduce mortality rates of stroke patients.

Patient satisfaction
No evidence
5

One fair quality RCT (Falconer et al. 1993) investigated the relationship between care pathway interventions and patient satisfaction. Significant differences were observed between groups for patient satisfaction on measures of general satisfaction in favor of the care pathway treatment group. No significant differences were noted on other satisfaction measures within the satisfaction questionnaire.

However, this study will not be included in the determination of the level of evidence for two reasons. First, the scale used to measure satisfaction was designed specifically for this study and has not been validated. Furthermore, in 46 of 80 cases (58%), family members completed the questionnaire (proxy respondent) because the patients had comprehension difficulties.

Conclusion: There is no evidence (level 5) that care pathways affect patient satisfaction post-stroke.

Preventing urinary tract infection
Effective
2B

One systematic review (Kwan and Sandercock, 2004) reported that patients managed with a care pathway were less likely to experience a urinary tract infection. However, the results were derived from non-randomized studies.

Conclusion: There is limited (Level 2b) evidence that care pathways decrease the rate of urinary tract infection.

Readmission
Effective
2B

One systematic review (Kwan and Sandercock, 2004) reported that patients managed with a care pathways were less likely to be readmitted to hospital. However, the results were derived from non-randomized studies.

Conclusion: There is limited (Level 2b) evidence that care pathways decrease readmission after discharge.

Self-perceived health status/Quality of life
Not effective
1b

One high quality RCT (Sulch et al. 2000) has investigated the efficacy of care pathways for improving self-perceived health status post-stroke. Patients treated using conventional care methods scored higher (better) on the Euro-QoL Visual Analogue Scale compared to patients treated within an Integrated Care Pathway (ICP) model of care.

Conclusion: There is moderate (Level 1b) evidence from one high quality RCT that care pathways reduce self-perceived health status/quality of life post-stroke.

References

Falconer J. A., Roth E. J., Sutin J. A., Strasser D. C., & Chang, R. W. (1993). The critical path method in stroke rehabilitation: lessons from an experiment in cost containment and outcome improvement. QRB Qual Rev Bull, 19(1), 8-16.

Hamrin E. K., & Lindmark, B. (1990). The effect of systematic care planning after acute stroke in general hospital medical wards. J Adv Nurs, 15(10), 1146-1153.

Kwan J., Hand P., Dennis M., & Sandercock, P. (2004). Effects of introducing an integrated care pathway in an acute stroke unit. Age Ageing, 33(4), 362-367.

Sulch D., & Kalra, L. (2000). Integrated care pathways in stroke management. Age Ageing, 29(4), 349-352.

Sulch D., Evans A., Melbourn A., & Kalra, L. (2002b). Does an integrated care pathway improve processes of care in stroke rehabilitation? A randomized controlled trial. Age Ageing, 31(3), 175-179.

Sulch D., Melbourn A., Perez I., & Kalra, L. (2002a). Integrated care pathways and quality of life on a stroke rehabilitation unit. Stroke, 33(6), 1600-1604.

Early Supported Discharge

Evidence Reviewed as of before: 21-12-2012
Author(s)*: Tatiana Ogourtsova, MSc OT; Annabel McDermott, OT; Nicol Korner- Bitensky, PhD OT
Table of contents

Introduction

A stroke can impact on different person’s abilities and rehabilitation is frequently required in order to attempt to improve the affected functions. Currently, the rehabilitation services are mostly provided within the hospital or rehabilitation center settings. Early supported discharge is an innovative approach to rehabilitation where the services are provided at home by a mobile rehabilitation team. This module provides information on the effectiveness of early supported discharge in managing patients’ and carers’ outcomes after stroke.

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 important to note that while in most instances ESD was not more effective than conventional care it was as effective as conventional care. Thus, ESD can be considered as a cost-effective option that results in comparable outcomes to conventional care.

We have reviewed 15 studies (nine high quality RCTs, three fair quality RCTs, one poor quality RCT, two quasi experimental studies) that have investigated the effectiveness of early supported discharge for patient and carer outcomes following stroke. While early supported discharge was not more effective than conventional care for most outcomes, there are very few instances where it is less effective than conventional care. Early supported discharge was shown to be less effective than conventional care on outcomes including carers’ participation household maintenance activities, carers’ mental health and social functioning, and patients’ literal paraphrasia scores. Overall there were no significant differences between early supported discharge and conventional care for other patient outcomes including aphasia, cognition, functional independence, balance and mobility, upper extremity function, spasticity and stroke severity, nor patient/carer outcomes regarding emotional wellbeing, family dynamics, health-related quality of life, health status and service satisfaction. However, early supported discharge was more effective than conventional care for improving patients’ motor capacity and quality of care provided by carers. Interestingly, early supported discharge was also more effective for improving functional independence and stroke severity in subgroup analyses of patients with moderate to severe stroke. Most studies also reviewed the impact on process measures. Not surprisingly, early supported discharge resulted in significantly shorter length of hospital stay than conventional care. Overall there were no significant differences between early supported discharge and conventional care for other process measures including rate of readmission, institutionalisation, use of health services, death, dependency or adverse events.

Results Table

View results table

Outcomes

Early supported discharge vs. control or alternative treatments

Activity participation - carers
Not effective
1B

One high quality RCT (Anderson et al., 2000) investigated the effects of early supported discharge on activity participation among carers of patients with stroke. This high quality RCT randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. There was a significant between-group difference in carers’ activity participation (Adelaide Activity Profile – household maintenance activities only) at 6 months post-stroke, in favour of conventional care compared to early supported discharge.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that early supported discharge is not more effective than conventional care for improving carers’ activity participation. In fact, early supported discharge was less effective than conventional care for improving carers’ participation in household maintenance activities.

Activity participation - patients
Not effective
1A

Four high quality RCTs (Widén Holmqvist et al., 1998, – von Koch et al., 2000 6-month follow-up study, von Koch et al., 2001 12-month follow-up study, Thorsén et al., 2005 5-year follow-up study – ; Anderson et al., 2000; Indredavik et al., 2000Fjærtoft et al, 2004 1-year follow-up study; Fjærtoft et al, 2011 5-year follow-up study –; and Mayo et al., 2000) investigated the effects of early supported discharge on activity participation among patients with stroke.

The first high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. There was no significant between-group difference in patients’ activity participation (Frenchay Activities Index) at 3 months post-stroke.

A 6-month follow-up to the study by Widén Holmqvist et al. (1998) (von Koch et al., 2000) revealed a significant between-group difference in only one activity (Frenchay Activities Index washing subscore), in favour of early supported discharge compared to conventional rehabilitation.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) found no significant between-group differences in patients’ activity participation (Frenchay Activities Index) at 12 months post-stroke.

A 5-year follow-up to the study by Widén Holmqvist et al., (1998) (Thorsén et al., 2005) found significant between-group differences in patients’ activity participation (Frenchay Activities Index washing dishes, washing clothes and reading books subscores) at 5 years post-stroke, favoring early supported discharge compared to conventional care.

The second high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in patients’ activity participation (Adelaide Activity Profile) at 6 months post-stroke.

The third high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form the stroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. Patients’ activity participation was reported in a one-year follow-up study (Fjæroft et al, 2004). There were no significant between-group differences in activity participation (Frenchay Activity Index) at 1 year post-stroke.

A five-year follow-up to the study by Indredavik et al. (2000) (Fjærtoft et al, 2011) also revealed no significant between-group difference in patients’ activity participation (Frenchay Activities Index) at 5 years post-stroke.

The fourth high quality RCT (Mayo et al., 2000) randomized patients with acute stroke to receive prompt discharge and home rehabilitation or usual care. The intervention group received home-based rehabilitation and nursing services for 4 weeks. There was a significant between-group difference in patients’ social participation (Reintegration to Normal Living Index) in favour of prompt discharge compared to usual care at post-treatment (4 weeks), but differences did not remain significant at follow-up (3 months).

Conclusion: There is strong evidence (level 1a) from three high quality RCTs that early supported discharge is not more effective than conventional care for improving patient’s activity participation.

Note: A fourth high quality RCT reported a significant difference in social participation in favour of prompt discharge and home rehabilitation compared to usual care, although results did not remain significant long-term. This study used a measure of social participation (Reintegration to Normal Living Index) different to the measures of activity participation used in other studies (Adelaide Activities Profile and Frenchay Activities Index), which may account for this discrepancy in results among studies.

Adverse events
Not effective
1b

One high quality RCT (Anderson et al., 2000) investigated the effects of early supported discharge on process measures (adverse events) following stroke. This high quality RCT randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. Process measures included length of stay/total bed days, use of health services, institutionalization, frequency of readmissions and incidence of adverse events (death or falls). This study only reported results at 6-month follow-up. Significant between-group differences were found in length of stay/total bed days only, favoring early supported discharge compared to conventional care. There were no other significant between-group differences in patient outcomes at 6 months.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that there is no significant difference in incidence of adverse events between early supported discharge and conventional care.

Aphasia
Not effective
1B

One high quality RCT (Widén Holmqvist et al., 1998 and von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies) and one fair quality RCT (Rudd et al., 1997) investigated the effect of early supported discharge on aphasia in patients with acute stroke.

The high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. There was no significant between-group difference in patients’ aphasia (aphasia Quotient) at 3 months post-stroke.

A 6-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2000) revealed a significant between-group difference in aphasia (Reinvang aphasia Test literal paraphrasia subscore only), favoring conventional therapy compared to early supported discharge.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) found no significant between-group differences in aphasia (Reinvang aphasia Test) at 12 months post-stroke.

A 5-year follow-up to the study by Widén Holmqvist et al., (1998) (Thorsén et al., 2005) found no significant between-group differences in aphasia (Reinvang aphasia Test ) at 5 years post-stroke.

The fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. There were no significant between-group differences in aphasia (Frenchay aphasia Screening Test) at 12 months post-stroke.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one fairquality RCTthat early supported discharge is not more effective than conventional care for improving patients’ aphasia. In fact, one study noted significantly better literal paraphrasia following conventional care compared to early supported discharge at 6 months post-stroke.

Balance
Not effective
1A

Two high quality RCTs (Widén Holmqvist et al., 1998 and von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies; Askim et al., 2006) investigated the effect of early supported discharge on balance in patients with stroke.

The first high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. There was no significant between-group difference in patients’ self-reported incidence of falls at 3 months post-stroke.

A 6-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2000) revealed no significant between-group difference in patients’ self-reported incidence of falls at 6 months post-stroke.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) found no significant between-group differences in patients’ self-reported incidence of falls at 12 months post-stroke.

A 5-year follow-up to the study by Widén Holmqvist et al., (1998) (Thorsén et al., 2005) found no significant between-group differences in patients’ self-reported incidence of falls at 5 years post-stroke.

The second high quality RCT (Askim et al., 2006) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received early supported discharge and home-based rehabilitation for 4 weeks post-discharge whereas the OSUS group received regular inpatient rehabilitation. There were no significant between-group differences in balance (Berg Balance Scale) at 6, 26, or 52 weeks post-stroke.

Conclusion: There is strong evidence (level 1 a) from two high quality RCTs that early supported discharge is not more effective than conventional care for improving balance following stroke.

Cognition
Not effective
1A

Two high quality RCTs (Anderson et al., 2000; Indredavik et al., 2000 and Fjærtoft et al, 2004 and Fjærtoft et al, 2011 follow-up studies) and one fair quality RCT(Rudd et al., 1997) investigated the effect of early supported discharge on cognition following stroke.

The first high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in patients’ cognitive function (Mini Mental State Examination) at 6 months post-stroke.

The second high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form the stroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. Patients’ cognition was reported in a one-year follow-up study (Fjærtoft et al, 2004). There were no significant between-group differences in cognition (Mini Mental State Examination) at 1 year post-stroke.

A five-year follow-up to the study by Indredavik et al. (2000) (Fjærtoft et al, 2011) also revealed no significant between-group difference in cognition (Mini Mental State Examination ) at 5 years post-stroke.

The fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. There were no significant between-group differences in patients’ cognition (Mini-Mental State Examination) at 12 months post-stroke.

Conclusion: There is moderate evidence (level 1a) from two high quality RCTs and one fairquality RCTthat early supported discharge is not more effective than conventional care for improving cognition following stroke.

Dependency
Not effective
1a

Two high qualities RCTs (Ronning & Guldvog, 1998; Widén Holmqvist et al., 1998 and von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies) and one fair quality RCT(Suwanwela et al., 2002 investigated the effects of early supported discharge on process measures (dependency) following stroke.

Two high qualities RCTs (Ronning & Guldvog, 1998; Widén Holmqvist et al., 1998 and von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies) and one fair quality RCT (Suwanwela et al., 2002 investigated the effects of early supported discharge on process measures (dependency) following stroke.

The first high quality RCT (Ronning & Guldvog, 1998) randomized patients with acute stroke to receive municipality rehabilitation or hospital rehabilitation. Municipality rehabilitation comprised nursing home rehabilitation on inpatient or day-patient basis, and further ambulatory rehabilitation by a visiting physical therapist, speech therapist and/or nurse. Hospital rehabilitation was provided in a generalized hospital rehabilitation unit that provided coordinated multidisciplinary rehabilitation consisting of nursing care, physical, occupational and speech therapy, social work and neurologist services. Process measures included mortality, institutionalization and dependency (Barthel Index score of <75). While no significant between-group differences in individual process measures were found, there was a significant between-group difference in combined death/dependency rates, in favour of hospital rehabilitation compared to municipality rehabilitation. Further, there were significant between-group differences in dependency and death/dependency rates among patients with moderate to severe stroke, in favour of hospital rehabilitation vs. municipality rehabilitation. Among patients with mild stroke (BI score ≥50) there was a significant between-group difference in need of long-term care (p=0.02), in favour of municipality rehabilitation compared to hospital rehabilitation.

The second high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge with home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. Process measures taken at 3 months post-stroke included length of stay, mortality, service use and dependency. Significant between-group differences in length of stay only were found, favoring early supported discharge and home rehabilitation compared to conventional rehabilitation.

A 6-month follow-up to the Widén Holmqvist et al., (1998) study (von Koch et al., 2000) found no significant between-group differences in process measures (length of stay, mortality, service use) at 6 months post-stroke.

A 12-month follow-up to the Widén Holmqvist et al., (1998) study (von Koch et al., 2001) found significant between-group differences in use of primary care and home rehabilitation services, whereby patients in the conventional rehabilitation received more outpatient occupational therapy, private physiotherapy and day-hospital services, whereas patients in the early supported discharge and home rehabilitation group received more nursing and home rehabilitation services. There were no significant between-group differences in other process measures (mortality, dependency, cost of health care).

A 5-year follow up to the Widén Holmqvist et al. (1998) study (Thorsén et al., 2005) found no significant between-group differences in process measures (mortality, dependency) at 5 years post-stroke.

The fair quality RCT (Suwanwela et al., 2002) randomized patients with acute stroke to receive early discharge and home rehabilitation or conventional rehabilitation. The home rehabilitation intervention consisted of 3 days hospitalization followed by home interventions for 10 consecutive days and follow-up by visits in the 2nd week, at 1, 3, and 6 months. Process measures included mortality and dependency. There were no significant between-group differences in process measures.

Conclusion: There is strong evidence (level 1a) from two high quality RCTand one fairquality RCTthat there is no significant difference in dependency rates between early supported discharge and conventional care.

Emotional wellbeing - carers
Not effective
1A

Five high quality RCTs (Anderson et al., 2000; Bautz-Holter et al., 2002; Donnelly et al., 2004; Rodgers et al., 1997; Indredavik et al., 2000 and Fjærtoft et al., 2004 follow-up study), one fair quality RCT (Rudd et al., 1997) and one quasi-experimental study (Gräsel et al., 2005) investigated the effects of early supported discharge on mood and emotional wellbeing of carers of patients with stroke.

The first high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in carers’ emotional wellbeing (General Health Questionnaire-28, Caregiver Strain Index) at 6 months post-stroke.

The second high quality RCT (Bautz-Holter et al., 2002) randomized patients with acute stroke to receive early supported discharge or conventional hospital rehabilitation. Patients in the early supported discharge group received multidisciplinary home rehabilitation, followed by outpatient clinic services. There were no significant between-group differences in carers’ emotional wellbeing (General Health Questionnaire-20) at 3 or 6 months post-stroke.

The third high quality RCT (Donnelly et al., 2004) randomly assigned patients with acute stroke to receive early supported discharge or usual hospital rehabilitation. The early discharge group received multidisciplinary home services for 3 months (average of 2.5 visits a week/45 minutes per session). There were no significant between-group differences in carers’ emotional wellbeing (Caregiver Strain Index) at 12 months post-stroke.

The fourth high quality RCT (Rodgers et al., 1997) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received home rehabilitation services from a community-based multidisciplinary stroke discharge team 5 days/week for a median of 9 weeks (range 1-44 weeks). There were no significant between-group differences in carers’ emotional wellbeing (General Health Questionnaire-30) at 7-10 days post discharge or at 3 months post-stroke.

The fifth high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form the stroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. Carers’ emotional wellbeing was reported in a 1-year follow-up fair quality RCT (Fjærtoft et al., 2004). There were no significant between-group differences in carers’ emotional wellbeing (Caregiver Strain Index) at 1 year post-stroke.

The fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to specialist community rehabilitation or conventional hospital care. The specialist community rehabilitation group received an individualised multidisciplinary daily care plan for up to 3 months. There were no significant between-group differences in carers’ emotional wellbeing (Caregiver Strain Index) at 12 months post-stroke.

The quasi-experimental study (Gräsel et al., 20055) allocated patients with acute stroke and their carers to an intervention group that received intensified transition consisting of education and support for patients and carers prior to and following discharge (ST+IT), or a control group that received standard transition (ST). There were no significant between-group differences in carers’ emotional wellbeing (Zerssen Depression Scale and the Burden Scale for Family Caregivers) at 4 weeks or 6 months post-discharge.

Conclusion: There is strong evidence (level 1a) from five high quality RCTs, one fair quality RCT and one quasi-experimental study that early supported discharge is not more effective than conventional care for improving carers’ emotional wellbeing.

Emotional wellbeing - patients
Not effective
1A

Five high quality RCTs (Rodgers et al., 1997; Anderson et al., 2000; Indredavik et al., 2000 and Fjærtoft et al., 2004 follow-up study; Bautz-Holter et al., 2002; Widén Holmqvist et al., 1998 and von Koch et al., 2000 and von Koch et al., 2001 follow-up studies) and two fair quality RCTs (Hui et al., 1995; Rudd et al., 1997) investigated the effects of early supported discharge on mood and emotional wellbeing of patients following stroke.

The first high quality RCT (Rodgers et al., 1997) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received home rehabilitation services from a multidisciplinary community-based stroke discharge team for 5 days/week for a median of 9 weeks (range 1-44 weeks). There were no significant between-group differences in patients’ mood (Wakefield Depression Scale) at 7-10 days post discharge or at 3 months post-stroke.

The second high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in patients’ emotional wellbeing (General Health Questionnaire – 28) at 6 months post-stroke.

The third high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form the stroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. Patients’ mood was reported in a 1-year follow-up study (Fjærtoft et al., 2004). There were no significant between-group differences in patients’ mood (Montgomery Asberg Depression Scale) at 1 year post-stroke.

The fourth high quality RCT (Bautz-Holter et al., 2002) randomized patients with acute stroke to receive early supported discharge or conventional hospital rehabilitation. Patients in the early supported discharge group received multidisciplinary home rehabilitation, followed by outpatient clinic services. There was a significant between-group difference in patients’ emotional wellbeing (General Health Questionnaire-20) in favour of early supported discharge compared to conventional hospital rehabilitation at 3 months post-stroke, but this did not remain significant at 6 months post-stroke. There were no significant differences in other measures of mood (Montgomery Asberg Depression Rating Scale) at 3 or 6 months post-stroke.

The fifth high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. Patient’s emotional wellbeing was reported in a 6-month follow-up study (von Koch et al., 2000). There were no significant between-group differences in patients’ emotional wellbeing (Sense of Coherence Test) at 6 months post-stroke.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) also found no significant between-group differences in patients’ emotional wellbeing (Sense of Coherence Test) at 12 months post-stroke.

The first fair quality RCT (Hui et al., 1995) randomized patients with acute stroke to an early supported discharge (ESD) geriatrician team or a conventional medical care team. Patients in the ESD team were discharged home with day hospital rehabilitation and management by a geriatrician. There were no significant between-group differences in patients’ mood (Geriatric Depression Scale) at 3 or 6 months post-stroke.

The second fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. There were no significant between-group differences in patients’ emotional wellbeing (Hospital Anxiety and Depression Scale) at 12 months post-stroke.

Conclusion: There is strong evidence (level 1a) from five high quality RCTs and two fairquality RCTs that early supported discharge is not more effective than conventional care for improving patients’ mood and emotional wellbeing.
Note:
A high quality RCT did report significant between-group differences in emotional wellbeing at 3 months post-stroke in favour of early supported discharge, but results were not maintained at 6 months post-stroke. This study measured patients’ emotional wellbeing using the GHQ-20, whereas other studies used the GHQ-28 or other measures of mood and emotional wellbeing.

Family dynamics - carers
Not effective
1B

One high quality RCT (Anderson et al., 2000) investigated the effects of early supported discharge on carers’ perception of family dynamics following stroke. This high quality RCT randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in family dynamics (McMaster Family Assessment Device – general functioning subscale) reported by carers at 6 months post-stroke.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that early supported discharge is not more effective than conventional care for improving carers’ perception of family dynamics following stroke.

Family dynamics - patients
Not effective
1B

One high quality RCT (Anderson et al., 2000) investigated the effects of early supported discharge on patients’ perception of family dynamics following stroke. This high quality RCT randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in family dynamics (McMaster Family Assessment Device – general functioning subscale) reported by patients at 6 months post-stroke.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that early supported discharge is not more effective than conventional care for improving patients’ perception of family dynamics following stroke.

Functional independence
Not effective
1A

Eight high quality RCTs (Rodgers et al., 1997; Ronning & Guldvog, 1998; Widén Holmqvist et al., 1998von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies –; Anderson et al., 2000; Indredavik et al., 2000 – Fjærtoft et al., 2011 follow-up study–; Mayo et al., 2000; Bautz-Holter et al., 2002; Donnelly et al., 2004), three fair quality RCTs (Hui et al., 1995; Rudd et al., 1997; Suwanwela et al., 2002), one poor quality RCT (Shyu et al., 2010) and two quasi-experimental studies (Gräsel et al., 2005; Pessah-Rasmussen & Wendel, 2009) investigated the effect of early supported discharge on patients’ functional independence following stroke.

The first high quality RCT (Rodgers et al., 1997) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received home rehabilitation services from a multidisciplinary community-based stroke discharge team for 5 days/week for a median of 9 weeks (range 1-44 weeks). There were no significant between-group differences in patients’ functional ability (Nottingham Extended ADL Scale, Oxford Handicap Scale) at 7-10 days post-discharge or at 3 months post-stroke.

The second high quality RCT (Ronning & Guldvog, 1998) randomized patients with acute stroke to receive municipality rehabilitation or standard hospital rehabilitation. Municipality rehabilitation comprised nursing home rehabilitation on inpatient or day-patient basis, and further ambulatory rehabilitation by a visiting physical therapist, speech therapist and/or nurse. There were no significant between-group differences in patients’ functional independence (Barthel Index) at 7 months post-stroke.

Note: Subgroup analysis showed a significant between-group difference among patients with moderate to severe stroke (BI score <50) in functional independence (Barthel Index) at 7 months, in favour of hospital rehabilitation compared to municipality rehabilitation. There were no significant between-group differences in the subgroup of patients with mild stroke (BI score ≥50).

The third high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. There were no significant between-group differences in patients’ functional independence (Barthel ADL Index, Katz ADL Index, Extended Katz ADL Index) at 3 months post-stroke.

A 6-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2000) found no significant between-group differences in functional independence (Barthel Index, Katz ADL Index, Extended Katz ADL Index) at 6 months post-stroke.

Note: there was a significant between-group difference in functional mobility (Barthel ADL Index mobility subscore), in favour of early supported discharge compared to conventional rehabilitation.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) found no significant between-group differences in patients’ functional independence (Barthel ADL Index, Katz ADL Index, Extended Katz ADL index) at 12 months post-stroke.

A 5-year follow-up to the study by Widén Holmqvist et al., (1998) (Thorsén et al., 2005) found no significant between-group differences in patients’ functional independence (Barthel ADL Index, Katz ADL index) at 5 years post-stroke. However, there was a significant between-group difference in extended ADLs (Extended Katz ADL Index), in favour of early supported discharge compared to conventional care.

The fourth high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in patients’ functional independence (modified Barthel Index) at 6 months post-stroke.

The fifth high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form the stroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. There were no significant between-group differences in patients’ functional independence (Barthel Index, Modified Rankin Scale) at 6 weeks post-stroke. There was a significant between-group difference in Modified Rankin Scale scores at 26 weeks post-stroke, favoring the ESUS compared to the OSUS. There were no significant differences in Barthel Index scores at 26 weeks post-stroke.

Note: subgroup analysis at 26 weeks post-stroke revealed significant between-group differences in patients’ functional ability (Barthel Index and Modified Rankin Scale) among patients with moderate to severe stroke, in favour of the ESUS compared to the OSUS.

A five-year follow-up to the study by Indredavik et al. (2000) (Fjærtoft et al., 2011) found no significant between-group difference in patients’ functional independence (Barthel Index and Modified Rankin Scale) at 5 years post-stroke.

The sixth high quality RCT (Mayo et al., 2000) randomized patients with acute stroke to receive prompt discharge and home rehabilitation or usual care. The intervention group received home-based rehabilitation and nursing services for 4 weeks. There were no significant between-group differences in patients’ functional independence (Barthel Index, Older American Resource Scale for Instrumental ADLs) at post-treatment (4 weeks). There was a significant between-group difference in instrumental activities of daily living (Older American Resource Scale for Instrumental ADLs) at follow-up (3 months post-stroke), in favour of prompt discharge compared to usual care.

The seventh high quality RCT (Bautz-Holter et al., 2002) randomized patients with acute stroke to receive early supported discharge or conventional hospital rehabilitation. The early supported discharge group received multidisciplinary rehabilitation at home for as long as considered necessary followed by outpatient clinic intervention. There were no significant between-group differences in patients’ functional independence (Nottingham Extended ADL) at 3 or 6 months post-stroke.

The eighth high quality RCT (Donnelly et al., 2004) randomized patients with acute stroke to receive early hospital discharge or usual hospital rehabilitation. The early discharge group received multidisciplinary home services for 3 months (average of 2.5 visits a week, 45 minutes per session). There were no significant between-group differences in patients’ functional independence (Barthel Index, Nottingham ADL scale) at 12 months post-stroke.

The first fair quality RCT (Hui et al., 1995) randomized patients with acute stroke to an early supported discharge (ESD) geriatrician team or a conventional medical team. Patients in the ESD group were discharged home with day hospital rehabilitation and management by a geriatrician. There was no significant between-group difference in functional independence (Barthel Index) at 3 or 6 months post-stroke.

Note: There was a significant between-group difference in BI change scores from baseline to 3 months post-stroke in a subgroup of patients with BI scores ≤15, in favour of ESD compared to conventional medical care.

The second fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. There were no significant between-group differences in patients’ functional independence (Barthel Index, Rivermead Activity of Daily Living Scale) at 12 months post-stroke.

The third fair quality RCT (Suwanwela et al., 2002) randomized patients with acute stroke to receive early discharge and home rehabilitation or conventional rehabilitation. Home rehabilitation intervention consisted of 3 days hospitalization followed by home interventions for 10 consecutive days and follow-up by visits. There were no significant between-group differences in patients’ functional independence (Barthel Index) at 6 months post-stroke.

The poor quality study (Shyu et al., 2009) randomised patients with acute stroke and their carers to receive a caregiver-oriented discharge preparation programme that comprised health education, referrals and problem-solving support, or routine discharge services. There were no significant between-group differences in patients’ functional independence (Chinese Barthel Index) at 1, 3, 6 or 12 months post-discharge.

The first quasi-experimental study (Gräsel et al., 2005) allocated patients with acute stroke and their carers to an intervention group that received intensified transition consisting of education and support for patients and carers prior to and following discharge (ST+IT), or a control group that received standard transition (ST). There were no significant between-group differences in patients’ functional independence (Barthel Index, Functional Independence Measure) at 4 weeks or 6 months post-discharge.

The second quasi-experimental study (Pessah-Rasmussen & Wendel, 2009) assigned patients with acute stroke to receive early supported discharge (ESD) that consisted of a pre-discharge home visit, coordinated planned discharge from the hospital and post-discharge multidisciplinary care. Patients demonstrated a significant improvement in functional independence (Katz ADL Index) at post-treatment (feeding, transfers, toileting, dressing, bathing grooming and communication) and at 6 months post-stroke (transfers, dressing), but no significant improvements were seen at 12 months post-stroke.

Conclusion: There is strong evidence (level 1a) from eight high quality RCTs, three fairquality RCTs, one poor quality RCT and one quasi-experimental study that early supported discharge is not more effective than conventional care for improving patients’ functional independence following stroke.

Note: However, 1 RCT reported better instrumental ADLs at 3 months, 1 RCT reported better functional independence at 6 month, and 1 RCT reported better functional mobility at 6 months and better extended ADLs at 5 years post-stroke, all in favour of early supported discharge compared to usual care. Furthermore, a second quasi-experimental study found a significant improvement in the short term for certain aspects of functional independence in patients who received early supported discharge.

Note: There is conflicting evidence regarding the effectiveness of early supported discharge for patients with moderate to severe impairment. One high quality RCT found that patients with moderate to severe stroke demonstrated better functional independence following hospital rehabilitation compared to early supported discharge with municipality rehabilitation; another high quality RCT and a fair quality RCT reported better functional independence or better gains in functional independence among patients with moderate to severe impairment who receive early supported discharge compared to those who received conventional care.

Health-related quality of life - carers
Not effective
1A

Two high quality RTCs (Widén Holmqvist et al., 1998; Anderson et al., 2000) and one poor quality RCT (Shyu et al., 2009) investigated the effects of early supported discharge on health-related quality of life of carers following stroke.

The first high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. There were no significant between-group differences in carers’ quality of life (measured according to time spent helping the patient with instrumental and self-care ADLs) at 3 months post-stroke.

The second high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received multidisciplinary rehabilitation at home for 5 weeks. There was a significant between-group difference in carers’ health related quality of life (Medical Outcomes Study Short Form – 36 mental health score only) at 6 months post-stroke, in favour of conventional care compared to early supported discharge.

The poor quality study (Shyu et al., 2009) randomised patients with acute stroke and their carers to receive a caregiver-oriented discharge preparation programme that comprised health education, referrals and problem-solving support, or routine discharge services. Carers’ quality of life was measured by the Medical Outcomes Study Short Form (SF-36) at 1, 3, 6 and 12 months post-discharge. At 3 months carers in the intervention group scored significantly worse on the SF-36 social functioning subtest than carers in the control group. No other between-group differences were seen at any time point.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs and one poorquality RCTthat early supported discharge is not more effective than conventional care in improving carers’ health-related quality of life in the acute care period. In fact, one highquality RCT reported significantly better mental health and one poor quality RCT reported significant better social functioning among carers following conventional care compared to early supported discharge.

Note: The authors of the poor quality study commented that the discharge preparation programme is likely to have increased carers’ awareness of the demands of caregiving, thus contributing to a consequent reduction in social activities. The study also found lower rates of institutionalization at 6 to 12 months post-discharge in the intervention group than the control group, which may have increased burden among carers in the intervention group and contributed to poorer social functioning.

Health-related quality of life - patients
Not effective
1A

Four high qualities RTCs (Ronning & Guldvog, 1998; Anderson et al., 2000; Mayo et al., 2000; Donnelly et al., 2004), one poor quality RCT (Shyu et al., 2009) and one quasi-experimental study (Gräsel et al., 2005) investigated the effects of early supported discharge on patients’ health-related quality of life following stroke.

The first high quality RCT (Ronning & Guldvog, 1998) randomized patients with acute stroke to receive municipality rehabilitation or hospital rehabilitation. Municipality rehabilitation comprised nursing home rehabilitation on inpatient or day-patient basis, and further ambulatory rehabilitation by a visiting physical therapist, speech therapist and/or nurse. Hospital rehabilitation was provided in a generalized hospital rehabilitation unit that provided coordinated multidisciplinary rehabilitation consisting of nursing care, physical, occupational and speech therapy, social work and neurologist services. There were no significant between-group differences in patients’ health-related quality of life (Medical Outcomes Study Short Form – SF 36) at 7 months post-stroke.

The second high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in patients’ health related quality of life (SF-36) at 6 months post-stroke.

The third high quality RCT (Mayo et al., 2000) randomized patients with acute stroke to receive prompt discharge and home rehabilitation or usual care. The intervention group received a home rehabilitation program for 4 weeks consisting of tailor-made rehabilitation and nursing services. There were no significant between-group differences in patients’ health related quality of life (SF-36) at post-treatment (4 weeks). There was a significant between-group difference in quality of life related to physical health (SF-36 Physical Health and Physical Role subscales) at follow-up (3 months post-stroke), favoring prompt discharge and home rehabilitation compared to usual care.

The fourth high quality RCT (Donnelly et al., 2004) randomly assigned patients with acute stroke to an early discharge rehabilitation service or usual hospital rehabilitation. The early discharge group received multidisciplinary home services for 3 months (average of 2.5 visits a week, 45 minutes per session). There was no significant between-group difference in patients’ health related quality of life (SF-36, EuroQoL, non-standardized quality of life questionnaire) at 12 months post-stroke.

The poor quality study (Shyu et al., 2009) randomised patients with acute stroke and their carers to receive a caregiver-oriented discharge preparation programme that comprised health education, referrals and problem-solving support, or routine discharge services. There were no significant between-group differences in patients’ health related quality of life (SF-36) at 1, 3, 6 and 12 months post-discharge.

The quasi-experimental study (Gräsel et al., 2005) allocated patients with acute stroke and their carers to an intervention group that received intensified transition consisting of education and support for patients and carers prior to and following discharge (ST+IT), or a control group that received standard transition (ST). There were no significant between-group differences in patients’ health-related quality of life (SF-36) at 4 weeks or 6 months post-discharge.

Conclusion: There is strong evidence (level 1a) from four high quality RCTs, one poorquality RCT and one quasi-experimental study that early supported discharge is not more effective than conventional care for improving health-related quality of life among patients with stroke.

Note: One high quality RCT found a significant between-group difference in quality of life related to physical health at follow-up (3 months post-stroke), favoring prompt discharge and home rehabilitation compared to usual care.

Health status - carers
Not effective
1B

One high quality RCT (Widén Holmqvist et al., 1998 and von Koch et al., 2001 follow-up study) and one quasi-experimental study(Gräsel et al., 2005) investigated the effects of early supported discharge on health status of carers of patients with stroke.

The high quality RCT (Widén Holmqvist et al., 1998) randomised patients with acute stroke to receive early supported discharge and home rehabilitation or conventional rehabilitation. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months after discharge. Carers’ health status was reported in a 12-month follow-up study (von Koch et al., 2001). There were no significant between-group differences in carers’ health status (Sickness Impact Profile) at 12 months post-stroke.

The quasi-experimental study (Gräsel et al., 2005) allocated patients with stroke and their carers to an intervention group that received intensified transition consisting of education and support for patients and carers prior to and following discharge (ST+IT), or a control group that received standard transition (ST). There were no significant between-group differences in carers’ health status (Giessen Symptom List) at 4 weeks or 6 months post-discharge.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one quasi-experimental studythat early supported discharge is not more effective than conventional care for improving carers’ health status.

Health status - patients
Not effective
1A

Four high qualities RCTs (Rodgers et al., 1997; Widén Holmqvist et al., 1998 and von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies; Anderson et al., 2000; Indredavik et al., 2000 and Fjærtoft et al., 2004 follow-up study) and two fair qualities RCTs (Hui et al., 1995; Rudd et al., 1997) investigated the effects of early supported discharge on patients’ health status following stroke.

The first high quality RCT (Rodgers et al., 1997) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received home rehabilitation services from a community-based multidisciplinary stroke discharge team 5 days/week for a median of 9 weeks (range 1-44 weeks). There were no significant between-group differences in patients’ health status (Dartmouth Coop Function Charts) at 7-10 days post discharge or at 3 months post-stroke.

The second high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. Early supported discharge and home rehabilitation comprised multidisciplinary home rehabilitation for 3-4 months. Significant between group differences in health status (Sickness Impact Profile – SIP, Psychological dimension, and emotional behavioural and communication subtests) were found at 3 months post-stroke, favoring conventional rehabilitation compared to early supported discharge.

A 6-month follow-up to the Widén Holmqvist et al. (1998) study (von Koch et al., 2000), found significant between-group differences in patients’ health status (SIP Communication subtest only) at 6 months post-stroke, this time favoring early supported discharge and home rehabilitation compared to conventional rehabilitation.

A 12-month follow-up to the Widén Holmqvist et al., (1998) study (von Koch et al., 2001) found no significant between-group differences in patients’ health status (Sickness Impact Profile) at 12 months post-stroke.

A 5-year follow-up to the Widén Holmqvist et al., (1998) study (Thorsén et al., 2005) found no significant between-group differences in patients’ health status (Sickness Impact Profile) at 5 years post-stroke.

The third high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received multidisciplinary rehabilitation at home for 5 weeks. There were no significant between-group differences in patients’ health status (Nottingham Health Profile) at 6 months post-stroke.

The forth high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form the stroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. Patients’ health status was reported in a 1-year follow-up study (Fjærtoft et al., 2004). There were significant between-group differences in patients’ health status (Nottingham Health Profile) at 1 year post-stroke, favoring the ESUS group compared to the OSUS group.

The first fair quality RCT (Hui et al., 1995) randomized patients with acute stroke to an early supported discharge (ESD) geriatrician team or a conventional medical team. Patients in the ESD group were discharged home with day hospital rehabilitation and management by a geriatrician. Patients’ health status was measured using non standardized general wellbeing and sleep quality scale. There were no significant between-group differences in patients’ health status (measured using non-standardized general wellbeing and sleep quality scales) at 3 or 6 months post-stroke.

The second fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. There were no significant between-group differences in patients’ health status (Nottingham Health Profile) at 12 months post-stroke.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs and two fairquality RCTs that early supported discharge is not more effective than conventional care for patients’ health status.

Note: While a high quality RCT found significant differences in health status (SIP psychological dimension, emotional behaviours and communication subtests) in favour of conventional rehabilitation at 3 months post-stroke, the study subsequently found significant differences in SIP communication scores in favour of early supported discharge at 6 months post-stroke. A second study found significant differences in health status in favour of early supported discharge compared to conventional care at 12 months post-stroke.

Institutionalization
Not effective
1A

Five high qualities RCTs (Rodgers et al., 1997; Ronning & Guldvog, 1998; Anderson et al., 2000; Indredavik et al., 2000 and Fjærtoft et al., 2011 follow up study; Bautz-Holter et al., 2002;), one fair quality RCT (Rudd et al., 1997), one poor quality RCT (Shyu et al., 2009) and two quasi-experimental studies (Gräsel et al., 2005 and Gräsel et al., 2006 follow-up study; Pessah-Rasmussen & Wendel, 2009) investigated the effects of early supported discharge on process measures (institutionalisation) following stroke.

The first high quality RCT (Rodgers et al., 1997) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received multidisciplinary rehabilitation home services 5 days per week. Process measures included length of stay, readmission rates, institutionalization and mortality. Significant between-group differences were found in length of stay only, favoring early supported discharge compared to conventional care.

The second high quality RCT (Ronning & Guldvog, 1998) randomized patients with acute stroke to receive municipality rehabilitation or hospital rehabilitation. Municipality rehabilitation comprised nursing home rehabilitation on inpatient or day-patient basis, and further ambulatory rehabilitation by a visiting physical therapist, speech therapist and/or nurse. Hospital rehabilitation was provided in a generalized hospital rehabilitation unit that provided coordinated multidisciplinary rehabilitation consisting of nursing care, physical, occupational and speech therapy, social work and neurologist services. Process measures included mortality, institutionalization and dependency (Barthel Index score of <75). While no significant between-group differences in individual process measures were found, there was a significant between-group difference in combined death/dependency rates, in favour of hospital rehabilitation compared to municipality rehabilitation. Further, there were significant between-group differences in dependency and death/dependency rates among patients with moderate to severe stroke, in favour of hospital rehabilitation vs. municipality rehabilitation. Among patients with mild stroke (BI score ≥50) there was a significant between-group difference in need of long-term care (p=0.02), in favour of municipality rehabilitation compared to hospital rehabilitation.

The third high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. Process measures included length of stay/total bed days, use of health services, institutionalization, frequency of readmissions and incidence of adverse events (death or falls). Significant between-group differences were found in length of stay/total bed days only, favoring early supported discharge compared to conventional care.

The fourth high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form the stroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. Process measures included mortality, institutionalization and length of stay. Significant between-group differences were found in average length of stay in hospital (stroke unit and rehabilitation clinic) recorded at discharge, and number of patients discharged home vs. institutions recorded at discharge and 6 weeks post-stroke, favoring the ESUS compared to the OSUS. Differences in residential status were no longer significant at long-term follow-up (26 weeks post-stroke). There were no significant between-group differences in mortality rates.

A 5-year follow-up to the Indredavik et al., (2000) study (Fjærtoft et al., 2011) found significant between-group differences in mortality and institutionalization rates at 5 years post-stroke, favoring the ESUS compared to the OSUS.

The fifth high quality RCT (Bautz-Holter et al., 2002) randomized patients with acute stroke to receive early supported discharge or conventional hospital rehabilitation. The early supported discharge group received multidisciplinary rehabilitation at home for as long as considered necessary followed by outpatient clinic intervention. Process measures included use of health services, mortality and institutionalization. No significant between-group differences were found.

The fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital and community care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. Process measures included length of stay, readmission rates, institutionalization, mortality and health service use. Significant between-group differences were found in length of stay only, favoring specialist community rehabilitation compared to conventional hospital and community care.

The poor quality study (Shyu et al., 2009) randomised patients with acute stroke and their carers to receive a caregiver-oriented discharge preparation programme that comprised health education, referrals and problem-solving support, or routine discharge services. Patient service use was measured at 1, 3, 6 and 12 months post-discharge according to length of hospital stay, hospital readmissions and institutionalisations. Patients in the intervention group demonstrated significantly less institutionalisation than patients in the control group 6 to 12 months post-discharge. There were no significant between-group differences in length of hospital stay or hospital readmissions at any time point.

The first quasi-experimental study (Gräsel et al., 2005) allocated patients with acute stroke and their carers to receive intensified transition consisting of education and support for patients and carers prior to and following discharge (ST+IT), or a control group that received standard transition (ST). Number of physician visits and newly appearing illnesses were measured at 4 weeks and 6 months post-discharge. Patients in the control group showed significantly more new illnesses than those in the intervention group at 4 weeks post-discharge, but this difference did not remain significant at 6 months. There was a significant between-group difference in the number of physician visits in favour of the intervention group compared to the control group at 6 months post-discharge (these differences were not present at four weeks post-discharge).

In a follow-up study (Gräsel et al., 2006), patients were contacted by telephone on average 31 months after discharge from hospital to determine whether the patient was (a) alive; and (b) living at home or in a nursing home. There was a significant difference between groups in the number of patients who were alive and living at home, in favour of the intervention group compared to the control group.

The second quasi-experimental study (Pessah-Rasmussen & Wendel, 2009) assigned patients with acute stroke to receive early supported discharge (ESD) and compared results with a control stroke population. Early supported discharge services consisted of a pre-discharge home visit, coordinated planned discharge from the hospital and post-discharge multidisciplinary care. Process measures included length of stay and institutionalization. A significant between-group difference was found in number of patients living alone, favoring ESD compared to the control cohort.

Conclusion: There is strong evidence (level 1a) from five high quality RCTs, one fair quality RCT, one poor quality RCT and two quasi-experimental studies that there is no significant difference in institutionalisation rates between early supported discharge and conventional care.

Length of stay
Effective
1A

Six high qualities RCTs (Rodgers et al., 1997; Widén Holmqvist et al., 1998 and von Koch et al., 2000, follow-up study; Anderson et al., 2000; Indredavik et al., 2000; Mayo et al., 2000; Donnelly et al., 2004), two fair qualities RCTs (Hui et al., 1995;Rudd et al., 1997), one poor quality RCT (Shyu et al., 2009) and one quasi-experimental study (Pessah-Rasmussen & Wendel, 2009) investigated the effects of early supported discharge on process measures (length of stay) following stroke.

The first high quality RCT (Rodgers et al., 1997) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received multidisciplinary rehabilitation home services 5 days per week. Process measures included length of stay, readmission rates, institutionalization and mortality. Significant between-group differences were found in length of stay only, favoring early supported discharge compared to conventional care.

The second high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge with home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. Process measures taken at 3 months post-stroke included length of stay, mortality, service use and dependency. Significant between-group differences in length of stay only were found, favoring early supported discharge and home rehabilitation compared to conventional rehabilitation.

A 6-month follow-up to the Widén Holmqvist et al., (1998) study (von Koch et al., 2000) found no significant between-group differences in process measures (length of stay, mortality, service use) at 6 months post-stroke.

The third high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. Process measures included length of stay/total bed days, use of health services, institutionalization, frequency of readmissions and incidence of adverse events (death or falls). Significant between-group differences were found in length of stay/total bed days only, favoring early supported discharge compared to conventional care.

The fourth high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form thestroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. Process measures included mortality, institutionalization and length of stay. Significant between-group differences were found in average length of stay in hospital (stroke unit and rehabilitation clinic) recorded at discharge, and number of patients discharged home vs. institutions recorded at discharge and 6 weeks post-stroke, favoring the ESUS compared to the OSUS. Differences in residential status were no longer significant at long-term follow-up (26 weeks post-stroke). There were no significant between-group differences in mortality rates.

The fifth high quality RCT (Mayo et al., 2000) randomized patients with acute stroke to receive prompt discharge and home rehabilitation or usual care. The intervention group received a home rehabilitation program for 4 weeks consisting of tailor-made rehabilitation and nursing services. Process measures included length of stay and health services use. Significant between-group differences were found in length of stay, favoring the intervention group.

The sixth high quality RCT (Donnelly et al., 2004) randomly assigned patients with acute stroke to early hospital discharge or usual hospital rehabilitation. The early discharge group received multidisciplinary home services for 3 months (average of 2.5 visits a week, 45 minutes per session). Process measures included length of stay, service use and cost. Significant between-group differences were found in use of occupational therapy, social work and rehabilitation assistant services (but not physiotherapy or Meals on Wheels services), favoring early discharge rehabilitation compared to conventional rehabilitation. There were no significant between-group differences in length of stay or cost.

The first fair quality RCT (Hui et al., 1995) randomized patients with acute stroke to an early supported discharge (ESD) team managed by a geriatrician or a conventional medical team managed by a neurologist. Patients in the ESD team were managed by a geriatrician and received rehabilitation at a day hospital. Process measures included length of stay, mortality, health service use (readmissions, outpatient services and community services) and cost. Significant between-group differences were found in number of outpatient visits only, favoring ESD compared to conventional care.

The second fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital and community care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. Process measures included length of stay, readmission rates, institutionalization, mortality and health service use. Significant between-group differences were found in length of stay only, favoring specialist community rehabilitation compared to conventional hospital and community care.

The poor quality study (Shyu et al., 2009) randomised patients with acute stroke and their carers to receive a caregiver-oriented discharge preparation programme that comprised health education, referrals and problem-solving support, or routine discharge services. Patient service use was measured at 1, 3, 6 and 12 months post-discharge according to length of hospital stay, hospital readmissions and institutionalisations. Patients in the intervention group demonstrated significantly less institutionalisation than patients in the control group 6 to 12 months post-discharge. There were no significant between-group differences in length of hospital stay or hospital readmissions at any time point.

The quasi-experimental study (Pessah-Rasmussen & Wendel, 2009) assigned patients with acute stroke to receive early supported discharge (ESD) and compared results with a control stroke population. Early supported discharge services consisted of a pre-discharge home visit, coordinated planned discharge from the hospital and post-discharge multidisciplinary care. Process measures included length of stay and institutionalization. A significant between-group difference was found in number of patients living alone, favoring ESD compared to the control cohort.

Conclusion: There is strong evidence (level 1a) from five high quality RCTs and one fair quality RCT that there is a significant difference in length of stay following early supported discharge compared to usual care.

Note: However, one high quality RCT, one fair quality RCT, one poor quality RCT and one quasi experimental study found no significant between-group differences following early supported discharge.

Mobility
Not effective
1A

Four high quality RCTs (Widén Holmqvist et al., 1998 and von Koch et al., 2000 and von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies; Mayo et al., 2000; Donnelly et al., 2004; Askim et al., 2006), one fair quality RCT (Rudd et al., 1997) and one quasi-experimental study (Gräsel et al., 2005) investigated the effect of early supported discharge on patients’ mobility following stroke.

The first high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. There was no significant between-group difference in mobility (10m walking test) at 3 months post-stroke.

A 6-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2000) revealed no significant between-group difference in mobility (10m walking test) at 6 months post-stroke.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) found no significant between-group differences in mobility (10m walking test) at 12 months post-stroke.

A 5-year follow-up to the study by Widén Holmqvist et al., (1998) (Thorsén et al., 2005) found no significant between-group differences in mobility (10m walking test) at 5 years post-stroke.

The second high quality RCT (Mayo et al., 2000) randomized patients with acute stroke to receive prompt discharge and home rehabilitation or usual care. The intervention group received home-based rehabilitation and nursing services for 4 weeks. There were no significant between-group differences in patients’ movement and mobility (stroke Rehabilitation Assessment of Movement, Timed Up and Go Test) at post-treatment (4 weeks) or follow-up (3 months post-stroke).

The third high quality RCT (Donnelly et al., 2004) randomized patients with acute stroke to receive early hospital discharge or usual hospital rehabilitation. The early discharge group received multidisciplinary home services for 3 months (average of 2.5 visits a week, 45 minutes per session). There were no significant between-group differences in patients’ mobility (10 meter timed walk test) at 12 months post-stroke.

The fourth high quality RCT (Askim et al., 2006) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received early supported discharge and home-based rehabilitation for 4 weeks post-discharge whereas the OSUS group received regular inpatient rehabilitation. There were no significant between-group differences in walking speed (5 Meter Walking Test) at 6, 26, or 52 weeks post-stroke.
Note: There was a significant between-group difference in walking speed at 1 week post-stroke (while both groups were receiving the same treatment), in favour of the OSUS group compared to the ESUS group.

The fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. There were no significant between-group differences in mobility (5 Meter Walking Test) at 12 months post-stroke.

The quasi-experimental study (Gräsel et al., 2005) allocated patients with acute stroke and their carers to an intervention group that received intensified transition consisting of education and support for patients and carers prior to and following discharge (ST+IT), or a control group that received standard transition (ST). There were no significant between-group differences in mobility (Timed Up and Go Test) at 4 weeks or 6 months post-discharge.

Conclusion: There is strong evidence (level 1a) from four high quality RCTs, one fair quality RCT and one quasi-experimental study that early supported discharge is not more effective than conventional care in improving patients’ mobility following stroke.

Mortality
Not effective
1A

Five high qualities RCTs (Rodgers et al., 1997; Ronning & Guldvog, 1998; Widén Holmqvist et al., 1998 and von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies; Indredavik et al., 2000 and Fjærtoft et al., 2011 follow up study; Bautz-Holter et al., 2002) and three fair qualities RCTs (Hui et al., 1995;Rudd et al., 1997; Suwanwela et al., 2002) investigated the effects of early supported discharge on process measures (mortality) following stroke.

The first high quality RCT (Rodgers et al., 1997) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received multidisciplinary rehabilitation home services 5 days per week. Process measures included length of stay, readmission rates, institutionalization and mortality. Significant between-group differences were found in length of stay only, favoring early supported discharge compared to conventional care.

The second high quality RCT (Ronning & Guldvog, 1998) randomized patients with acute stroke to receive municipality rehabilitation or hospital rehabilitation. Municipality rehabilitation comprised nursing home rehabilitation on inpatient or day-patient basis, and further ambulatory rehabilitation by a visiting physical therapist, speech therapist and/or nurse. Hospital rehabilitation was provided in a generalized hospital rehabilitation unit that provided coordinated multidisciplinary rehabilitation consisting of nursing care, physical, occupational and speech therapy, social work and neurologist services. Process measures included mortality, institutionalization and dependency (Barthel Index score of <75). While no significant between-group differences in individual process measures were found, there was a significant between-group difference in combined death/dependency rates, in favour of hospital rehabilitation compared to municipality rehabilitation. Further, there were significant between-group differences in dependency and death/dependency rates among patients with moderate to severe stroke, in favour of hospital rehabilitation vs. municipality rehabilitation. Among patients with mild stroke (BI score ≥50) there was a significant between-group difference in need of long-term care (p=0.02), in favour of municipality rehabilitation compared to hospital rehabilitation.

The third high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge with home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. Process measures taken at 3 months post-stroke included length of stay, mortality, service use and dependency. Significant between-group differences in length of stay only were found, favoring early supported discharge and home rehabilitation compared to conventional rehabilitation.

A 6-month follow-up to the Widén Holmqvist et al., (1998) study (von Koch et al., 2000) found no significant between-group differences in process measures (length of stay, mortality, service use) at 6 months post-stroke.

A 12-month follow-up to the Widén Holmqvist et al., (1998) study (von Koch et al., 2001) found significant between-group differences in use of primary care and home rehabilitation services, whereby patients in the conventional rehabilitation received more outpatient occupational therapy, private physiotherapy and day-hospital services, whereas patients in the early supported discharge and home rehabilitation group received more nursing and home rehabilitation services. There were no significant between-group differences in other process measures (mortality, dependency, cost of health care).

A 5-year follow up to the Widén Holmqvist et al. (1998) study (Thorsén et al., 2005) found no significant between-group differences in process measures (mortality, dependency) at 5 years post-stroke.

The fourh high quality RCT (Indredavik et al., 2000) randomized patients with acute stroke to an extended stroke unit service (ESUS) or an ordinary stroke unit service (OSUS). The ESUS group received multidisciplinary home services that included a home assessment, discharge form thestroke unit, follow up rehabilitation program, out-patient clinic 4 weeks after discharge, and information meeting 3 months after discharge. Process measures included mortality, institutionalization and length of stay. Significant between-group differences were found in average length of stay in hospital (stroke unit and rehabilitation clinic) recorded at discharge, and number of patients discharged home vs. institutions recorded at discharge and 6 weeks post-stroke, favoring the ESUS compared to the OSUS. Differences in residential status were no longer significant at long-term follow-up (26 weeks post-stroke). There were no significant between-group differences in mortality rates.

A 5-year follow-up to the Indredavik et al., (2000) study (Fjæroft et al., 2011) found significant between-group differences in mortality and institutionalization rates at 5 years post-stroke, favoring the ESUS compared to the OSUS.

The fifth high quality RCT (Bautz-Holter et al., 2002) randomized patients with acute stroke to receive early supported discharge or conventional hospital rehabilitation. The early supported discharge group received multidisciplinary rehabilitation at home for as long as considered necessary followed by outpatient clinic intervention. Process measures included use of health services, mortality and institutionalization. No significant between-group differences were found.

The first fair quality RCT (Hui et al., 1995) randomized patients with acute stroke to an early supported discharge (ESD) team managed by a geriatrician or a conventional medical team managed by a neurologist. Patients in the ESD team were managed by a geriatrician and received rehabilitation at a day hospital. Process measures included length of stay, mortality, health service use (readmissions, outpatient services and community services) and cost. Significant between-group differences were found in number of outpatient visits only, favoring ESD compared to conventional care.

The second fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital and community care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. Process measures included length of stay, readmission rates, institutionalization, mortality and health service use. Significant between-group differences were found in length of stay only, favoring specialist community rehabilitation compared to conventional hospital and community care.

The third fair quality RCT (Suwanwela et al., 2002) randomized patients with acute stroke to receive early discharge and home rehabilitation or conventional rehabilitation. The home rehabilitation intervention consisted of 3 days hospitalization followed by home interventions for 10 consecutive days and follow-up by visits in the 2nd week, at 1, 3, and 6 months. Process measures included mortality and dependency. There were no significant between-group differences in process measures.

Conclusion: There is strong evidence (level 1a) from five high quality RCTs and three fairquality RCTs that there is no significant difference in mortality rates following early supported discharge compared to conventional care.

Motor skills
Effective
1B

One high quality RCT (Widén Holmqvist et al., 1998 and von Koch et al., 2000 and von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies) and one fair quality RCT (Rudd et al., 1997) investigated the effect of early supported discharge on patients’ motor skills following stroke.

The high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. At 3 months post-stroke, there was a significant between-group difference in motor capacity (Lindmark Motor Capacity Assessment coordination subtest), favoring early supported discharge compared to conventional rehabilitation.

A 6-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2000) also revealed significant between-group differences in motor capacity (Lindmark Motor Capacity Assessment total maximal motor score) at 6 months post-stroke, in favour of early supported discharge compared to conventional rehabilitation.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) found no significant between-group differences in patients’ motor capacity (Lindmark Motor Capacity Assessment) at 12 months post-stroke.

A 5-year follow-up to the study by Widén Holmqvist et al., (1998) (Thorsén et al., 2005) found no significant between-group differences in patients’ motor capacity (Lindmark Motor Capacity Assessment) at 5 years post-stroke.

The fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. There were no significant between-group differences in patients’ motor abilities (Motricity Index) at 12 months post-stroke.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that early supported discharge is more effective than conventional care for improving patients’ motor capacity following stroke.

Note: Significant between-group differences were not maintained long term. A fair quality RCT found no significant between-group differences in patients’ motor abilities.

Quality of care
Effective
2b

One poor quality RCT (Shyu et al., 2009) investigated the effects of early supported discharge on quality of care provided by carers of patients with stroke. This poor quality study randomised patients with acute stroke and their carers to receive a caregiver-oriented discharge preparation programme that comprised health education, referrals and problem-solving support, or routine discharge services. There was a significant between-group difference in quality of care (Family Caregiving Consequence Inventory – frail elder outcome subscale) at 6 months, in favour of the intervention group compared to the control group, and caregivers in the intervention group provided significantly better overall quality of care in the first 12 months than those in the control group.

Conclusion: There is limited evidence (level 2b) from one poor quality RCT that early supported discharge is more effective than conventional care for improving carers’ quality of care.

Readmission
Not effective
1a

Two high qualities RCTs (Rodgers et al., 1997; Anderson et al., 2000), two fair qualities RCTs (Hui et al., 1995; Rudd et al., 1997) and one poor quality RCT (Shyu et al., 2009) investigated the effects of early supported discharge on process measures (readmission rates) following stroke.

The first high quality RCT (Rodgers et al., 1997) randomized patients with acute stroke to receive early supported discharge or conventional care. The early supported discharge group received multidisciplinary rehabilitation home services 5 days per week. Process measures included length of stay, readmission rates, institutionalization and mortality. Significant between-group differences were found in length of stay only, favoring early supported discharge compared to conventional care.

The second high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to receive early supported discharge or conventional care. The early discharge group received multidisciplinary rehabilitation at home for 5 weeks. Process measures included length of stay/total bed days, use of health services, institutionalization, frequency of readmissions and incidence of adverse events (death or falls). Significant between-group differences were found in length of stay/total bed days only, favoring early supported discharge compared to conventional care.

The first fair quality RCT (Hui et al., 1995) randomized patients with acute stroke to an early supported discharge (ESD) team managed by a geriatrician or a conventional medical team managed by a neurologist. Patients in the ESD team were managed by a geriatrician and received rehabilitation at a day hospital. Process measures included length of stay, mortality, health service use (readmissions, outpatient services and community services) and cost. Significant between-group differences were found in number of outpatient visits only, favoring ESD compared to conventional care.

The second fair quality RCT (Rudd et al., 1997) randomized patients with acute stroke to receive specialist community rehabilitation or conventional hospital and community care. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. Process measures included length of stay, readmission rates, institutionalization, mortality and health service use. Significant between-group differences were found in length of stay only, favoring specialist community rehabilitation compared to conventional hospital and community care.

The poor quality study (Shyu et al., 2009) randomised patients with acute stroke and their carers to receive a caregiver-oriented discharge preparation programme that comprised health education, referrals and problem-solving support, or routine discharge services. Patient service use was measured at 1, 3, 6 and 12 months post-discharge according to length of hospital stay, hospital readmissions and institutionalisations. Patients in the intervention group demonstrated significantly less institutionalisation than patients in the control group 6 to 12 months post-discharge. There were no significant between-group differences in length of hospital stay or hospital readmissions at any time point.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs and two fair quality RCTs and one poor quality RCT that there is no significant difference in rate of readmission following early supported discharge compared to conventional care.

Satisfaction - carers
Not effective
1A

Four high quality RTCs (Widén Holmqvist et al., 1998 and von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies; Anderson et al., 2000; Bautz-Holter et al., 2002; Donnelly et al., 2004) and two fair quality RCTs (Hui et al., 1995; Rudd et al, 1997) investigated the effects of early supported discharge on satisfaction among carers’ of patients with stroke.

The first high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. No significant between-group differences in carers’ satisfaction (measured by non-standardized questionnaire) were found at 3 months post-stroke.

A 6-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2000) also found no significant between-group differences in carers’ satisfaction (measured by non-standardized questionnaire) at 6 months post-stroke.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) also found no significant between-group differences in carers’ satisfaction (measured by non-standardized questionnaire) at 12 months post-stroke.

A 5-year follow-up to the study by Widén Holmqvist et al., (1998) (Thorsén et al., 2005) found no significant between-group differences in carers’ satisfaction (measured by non-standardized questionnaire) at 5 years post-stroke.

The second high quality RCT (Anderson et al., 2000) randomized patients with acute stroke to the early supported discharge or the conventional care group. In the early discharge group, patients received multidisciplinary rehabilitation at home for 5 weeks. No significant between-group differences in carers’ satisfaction (measured by a non-standardized questionnaire) were found at 6 months post-stroke.

The third high quality RCT (Bautz-Holter et al., 2002) randomized patients with acute stroke to receive early supported discharge or conventional hospital rehabilitation. The early supported discharge group received multidisciplinary rehabilitation at home for as long as considered necessary followed by outpatient clinic intervention. No significant between-group differences in carers’ satisfaction (measured by a 5-point Likert scale) were found at 3 or 6 months post-stroke.

The fourth high quality RCT (Donnelly et al., 2004) randomly assigned patients with acute stroke to an early hospital discharge service or usual hospital rehabilitation. The early discharge group received multidisciplinary home services for 3 months (average of 2.5 visits a week, 45 minutes per session). No significant between-group difference in carers’ satisfaction (measured by non-standardized questionnaire) were found 12 months post-stroke.

The first fair quality RCT (Hui et al., 1995) randomized patients with acute stroke to an early supported discharge (ESD) geriatrician team or a conventional medical team. Patients in the ESD group were discharged home with day hospital rehabilitation and management by a geriatrician. No significant between-group differences were found for carers’ satisfaction (measured by non-standardized questionnaire) at 3 or 6 months post-stroke.

The second fair quality RCT (Rudd et al, 1997) randomized patients with acute stroke to the specialist community rehabilitation or the conventional hospital care group. The specialist community rehabilitation group received an individual multidisciplinary daily care plan for 3 months. No significant between group difference in carers’ satisfaction with hospital care, therapy provision, community support and general satisfaction (measured with stroke-specific questionnaires) were found at 12 months post-stroke.

Conclusion: There is strong evidence (level 1a) from four high quality RCTs and two fairquality RCTs that early supported discharge is not more effective than conventional care for improving satisfaction among carers of patients with stroke.

Satisfaction - patients
Not effective
1A

Four high qualities RTCs (Widén Holmqvist et al., 1998 and von Koch et al., 2000, von Koch et al., 2001 and Thorsén et al., 2005 follow-up studies; Anderson et al., 2000; Bautz-Holter et al., 2002; Donnelly et al., 2004), and three fair quality RCTs (Hui et al., 1995; Rudd et al,, 1997; Suwanwela et al., 2002) investigated the effects of early supported discharge on satisfaction among patients with stroke.

The first high quality RCT (Widén Holmqvist et al., 1998) randomized patients with acute stroke to receive early supported discharge and home rehabilitation or conventional care. The home rehabilitation group received multidisciplinary home rehabilitation for 3-4 months. No significant between-group differences in patients’ satisfaction (measured by non-standardized questionnaire) were found at 3 months post-stroke.

A 6-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2000) also found no significant between-group differences in patients’ satisfaction (measured by non-standardized questionnaire) at 6 months post-stroke.

A 12-month follow-up to the study by Widén Holmqvist et al., (1998) (von Koch et al., 2001) also found no significant between-group differences in patients’ satisfaction (measured by non-standardized questionnaire) at 12 months post-stroke.

A 5-year follow-up to the study by Widén Holmqvist et al., (1998) (Thorsén et al., 2005) found no significant between-group differences in patients’ satisfaction (measured by non-standardized questionnaire) at 5 years post-stroke.

The second high quality RCT (Anderson et al., 2000) randomized patients with acute stroke