Circuit class therapy for improving mobility after stroke

Review question

Is circuit class therapy better than conventional physiotherapy for improving people's walking after a stroke?

Background

After stroke, people can have difficulty walking. They may become slower, only manage short distances, and may need assistance. They may lose balance more easily and be more fatigued. This can mean they walk even less, and so walking ability can worsen. Rehabilitation can help improve walking, but it is hard to access, particularly later after stroke. Circuit class therapy involves working in groups (rather than individually with a therapist), and doing specific practice of meaningful tasks, and may offer a solution that is more accessible.

Study characteristics

This is an update of the original review in 2010. We considered studies comparing circuit class therapy with conventional therapy for people with stroke, and included only high-quality studies with a low risk of being biased. We were interested in studies that compared these two approaches and their effects on the way people walk, how far, how fast, and how independently. We also looked for studies that investigated if the circuit classes were more or less likely to be harmful than conventional approaches. The evidence is current to January 2017.

Main results

We found seventeen studies, involving 1297 participants, that compared circuit class rehabilitation with usual care or sham rehabilitation. Most trials reported the benefits of circuit classes for improving walking ability. More specifically, we combined the results from the studies and found moderate evidence that circuit classes were more effective in improving the person's ability to walk further, more independently, and faster and, in some cases, to balance more easily and confidently when compared with other types of therapy. There was a suggestion that people might fall more often in the circuit classes, and that they may be able to get home from rehabilitation hospital more quickly, but these two aspects were not confirmed using statistics. We also found that the positive effects of the circuit classes were experienced equally by people who had had their stroke more than a year ago compared with people who had had their stroke within the year. This means people can continue to improve longer after their stroke than was previously reported. More research is needed to see if it works for all people with any severity of stroke and if some tasks are better to practise than others.

Quality of the evidence

The quality of the studies overall was acceptable, given it is difficult to keep some aspects tightly controlled in rehabilitation studies. However, we have downgraded the quality rating to 'moderate' to acknowledge that some trials have the potential for bias.

Authors' conclusions: 

There is moderate evidence that CCT is effective in improving mobility for people after stroke - they may be able to walk further, faster, with more independence and confidence in their balance. The effects may be greater later after the stroke, and are of clinical significance. Further high-quality research is required, investigating quality of life, participation and cost-benefits, that compares CCT with standard care and that also investigates the influence of factors such as stroke severity and age. The potential risk of increased falls during CCT needs to be monitored.

Read the full abstract...
Background: 

Circuit class therapy (CCT) offers a supervised group forum for people after stroke to practise tasks, enabling increased practice time without increasing staffing. This is an update of the original review published in 2010.

Objectives: 

To examine the effectiveness and safety of CCT on mobility in adults with stroke.

Search strategy: 

We searched the Cochrane Stroke Group Trials Register (last searched January 2017), CENTRAL (the Cochrane Library, Issue 12, 2016), MEDLINE (1950 to January 2017), Embase (1980 to January 2017), CINAHL (1982 to January 2017), and 14 other electronic databases (to January 2017). We also searched proceedings from relevant conferences, reference lists, and unpublished theses; contacted authors of published trials and other experts in the field; and searched relevant clinical trials and research registers.

Selection criteria: 

Randomised controlled trials (RCTs) including people over 18 years old, diagnosed with stroke of any severity, at any stage, or in any setting, receiving CCT.

Data collection and analysis: 

Review authors independently selected trials for inclusion, assessed risk of bias in all included studies, and extracted data.

Main results: 

We included 17 RCTs involving 1297 participants. Participants were stroke survivors living in the community or receiving inpatient rehabilitation. Most could walk 10 metres without assistance. Ten studies (835 participants) measured walking capacity (measuring how far the participant could walk in six minutes) demonstrating that CCT was superior to the comparison intervention (Six-Minute Walk Test: mean difference (MD), fixed-effect, 60.86 m, 95% confidence interval (CI) 44.55 to 77.17, GRADE: moderate). Eight studies (744 participants) measured gait speed, again finding in favour of CCT compared with other interventions (MD 0.15 m/s, 95% CI 0.10 to 0.19, GRADE: moderate). Both of these effects are considered clinically meaningful. We were able to pool other measures to demonstrate the superior effects of CCT for aspects of walking and balance (Timed Up and Go: five studies, 488 participants, MD -3.62 seconds, 95% CI -6.09 to -1.16; Activities of Balance Confidence scale: two studies, 103 participants, MD 7.76, 95% CI 0.66 to 14.87). Two other pooled balance measures failed to demonstrate superior effects (Berg Blance Scale and Step Test). Independent mobility, as measured by the Stroke Impact Scale, Functional Ambulation Classification and the Rivermead Mobility Index, also improved more in CCT interventions compared with others. Length of stay showed a non-significant effect in favour of CCT (two trials, 217 participants, MD -16.35, 95% CI -37.69 to 4.99). Eight trials (815 participants) measured adverse events (falls during therapy): there was a non-significant effect of greater risk of falls in the CCT groups (RD 0.03, 95% CI -0.02 to 0.08, GRADE: very low). Time after stroke did not make a difference to the positive outcomes, nor did the quality or size of the trials. Heterogeneity was generally low; risk of bias was variable across the studies with poor reporting of study conduct in several of the trials.

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