Scolaris Content Display Scolaris Content Display

PRISMA flow diagram
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Figure 1

PRISMA flow diagram

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
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Figure 3

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

Comparison 1 Circuit class therapy versus other, Outcome 1 6mWT early and late.
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Analysis 1.1

Comparison 1 Circuit class therapy versus other, Outcome 1 6mWT early and late.

Comparison 1 Circuit class therapy versus other, Outcome 2 Gait speed early and late.
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Analysis 1.2

Comparison 1 Circuit class therapy versus other, Outcome 2 Gait speed early and late.

Comparison 1 Circuit class therapy versus other, Outcome 3 Cadence.
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Analysis 1.3

Comparison 1 Circuit class therapy versus other, Outcome 3 Cadence.

Comparison 1 Circuit class therapy versus other, Outcome 4 Timed Up and Go.
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Analysis 1.4

Comparison 1 Circuit class therapy versus other, Outcome 4 Timed Up and Go.

Comparison 1 Circuit class therapy versus other, Outcome 5 Rivermead Mobility Index.
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Analysis 1.5

Comparison 1 Circuit class therapy versus other, Outcome 5 Rivermead Mobility Index.

Comparison 1 Circuit class therapy versus other, Outcome 6 Functional Ambulation Classification.
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Analysis 1.6

Comparison 1 Circuit class therapy versus other, Outcome 6 Functional Ambulation Classification.

Comparison 1 Circuit class therapy versus other, Outcome 7 Berg Balance Scale.
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Analysis 1.7

Comparison 1 Circuit class therapy versus other, Outcome 7 Berg Balance Scale.

Comparison 1 Circuit class therapy versus other, Outcome 8 Step Test.
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Analysis 1.8

Comparison 1 Circuit class therapy versus other, Outcome 8 Step Test.

Comparison 1 Circuit class therapy versus other, Outcome 9 Activities‐specific Balance Confidence Scale.
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Analysis 1.9

Comparison 1 Circuit class therapy versus other, Outcome 9 Activities‐specific Balance Confidence Scale.

Comparison 1 Circuit class therapy versus other, Outcome 10 Stroke Impact Scale (physical).
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Analysis 1.10

Comparison 1 Circuit class therapy versus other, Outcome 10 Stroke Impact Scale (physical).

Comparison 1 Circuit class therapy versus other, Outcome 11 VO2 peak.
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Analysis 1.11

Comparison 1 Circuit class therapy versus other, Outcome 11 VO2 peak.

Comparison 1 Circuit class therapy versus other, Outcome 12 Steps per day.
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Analysis 1.12

Comparison 1 Circuit class therapy versus other, Outcome 12 Steps per day.

Comparison 1 Circuit class therapy versus other, Outcome 13 Length of stay.
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Analysis 1.13

Comparison 1 Circuit class therapy versus other, Outcome 13 Length of stay.

Comparison 1 Circuit class therapy versus other, Outcome 14 Sensitivity: 6mWT.
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Analysis 1.14

Comparison 1 Circuit class therapy versus other, Outcome 14 Sensitivity: 6mWT.

Comparison 2 CCT + education versus no therapy, Outcome 1 Timed Up and Go.
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Analysis 2.1

Comparison 2 CCT + education versus no therapy, Outcome 1 Timed Up and Go.

Comparison 2 CCT + education versus no therapy, Outcome 2 Carer Strain Index.
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Analysis 2.2

Comparison 2 CCT + education versus no therapy, Outcome 2 Carer Strain Index.

Comparison 3 CCT +/‐ education versus any other intervention, Outcome 1 Adverse events (falls).
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Analysis 3.1

Comparison 3 CCT +/‐ education versus any other intervention, Outcome 1 Adverse events (falls).

Summary of findings for the main comparison. Circuit class therapy compared with other intervention for improving mobility

Circuit class therapy compared with other intervention for improving mobility

Patient or population: people with stroke

Settings: in hospital or community

Intervention: mobility‐related circuit class therapy

Comparison: any other intervention

Outcomes

Illustrative comparative effects (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed effect

Absolute effect

Other intervention

Mobility‐related circuit class therapy

Walking capacity: 6mWT

Continous measure of distance walked in 6 minutes in m

The mean 6mWT distance ranged across control groups from 106 m to 441 m

The mean 6mWT distance in the intervention groups was
60.86 m further

(44.55 to 77.17)

835 (10)

⊕⊕⊕⊝
moderate

Applicable: difference greater than minimal clinically important difference (MDC) = 34.4m Eng 2004, and 95% CI of difference does not cross MDC

Test for differences between subgroups 'early' versus 'later' (< 1 year vs > 1 year post stroke) were not significant.

Some studies have unclear risk of bias (downgraded)

Walking speed

Continuous measure of walking speed measured over a short distance in m/s

The mean gait speed ranged across control groups from 0.43 m/s to 1.3 m/s

The mean gait speed in the intervention groups was 0.15 m/s faster (0.10 to 0.19)

744 (8)

⊕⊕⊕⊝
moderate

Applicable: difference greater than MDC = 0.06 m/s Perera 2006, and 95% CI of difference does not cross MDC

Some studies have unclear risk of bias (downgraded)

Balance and mobility

Timed up and go test. Standing up, walking, returning to sit down in seconds

The mean speed ranged across control groups from 15 s to 28.6 s.

The mean speed in the intervention group was 3.62 s faster (‐6.06 to ‐1.16)

488 (5)

⊕⊕⊝⊝

low

Applicable: somewhat as difference is not greater than MDC (8 s or 28%) (downgraded).

Some studies have unclear risk of bias (downgraded)

Independence in mobility

Functional ambulation classification. Indicates need for assistance/not to safely mobilise

The number of independent participants ranged across the control groups from 2 to 92

The odds ratio of independent classifications in favour of the intervention group was 1.91 (1.01 to 3.6)

469 (3)

⊕⊕⊕⊝
moderate

Applicable: better odds of independence in walking is clinically useful.

Some studies have unclear risk of bias (downgraded)

Physical ability Stroke Impact Scale. A self report of overall physical ability (subscale of total Impact)

The mean score for the control groups ranged from 55.4 to 83.73 points (higher is better)

The mean score for the intervention groups was 2.91 points higher (0.00 to 5.82)

437 (2)

⊕⊕⊝⊝

low

Applicable: only somewhat as the mean change score should be 4.5 points to be regarded as clinically important (downgraded)

Only two trials (downgraded)

Adverse events (falls) from all available trials

Counts of numbers of falls

High risk population

RD 0.03 (‐0.02 to 0.08)

815 (8)

⊕⊝⊝⊝
very low

Applicable: 8 out of 17 studies reported falls; 4 of these studies reported no falls in either group.

Only small number of studies reported that falls occurred (low event rate with low reporting), wide CIs

Difference not statistically significant (downgraded)

Some studies have unclear risk of bias (downgraded)

Heterogeneity I2 > 50%, (downgraded)

91.4 per 1000

134 per 1000

CI: confidence interval; RD: risk difference; MDC: minimal detectable change

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of effect.
Moderate quality: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of effect, but there is a possibility that it is substantially different.
Low quality: OUr confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of effect.
Very low quality: We have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.

Figures and Tables -
Summary of findings for the main comparison. Circuit class therapy compared with other intervention for improving mobility
Table 1. Summary of circuit class content in all trials

Study ID

What

(CCT content)

Who

How

(timing, number and duration of sessions)

Where

Blennerhassett 2004

Mobility CCT in addition to usual care; functional tasks, strengthening exercises

Physiotherapist

1‐hour sessions

5 days per week for 4 weeks

Inpatient rehabilitation unit

Dean 2000

Multiple task‐specific training strengthening LL; practice locomotor‐related tasks

Physiotherapists

1‐hour sessions, 3 days per week for 4 weeks

Community setting

Dean 2012

Progressive balance and strengthening exercises; walking and stair climbing. Home exercise programme and advice to increase walking

Physiotherapist

45 to 60 minutes per week for 40 weeks over a one‐year period

Community setting

English 2015

Task‐specific, part‐ as well as whole‐practice of tasks; emphasis on repetition and feedback

Physiotherapists, assistants, and physiotherapy students

90‐minute sessions, 5 times per week for 4 weeks

Inpatient rehabilitation

Harrington 2010

Individual, easily progressed; balance, endurance, strength, flexibility, function and well‐being. Home exercise manuals and encouraged for on‐going exercise

Instructor and physiotherapist with support from volunteers (partners, carers, family members)

2 sessions per week for 8 weeks.

(1 hour exercise plus 1 hour interactive education

Community setting

Holmgren 2010

Individualised physical activity, functional performance; educational group discussions about fall risk and security

Physiotherapist and occupational therapist

7 sessions per week divided over 3 days for 5 weeks

Community setting

Kim 2016a

Progressive, focused on mobility and gait training as well as physical fitness

Physiotherapist

90‐minute sessions, 5 days per week for 4 weeks

Inpatient rehabilitation

Marigold 2005

Focused on walking, standing, balance, and sit‐to‐stand tasks

Physical therapist, kinesiologist, and recreation therapist

1‐hour sessions, 3 times per week for 10 weeks

Community setting

Marsden 2010

Education and exercises for LL function: functional tasks, strength training and balance training

Multidisciplinary team including a physiotherapist, social worker, dietician, clinical nurse consultant, speech pathologist and occupational therapist

2‐hour sessions (1 hour education + 1 hour exercise) weekly for 7 weeks

Community setting

Moore 2015

Functional movement including stretching, functional strengthening, balance, agility and fitness

Physiotherapist and physical activity instructor

3 x 45‐ to 60‐minute sessions per week for 19 weeks

Community setting

Mudge 2009a

Task‐oriented gait or standing balance activity, strengthening LL

Physiotherapist and 2 physiotherapy students

50‐ to 60‐minute sessions, 3 times a week for 4 weeks

Community setting

Outermans 2010

Postural control and gait‐related activities: stair climbing, walking and turning

Therapists

45‐minute sessions, 3 times per week for 4 weeks

Inpatient and outpatient settings

Pang 2005

Fitness and mobility exercise: cardiorespiratory fitness, mobility, leg muscle strength, balance, and hip bone mineral density

Physical therapist, occupational therapist, and exercise instructor

1‐hour sessions, 3 times per week for 19 weeks

Community setting

Song 2015

Functional training tasks

Physiotherapists

30‐minute sessions, 3 times per week for 4 weeks

Inpatient rehabilitation

Tang 2014

Brisk level and inclined overground walking, upright and recumbent cycle ergometry, functional movements

3 instructors

60‐minute classes, 3 times per week for 6 months

Community setting

Van de Port 2012

Meaningful tasks related to walking competency

Physiotherapist and sports therapists

90‐minute sessions, 2 times per week for 12 weeks

Community setting

Verma 2011

Meaningful tasks related to walking competency: balance control, stair walking, turning, transfers, and speed walking

Physiotherapist or occupational therapist

1 caretaker to ensure safety

40‐minute sessions, 7 days per week for 2 weeks

Inpatient and outpatient settings

CCT: circuit class therapy
LL: lower limb

Figures and Tables -
Table 1. Summary of circuit class content in all trials
Comparison 1. Circuit class therapy versus other

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 6mWT early and late Show forest plot

10

835

Mean Difference (IV, Fixed, 95% CI)

60.86 [44.55, 77.17]

1.1 Early

4

487

Mean Difference (IV, Fixed, 95% CI)

46.56 [21.35, 71.77]

1.2 Late

6

348

Mean Difference (IV, Fixed, 95% CI)

71.15 [49.76, 92.54]

2 Gait speed early and late Show forest plot

8

744

Mean Difference (IV, Fixed, 95% CI)

0.15 [0.10, 0.19]

2.1 Early

2

437

Mean Difference (IV, Fixed, 95% CI)

0.17 [0.10, 0.25]

2.2 Late

6

307

Mean Difference (IV, Fixed, 95% CI)

0.13 [0.07, 0.19]

3 Cadence Show forest plot

2

50

Mean Difference (IV, Random, 95% CI)

13.57 [7.52, 19.62]

4 Timed Up and Go Show forest plot

5

488

Mean Difference (IV, Fixed, 95% CI)

‐3.62 [‐6.09, ‐1.16]

5 Rivermead Mobility Index Show forest plot

2

296

Mean Difference (IV, Fixed, 95% CI)

0.56 [0.17, 0.95]

6 Functional Ambulation Classification Show forest plot

3

469

Odds Ratio (M‐H, Random, 95% CI)

1.91 [1.01, 3.60]

7 Berg Balance Scale Show forest plot

4

171

Mean Difference (IV, Random, 95% CI)

1.21 [‐0.62, 3.04]

8 Step Test Show forest plot

3

190

Mean Difference (IV, Fixed, 95% CI)

0.98 [‐0.40, 2.37]

9 Activities‐specific Balance Confidence Scale Show forest plot

2

103

Mean Difference (IV, Fixed, 95% CI)

7.76 [0.66, 14.87]

10 Stroke Impact Scale (physical) Show forest plot

2

437

Mean Difference (IV, Random, 95% CI)

2.91 [0.00, 5.82]

11 VO2 peak Show forest plot

2

103

Mean Difference (IV, Fixed, 95% CI)

2.81 [0.90, 4.72]

12 Steps per day Show forest plot

2

206

Mean Difference (IV, Fixed, 95% CI)

1325.66 [411.09, 2240.22]

13 Length of stay Show forest plot

2

217

Mean Difference (IV, Random, 95% CI)

‐16.35 [‐37.69, 4.99]

14 Sensitivity: 6mWT Show forest plot

3

393

Mean Difference (IV, Fixed, 95% CI)

46.32 [17.40, 75.24]

Figures and Tables -
Comparison 1. Circuit class therapy versus other
Comparison 2. CCT + education versus no therapy

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Timed Up and Go Show forest plot

2

269

Mean Difference (IV, Fixed, 95% CI)

0.90 [‐0.94, 2.75]

2 Carer Strain Index Show forest plot

2

174

Mean Difference (IV, Fixed, 95% CI)

1.06 [0.39, 1.73]

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Comparison 2. CCT + education versus no therapy
Comparison 3. CCT +/‐ education versus any other intervention

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Adverse events (falls) Show forest plot

8

815

Risk Difference (M‐H, Random, 95% CI)

0.03 [‐0.02, 0.08]

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Comparison 3. CCT +/‐ education versus any other intervention