Repetitive task training for improving functional ability after stroke

Beverley French; Lois H Thomas; Michael J Leathley; Christopher J Sutton; Joanna McAdam; Anne Forster; Peter Langhorne; Christopher IM Price; Andrew Walker; Caroline L Watkins; Louise Connell; Jacqueline Coupe; Naoimh McMahon

doi:10.1002/14651858.CD006073.pub2

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Analysis 1.1

Comparison 1 Upper limb function: post treatment, Outcome 1 Arm function.

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Analysis 1.2

Comparison 1 Upper limb function: post treatment, Outcome 2 Hand function.

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Analysis 1.3

Comparison 1 Upper limb function: post treatment, Outcome 3 Sitting balance/reach.

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Analysis 2.1

Comparison 2 Upper limb function: follow up, Outcome 1 All outcomes.

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Analysis 3.1

Comparison 3 Upper limb function: subgroup analyses, Outcome 1 Dosage of task practice.

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Analysis 3.2

Comparison 3 Upper limb function: subgroup analyses, Outcome 2 Time since stroke.

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Analysis 3.3

Comparison 3 Upper limb function: subgroup analyses, Outcome 3 Type of intervention.

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Analysis 4.1

Comparison 4 Lower limb function: post treatment, Outcome 1 Walking distance: change from baseline.

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Analysis 4.2

Comparison 4 Lower limb function: post treatment, Outcome 2 Walking speed.

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Analysis 4.3

Comparison 4 Lower limb function: post treatment, Outcome 3 Functional ambulation.

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Analysis 4.4

Comparison 4 Lower limb function: post treatment, Outcome 4 Sit to stand: post treatment/change from baseline.

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Analysis 4.5

Comparison 4 Lower limb function: post treatment, Outcome 5 Lower limb functional measures.

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Analysis 4.6

Comparison 4 Lower limb function: post treatment, Outcome 6 Standing balance/reach.

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Analysis 5.1

Comparison 5 Lower limb function: follow up, Outcome 1 All outcomes.

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Analysis 6.1

Comparison 6 Lower limb function: subgroup analyses, Outcome 1 Dosage of task practice.

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Analysis 6.2

Comparison 6 Lower limb function: subgroup analyses, Outcome 2 Time since stroke.

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Analysis 6.3

Comparison 6 Lower limb function: subgroup analyses, Outcome 3 Type of intervention.

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Analysis 7.1

Comparison 7 Global motor function, Outcome 1 Global motor function scales.

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Analysis 8.1

Comparison 8 Secondary outcomes, Outcome 1 Activities of daily living function.

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Analysis 8.2

Comparison 8 Secondary outcomes, Outcome 2 Upper limb impairment.

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Analysis 8.3

Comparison 8 Secondary outcomes, Outcome 3 Lower limb impairment.

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Analysis 8.4

Comparison 8 Secondary outcomes, Outcome 4 Quality of life/health status.

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Analysis 9.1

Comparison 9 Sensitivity analyses, Outcome 1 Allocation concealment.

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Analysis 9.2

Comparison 9 Sensitivity analyses, Outcome 2 Comparison groups.

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Analysis 9.3

Comparison 9 Sensitivity analyses, Outcome 3 Equivalence of therapy time.

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Table 1. Criteria for subgroup and sensitivity analyses

STUDY	Task practice dose	Time since stroke	Type of intervention	Practice intensity	Allocation conceal	Comparison group	Therapy equivalence	Small trials
	1 = 20 hours or less 2 = more than 20 hours	1 = 1 to 14 days 2 = 15 days to 6 months 3 = more than 6 months	1 = whole therapy 2 = mixed task 3 = single task	1 = 1 to 4 weeks or less 2 = more than 4 weeks	A = adequate B = inadequate/unclear	AC = attention control UC = usual care	EQ = equivalent therapy time ADD = additional therapy time	1 = less than 25 participants 2 = 25 or more participants
Blennerhassett 2004	1	2	2	1	A	AC	EQ	2
Dean 1997	1	3	3	1	B	AC	EQ	1
Dean 2000	1	3	2	1	A	AC	EQ	1
De Sèze 2001	1	2	3	1	B	UC	EQ	2
Howe 2005	1	2	3	1	A	UC	EQ	2
Kwakkel 1999	2	1	2	2	A	AC	EQ	2
Langhammer 2000	1	1	1	1	B	UC	EQ	2
McClellan 2004	2	3	2	2	A	AC	EQ	2
Salbach 2004	1	3	2	2	A	AC	EQ	2
Turton 1990	2	2	2	2	B	UC	ADD	1
Van Vliet 2005	1	1	1	1	A	UC	EQ	2
Winstein 2004	1	1	2	1	A	UC	ADD	2
Yen 2005	2	3	2	1	B	UC	EQ	2

Table 1. Criteria for subgroup and sensitivity analyses

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Table 2. Outcome measures used from the included trials

Author and year	Global function	Lower limb function	Balance/sit to stand	Upper limb function	Hand function	ADL function	Impairment	QOL, health status	Adverse events
Barreca 2004			Number able to stand					Dartmouth COOP	Falls
Blennerhassett 2004		6 Minute Walk Test, Step Test	Timed Up & Go Test	Motor Assessment Scale arm	Motor Assessment Scale hand
Dean 1997		10 Metre Walk Speed	Reaching distance
Dean 2000		6 Minute Walk Test, 10 Metre Walk Speed, Step Test
De Seze 2001		Functional Ambulation Classification	Sitting and Standing Equilibrium Index			Functional Independence Measure	Trunk Control Test
Howe 2005			Lateral reach ‐ time, sit to stand ‐ time
Kwakkel 1999		Functional Ambulation Classification		Action Research Arm Test		Barthel Index		Nottingham Health Profile
Langhammer 2000	Motor Assessment Scale	Motor Assessment Scale walking, Sodring Motor Evaluation Scale trunk, balance and gait	Motor Assessment Scale balanced sitting, Motor Assessment Scale sit to stand	Motor Assessment Scale arm	Motor Assessment Scale hand	Barthel Index	Sodring Motor Evaluation Scale leg subscale, Sodring Motor Evaluation Scale arm subscale	Nottingham Health Profile
McClellan 2004		Motor Assessment Scale walking	Functional Reach
Salbach 2004, Higgins 2006		6 Minute Walk Test, 5 Metre Walk Speed	Timed Up & Go Test, Berg Balance	Box & Block Test	9 Hole Peg Test	Barthel Index
Turton 1990				Southern Motor Group Assessment ‐ upper extremity	10 Hole Peg Test
Van Vliet 2005	Rivermead Motor Assessment Gross Function	Rivermead Motor Assessment leg and trunk, 6 Minute Walk Test, Motor Assessment Scale walking, Rivermead Motor Assessment leg and trunk	Motor Assessment Scale balanced sitting, Motor Assessment Scale sit to stand	Motor Assessment Scale arm	Motor Assessment Scale hand	Barthel Index
Winstein 2004				Functional Test of the Hemiparetic Upper Extremity			Fugl Meyer Assessment
Yen 2005				Wolf Motor Function Test

Table 2. Outcome measures used from the included trials

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Comparison 1. Upper limb function: post treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Arm function Show forest plot	8	412	Std. Mean Difference (IV, Fixed, 95% CI)	0.17 [‐0.03, 0.36]

2 Hand function Show forest plot	5	281	Std. Mean Difference (IV, Fixed, 95% CI)	0.16 [‐0.07, 0.40]

3 Sitting balance/reach Show forest plot	5	210	Std. Mean Difference (IV, Fixed, 95% CI)	0.23 [‐0.05, 0.50]

Comparison 1. Upper limb function: post treatment

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Comparison 2. Upper limb function: follow up

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All outcomes Show forest plot	6	246	Std. Mean Difference (IV, Fixed, 95% CI)	0.08 [‐0.17, 0.33]

1.1 Under 6 months post treatment	2	51	Std. Mean Difference (IV, Fixed, 95% CI)	0.50 [‐0.06, 1.06]
1.2 6 to 12 months post treatment	4	195	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.02 [‐0.31, 0.26]

Comparison 2. Upper limb function: follow up

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Comparison 3. Upper limb function: subgroup analyses

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Dosage of task practice Show forest plot	11	484	Std. Mean Difference (IV, Fixed, 95% CI)	0.23 [0.05, 0.41]

1.1 0 to 20 hours	8	371	Std. Mean Difference (IV, Fixed, 95% CI)	0.18 [‐0.02, 0.39]
1.2 More than 20 hours	3	113	Std. Mean Difference (IV, Fixed, 95% CI)	0.40 [0.03, 0.78]
2 Time since stroke Show forest plot	11	484	Std. Mean Difference (IV, Fixed, 95% CI)	0.23 [0.05, 0.41]

2.1 0 to 15 days	4	239	Std. Mean Difference (IV, Fixed, 95% CI)	0.21 [‐0.04, 0.47]
2.2 16 days to 6 months	4	105	Std. Mean Difference (IV, Fixed, 95% CI)	0.24 [‐0.14, 0.63]
2.3 More than 6 months	3	140	Std. Mean Difference (IV, Fixed, 95% CI)	0.25 [‐0.08, 0.59]
3 Type of intervention Show forest plot	11	484	Std. Mean Difference (IV, Fixed, 95% CI)	0.23 [0.05, 0.41]

3.1 Whole therapy	2	138	Std. Mean Difference (IV, Fixed, 95% CI)	0.16 [‐0.18, 0.49]
3.2 Mixed training	6	274	Std. Mean Difference (IV, Fixed, 95% CI)	0.20 [‐0.04, 0.44]
3.3 Single task training	3	72	Std. Mean Difference (IV, Fixed, 95% CI)	0.51 [0.03, 0.99]

Comparison 3. Upper limb function: subgroup analyses

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Comparison 4. Lower limb function: post treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Walking distance: change from baseline Show forest plot	3	130	Mean Difference (IV, Random, 95% CI)	54.59 [17.50, 91.68]

2 Walking speed Show forest plot	5	263	Std. Mean Difference (IV, Fixed, 95% CI)	0.29 [0.04, 0.53]

3 Functional ambulation Show forest plot	5	238	Std. Mean Difference (IV, Fixed, 95% CI)	0.25 [‐0.00, 0.51]

4 Sit to stand: post treatment/change from baseline Show forest plot	7	346	Standardised effect (Fixed, 95% CI)	0.35 [0.13, 0.56]

5 Lower limb functional measures Show forest plot	4	177	Std. Mean Difference (IV, Fixed, 95% CI)	0.20 [‐0.10, 0.50]

6 Standing balance/reach Show forest plot	3	132	Std. Mean Difference (IV, Fixed, 95% CI)	0.29 [‐0.06, 0.63]

Comparison 4. Lower limb function: post treatment

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Comparison 5. Lower limb function: follow up

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All outcomes Show forest plot	7	250	Std. Mean Difference (IV, Fixed, 95% CI)	0.03 [‐0.22, 0.28]

1.1 Under 6 months post treatment	4	80	Std. Mean Difference (IV, Fixed, 95% CI)	0.11 [‐0.33, 0.56]
1.2 6 to 12 months post treatment	3	170	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.01 [‐0.32, 0.29]

Comparison 5. Lower limb function: follow up

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Comparison 6. Lower limb function: subgroup analyses

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Dosage of task practice Show forest plot	10	416	Std. Mean Difference (IV, Fixed, 95% CI)	0.26 [0.06, 0.45]

1.1 0 to 20 hours	8	336	Std. Mean Difference (IV, Fixed, 95% CI)	0.19 [‐0.03, 0.40]
1.2 More than 20 hours	2	80	Std. Mean Difference (IV, Fixed, 95% CI)	0.56 [0.11, 1.01]
2 Time since stroke Show forest plot	10	416	Std. Mean Difference (IV, Fixed, 95% CI)	0.26 [0.06, 0.45]

2.1 0 to 15 days	3	197	Std. Mean Difference (IV, Fixed, 95% CI)	0.24 [‐0.04, 0.52]
2.2 16 days to 6 months	4	101	Std. Mean Difference (IV, Fixed, 95% CI)	0.29 [‐0.11, 0.69]
2.3 More than 6 months	3	118	Std. Mean Difference (IV, Fixed, 95% CI)	0.26 [‐0.11, 0.62]
3 Type of intervention Show forest plot	10	416	Std. Mean Difference (IV, Fixed, 95% CI)	0.26 [0.06, 0.45]

3.1 Whole therapy	2	138	Std. Mean Difference (IV, Fixed, 95% CI)	0.10 [‐0.24, 0.43]
3.2 Mixed training	5	210	Std. Mean Difference (IV, Fixed, 95% CI)	0.48 [0.20, 0.75]
3.3 Single task training	3	68	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.07 [‐0.55, 0.41]

Comparison 6. Lower limb function: subgroup analyses

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Comparison 7. Global motor function

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Global motor function scales Show forest plot	2	138	Std. Mean Difference (IV, Fixed, 95% CI)	0.32 [‐0.01, 0.66]

Comparison 7. Global motor function

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Comparison 8. Secondary outcomes

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Activities of daily living function Show forest plot	5	325	Std. Mean Difference (IV, Fixed, 95% CI)	0.29 [0.07, 0.51]

2 Upper limb impairment Show forest plot	3	184	Std. Mean Difference (IV, Fixed, 95% CI)	0.14 [‐0.15, 0.43]

3 Lower limb impairment Show forest plot	2	73	Std. Mean Difference (IV, Fixed, 95% CI)	0.13 [‐0.33, 0.59]

4 Quality of life/health status Show forest plot	3	148	Std. Mean Difference (IV, Fixed, 95% CI)	0.08 [‐0.24, 0.41]

Comparison 8. Secondary outcomes

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Comparison 9. Sensitivity analyses

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Allocation concealment Show forest plot	13	512	Std. Mean Difference (IV, Fixed, 95% CI)	0.38 [0.21, 0.56]

1.1 Adequate	8	368	Std. Mean Difference (IV, Fixed, 95% CI)	0.37 [0.17, 0.58]
1.2 Inadequate/unclear	5	144	Std. Mean Difference (IV, Fixed, 95% CI)	0.40 [0.07, 0.74]
2 Comparison groups Show forest plot	13	512	Std. Mean Difference (IV, Fixed, 95% CI)	0.38 [0.21, 0.56]

2.1 Usual care	7	283	Std. Mean Difference (IV, Fixed, 95% CI)	0.27 [0.03, 0.50]
2.2 Attention control	6	229	Std. Mean Difference (IV, Fixed, 95% CI)	0.53 [0.26, 0.80]
3 Equivalence of therapy time Show forest plot	13	512	Std. Mean Difference (IV, Fixed, 95% CI)	0.38 [0.21, 0.56]

3.1 Additional therapy time	2	62	Std. Mean Difference (IV, Fixed, 95% CI)	0.09 [‐0.41, 0.59]
3.2 Equivalent therapy time	11	450	Std. Mean Difference (IV, Fixed, 95% CI)	0.42 [0.23, 0.61]

Comparison 9. Sensitivity analyses

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