AMSTAR questions/criteria

Dichotomous questions used to assess quality of reviews

1. Was an 'a priori' design provided?

The research question and inclusion criteria should be established before the conduct of the review.

1.1 Were review subjects clearly defined?

1.2 Were review interventions described?

1.3 Were review comparisons specified?

1.4 Were review outcomes specified?

2. Was there duplicate study selection and data extraction?

There should be at least two independent data extractors, and a consensus procedure for disagreements should be in place.

2.1 Were studies assessed for inclusion by two independent review authors?

2.2 Were data extracted by two independent review authors?

2.3 Was there a clear procedure for resolving any disagreements?

3. Was a comprehensive literature search performed?

At least two electronic sources should be searched. The report must include years and databases used (e.g. CENTRAL, EMBASE, MEDLINE). Key words and/or MeSH terms must be stated and, where feasible, the search strategy should be provided. All searches should be supplemented by consulting current contents, reviews, textbooks, specialised registers or experts in the particular field of study, and by reviewing the references in the studies found.

3.1 Were at least two major databases searched?

3.2 Were dates searched reported?

3.3 Were key words stated?

3.4 Were MeSH terms stated?

3.5 Was the search strategy provided or available on request?

3.6 Were searches supplemented by consulting current contents, reviews, textbooks, specialised registers or experts in the particular field of study, and by reviewing the references in the studies found?

4. Was the status of publication (i.e. grey literature) used as an inclusion criterion? The review authors should state that they searched for reports regardless of their publication type. The review authors should state whether or not they excluded any reports (from the systematic review), based on their publication status, language, etc.

4.1 Were studies searched for and included regardless of their publication type?

4.2 Were papers included regardless of language of publication?

5. Was a list of studies (included and excluded) provided?

A list of included and excluded studies should be provided.

5.1 Was there a list of included studies?

5.2 Was there a list of excluded studies?

5.4 Was there a flow diagram?

6. Were the characteristics of the included studies provided?

In an aggregated form such as a table, data from the original studies should be provided on the participants, interventions and outcomes. The ranges of characteristics in all the studies analysed (e.g. age, race, sex, relevant socioeconomic data, disease status, duration, severity, other diseases) should be reported.

6.1 Were details provided on the participants of included studies (including age, gender, severity of stroke, time since stroke)?

6.2 Were details provided on the interventions of included studies?

6.3 Were details provided on the outcomes reported by included studies?

7. Was the scientific quality of the included studies assessed and documented? 'A priori' methods of assessment should be provided (e.g. for effectiveness studies if the author(s) chose to include only randomised, double‐blind, placebo‐controlled studies, or allocation concealment as inclusion criteria); for other types of studies, alternative items will be relevant.

7.1 Was the scientific quality of included studies assessed?

7.2 Was this done by at least two independent review authors?

7.3 Was the scientific quality of studies documented?

8. Was the scientific quality of the included studies used appropriately in formulating conclusions? The results of the methodological rigour and scientific quality should be considered in the analysis and the conclusions of the review, and explicitly stated in formulating recommendations.

8.1 Were the results of methodological rigour of the included studies considered in the analysis of the review?

8.2 Were the results of the scientific quality of the included studies considered in the conclusions and/or recommendations of the review?

9. Were the methods used to combine the findings of studies appropriate? For the pooled results, a test should be done to ensure the studies were combinable, to assess their homogeneity (i.e. Chi² test for homogeneity, I²). If heterogeneity exists, a random‐effects model should be used and/or the clinical appropriateness of combining should be taken into consideration (i.e. Is it sensible to combine?).

9.1 Were the methods used to combine the findings of studies clearly described or referenced to appropriate text, or both? 

9.2 If results are pooled, are the mean and confidence intervals (or equivalent data) reported? 

9.3 If results are pooled, is a test of heterogeneity reported?

9.4 Have the review authors stated a definition of statistical heterogeneity?

9.5 If statistical heterogeneity is present or suspected, has a random‐effects model been used?

10. Was the likelihood of publication bias assessed?

An assessment of publication bias should include a combination of graphical aids (e.g. funnel plot, other available tests) and/or statistical tests (e.g. Egger regression test).

10. Was the likelihood of publication bias assessed?

11. Was the conflict of interest stated? Potential sources of support should be clearly acknowledged in both the systematic review and the included studies.

11.1 Was there a conflict of interest statement?

11.2 Was the review free of any conflicts of interest?

Intervention

Included reviews

Moderate‐quality evidence of effect on upper limb function

Moderate‐quality evidence of effect on upper limb impairment

Moderate‐quality evidence of effect on ADL outcomes

Low‐ or very low‐quality evidence

Implications for clinical practice

Recommendations for research

Bilateral arm training

Coupar 2010 (vs usual care or control)

van Delden 2012 (vs unilateral arm training)

Unilateral arm training more effective than bilateral arm training

(6 trials, n = 375)

No difference between unilateral arm training and bilateral arm training (4 trials, n = 228)

Unilateral arm training more effective than bilateral arm training

Low‐quality evidence for bilateral arm training compared with usual care or other interventions

Evidence does not support bilateral arm training as a replacement for unilateral arm training

A sound theoretical rationale is essential to justify further research into bilateral arm training

Biofeedback

Woodford 2007 (EMG biofeedback)

Molier 2010 (qualitative data only)

Current evidence of low quality

Insufficient evidence to support any change in current clinical practice

Up‐to‐date reviews required

Bobath therapy

Luke 2004

Current evidence of low quality

Insufficient evidence to support any change in current clinical practice

Up‐to‐date reviews required

Brain stimulation: tDCS

Elsner 2013

tDCS beneficial for impairment (7 trials, n = 304)

High‐quality evidence of no benefit or harm of tDCS (5 trials, n = 286)

Evidence insufficient to support introduction into routine clinical practice

High‐quality RCTs required

Brain stimulation: rTMS

Hao 2013

Current evidence of low quality

Insufficient evidence to support introduction into routine clinical practice

High‐quality RCTs required

Constraint‐induced movement therapy (CIMT)

Corbetta 2010 (subgroup analyses)

Sirtori 2009

CIMT beneficial when compared with control (14 trials, n = 477)

Evidence of low quality for measures of ADLs (because of methodological limitations within review)

Moderate‐quality evidence that CIMT may be effective intervention for selected patients

Phase III RCTs recommended Dose must be considered

Electrical stimulation

Farmer 2014

Nascimento 2014

Meilink 2008

Current evidence of low quality

Insufficient evidence to support any change in current clinical practice

Meta‐analysis of current trials/completion of ongoing review required (Howlett)

"Hands‐on" therapy (manual therapy techniques)

Winter 2011 (qualitative data only)

in

Current evidence of low quality

Insufficient evidence to support any change in current clinical practice

High‐quality RCTs required

Mental practice

Barclay‐Goddard 2011 (subgroup analyses)

Braun 2013

Wang 2011 (includes Chinese trials)

Mental practice beneficial when given in addition to conventional interventions (7 trials, n = 197)

Mental practice beneficial when given in addition to conventional interventions (5 trials, n = 216)

No benefit or harm of mental practice

Moderate‐quality evidence that mental practice may be effective intervention for some patients

Phase III RCTs recommended

Mirror therapy

Thieme 2012

Mirror therapy beneficial (10 trials, n = 421): combined upper limb function and impairment outcomes

(see upper limb function)

Mirror therapy beneficial (4 trials, n = 217)

Moderate‐quality evidence that mirror therapy may be effective intervention for some patients

Phase III RCTs recommended

Music therapy

Bradt 2010

Lack of trial evidence

Insufficient evidence to support any change in current clinical practice

High‐quality RCTs required

Pharmacological interventions

Elia 2009 (botulinum toxin for spasticity)

Olvey 2010 (botulinum toxin for spasticity; qualitative data only)

Demetrios 2013 (multi‐disciplinary rehabilitation following pharmacological interventions; qualitative data only)

Singh 2010 (pharmacological interventions for shoulder pain)

Current evidence of low quality

Insufficient evidence to support any change in current clinical practice

Reviews require updating

High‐quality RCTs required

Repetitive task training (RTT)

French 2007

French 2008

No benefit or harm of RTT (8 trials, n = 412)

Beneficial effect when dose > 20 hours (3 trials, n = 113)

Moderate‐quality evidence that a higher dose of RTT

may be beneficial

Review requires updating

Large‐scale RCTs to explore dose is a research priority, including number of repetitions during RTT

Robotics

Mehrholz 2012

Norouzi‐Gheidari 2012

Beneficial effect of robotics as compared with any comparison on impairment scales (16 trials, n = 586)

No benefit or harm as compared with the same duration of conventional therapy (6 trials, n = 204)

No benefit or harm on measures of strength (10 trials, n = 321)

Beneficial effect of robotics as compared with any comparison on ADLs (13 trial, n = 552)

Current evidence does not support Introduction into routine clinical practice

High‐quality RCTs required, including consideration of dose

Sensory interventions

Doyle 2010

Schabrun 2009 (qualitative data only)

Beneficial effect of sensory stimulation as compared with no treatment (1 trial, n = 29)

Beneficial effect of sensory stimulation as compared with no treatment (1 trial, n = 29)

Low‐quality evidence for all other interventions

Current evidence does not support any change in current clinical practice

High‐quality RCTs required

Strength training

Harris 2010

Low‐quality evidence of a beneficial effect on upper limb function (11 trials, n = 465) and grip strength (6 trials, n = 306). (Quality judgement influenced by poor reporting within review)

Insufficient evidence to support any change in current clinical practice

High‐quality up‐to‐date review required

High‐quality RCTs required

Stretching and positioning

Katalinic 2010 (stretching and positioning)

Borisova 2009 (positioning of shoulder)

Ada 2005 (shoulder supports)

Lannin 2003 (hand splinting)

Hijmans 2004 (elbow orthoses; qualitative data only)

No benefit or harm of stretching as compared with any other intervention on joint mobility and spasticity

No benefit or harm of stretching as compared with any other intervention on ADLs

Low‐quality evidence of no benefit of shoulder supports

Current evidence does not support any change in current clinical practice

High‐quality up‐to‐date review required

Essential that research protocols comprise doses that are theoretically predicted to effect change

Task‐specific training (reach‐to‐grasp exercise)

Pelton 2012 (qualitative data only)

Urton 2007 (qualitative data only)

Current evidence of low quality

Insufficient evidence to support any change in current clinical practice

High‐quality, up‐to‐date review required

Virtual reality

Laver 2011

Virtual reality beneficial (7 trials, n = 205): combined upper limb function and impairment outcomes

(see upper limb function)

No benefit or harm for grip strength (2 trials, n = 44)

Moderate‐quality evidence that virtual reality may be effective intervention for some patients

Phase III RCTs recommended, including consideration of dose

Review (source)

Intervention

Date of search

Objective

(as stated within review)

Types of studies included

Participants included

Interventions included

Comparisons included

Outcomes

(as defined within review)

Number of studies included (number of participants included)

Ada 2005 (CDSR); Foongchomchaey 2005 (DARE)

Stretch or positioning

22/03/2004

To investigate the effects of supportive devices in preventing subluxation, repositioning the head of the humerus in the glenoid fossa,
decreasing pain, increasing function and adversely increasing contracture in the shoulder after stroke

RCTs, quasi‐randomised and controlled trials

Stroke

Supportive devices

Alternative supportive device or no support

Distance of subluxation (from x‐ray), pain, function, contracture

4 (142)

Barclay‐Goddard 2011 (CDSR)

Mental practice

24/11/2010

To determine whether mental practice improves the outcomes of upper extremity rehabilitation for individuals living with the effects of stroke

RCTs

Stroke, UL functional deficits

Mental practice of upper extremity
movements or tasks alone or in combination with other therapies

No intervention; conventional intervention; placebo mental practice; or other novel therapies

Upper
extremity function: Arm and hand—e.g. Box and Block Test, Test Evaluant des Membres Supérieurs des Personnes Agées
(TEMPA), Action Research Arm Test, Motor Assessment Scale, upper extremity component, Frenchay Arm Test,
Wolf Motor Function Test, components of the Barthel Index or
the Functional Independence Measure. Hand function—Jebsen Test of Hand Function, Motor Assessment Scale Hand

6 (119)

Borisova 2009 (DARE)

Stretch or positioning

30/06/2005

To assess the effectiveness of positioning on range of motion of the paretic shoulder following stroke

RCTs

Stroke

Positioning

Control

Range of motion

5 (126)

Bradt 2010 (CDSR)

Music therapy

25/02/2010

To examine the effects of music therapy with standard care versus standard care alone or standard care combined with other therapies
on gait, upper extremity function, communication, mood and emotions, social skills, pain, behavioural outcomes, activities of daily
living and adverse events

RCTs, quasi‐RCTs

Acquired brain injury

Music therapy

Standard care or standard care with other therapies

Upper extremity function:measured by
hand grasp strength, frequency and duration of identified hand
function, spatiotemporal arm control

Secondary outcomes:
Communication, mood and emotions, social skills and interactions, pain, behavioural outcomes, activities of daily living

Adverse events (e.g. death, fatigue, falls)

7 (184)

Braun 2013 (DARE)

Mental practice

01/06/2012

To investigate the beneficial and adverse effects of a mental practice intervention on activities, cognition and emotion in patients after stroke, patients with Parkinson’s disease or multiple sclerosis

RCTs

Stroke, Parkinson's or multiple sclerosis (but no studies with participants with multiple sclerosis found)

Mental practice as therapy or embedded in therapy

Control that allows assessment of the possible effects of mental practice

Measures of function, activity and participation

Stroke—14 (421) Parkinson's—2(60)

Cooke 2010 (DARE)

Exercise therapy

01/10/2009

To determine the strength of current evidence for provision of a
higher dose of the same types of exercise‐based therapy to enhance motor recovery after stroke

RCTs or quasi‐RCTs

Stroke

Experimental and control group interventions identical
except for dose described by duration and effort. Therapy dose could be described in terms
of time spent in therapy and/or of effort expended

See previous column—exercises but without increased duration

Motor impairment:
Motricity Index, muscle tone, joint range of
motion; co‐ordination, reaction time

Motor activity:Modified
Rivermead Mobility Index, Action Research Arm Test,
Functional Ambulation Categories, Nine‐Hole Peg Test

7 (680)

Corbetta 2010 (DARE)

CIMT (constraint‐ induced movement therapy)

01/04/2010

This article aims to present an update of the Cochrane review and to assess the effects of CIMT, modified CIMT and forced use on disability and arm motor function

RCTs and quasi‐RCTs

Stroke

CIMT, modified CIMT or forced use

Usual care

Disability:Functional Independence measure, Barthel Index

Arm motor function:Action Research Arm Test, Wolf Motor Function Test, Emory Function Test, Motor Assessment Scale

18 (674)

Coupar 2010 (CDSR)

Bilateral arm training

28/08/2009

To determine the effects of simultaneous bilateral training for improving arm function after stroke

RCTs

Stroke

Simultaneous bilateral training

Control, usual care

Performance in ADLs: functional movement of the upper limb;
Performance in extended activities of daily living: motor impairment of the arm

18 (549)

Coupar 2012 (CDSR)

Service delivery

21/05/2011

To determine the effects of home‐based therapy programmes for upper limb recovery in patients with upper limb impairment following
stroke

RCTs

Stroke

Home‐based therapy for UL rehabilitation

Placebo, no intervention or usual care

ADLs and functional movement, extended ADLs, motor impairment

4 (166)

Demetrios 2013 (CDSR)

Pharmacological

01/09/2012

To assess the effectiveness of multi‐disciplinary rehabilitation, following botulinum neurotoxin and other focal intramuscular treatments such as phenol, in improving
activity limitations and other outcomes in adults and children with poststroke spasticity. To explore what settings, types and intensities
of rehabilitation programmes are effective

RCTs

Adults and children with poststroke spasticity (clinical diagnosis)

Multi‐disciplinary rehabilitation after botulinum neurotoxin or other focal intramuscular treatments

Multi‐disciplinary rehabilitation

Passive function: Leeds Arm Spasticity Impact Scale, Disability Assessment Scale,
Arm Activity Measure

Active function of the upper limb: e.g. Motor Activity Log (MAL) or Action Research Arm Test

Active function of the lower limb: e.g. tests of walking speed, balance and gait
pattern

Impairments—pain, spasm frequency, joint range
of movement, involuntary movements, measures of spasticity (Modified Ashworth Scale,
Tardieu Scale)

Participation and impact on caregivers: WHO QoL‐BREF, Caregiver Strain
Index

Adverse events

3 (91)

Doyle 2010 (CDSR)

Sensory intervention

16/09/2009

To determine the effects of interventions that target upper limb sensory impairment after stroke

RCTs and controlled clinical trials

Stroke

For sensory impairment

No treatment,
conventional treatment, attention with placebo or with other interventions for sensory impairment

Functional use of the upper limb:
including Jebsen
Taylor Hand Function Test, Fugl‐Meyer, Modified Motor Assessment Scale,
Chedoke‐McMaster Motor Activity Log Scales (identifying perceived level of
use and satisfaction with level and quality of upper limb use)

Activity limitations:
Barthel Index; Functional Independence Measure; Frenchay Activites Index; global dependency scales

Participation: Stroke Impact Scale,
quality of life measures

13 (467)

Elia 2009 (DARE)

Botulinum toxin injection by any route, including but not limited
to intramuscular, subcutaneous, intradermal and intra‐articular
routes

01/09/2006

The aim of this systematic review was to determine
whether botulinum neurotoxin reduces spasticity
or improves function in adult patients after stroke

All levels of evidence

Stroke

Intramuscular injections, botulinum neurotoxin A or botulinum neurotoxin B

Ashworth Scale, Improvement of Global Assessment Scale (area under the curve of Ashworth scores),

functional
disability, pain and quality of life measured by
validated scales; occurrence of serious adverse events

11 (782)

Elsner 2013 (CDSR)

Transcranial direct current stimulation (tDCS)

May 2013

To assess the effects of tDCS on generic activities of daily living and motor function in people with stroke

RCTs, first period of randomised cross‐over trials

Stroke

Active tDCS

Placebo, sham tDCS, no intervention or conventional rehabilitation

Primary outcome: Activities of daily living—Frenchay Activities Index, Barthel Index, Rivermead Activities of Daily Living Assessment, Modified Rankin Scale and Functional Independence Measure

Secondary outcomes:

Upper limb function—Action Research Arm Test, Fugl‐Meyer Score, Nine‐Hole Peg Test or Jebsen Taylor Hand Function Test.

Muscle strength—grip force or motricity index

Lower limb function

15 (455)

Farmer 2014 (personal communication)

Assistive technologies, including electrical stimulation

01/09/2011

To identify and explore evidence for use of assistive technologies in poststroke upper limb rehabilitation

RCTs

Stroke

Assistive technologies including electrical stimulation

(An assistive technology was defined as "a mechanical
or electrical device used in a functional task orientated training process which will have a systematic or rehabilitative effect on a person" and stated to include biofeedback, brain stimulation, constraint‐induced movement, neuromuscular electrical stimulation (NMES), robotics and virtual reality.)

Placebo, alternative treatments, usual care

Impairment: Range of motion, grip strength, subjective assessment of strength, Fugl‐Meyer

Activity: Action Research Arm Test and Wolf Motor Function Test

Partcipation: Motor Activity Log Amount of Use; Motor Activity Log Quality of Movement; Functional Independence Measure; Barthel index; Rankin Score and Stroke Impact Scale

11 (474)

French 2007 (CDSR); French 2010 (DARE)

Repetitive task training

16/10/2006

To determine whether repetitive task training after stroke improves global, upper or lower limb function, and whether treatment effects are dependent on the amount, type or timing of practice

RCTs, controlled clinical trials

Stroke

Repetitive tasks training; an active motor sequence (multi‐joint motion) performed repetitively

Attention control, recreation, cognitive therapy, upper limb versus lower limb

Arm function: Motor Assessment Scale—Upper Limb Component, Action Research Arm Test, Frenchay Arm Test, Wolf Motor Function Test, Functional Test of the Hemiparetic Upper Extremity, Box and Block Test, Southern Motor Group Assessment

Hand function: Motor Assessment Scale Hand; Jebsen Test of Hand Function, Peg Test

Sitting balance/reach: Reaching Performance Scale, Functional Reach.

Lower limb function: walking distance, walking speed, functional ambulation, Timed Up and Go Test/Sit to Stand; Rivermead Motor Assessment, Sodring Motor Evaluation Scale Standing Balance/Reach: Berg Balance Scale, Sitting Equilibrium Index, Standing Equilibrium Index, Functional Reach

Global motor function: Motor Assessment Scale, Rivermead Motor Assessment Scale, Sodring Motor Evaluation Scale

Activities of daily living measures: Barthel Index, Functional Independence Measure, Modified Rankin Scale, Global Dependency Scale

Measures of task performance or impairment:
Motricity Index, Fugl‐Meyer Assessment, Sodring Motor Evaluation Scale Leg and Arm Subscales, Trunk Control Test

Measures of quality of life, health status, user satisfaction, carer burden, motivation or perceived improvement:e.g.
Nottingham Health Profile, SF‐36, Dartmouth Cooperative Chart

Adverse outcomes

14 (659)

French 2008 (DARE)

Repetitive task training

01/09/2006

To determine whether repetitive
functional task practice (RFTP) after stroke improves
limb‐specific or global function or activities of daily
living, and whether treatment effects are dependent on
the amount of practice, or the type or timing of the
intervention. Also to provide estimates of the cost‐effectiveness
of RFTP

RCTs, quasi‐RCTs, cross‐over trials (first part)

Stroke

Repetitive task training

Usual practice or attention control, alternative training

Arm function: Action Research Arm Test; Motor Assessment Scale—Upper
Limb Component, Frenchay Arm Test, Wolf
Motor Function Test, Functional Test of the Hemiparetic Upper Extremity, Box and Block Test, Test Evaluant des
Membres Supérieurs des Personnes Agées, University of Maryland Arm
Questionnaire for Stroke, Motor Activity Log

Hand function: Motor Assessement Scale Hand; Jebsen Test of Hand
Function; Peg Test, Purdue Pegboard.

Sitting Balance/Reach—Reaching Performance
Scale, Functional Reach

31 (1078)

Hao 2013 (CDSR)

Repetitive transcranial magnetic stimulation (rTMS)

23/04/2012

To assess the efficacy and safety of rTMS for improving function in people with stroke

RCTs

Stroke (any age)

rTMS, rTMS added to standard treatment

Sham treatment, sham treatment added to baseline treatment, baseline treatment alone

ADLs: Barthel Index, Functional Independence Measure, Modified Rankin

Motor function:Upper limb function—Motor Assessment Scale, Action Research Arm Test, Nine‐Hole Peg Test. Lower limb function—changes in stride length or speed, Timed Up and Go Test, Rivermead Motor Assessment Scale. Global motor function—Motor Assessment Scale, Rivermead Motor
Assessment Scale

Death or disability

Any other impairment improvement (e.g. visual, perceptual, depression, cognition, etc)

19 (588)

Harris 2010 (DARE)

Exercise

04/2009

To examine the evidence
for strength training of the paretic upper limb in improving
strength, upper limb function and ADLs

RCTs

Stroke

Strength training (voluntary exercise against resistance)

No treatment, placebo, non‐strengthening intervention

Upper limb strength, upper limb function or ADLs

13 (517)

Hijmans 2004 (DARE)

Stretch or positioning

01/06/2003

To assess the scientific base of elbow
orthoses

All designs considered

Elbow condition

Splinting

No comparisons prespecified

Range of motion, pain, grip strength

Stroke RCT—1 (18),

Cohort—1 (16)

Katalinic 2010 (CDSR)

Stretch or positioning

01/04/2009

To determine the effects of stretch on contractures in people with, or at risk of, contractures

RCTs and controlled
clinical trials; parallel‐group designs, within‐subject
designs or cross‐over designs

• Neurological conditions (e.g. stroke, multiple sclerosis,
spinal cord injury, traumatic brain injury, Guillain‐Barré
syndrome, Parkinson’s disease)
• Advanced age (e.g. frailty);
• History of trauma or surgery (e.g. burns, joint replacement
surgery)
• Underlying joint or muscle pathology and disease processes
(e.g. inflammatory arthritis, osteoarthritis)

Stretch, stretch plus co‐intervention

No stretch, placebo or sham stretch, co‐intervention

Range of motion, torques, QoL, SF‐36, Tardieu, Modified Ashworth Scale, Functional Independence Measure, motor ability score

35 (1391)

Lannin 2003 (DARE)

Stretch or positioning

26/05/2003

To assess the effectiveness of hand splinting on the hemiplegic
upper extremity following stroke

All designs considered

Stroke

Splinting

No comparisons prespecified

Functional use of hand, range of motion, tone, spasticity, oedema, pain

21 (230)

Laver 2011 (CDSR)

Virtual reality

30/03/2010

To evaluate the effects of virtual reality and interactive video gaming on upper limb, lower limb and global motor function after stroke

RCTs

Stroke

Immersive or non‐immersive virtual reality

Alternative intervention, no Intervention

Upper limb function and activity:
Arm function and activity—Motor Assessment Scale (Upper Limb), Action Research
Arm Test, Wolf Motor Function Test;
Hand function and activity—Nine‐Hole Peg Test, Box and Block Test.

Gait and balance function and activity:
Lower limb function and activity—walking distance, walking speed, Community
Walk Test, functional ambulation, Timed Up and Go Test;
Standing reach—Berg
Balance Scale and laboratory‐based force plate measures

Global motor function: Motor Assessment Scale

Secondary outcomes: Cognitive function—Trail Making Test, Useful Field of View Test;

Activity limitation—
Functional Independence Measure (FIM), Barthel Index,
Activities‐Specific Balance; Confidence Scale, On‐Road Driving
Test;
Participation restriction and quality of life—SF‐36, EQ5D, Stroke Impact Scale or other patient‐reported outcomes;
Functional magnetic resonance
imaging (MRI)

Adverse events: motion sickness, pain, injury, falls
and death

19 (565)

Laver 2013 (CDSR)

Service delivery

09/07/2013

To evaluate the effects of telerehabilitation, in comparison with in‐person or no rehabilitation, on activities of daily living for people after
stroke. Secondary objectives included determining the effects of telerehabilitation on mobility, health‐related quality of life, upper
limb function, cognitive function or functional communication

RCTs

Stroke

Telerehabilitation

"In‐Person Rehabilitation" or no rehabilitation or alternative method of delivering telerehabilitation

Primary outcomes:

Activities of daily living—Functional Independence Measure; Nottingham Extended Activities of Daily Living

Secondary outcomes:

Self‐care and domestic life;
mobility (e.g. Timed Up and Go Test, walking
speed, functional ambulation category);

Patient satisfaction with the intervention—self‐reported health‐related quality of life; upper limb function (e.g. Action Research Arm Test, Wolf Motor Function Test, Fugl‐Meyer Upper Extremity
Measure); cognitive function (e.g. Mini
‐Mental State Examination, specific measures such as tests of
attention or executive functioning); Functional communication; Cost‐effectiveness.

Adverse events

10 (933)

Luke 2004 (DARE)

Exercise therapy

2003

To determine the effectiveness of the Bobath concept in reducing upper limb impairments, activity limitations and participation restrictions after stroke

RCTs, cross‐over and single case series

Stroke

Stated use of the Bobath concept
or neurodevelopmental therapy in isolation

A control for Bobath
intervention in the form of a group with no
intervention or a group with a comparison intervention,
or a baseline phase

Any outcome
measure reflecting change in upper limb impairment,
activity limitation or participation restriction

RCTs—5 (209)

Cross‐over—1 (131)

Single‐case study—2 (34)

Mehrholz 2012 (CDSR)

Robotics

01/08/2011

To assess the effectiveness of electromechanical and robot‐assisted arm training in improving generic activities of daily living, arm function and arm muscle strength in patients after stroke

RCTs

Stroke

Electromechanical and robot‐assisted arm training for recovery of arm function

Other rehabilitation or placebo interventions, or no treatment

ADLs (Barthel Index, Functional Independence Measure), Fugl‐Meyer, Motricity Index and other measures of arm function or strength

19 (666)

Meilink 2008 (DARE)

Electrostimulation

01/06/2006

To assess whether EMG‐triggered neuromuscular electrical
stimulation (EMG‐NMES) applied to the extensor muscles of the forearm
improves hand function after stroke.

RCTs

Stroke

EMG‐NMES

Usual care

Reaction time, Fugl‐Meyer Assessment, Box and Block Test, peak velocity, deceleration time, Functional Independence Measure (self‐care), Action Research Arm Test, grip strength, Motricity Index, pinch and grip strength, elbow flexion/shoulder abduction, goniometry

8 (157)

Molier 2010 (DARE)

Biofeedback

01/03/2009

To investigate the effects of different aspects and types of augmented feedback on motor functions and motor
activities of the hemiparetic arm after stroke

All levels of evidence

Stroke

Intervention augmented by biofeedback

Comparisons were not defined a priori but included practising movements without feedback or robotic guidance

Fugl‐Meyer, Composite Spasticity Index, Ashworth Scale, Test Evaluant des
Membres Supérieurs des Personnes Agée, Block and Box Test, Motor Power Score, Motor Status Score, Motor Assessment Scale, Jebsen Taylor Hand Test, ABILHAND, Purdue Pegboard Test, Chedoke McMaster, Wolf Motor Function Measure, Stroke Impact Scale, Functional Test of the Hemiparetic Upper Extremity

23 (328):

RCTs—8 (148)

Cohort—10 (106)

Matched pairs—2 (52)

Not randomised—1 (16)

Observational study—1 (5)

Single case study—1 (1)

Nascimento 2014 (PROSPERO)

Electrical stimulation

December 2012

To determine whether electrical stimulation is effective in increasing strength after stroke, and whether any benefits are maintained beyond the intervention period or carried over to activity

RCTs and controlled trials

Stroke

Cyclical electrical stimulation for strengthening

1. No treatment, placebo, non‐strengthening interventions

2. Other strengthening interventions

3. Different modes of electrical stimulation

Strength: peak force generation

Activity: Block and Box Test, Action Research Arm Test

General activity: Barthel Index

16 (638)

Norouzi‐Gheidari 2012 (DARE)

Robotics

01/07/2010

To find evidence regarding the effectiveness
of robot therapy compared with conventional therapy in improving motor
recovery and functional abilities of the paretic upper limb of
patients with stroke

RCTs

Stroke

Robot therapy

Conventional therapy

Fugl‐Meyer, Functional Independence Measure, Motor Power Scale, Motor Status Scale

12 (383)

Olvey 2010 (DARE)

Pharmacological

01/07/2010

To review
studies focusing on contemporary pharmacological therapies
for upper limb spasticity after stroke

RCTs, open‐labelled non‐randomised or observational studies

Stroke

Pharmacological treatments for spasticity

Dose comparisons or placebo with or without other treatment

Spasticity (Ashworth Scale or Modified Ashworth Scale or Tardieu Scale), pain, Fugl‐Meyer Assessment, Functional Independence Measure, Barthel Index, Disability Assessment Scale, range of motion, health‐related quality of life

RCTs—23 (1039)

Other—31 (1288)

Pelton 2012 (DARE)

Exercise

04/2010

To identify all existing interventions targeted at co‐ordination of arm and hand segments for reach‐to‐grasp
following stroke. To determine the effectiveness of current treatments for improving co‐ordination of reach‐to‐grasp
after stroke

All types of study design

Stroke

Treatment to develop co‐ordination of hand and arm during reach‐to‐grasp

Specific measures of co‐ordination such
as movement velocity, acceleration, deceleration and movement
duration, maximum hand aperture and reaction time; Fugl‐Meyer Assessment

8 (155)

Schabrun 2009 (DARE)

Sensory training

Not reported

We examined the volume and quality of the evidence available for
both passive and active sensory training following stroke

All types of study design

Stroke

Sensory retraining

Jebsen Taylor Hand Function, Action Research Arm Test, Modified Ashworth Assessment Scale, Modified Motor Assessment Scale

14 (296)

Singh 2010 (CDSR)

Pharmacological

22/01/2010

To assess the benefits and safety of botulinum toxin compared with placebo or alternative treatments in adults with shoulder pain

RCTs

Shoulder pain

Botulinum toxin injection by any route, including but not limited
to intramuscular, subcutaneous, intradermal and intra‐articular
routes

Placebo injection or another active treatment

Pain: measured on a visual analogue scale, numerical
rating scale or semi‐quantitative descriptive scale

Adverse effects

Function or disability: measured using validated shoulder‐specific
instruments (e.g. Constant Score, University of
California and Los Angeles Shoulder Scale (UCLA) or American
Shoulder and Elbow Surgeons Shoulder Score, Western Ontario Osteoarthritis of the Shoulder)

General
disability measures: e.g. Health Assessment Questionnaire

Joint range of motion

Quality of life: e.g.
Short‐Form 36 (SF‐36)

6 (164)

Sirtori 2009 (CDSR)

Constraint‐induced movement therapy (CIMT)

01/06/2008

To assess the efficacy of CIMT, modified CIMT (mCIMT) or forced use (FU) for arm management in hemiparetic patients

RCTs and quasi‐RCTs

Stroke

CIMT, mCIMT or forced use

Other rehabilitation techniques or none

Arm motor function: perceived arm motor function, arm impairment, dexterity, quality of life

19 (619)

Thieme 2012 (CDSR)

Sensory intervention

08/06/2011

To summarise the effectiveness of mirror therapy for improving motor function, activities of daily living, pain and visuospatial neglect in patients after stroke

RCTs and randomised cross‐over trials

Stroke

Mirror therapy

Any control intervention

Upper limb and hand function: Fugl‐Meyer, Action Reseach Arm Test, Wolf Motor Function Test, Brunnstrom Stages of Upper Extremity, Motricity Index

Lower limb function: Functional Independence Measure, Barthel Index

14 (567)

Urton 2007 (DARE)

Mixed

06/2005

To critically analyse the literature on effective interventions for upper extremity
hemiparesis following stroke

RCTs and CCTs

Stroke

For upper limb hemiparesis

Fugl‐Meyer Assessment, Box and Block Test, Purdue Pegboard Test, Action Research Arm Test, Functional Independence Measure, TEMPA, Wolf Motor Function Test, grip strength, Caregiver Strain Index, Geriatric Depression Score, Ashworth Scale, Motor Activity Log and other study‐specific measures

11 (269)

van Delden 2012 (DARE)

Bilateral arm training

01/06/2011

To compare the effects of unilateral and bilateral
training on upper limb function after stroke with regard to 2 key factors: severity of upper limb paresis and time of intervention post stroke

RCTs

Stroke up to 1 month = acute, 1‐6 months = subacute, after 6 months = chronic

Unilateral arm training; bilateral arm training

Alternative treatment

Wolf Motor Function Measure, Canadian Occupational Performance Measure, Fugl‐Meyer Assessment, Functional Independence Measure, Motor Activity Log, Stroke Impact Scale, Action Research Arm Test, Rivermead Motor Assessment, Nine‐Hole Peg Test, Modified Barthel Index, Nottingham Health Profile, Hospital Anxiety and Depression Scale, Motor Status Scale, Motor Assessment Scale, dynamometry, Rehabilitation Activities Profile, fMRI, additional kinematics

9 (452)

Wang 2011 (DARE)

Mental practice

10/2010

To evaluate mental imagery on rehabilitation of functions in patients with stroke

RCTs

Stroke

Mental practice or mental imagery. Other clinical and rehabilitative treatments were the same as control group

Conventional stroke rehabilitation methods (such as physiotherapy and occupational therapy)

Upper limb function: Upper Limb Section of Fugl‐Meyer Assessment of Motor Recovery, Action Research Arm Test

Other outcomes: Motor Assessment Scale, Modified Ashworth Scale, Upper Extremity Function Test, Functional independence Measure, Motor Activity Log, Color Trails Test, Task Performance Test, Motricity Index, The Arm Functional Test, simple test for evaluating hand function, Modified Barthel Index

16 (652) (191 total participants for English papers, 461 total participants for Chinese papers)

Winter 2011 (CDSR)

Stretch or positioning

22/03/2010

To identify whether specific hands‐on therapeutic interventions enhance motor activity and function of the upper limb post stroke

RCTs

Stroke

Manual therapy techniques

Unclear

UL function: Action Research Arm Test, Motricity Index, Functional Independence Measure, Barthel Index

3 (86)

Woodford 2007 (CDSR)

Biofeedback

29/03/2006

To assess the effects of EMG‐BFB for motor function recovery following stroke

RCTs and quasi‐RCTs

Stroke

EMG biofeedback with standard physiotherapy

Standard physiotherapy or standard physiotherapy and sham feedback

Range of motion, improvement in gait (stride length, speed, need for ambulation aids),
functional ability, electromyographic activity, muscle weakness

13 (269)

Reference

Brief description of review/review aim

Dates/Notes

Diermayr (Ongoing)

Effects of reach‐to‐grasp training using trunk restraint in individuals with hemiparesis post stroke: a systematic review

Anticipated publication stated as May 2013. Personal communication with author: completion date currently unknown

PROSPERO 2012: CRD42012003464

Galvin 2012 (Ongoing)

To assess whether additional exercise therapy has an impact on recovery following stroke when compared with routine exercise therapy

Protocol published June 2012

Howlett (Ongoing)

Systematic review of functional electrical stimulation to improve activity and participation after stroke

Anticipated publication stated as October 2013. Personal communication with author: February 2014 in final stages

PROSPERO 2012: CRD42012003054

Kidd (Ongoing)

Systematic review of self‐management interventions for stroke survivors

Protocol published February 2013

PROSPERO 2013: CRD42013003592

Kinnear (Ongoing)

Physical therapies as an adjunct to botulinum toxin—injection to the upper or lower limb for the treatment of spasticity following neurological impairment: a systematic review

Personal communication with author: August 2013, in press

PROSPERO 2011: CRD42011001491

Liang 2011 (Ongoing)

To assess the efficacy and possible adverse effects of acupuncture for the treatment of poststroke upper limb pain

Protocol published April 2011

Lindsay 2013 (Ongoing)

To determine whether pharmacological interventions for spasticity are more effective than no intervention, normal practice or control in improving function following stroke

Protocol published February 2013

Meeran (Ongoing)

To assess the effects of assistive technologies for the management of contractures in people with stroke

Protocol published October 2013

Monaghan 2011 (Ongoing)

To determine whether physical treatment interventions are effective in preventing or minimising activity limitation and participation restrictions in patients developing spasticity post stroke

Protocol published July 2011

Schneider (Ongoing)

Intensive treatment versus normal treatment for improved motor recovery after stroke: a systematic review

Personal communication with author: Publication date anticipated around May 2014

PROSPERO 2012: CRD42012003221

Straudi (Ongoing)

The role of transcranial direct current stimulation (tDCS) in motor rehabilitation in stroke survivors: a systematic review

Protocol published May 2013

PROSPERO 2013: CRD42013003970

Review (source)

Intervention

Reason for exclusion

Date of search

Objective

(as stated within review)

Types of studies included

Participants included

Interventions included

Comparisons included

Outcomes

(as defined within review)

Number of studies included (number of participants included)

Ada 2002 (DARE)

Electrical stimulation

Superseded by more up‐to‐date review

July 2002

A meta‐analysis of all eligible randomised or quasi‐randomised trials of electrical stimulation for the treatment of shoulder subluxation

RCTs and quasi‐randomised trials

Stroke

Surface electrical stimulation with motor response

Conventional therapy

Subluxation, pain or function

5 (183)

Aziz 2008 (CDSR)

Home rehabilitation therapy

No UL specific outcome

‐

‐

‐

‐

‐

‐

‐

‐

Bjorklund 2006 (DARE)

CIMT

Superseded by more up‐to‐date review

2004

To investigate the outcomes of numerous CIMT trials to gauge improvement in upper extremity motor function among individuals suffering from hemiparesis experienced after stroke

RCTs, controlled trials, pre/post cohorts

Ischaemic

or haemorrhagic stroke

CIMT

Self as control, conventional therapy

Fugl‐Meyer Assessment, Action Research Arm Test, Wolf Motor Function Test,
Actual Amount of Use Test, Motor Activity Log, Functional Independence Measure, Arm Motor Ability Test

11 (179)

Bolton 2004 (DARE)

EMG‐triggered electrical stimulation

Superseded by more up‐to‐date review

3rd quarter 2003

To assess the mean effect size of EMG‐triggered neuromuscular
stimulation on motor recovery of the upper limb

RCTs, controlled trials

Stroke

EMG‐triggered
neuromuscular electrical stimulation (active stimulation)
with surface electrodes used to monitor muscle activity
and to provide electrical stimulation

Usual therapy, stretching

Fugl‐Meyer Assessment,

Block and Box Test,

Rivermead Motor Assessment

5 (86)

Bonaiuti 2007 (DARE)

CIMT

Superseded by up‐to‐date review

July 2004

To analyse the evidence of effectiveness on adult stroke patients of CIMT

RCTs

Stroke

CIMT

Conventional therapy

Measures of impairment

9 (243)

Braun 2006 (DARE)

Mental practice

Superseded by up‐to‐date review

August 2005

To assess the effects of a mental practice intervention
on recovery in stroke patients

RCTs, controlled trials

Stroke

Mental practice

Not clear

Measures of activity limitation or impairment

4 RCTs ("Study sizes were small
(4 studies had 20 participants, 1 study had 46 patients)")

Cardoso 2005 (DARE)

Botulinum toxin A

Superseded by up‐to‐date review

2004

To assess whether botulinum toxin is an adequate treatment for spasticity due to stroke

RCT

Stroke

Botulinum toxin A injections for upper limb spasticity

Placebo

Modified Ashworth Scale,

Global Assessment Scale

5 (329)

Crosbie 2007 (DARE)

Virtual reality

Superseded by up‐to‐date review

February 2005

To assess the utility of virtual reality (VR) in stroke rehabilitation

RCTs, pre/post case series

Stroke

Virtual reality intervention

Self as control, healthy controls, age‐matched controls

Impairment or activity measurement

5 (30)

Galvin 2008 (DARE)

Exercise therapy

Superseded by up‐to‐date review

(3 trials included in this review were excluded from more up‐to‐date review)

Not reported (2006)

This article focuses on the impact of increased duration of exercise therapy on functional recovery after stroke

RCTs

Stroke

"Additional," "augmented" or "increased
duration" of exercise therapy

Exercise therapy was defined as
motion of the body or its parts to relieve symptoms
or to improve function, leading to physical fitness,
but not physical education and training

The same exercise therapy, but a lesser duration or dose

Fugl‐Meyer Upper Limb, Action Research Arm Test, Dynamometer, Functional Test
of the Hemiparetic Upper Extremity, Jebsen Test of Hand Function, Motor Assessment Scale, Motricity Index, Frenchay Arm Test, Barthel Index, Activities of Daily Living Index, Rivermead Motor Assessment, Ten‐Hole Peg Test, Motor Club Assessment, Nine‐Hole Peg Test

8 (863)

Glanz 1996 (DARE)

Biofeedback

Superseded by up‐to‐date review

Not reported

To assess the efficacy of biofeedback therapy in poststroke rehabilitation

RCTs

Stroke

Biofeedback for upper extremity paresis

Conventional therapy

Impairment

3 (82)

Glanz 1996 (DARE)

Electrical stimulation

Superseded by up‐to‐date review

1994

To assess the efficacy of functional electrical
stimulation (FES) in the rehabilitation of hemiparesis in stroke

RCT

Stroke

Functional electrical stimulation

Control

Wrist torque

1 UL ( 30)

Green 2003 (CDSR)

Interventions for shoulder pain

Not stroke

‐

‐

‐

‐

‐

‐

‐

‐

Hakkennes 2005 (DARE)

CIMT

Superseded by up‐to‐date review

March 2005

To investigate the effects on function, quality of life, healthcare costs and patient/carer satisfaction of constraint‐induced movement therapy (CIMT) for upper limb hemiparesis following stroke

RCTs and systematic reviews

Stroke

CIMT or mCIMT

Alternative therapy, control,

dose‐matched therapy or comparison between CIMT and mCIMT

Action Research Arm Test, Functional Independence Measure, Fugl‐Meyer Assessment, Motor Activity Log and Wolf Motor Function Test

14 (292)

Handy 2003 (DARE)

Electrical stimulation

Superseded by up‐to‐date review

2002

To examine the effectiveness of electrical stimulation in treating the upper extremities of patients who suffer cerebrovascular
accidents (strokes)

RCTs and quasi‐experimental studies

Stroke

Functional electrical stimulation or transcutaneous electrical nerve stimulation

Control or alternative therapy

Subluxation, pain, range of motion or function

5 (224)

Hayward 2010 (DARE)

Mixed

No additional studies

March 2009

To investigate the effects of interventions that promote UL recovery in stroke survivors with severe paresis

RCTs

Stroke with severe UL paresis

Interventions that enabled stroke
survivors with severe UL paresis to participate in
repetitive task‐oriented training

Alternative or control treatment

Outcomes for impairment, activity and/or participation

17 (486)

Henderson 2007 (DARE)

Virtual reality

Superseded by more up‐to‐date review

January 2006

To evaluate scientific evidence for the effectiveness of virtual reality in rehabilitation of the UL post stroke

RCTs,
single‐subject studies and pre/post study designs

Stroke (acute, subacute and chronic)

Immersive or non‐immersive virtual reality

Conventional therapy or no therapy

Fugl‐Meyer Assessment, Functional Independence Measure, Wolf Motor Function Test

6 (95)

Koog 2010 (DARE)

Treatment for shoulder pain

No UL function–specific outcome

‐

‐

‐

‐

‐

‐

‐

‐

de Kroon 2002 (DARE)

Electrical stimulation

Superseded by up‐to‐date review

December 2001

Assessment of available evidence on the effects of therapeutic electrical stimulation of the affected upper extremity in improving motor control and functional abilities after stroke

RCTs

Stroke

Therapeutic electrical stimulation

Standard therapy, sensory stimulation, dose‐matched therapy

Measurement of motor control or functional abilities

6 (207)

de Kroon 2005 (DARE)

Electrical stimulation

Superseded by up‐to‐date review

December 2003

To explore the relationship between
characteristics of stimulation and the effects of electrical stimulation on the recovery of upper limb motor control following stroke

Clinical trials

Stroke

Surface electrical stimulation

No treatment, exercises, placebo, dose‐matched therapy

Range of motion, grip strength, Fugl‐Meyer Assessment, Motor Assessment Scale, Box and Block Test, Motor Activity Log, Ashworth Scale, Barthel Index, Rankin Scale, Pain

19 (578)

Kwakkel 2008 (DARE)

Robotics

Superseded by more up‐to‐date review

October 2006

The aim of the study was to present a systematic
review of studies that investigate the effects of robot‐assisted
therapy on motor and functional recovery in patients with
stroke

RCTs

Stroke

Robot‐assisted therapy for the upper limb

Control (robot exposure), neurodevelopmental therapy, electrical stimulation

Fugl‐Meyer, Chedoke‐ McMaster

10 (218)

Latimer 2010 (DARE)

Bilateral arm training

Superseded by more up‐to‐date review

Before 2008

To determine the evidence for bilateral therapy interventions aimed at improving upper limb function in
adults with a range of upper limb activity limitations due to a first‐time chronic stroke

RCTs and cohort studies

6 months post stroke

Bilateral upper limb intervention

RCTs:

• Dose‐matched exercises

• No treatment

• Motor practice

• Unilateral training

Upper Extremity of Fugl‐Meyer Assessment, Frenchay Arm Test, Rivermead Motor Assessment, Wolf Motor Function Test, Modified Motor Assessment Scale

9 (166):

RCTs—4 (85)

Cohort studies—5 (81)

Legg 2006 (CDSR)

Therapy for ADL

No UL‐specific outcome

‐

‐

‐

‐

‐

‐

‐

‐

Ma 2002 (DARE)

Therapy

No UL outcome measure

‐

‐

‐

‐

‐

‐

‐

‐

McIntyre 2012 (DARE)

CIMT

No additional studies

July 2012

To determine the effectiveness of constraint‐induced
movement therapy (CIMT) in the hemiparetic upper extremity (UE) among individuals who were more than 6 months post stroke

RCTs

Over 50% stroke; ≥ 6 months post stroke

CIMT

Traditional rehabilitation therapy

Motor Activity Log Amount of Use, Motor Activity Log Quality of Movement, Wolf Motor Function Test, Fugl‐Meyer Assessment, Action Research Arm Test, Functional Independence Measure

16 (572)

Mehrholz 2011 (CDSR)

Exercise

No UL outcome measure

‐

‐

‐

‐

‐

‐

‐

‐

Moreland 1994 (DARE)

Biofeedback

Superseded by more up‐to‐date review

1992

To examine the efficacy
of electromyographic (EMG) biofeedback compared with conventional physical therapy
for improving upper extremity function in patients following a stoke

RCTs

Stroke

EMG biofeedback alone or with
conventional physical therapy

Conventional physical
therapy (exclusion of feedback
devices or functional electrical
stimulation)

Any functional measure
of the upper extremity, including
upper extremity function testing,
stage of motor recovery, range of
motion and muscle strength

6 RCTs

Moreland 1998 (DARE)

Biofeedback

LL outcomes only

‐

‐

‐

‐

‐

‐

‐

‐

Mortenson 2003 (DARE)

Positioning and stretching

Brain injury and stroke outcomes combined

‐

‐

‐

‐

‐

‐

‐

‐

Nijland 2011 (DARE)

Constraint‐induced movement therapy (CIMT)

No additional studies

January 12, 2010

To examine the literature
on the effects of constraint‐induced movement therapy
in acute or subacute stroke

RCTs

Acute or subacute stroke (within 10 weeks of stroke)

High‐intensity CIMT, low‐intensity CIMT

Usual care implied

Fugl‐Meyer Assessment, Action Research Arm Test, Motor Activity Log Amount of Use, Motor Activity Log Quality of Movement

5 (106)

Nilsen 2010 (DARE)

Mental practice

Superseded by more up‐to‐date review

February 2009

To determine whether mental practice is an effective intervention to improve upper limb
recovery after stroke

Categorised all levels of evidence, RCTs to case reports

Stroke

Mental practice alone or in combination with other therapies

Other therapies

Fugl‐Meyer Assessment, Wolf Motor Function Test, Action Research Arm Test, Motor Activity Log, Motricity Index, Pegboard Test, Dynamometer, position sense, 2‐point discrimination, Recovery Locus of Control Scale, Barthel Index, Functional Limitations Profile, kinemetics of reaching and grasping, Jebsen Hand Function Test, pinch strength, grip strength, Chedoke McMaster, range of motion

15 (145)

RCTs—4 (72)

Cohort 3 (43)

Case series or single case studies—8 (30)

Outpatients Service Trialists 2003 (CDSR)

Therapy‐based rehabilitation services

No UL‐specific outcome

‐

‐

‐

‐

‐

‐

‐

‐

Peurala 2011 (DARE)

Constraint‐induced movement therapy (CIMT)

Superseded by more up‐to‐date review

January 5, 2011

To examine the effects of constraint‐induced movement therapy and modified constraint‐induced
movement therapy on activity and participation of patients with stroke (i.e. the effects of different
treatment duration and frequency)

RCTs

Stroke

CIMT; modified CIMT (not forced use)

Usual care implied

Motor Activity Log, Action Research Arm Test, Wolf Motor Function Test, Functional Independence Measure, Stroke Impact Scale, Barthel Index

27 RCTs
12 (560) within meta‐analysis

Platz 2003 (DARE)

Mixed

Superseded by more up‐to‐date review

October 2002

To identify all studies providing evidence to support interventions comprising exercise therapy or neuromuscular electrical stimulation to improve arm paresis or ensuing activity limitations after stroke

Systematic reviews, meta‐analyses, RCTs, controlled cohort studies

Stroke with hemiparesis/ hemiplegia affecting the upper limb

Exercise therapy or neuromuscular electrical stimulation aimed at improving arm paresis or ensuing activity limitations after stroke. This included physiotherapy approaches, arm ability training, CIMT, repetitive sensorimotor training, EMG biofeedback, kinesthetic feedback, electrostimulation, robot‐assisted arm rehabilitation. Training intensity was also investigated

Not stated

No measures or scores reported, only generic terms, e.g. "strength," "function," "selectivity," "efficiency of arm function"

30 references

Poltawski 2012

(PROSPERO)

No intervention

No upper limb interventions

‐

‐

‐

‐

‐

‐

‐

‐

Pomeroy 2006 (CDSR)

Electrostimulation

Superseded by more up‐to‐date review

January 1, 2004

To find whether electrostimulation improved functional motor ability and the ability to undertake activities of daily living

RCTs or quasi‐RCTs

Stroke

Electrostimulation

No treatment, placebo, conventional therapy

Functional motor ability—included the following:
Rivermead Mobility Index, Walking Endurance, Timed Up and Go Test, Motor Assessment Scale, Box and Block Test, Upper Extremity Drawing Test, Action Research Arm Test, Jebsen Hand Function Test, Nine‐‐Hole Peg Test

Measures of ADL—included the following: Barthel Index, Functional Independent Measure

Measures
of motor impairment—included the following: Muscle tone—Ashworth and spasticity scores, resistance to passive movement, Wartenberg Pendulum Test Relaxation Index; Muscle function—joint movement, sustained muscle contraction, premotor reaction time, motor reaction time, isometric torque, co‐contraction ratio of agonist and
antagonist muscles, grip strength, joint range of active movement, physiological cost index, Fugl‐Meyer Assessment

24 (888)

Prange 2006 (DARE)

Robotics

Superseded by more up‐to‐date review

August 1, 2005

To investigate the effects of robot‐aided therapy on upper limb motor control and functional abilities of stroke patients

Pre/post studies and RCTs

Stroke

Robot therapy

Conventional therapy

Fugl‐Meyer Assessment, Motor Status Score, Motor Power, Functional Independence Measure, Barthel Index

8 (246)

Price 2000 (CDSR)

Electrical stimulation

Pain outcomes, no functional UL outcomes

‐

‐

‐

‐

‐

‐

‐

‐

Péter 2011 (DARE)

Robotics

Superseded by more up‐to‐date review

January 11, 2010

To review robot‐supported upper limb physiotherapy focusing on
the shoulder, elbow and wrist.

Clinical trial (randomised or non‐randomised, self‐controlled or with control group)

Hemiparesis due to upper motor neuron lesion

Shoulder, elbow and/or wrist robot‐mediated therapy

Conventional therapy or electrical stimulation

Fugl‐Meyer Assessment, Functional Independence Measure, Barthel Index, Motor Power Scale, Motor Status Scale, Medical Research Council Muscle Grading, Wolf Motor Function Test, range of motion, spasticity, Arm Motor Ability Test, Rancho Los Amigos Functional Test

30 (393)

Richards 2008 (DARE)

TMS

No functional outcomes

‐

‐

‐

‐

‐

‐

‐

‐

Saposnik 2010 (DARE)

Virtual reality

Superseded by more up‐to‐date review

January 7, 2010

To determine the added benefit of virtual reality technology for arm motor recovery after stroke

RCTs and pre/post design

Stroke

Immersive or non‐immersive virtual reality

Conventional rehabilitation, sham virtual reality, recreational activities or orthoses

Fugl‐Meyer Assessment, Wolf Motor Function Test, Box and Block Test, Jebsen Hand Function Test

12 (195)

Shi 2011 (DARE)

Constraint‐induced movement therapy (CIMT)

Superseded by more up‐to‐date review

January 4, 2010

To compare the effectiveness of modified constraint‐
induced movement therapy with traditional rehabilitation
therapy in patients with upper extremity dysfunction
after stroke

RCTs

Stroke

Modified CIMT

Traditional rehabilitation therapy

Fugl‐Meyer Assessment, Action Research Arm Test, Functional Independence Measure, Motor Activity Log Amount of Use, Motor Activity Log Quality of Movement, reaction time, peak velocity

13 (278)

Stevenson 2012 (DARE)

Constraint‐induced movement therapy (CIMT)

No additional studies

January 2, 2011

To examine constraint‐induced movement therapy, relative to dose‐matched control interventions, for
upper limb dysfunction in adult survivors of stroke

RCTs or cross‐over design

Stroke

CIMT

Dose‐matched control

Motor capacity—Fugl‐Meyer Assessment, kinematics, indirect indicators of neurophysiological mechanisms

UL ability—Action Research Arm Test, Nine‐Hole Peg Test, Wolf Motor Function Measure

Comprehensive—Functional Independence Measure, Barthel Index, self‐report (Motor Activity Log, Stroke Impact Scale)

Motor capacity—15 (432)

UL ability—14 (351)

FIM 6 (182) Motor Activity Log 12 (352)

Stewart 2006 (DARE)

Bilateral arm training

Superseded by more up‐to‐date review

2nd quarter 2005

To determine the overall effectiveness of
rehabilitation with bilateral movements

Pre/post and RCTs

Upper extremity stroke hemiparesis, with enough
residual motor control in the impaired arm to permit
performance of motor capabilities tests

Bilateral movement training or bilateral training with auditory cuing or active neuromuscular stimulation

Pretreatment/single‐arm tasks

Kinematic performance, Fugl‐Meyer Upper Extremity Test, Motor Assessment Scale, Box and Block Test

11 (171)

Tang 2012 (DARE)

Repetitive transcranial magnetic stimulation (rTMS)

Unable to find full paper

‐

‐

‐

‐

‐

‐

‐

‐

Timmermanns 2009 (DARE)

No intervention

Scoping review of treatment rationale

‐

‐

‐

‐

‐

‐

‐

‐

Tyson 2011 (DARE)

Stretching (orthoses)

No additional studies

July 2009

To establish whether an orthosis can improve function and/or impairments

RCTs

Adults with stroke or the stable non‐progressive sequelae of a brain lesion (such as infection or traumatic brain injury) that resulted in motor impairments

Orthoses to manage upper limb motor impairments (The following types of orthoses were excluded: splinting during constraint‐induced movement therapy, devices to prevent shoulder subluxation, orthoses that were part of a hybrid device to deliver functional electrical stimulation, taping, strapping, air‐pressure splints, serial casting)

Comparison of an orthosis with no treatment, normal care, placebo treatment. Or comparison of an orthosis plus normal management versus normal management alone

Upper limb impairments, activity limitations or incidence of adverse events

4 (126)

van der Lee 2001 (DARE)

Exercise therapy

Superseded by more up‐to‐date review

August 2000

Assessment of available evidence for the effectiveness of exercise therapy

RCTs

Stroke

Exercise therapy

Other treatment or no treatment

Barthel Index, Action Research Arm Test, Fugl‐Meyer Assessment

13 (939)

van Dijk 2005 (DARE)

Biofeedback

Superseded by more up‐to‐date review

December 2004

Assessment of available evidence regarding
the effects of augmented feedback on motor function of the
upper extremity in rehabilitation patients

RCTs

Upper limb rehabilitation patients

(Parkinson's disease—3 studies; spinal cord injury—2 studies; cerebral palsy—1 study, traumatic brain injury—1 study; stroke and traumatic brain injury—2 studies, stroke—16 studies

Augmented feedback

Placebo, conventional therapy, no treatment

Active range of motion, Brunnstrom's stages of recovery, electromyographical activity, Upper Extremity Functional Scale, Nine‐Hole Peg Test, est Evaluant des
Membres Supérieurs des Personnes Agées, Box and Block Test, Fugl‐Meyer Assessment, wrist extension torque, Action Research Arm Test, Frenchay Arm Test, McGill Pain Questionnaire

26 (927)

van Kuijk 2002 (DARE)

Botulinum toxin injection by any route, including but not limited
to intramuscular, subcutaneous, intradermal and intra‐articular
routes

Superseded by more up‐to‐date review

January 10, 2000

The goal of this
study was to provide preliminary clinical guidelines as to the method of administration and optimal dosage in
the focal treatment of upper limb spasticity following stroke

Excluded studies with fewer than 10 participants, but included case series (for phenol or alcohol injections)

Stroke

Botulinum toxin

Placebo but not always specified

Modified Ashworth Scale, grip strength, Fugl‐Meyer Assessment, Functional Independence Measure, Barthel Index, Frenchay Arm Test, Motricity Index

12 (not reported)

van Peppen 2004 (DARE)

Physical therapy interventions

Superseded by more up‐to‐date review

January 2004

To determine the evidence for physical therapy interventions aimed at
improving functional outcomes after stroke

RCTs and CCTs

Stroke

Exercises for upper limb

Control

Action Research Arm Test, Arm Motor Activity Test, Motor Activity Log

5 (104)

Wu 2006 (CDSR)

Acupuncture

No UL‐specific intervention

‐

‐

‐

‐

‐

‐

‐

‐

Zimmermann‐Schlatter 2008 (DARE)

Mental practice

Superseded by more up‐to‐date review

January 8, 2005

To evaluate how motor imagery and conventional therapy (physiotherapy or
occupational therapy) compare with conventional therapy only in their effects on clinically relevant
outcomes during rehabilitation of persons with stroke

RCTs

Stroke

Motor imagery plus conventional therapy

Conventional therapy

Fugl‐Meyer Upper Extremity Score; Action Research Arm Test

4 (86)

Intervention

Reviews included in

qualitative synthesis

Reviews included in

quantitative synthesis

Ongoing reviews

Excluded, as superseded

by more up‐to‐date review/

contains no additional studies

Acupuncture

Liang 2011 (Ongoing)

Bilateral arm training

Coupar 2010

van Delden 2012

Coupar 2010

van Delden 2012

Latimer 2010

Stewart 2006

Biofeedback

Molier 2010

Woodford 2007

Woodford 2007

Glanz 1995

Moreland 1994

van Dijk 2005

Bobath therapy

Luke 2004

Luke 2004

Brain stimulation

Elsner 2013

Hao 2013

Elsner 2013

Hao 2013

Straudi (Ongoing)

CIMT

Corbetta 2010

Sirtori 2009

Corbetta 2010 (SG only)

Sirtori 2009

(Farmer 2014*)

Bjorklund 2006

Bonaiuti 2007

Hakkennes 2005

McIntyre 2012

Nijland 2011

Peurala 2011

Shi 2011

Stevenson 2012

Electrical stimulation

(Farmer 2014^a)

Meilink 2008

Nascimento 2014

(Farmer 2014^a)

Meilink 2008

Nascimento 2014

Howlett (Ongoing)

Ada 2002

Bolton 2004

Glanz 1996

Handy 2003

de Kroon 2002

de Kroon 2005

Pomeroy 2006

Tyson 2011

"Hands‐on" therapy

Winter 2011

van der Lee 2001

Mental practice

Barclay‐Goddard 2011

Braun 2013

Wang 2011

Barclay‐Goddard 2011 (SG only)

Braun 2013

Wang 2011

Braun 2006

Nilsen 2010

Zimmermann‐Schlatter 2008

Mirror therapy

Thieme 2012

Thieme 2012

Music therapy

Bradt 2010

Pharmacological interventions

Demetrios 2013

Elia 2009

Olvey 2010

Singh 2010

Elia 2009

Singh 2010

Kinnear (Ongoing)

Lindsay 2013 (Ongoing)

Cardoso 2005

van Kuijk 2002

Repetitive task training

French 2007

French 2008

French 2007

Robotics

Mehrholz 2012

Norouzi‐Gheidari 2012

Mehrholz 2012

Norouzi‐Gheidari 2012 (SG only)

(Farmer 2014*)

Kwakkel 2008

Prange 2006

Péter 2011

Self‐management

Kidd (Ongoing)

Sensory interventions

Doyle 2010

Schabrun 2009

Doyle 2010

Schabrun 2009

Strength training

Harris 2010

Harris 2010

Stretching and positioning

Ada 2005

Borisova 2009

Hijmans 2004

Katalinic 2010

Lannin 2003

Ada 2005

Borisova 2009 (SG only)

Katalinic 2010

Lannin 2003

Meeran (Ongoing)

Task‐specific training (reach‐to‐grasp exercise)

Pelton 2012

(Urton 2007^a)

Diermayr (Ongoing)

Virtual reality

Laver 2011

Laver 2011

Crosbie 2007

Henderson 2007

Saposnik 2010

Mixed

Farmer 2014

Urton 2007

Farmer 2014

Monaghan 2011 (Ongoing)

Hayward 2010

Platz 2003

van Peppen 2004

Factors in service delivery: dose of intervention

Cooke 2010

Cooke 2010

Galvin 2012 (Ongoing)

Schneider (Ongoing)

Galvin 2008

Factors in service delivery: location of intervention

Coupar 2012

Laver 2013

Coupar 2012

Laver 2013

Numbers of reviews

40

31 of 40 reviews

27 of 31 reviews—data from

main comparisons included;

4 of 31 reviews—overlap with trials

included in main comparisons:

data from subgroup

comparisons included only

(marked as "SG only")

11

37

Review

Intervention

Brief description of review

Results: effects of interventions

Reasons for not including quantitative data from review

Bradt 2010 (CDSR)

Music therapy

The aim of this review was to examine the effects of music therapy with standard care versus standard care alone or standard care combined with other therapies on gait, upper extremity function, communication, mood and emotions, social skills, pain, behavioural outcomes, activities of daily living and adverse events in participants with brain injury.

A total of 7 studies (184 participants) were included, but only 2 (41 participants) were relevant to the upper limb: “Two trials measured the effects of music therapy on upper extremity function in hemispheric stroke patients. Elbow extension angle was the only common outcome measure

in these two studies. However, because of the significant clinical heterogeneity of the studies, their effect sizes were not pooled”

Narrative descriptions of the results of the trials are provided:

One trial: “examined the effects of RAS on spatiotemporal control of reaching movements of the paretic arm in 21 patients. Results indicated that RAS increased the elbow extension angle by 13.8% compared to the non‐rhythmic trial, and this difference was statistically significant (P = 0.007). Results further indicated that variability of timing and reaching trajectories were reduced

significantly (35% and 40.5%, respectively, P < 0.05).”

One trial: “evaluated the effects of music‐making activity on elbow extension in 20 participants with hemiplegia. The elbow extension (measured from 135 to 0 with negative numbers expressing limitations) post‐intervention was ‐29.4 (SD 29.49) for the experimental group and ‐39.2 (SD 38.19) for the control group. This difference was not statistically significant. Post‐test shoulder

flexion data indicated no statistically significant difference (P = 0.44) between the music therapy group (85.6°, SD 26.71) and the

control group (71.8°, SD 39)”

Data from the 2 trials were not pooled

Demetrios 2013 (CDSR)

Multi‐disciplinary rehabilitation following botulinum toxin or other focal neuromuscular treatment

The aim of this review was to assess the effectiveness of multi‐disciplinary rehabilitation, following botulinum neurotoxin and other focal intramuscular treatments such as phenol, in improving activity limitations and other outcomes in adults and children with post‐stroke spasticity.

Three RCTs (91 participants), all classed as 'low quality,' were included. "All studies investigated various types and intensities of outpatient rehabilitation programmes following botulinum neurotoxin for upper limb spasticity in adults with chronic stroke. Rehabilitation programmes included: modified constraint‐induced movement therapy (mCIMT) compared with a neurodevelopmental therapy programme; task practice therapy with cyclic functional electrical stimulation (FES) compared with task practice therapy only; and occupational, manual therapy with dynamic elbow extension splinting compared with occupational therapy only."

"Due to the limited number of included studies, with clinical, methodological and statistical heterogeneity, quantitative meta‐analysis was not possible"

Descriptions of the results from the 3 included studies are provided. The review authors classify all evidence as "low quality" and conclude: "At best there was 'low level' evidence for the effectiveness of outpatient MD rehabilitation in improving active function and impairments following botulinum neurotoxin for upper limb spasticity in adults with chronic stroke." The review authors conclude that there is a need for "robust trials"

Data from the 3 trials were not pooled

French 2008 (DARE)

“Repetitive functional task practice,” including repetitive task training (RTT), constraint‐induced movement therapy (CIMT) and treadmill training

The aim was to determine whether repetitive functional task practice (RFTP) after stroke improves limb‐specific or global function or activities of daily living and whether treatment effects are dependent on the amount of practice, or the type or timing of the intervention. Also to provide estimates of the cost effectiveness of RFTP.

Eighteen trials (634 participants)

measured arm function. These included 8 RTT trials (467 participants) and 10 CIMT trials (167 participants)

Arm function

Data from 8 RTT trials (412 participants) and 7 CIMT trials (285 participants) were pooled. The pooled effect for the impact of RFTP on arm

function was as follows: SMD 0.24, 95% CI 0.06 to 0.42; I² = 22%

Hand function

Data from 5 RTT trials (281 participants) and 2 CIMT trials (27 participants) were pooled. The pooled effect for RFTP on hand function was as follows: SMD 0.19, 95% CI –0.03 to 0.42; I² = 0%

This review pools the data from 2 interventions: RTT and CIMT. Data from these interventions are included from French 2010 (RTT) and Corbetta 2010 and Sirtori 2009 (CIMT). The French 2010 RTT data are exactly the same as these French 2008 data. The Corbetta 2010 and Sirtori 2009 data are more comprehensive than the French 2008 data; this review has a much earlier search date and includes far fewer trials

Including the data from this French 2008 review would effectively result in “double‐counting” of the data presented under the separate intervention headings of RTT and CIMT

Hijmans 2004 (DARE)

Elbow orthoses

The aim was to review papers related to the use of elbow
orthoses.

Only 2 studies included participants with stroke. One was an RCT (18 participants), and one used a cross‐over design (16 participants)

No data are provided. The review authors state that (based on the cross‐over study) “wrist function and elbow range of movement seem to benefit from custom made Lycra garments applied at the elbow,” but (based on the RCT) probably no benefits are associated with an inflatable pressure splint

No data are available for inclusion

Molier 2010 (DARE)

Augmented feedback

The aim was to investigate the effects of different aspects and types of augmented feedback on motor functions and motor activities of the hemiparetic arm after stroke.

8 RCTs, 4 non‐randomised studies, 9 pre/post treatment design, 1 observational study and 1 single case study were included

For each study, it was stated whether beneficial effect, no effect or inconclusive effect was found for each outcome assessed. No data were provided.

The results are discussed in the text. The authors state:

“There are some trends in favour of providing augmented knowledge of performance feedback, augmented auditory and combined sensory and visual feedback. No consistent effects on motor relearning were observed for summary or faded, terminal or concurrent, solely visual or solely sensory augmented feedback.” And conclude that “ it was not possible to determine which combinations of aspects and types of augmented feedback are most essential for a beneficial effect on motor activities and motor functions of the hemiparetic arm after stroke. This was due to the combination of multiple aspects and types of augmented feedback in the included studies.

This systematic review indicates that augmented feedback in general has an added value for stroke rehabilitation”

No data are available for inclusion

Olvey 2010 (DARE)

Pharmacological therapies for upper limb spasticity

The aim was to review studies of “contemporary pharmacological therapies” for upper limb spasticity after stroke.

54 studies were included: 23 RCTs and 31 non‐randomised studies. 51 of these investigated botulinum toxin

The results of the included studies are tabulated, with data from individual studies described.

23 studies assessed functional ability:

FIM—6 studies. 5 found no benefit; 1 significant benefit.

Fugl‐Meyer—5 studies. 2 found significant benefit.

Barthel Index—8 studies. 2 report improvement; 6 no improvement.

Disability Assessment Scale—5 studies. All report some benefit.

Results from measures of upper limb function “were inconsistent.”

26 studies evaluated range of motion; 15 reported a significant improvement in 1 or more parameters after treatment

No data are available for inclusion

Pelton 2012 (DARE)

Any intervention targeted at co‐ordination of arm and hand segment for reach to grasp after stroke

The aim was to determine the effectiveness of current treatments for improving co‐ordination of reach to grasp following stroke.

7 studies were included: 1 RCT, 2 case‐control studies, 2 pre/post tests, 1 cross‐over, 1 observational.

Interventions identified fell into 3 categories: “functional therapy, biofeedback or electrical stimulation and robot or computerised training”

The results of each study are tabulated, and the effect is reported as positive, negative or no effect.

“Four studies (one RCT and three experimental studies without controls) report a result in favour of the experimental intervention for improved hand and arm coordination, whereas one experimental study without controls found no benefit. Two experimental studies with controls did not report specific training effects for hand and arm coordination after stroke”

No data are available for inclusion

Urton 2007 (DARE)

Any interventions for upper extremity hemiparesis following stroke

The aim was to critically analyse the literature on effective interventions for upper extremity hemiparesis following stroke.

11 experimental studies that evaluated interventions for upper extremity hemiparesis after stroke were included.

Interventions included augmented exercise therapy, electrical stimulation, goal‐directed reaching and reach‐to‐grasp movements

Study details are tabulated, and the results of each study are described narratively

No data are available for inclusion

Winter 2011 (CDSR)

Hands‐on physical interventions (manual therapy techniques)

The aim was to explore the effectiveness of "clearly described hands‐on physical intervention (manual therapy techniques), or treatment component schedules, for the upper limb following stroke, either as the experimental intervention or as the control group." Pharmacological, electrical or psychological (e.g. mental imagery, relaxation) techniques were excluded, and only trials with interventions that addressed physical impairment were included.

Three trials (86 participants) were included, each of which investigated different interventions (including manual stretch, passive extension and hands‐on therapy).

Note: In the trial of passive extension (22 participants), passive extension was actually delivered as the control intervention and electrostimulation as the experimental intervention

Because of the heterogeneity between studies, no meta‐analysis is performed. The results of each of the 3 studies are described narratively. Methodological limitations are identified for all 3 studies

The study authors conclude: "The findings of the review demonstrated that the limited evidence of benefit of stretching, passive exercises and mobilization when applied to the hemiplegic upper limb following stroke merits further research."

No data are available for inclusion

Review source

Author

1. Was an 'a priori' design provided? The research question and inclusion criteria should be established before the conduct of the review

2. Was there duplicate study selection and data extraction?There should be at least two independent data extractors, and a consensus procedure for disagreements should be in place

3. Was a comprehensive literature search performed? At least two electronic sources should be searched. The report must include years and databases used (e.g. CENTRAL, EMBASE, and MEDLINE). Key words and/or MeSH terms must be stated and where feasible the search strategy should be provided. All searches should be supplemented by consulting current contents, reviews, textbooks, specialised registers or experts in the particular field of study, and by reviewing the references in the studies found

4. Was the status of publication (i.e. grey literature) used as an inclusion criterion? The authors should state that they searched for reports regardless of their publication type. The authors should state whether or not they excluded any reports (from the systematic review), based on their publication status, language, etc

5. Was a list of studies (included and excluded) provided? A list of included and excluded studies should be provided

6. Were the characteristics of the included studies provided? In an aggregated form such as a table, data from the studies should be provided on the participants, interventions and outcomes. The ranges of characteristics in all the studies analysed (e.g. age, race, sex, relevant socioeconomic data, disease status, duration, severity) or other diseases should be reported

7. Was the scientific quality of the included studies assessed and documented? 'A priori' methods of assessment should be provided (e.g. for effectiveness studies if the author(s) chose to include only randomised, double‐blind, placebo‐ controlled studies, or allocation concealment as inclusion criteria); for other types of studies, alternative items will be relevant

8. Was the scientific quality of the included studies used appropriately in formulating conclusions? The results of the methodological rigour and scientific quality should be considered in the analysis and the conclusions of the review, and explicitly stated in formulating recommendations

9. Were the methods used to combine the findings of studies appropriate? For the pooled results, a test should be done to ensure the studies were combinable, to assess their homogeneity (i.e. Chi² test for homogeneity, I²). If heterogeneity exists, a random‐effects model should be used and/or the clinical appropriateness of combining should be taken into consideration (i.e. is it sensible to combine?)

10. Was the likelihood of publication bias assessed? An assessment of publication bias should include a combination of graphical aids (e.g. funnel plot, other available tests) and/or statistical tests (e.g. Egger regression test)

11. Was the conflict of interest stated? Potential sources of support should be clearly acknowledged in both the systematic review and the included studies

CDSR

Ada 2005; Foongchomchaey 2005

Y

U

Y

Y

Y

Y

U

N

Y

N

Y

CDSR

Barclay‐Goddard 2011

Y

Y

Y

Y

Y

Y

Y

N

Y

N

Y

DARE

Borisova 2009

Y

N

N

U

N

N

Y

N

U

N

N

CDSR

Bradt 2010

Y

Y

Y

Y

Y

Y

Y

Y

N/A

N

Y

OTHER

Braun 2013

Y

Y

Y

N

Y

N

Y

Y

Y

Y

Y

DARE

Cooke 2010

Y

Y

Y

N

Y

N

Y

N

Y

N

Y

DARE

Corbetta 2010

Y

N

U

Y

N

N

Y

Y

Y

N

Y

CDSR

Coupar 2010

Y

Y

Y

U

Y

Y

Y

Y

Y

N

Y

CDSR

Coupar 2012

Y

Y

Y

Y

Y

Y

Y

Y

Y

N

Y

CDSR

Demetrios 2013

Y

Y

Y

Y

Y

Y

Y

Y

N/A

N

Y

CDSR

Doyle 2010

Y

Y

Y

Y

Y

Y

Y

Y

N/A

N

Y

DARE

Elia 2009

Y

U

N

U

Y

Y

U

Y

Y

N

Y

CDSR

Elsner 2013

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

OTHER

Farmer 2014

Y

N

N

N

N

N

U

N

N/A

N

Y

DARE

French 2008

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

n

CDSR

French 2007; French 2010

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

CDSR

Hao 2013

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

DARE

Harris 2010

Y

U

N

N

N

Y

N

Y

Y

N

Y

DARE

Hijmans 2004

N

N

Y

U

Y

N

N

N

N/A

N

N

CDSR

Katalinic 2010

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

DARE

Lannin 2003

Y

N

Y

N

Y

N

Y

Y

N/A

N

N

CDSR

Laver 2011

Y

Y

Y

Y

Y

Y

Y

Y

Y

N

Y

CDSR

Laver 2013

Y

Y

Y

Y

Y

Y

Y

Y

Y

N

Y

DARE

Luke 2004

y

N

N

N

N

Y

Y

Y

N

N

N

CDSR

Mehrholz 2012

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

DARE

Meilink 2008

N

U

Y

N

N

N

Y

Y

Y

N

N

DARE

Molier 2010

Y

Y

Y

N

N

Y

N

N

N/A

N

Y

PROSPERO

Nascimento 2014

Y

Y

Y

Y

Y

Y

Y

Y

Y

N

Y

DARE

Norouzi‐Gheidari 2012

Y

U

Y

N

Y

N

U

U

Y

N

Y

DARE

Olvey 2010

N

N

Y

N

N

N

N

Y

N/A

N

Y

DARE

Pelton 2012

Y

Y

Y

N

N

Y

Y

Y

N/A

N

U

DARE

Schabrun 2009

Y

U

N

N

Y

Y

N

Y

Y

N

Y

CDSR

Singh 2010

Y

U

Y

U

Y

Y

Y

Y

Y

N

Y

CDSR

Sirtori 2009

Y

Y

Y

U

Y

Y

U

Y

Y

N

Y

CDSR

Thieme 2012

Y

Y

Y

Y

Y

Y

Y

Y

Y

N

Y

DARE

Urton 2007

N

N

N

N

N

N

N

N

N/A

N

N

DARE

van Delden 2012

Y

Y

Y

N

Y

Y

Y

U

Y

N

N

DARE

Wang 2011

Y

U

U

N

N

N

Y

U

Y

Y

N

CDSR

Winter 2011

Y

Y

Y

Y

Y

Y

Y

Y

N/A

N

Y

CDSR

Woodford 2007

Y

U

Y

Y

Y

U

Y

Y

Y

N

Y

Number of responses: all reviews

YES

36

23

31

19

29

27

29

29

27

8

30

NO

4

8

7

15

11

12

6

8

1

32

9

UNCLEAR

0

9

2

6

0

1

5

3

1

0

1

N/A

0

0

0

0

0

0

0

0

11

0

0

Number of responses: CDSR reviews

YES

19

16

19

16

19

18

17

17

15

5

19

NO

0

0

0

0

0

0

0

2

0

14

0

UNCLEAR

0

3

0

3

0

1

2

0

0

0

0

N/A

0

0

0

0

0

0

0

0

4

0

0

Number of responses: other reviews

YES

17

7

12

3

10

9

12

12

12

3

11

NO

4

8

7

15

11

12

6

6

1

18

9

UNCLEAR

0

6

2

3

0

0

3

3

1

0

1

N/A

0

0

0

0

0

0

0

0

7

0

0

Intervention

Reviews contributing data to main comparisons

Reviews contributing data to subgroup comparisons only

Justification for decisions

Constraint‐induced movement therapy (CIMT)

Corbetta 2010

Sirtori 2009

Studies included in these 2 reviews overlap. Corbetta 2010 was judged to be most up‐to‐date and comprehensive. Corbetta 2010 pools data comparing CIMT with control. However, no sub‐group analyses are reported. Sirtori 2009 includes subgroup analyses to explore time post stroke and extent of treatment. Data related to main comparisons are therefore extracted from Corbetta 2010, and data related to subgroup comparisons are extracted from Sirtori 2009

Mental practice

Braun 2013; Wang 2011

Barclay‐Goddard 2011

Braun 2013 has the most up‐to‐date search and includes trials that are not included within (or considered for inclusion in) Barclay‐Goddard 2011. Methodological quality is similar. Data from Braun 2013 are therefore extracted for the main comparisons. However, no subgroup analyses are reported. Barclay‐Goddard 2011 includes subgroup analyses to explore time post stroke and extent of treatment. Data related to main comparisons are therefore extracted from Braun 2013, and data related to subgroup comparisons are extracted from Barclay‐Goddard 2011. Additional impairment data were extracted for the main comparisons from Wang 2011, as this included Chinese language trials not included within Braun 2013

Robotics

Mehrholz 2012

Norouzi‐Gheidari 2012

Mehrholz 2012 has the most up‐to‐date search and includes trials that are included within (or considered for inclusion in) Norouzi‐Gheidari 2012. Methodological quality of Mehrholz 2012 was judged to be considerably greater than that of Norouzi‐Gheidari 2012. Data from Mehrholz 2012 are therefore extracted for the main comparisons. However, no subgroup analyses are reported. Norouzi‐Gheidari 2012 includes subgroup analyses to explore time post stroke and extent of treatment. Data related to main comparisons are therefore extracted from Mehrholz 2012, and data related to subgroup comparisons are extracted from Norouzi‐Gheidari 2012

Stretching and positioning

Katalinic 2010

Borisova 2009

Katalinic 2010 is a review of stretching interventions, including positioning interventions. Borisova 2009 includes positioning interventions only. The methodological quality of Katalinic 2010 is judged to be considerably greater than that of Borisova 2009, and data from Katalinic 2010 are therefore extracted for the main comparisons. All trials included in Borisova 2009 are also included in Katalinic 2010; however, as this is a subgroup of a particular type of stretching intervention, data from Borisova 2009 have been included as a subgroup analysis

Intervention

Comparison

Review

Outcome category

Outcome measures

Number of trials

Number of participants

Effect size

95% CI

Evidence of effect?

Bilateral arm training (bilateral exercise training)

Unilateral exercise training

van Delden 2012

Arm function

ARAT, WMFT

6

375

SMD 0.20

(‐0.00 to 0.41)

Favours unilateral exercise training

CIMT

Control

Corbetta 2010

Arm function

ARAT, WMFT, EFT, MAS

14

477

SMD 0.44

(0.03 to 0.84)

Beneficial effect

Repetitive task training

Any control

French 2007

Arm function

ARAT, WMFT, BBT, FTHUE, SMGA

8

412

SMD 0.17

(‐0.03 to 0.36)

No benefit or harm

Hand function

9HPT, 10HPT, MAS

5

281

SMD 0.16

(‐0.07 to 0.40)

No benefit or harm

Mental practice

Any control

Braun 2013

Arm function

ARAT

7

197

SMD 0.62

(0.05 to 1.19)

Beneficial effect

Mirror therapy

Any other intervention

Thieme 2012

UL function + impairment

ARAT, MAS, FMA

10

421

SMD 0.53

(0.04 to 1.01)

Beneficial effect

Sensory impairment

No treatment

Doyle 2010

Arm function

mMAS

1

29

MD 1.58

(0.98 to 2.18)

Beneficial effect

Virtual reality

Other treatment

Laver 2011

UL function + impairment

ARAT, WMFT, FMA

7

205

SMD 0.53

(0.25 to 0.81)

Beneficial effect

Factors in service delivery: dose of intervention (augmented therapy)

Standard therapy

Cooke 2010

Arm function

ARAT

3

258

ES 0.1

(‐5.7 to 6.0)

No benefit or harm

Factors in service delivery: location: home‐based therapy

Usual care

Coupar 2012

Arm function

WMFT

1

100

MD 2.25

(‐0.24 to 4.73)

No benefit or harm

Intervention

Comparison

Review

Outcome category

Outcome measures

Number of trials

Number of participants

Effect size

95% CI

Evidence of effect?

FU time

Repetitive task training

Any control

French 2007

Upper limb function

ARAT, WMFT, BBT, FTHUE, SMGA, JTHF, SMES, 10HPT

6

246

SMD 0.08

(‐0.17 to 0.33)

No benefit or harm

All FU outcomes

Factors in service delivery: dose of intervention (augmented therapy)

Standard therapy

Cooke 2010

Arm function

ARAT

3

319

ES ‐6.4

(‐12.8 to 0.0)

No benefit or harm

6 months

Intervention

Comparison

Review

Outcome category

Outcome measures

Number of trials

Number of participants

Effect size

95% CI

Evidence of effect?

Bilateral arm training (bilateral exercise training)

Unilateral exercise training

van Delden 2012

Motor impairment

FMA, MSS

4

228

SMD 0.06

(‐0.20 to 0.33)

No difference

Brain stimulation: tDCS

Placebo or control

Elsner 2013

Motor impairment

FMA

7

304

SMD 3.45

(1.24 to 5.67)

Beneficial effect

Mental practice

Conventional treatment

Wang 2011

Motor impairment

FMA

5

216

MD 7.81

(1.96 to 13.65)

Beneficial effect

Robotics

Any other intervention

Mehrholz 2012

Motor impairment

FMA

16

586

SMD 0.45

(0.2 to 0.69)

Beneficial effect

Strength

Strength

10

321

SMD 0.48

(‐0.06 to 1.03)

No benefit or harm

Sensory impairment

No treatment

Doyle 2010

Motor impairment

BMR

1

29

MD 0.19

(0.09 to 0.29)

Beneficial effect

Stretching and positioning (stretch)

Any

Katalinic 2010

Range of movement

Joint mobility

7

193

MD 2.17

(‐1.63 to 5.97)

No benefit or harm

Spasticity

Spasticity

4

109

SMD 0.08

(‐0.30 to 0.45)

No benefit or harm

Virtual reality

Other treatment

Laver 2011

Motor impairment

FMA

5

171

MD 4.43

(1.98 to 6.88)

Beneficial effect

Strength

Grip strength

2

44

MD 3.55

(‐0.20 to 7.30)

No benefit or harm

Factors in service delivery: dose of intervention (augmented therapy)

Standard therapy

Cooke 2010

Strength

Hand grip force/strength

2

195

ES ‐10.1

(‐19.1 to ‐1.2)

Benefit of standard therapy dose

Factors in service delivery: location: home‐based therapy

Usual care

Coupar 2012

Motor impairment

FMA

3

156

MD 1.46

(‐0.58 to 3.51)

No benefit or harm

Factors in service delivery: location: telemedicine

Usual care

Laver 2013

Motor impairment

FMA

2

46

MD 3.65

(‐0.26 to 7.57)

No benefit or harm

Intervention

Comparison

Review

Outcome category

Outcome measures

Number of trials

Number of participants

Effect size

95% CI

Evidence of effect?

FU time

Stretching and positioning (stretch)

Any

Katalinic 2010

Range of movement

Joint mobility

3

77

MD ‐0.09

(‐3.58 to 3.40)

No benefit or harm

24 hours to 1 week

4

134

MD ‐0.32

(‐4.09 to 3.44)

No benefit or harm

> 1 week

Katalinic 2010

Spasticity

Spasticity

1

42

SMD ‐0.5

(‐1.12 to 0.11)

No benefit or harm

> 1 week

Factors in service delivery: location: home‐based therapy

Usual care

Coupar 2012

Motor impairment

FMA

1

36

MD 4.3

(0.19 to 8.41)

Beneficial effect

Any FU

Intervention

Comparison

Review

Outcome category

Outcome measures

Number of trials

Number of participants

Effect size

95% CI

Evidence of effect?

Bilateral arm training (bilateral exercise training)

Unilateral exercise training

van Delden 2012

Activity

MAL: AOU

3

146

SMD 0.42

(0.09 to 0.76)

Favours unilateral exercise training

Bilateral arm training (bilateral exercise training)

Unilateral exercise training

van Delden 2012

Activity

MAL: QOM

3

146

SMD 0.45

(0.12 to 0.78)

Favours unilateral exercise training

Brain stimulation: tDCS

Placebo or control

Elsner 2013

Generic ADL

BI

5

286

SMD 5.31

(‐0.52 to 11.14)

No benefit or harm

Mental practice

Any control

Braun 2013

Generic ADL

BI

3

135

MD 0.87

(‐0.8 to 2.53)

No benefit or harm

Mirror therapy

Any other intervention

Thieme 2012

Generic ADL

BI, FIM

4

217

SMD 0.33

(0.05 to 0.60)

Beneficial effect

Robotics

Any other intervention

Mehrholz 2012

Generic ADL + UL function

BI, FIM, ABILHAND, SIS, FAT

13

552

SMD 0.43

(0.11 to 0.75)

Beneficial effect

Stretching and positioning (stretch)

Any

Katalinic 2010

Generic ADL

MAS, mBI, DASH

4

130

SMD 0.2

(‐0.24 to 0.65)

No benefit or harm

Factors in service delivery: location: home‐based therapy

Usual care

Coupar 2012

Generic ADL

BI

2

113

MD 2.85

([‐1.43 to 7.14)

No benefit or harm

Intervention

Comparison

Review

Outcome category

Outcome measures

Number of trials

Number of participants

Effect size

95% CI

Evidence of effect?

FU time

Stretching and positioning (stretch)

Any

Katalinic 2010

Generic ADL

MAS

1

40

MD 1.7

(‐0.40 to 3.80)

No benefit or harm

24 hours to 1 week

MAS, DASH

4

136

SMD 0.14

(‐0.29 to 0.58)

No benefit or harm

> 1 week

Factors in service delivery: location: home‐based therapy

Usual care

Coupar 2012

Generic ADL

BI

1

80

MD ‐1.70

(‐5.51 to 2.11)

No benefit or harm

Any

Intervention

Outcome

Review

Outcome category

Outcome measure

Studies

Participants

Effect size

95% confidence interval

Study size downgrades

ROB downgrades

I²

AMSTAR downgrades

GRADE level of evidence

Bilateral arm training

Usual care

Coupar 2010

Arm function + ADL

BBT, WMFT, MAL: AOU

4

127

SMD ‐0.07

(‐0.42 to 0.28)

1

1

0

1

Low

Other upper limb intervention

Coupar 2010

Arm function

BBT, ARAT, MAS, mMAS

5

189

SMD ‐0.2

(‐0.49 to 0.09)

1

1

0

1

Low

Usual care

Coupar 2010

Hand function

PPT

2

73

SMD ‐0.04

(‐0.5 to 0.42)

2

1

0

1

Low

Other upper limb intervention

Coupar 2010

Hand function

MAS, mMAS, SIS (hand function), 9HPT

4

173

SMD ‐0.21

(‐0.51 to 0.09)

1

1

0

1

Low

Biofeedback: EMG BF

Physiotherapy

Woodford 2007

Arm function

UEFT

1

29

SMD ‐0.17

(‐0.9 to 0.56)

2

1

0

1

Low

Bobath therapy

Control

Luke 2004

Arm function

UEFT

1

29

ES 0.17

(‐0.56 to 0.90)

2

1

0

2

Low

MAS

1

61

ES ‐0.29

(‐0.80 to 0.21)

2

1

0

2

Low

Arm function

SMES

1

61

ES ‐0.32

(‐0.83 to 0.19)

2

1

0

2

Very low

Brain stimulation: rTMS

Control

Hao 2013

Upper limb function

JTHF, PPT, WMFT, ARAT

4

73

SMD 0.51

(‐0.99 to 2.01)

2

1

1

0

Low

Electrical stimulation (for strength)

Control

Nascimento 2014

Arm function + ADL

ARAT, BBT, BI

3

122

SMD 0.79 (random effects)

(‐0.11 to 1.69)

1

1

0

1

Low

Electrical stimulation (NMES)

No treatment

Farmer 2014

Arm function

ARAT

4

319

0.04 to 0.5

(‐0.35 to 0.44) to (‐0.69 to 1.68)

0

0

1

2

Low

Electrical stimulation (stochastic resonance)

Control

Farmer 2014

Arm function

ARAT

1

30

0.15

(‐0.66 to 0.96)

2

0

0

2

Low

Electrical stimulation (EMG‐triggered)

No treatment

Meilink 2008

Arm function

BBT

3

42

0.37

(‐0.27 to 1.01)

2

1

0

2

Very low

Cyclical electrical stimulation

Meilink 2008

Arm function

ARAT

2

48

0

(‐0.56 to 0.57)

2

0

0

2

Low

Sensory impairment (interventions for sensory impairment)

No treatment

Doyle 2010

Hand function

Hand FunctionTest

1

36

MD ‐1.16

(‐2.10 to ‐0.22)

2

1

0

0

Low

Placebo or attention control

Doyle 2010

Arm function

ARAT

1

21

MD 12.9

(5.65 to 20.15)

2

1

0

0

Low

Sensory impairment (passive sensory retraining)

Not reported

Schabrun 2009

Hand function

JTHF

3

Unclear

MD 8.72

(2.48 to 14.95)

2

1

1

2

Very low

Strength training

Control

Harris 2010

Upper limb function

MAS, TEMPA, RMA, PPB, WMFT, BBT, ARAT, FTHUE

11

465

SMD 0.21

(0.03 to 0.39)

0

1

0

2

Low

Stretching and positioning: shoulder support

Control

Ada 2005

Arm function

MAS

1

83

MD 0.83

(‐1.46 to 3.12)

2

0

0

1

Low

Intervention

Outcome

Review

Outcome category

Outcome measure

Studies

Participants

Effect size

95% confidence interval

Study size downgrades

ROB downgrades

I²

AMSTAR downgrades

GRADE level of evidence

Follow‐up

Factors in service delivery: dose of intervention (augmented therapy)

Standard therapy

Cooke 2010

Arm function

ARAT

2

168

2.2

(‐6.0 to 10.4)

1

1

1

1

Low

FU1

Intervention

Outcome

Review

Outcome category

Outcome measure

Studies

Participants

Effect size

95% confidence interval

Study size downgrades

ROB downgrades

I²

AMSTAR downgrades

GRADE level of evidence

Bilateral arm training

Usual care

Coupar 2010

Motor impairment

FMA

4

127

SMD 0.67

(‐0.43 to 1.77)

1

1

1

1

Low

Other upper limb intervention

Coupar 2010

Motor impairment

FMA, RMA

4

175

SMD ‐0.25

(‐0.55 to 0.05)

1

1

0

1

Low

Biofeedback: EMG BF

Physiotherapy

Woodford 2007

Range of movement

Wrist ROM

1

9

SMD 0.96

(‐0.48 to 2.40)

2

1

0

1

Low

Shoulder ROM

1

26

SMD 0.88

(0.07 to 1.70)

2

1

0

1

Low

Motor impairment

BMR