Caregiver‐mediated exercises for improving outcomes after stroke

Judith DM Vloothuis; Marijn Mulder; Janne M Veerbeek; Manin Konijnenbelt; Johanna MA Visser‐Meily; Johannes CF Ket; Gert Kwakkel; Erwin EH van Wegen

doi:10.1002/14651858.CD011058.pub2

Cochrane Database of Systematic Reviews

Ejercicios mediados por el cuidador para mejorar los resultados después del accidente cerebrovascular

Información

DOI:

https://doi.org/10.1002/14651858.CD011058.pub2 Copiar DOI

Base de datos:

Cochrane Database of Systematic Reviews

Versión publicada:

21 diciembre 2016see what's new

Tipo:

Intervention

Etapa:

Review

Grupo Editorial Cochrane:

Grupo Cochrane de Accidentes cerebrovasculares

Copyright:

Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

Judith DM Vloothuis

Correspondencia a: Department of Neurorehabilitation, Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, Netherlands

[email protected]
Marijn Mulder

Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, Netherlands
Janne M Veerbeek

Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, Netherlands

Department of Rehabilitation Medicine, Physical Therapy, VU University Medical Center, Amsterdam, Netherlands
Manin Konijnenbelt

Department of Neurorehabilitation, Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, Netherlands
Johanna MA Visser‐Meily

Brain Center Rudolf Magnus, University Medical Center Utrecht and De Hoogstraat, Utrecht, Netherlands
Johannes CF Ket

Medical Library, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
Gert Kwakkel

Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, Amsterdam Neurosciences, VU University Medical Center, Amsterdam, Netherlands
Erwin EH van Wegen

Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, Amsterdam Neurosciences, VU University Medical Center, Amsterdam, Netherlands

Contributions of authors

Judith Vloothuis wrote the protocol with the support of the other authors who directed protocol focus and quality, and commented on the protocol.

Johannes Ket helped to develop search strategies.

Marijn Mulder and Judith Vloothuis screened the references, with the help of Janne Veerbeek.

Erwin van Wegen helped resolving questions and disagreements.

Judith Vloothuis extracted the data and Marijn Mulder cross‐checked these data.

Judith Vloothuis entered data in RevMan and performed analyses.

All authors interpreted the analysis.

Judith Vloothuis drafted the review.

All authors gave input, read, revised, and approved the final version.

Declarations of interest

Judith DM Vloothuis: none known.
Marijn Mulder: none known.
Janne M Veerbeek: none known.
Manin Konijnenbelt: none known.
Johanna MA Visser‐Meily: none known.
Johannes CF Ket: none known.
Gert Kwakkel: none known.
Erwin EH van Wegen: none known.

Acknowledgements

We acknowledge the support of Brenda Thomas and Hazel Fraser from the Cochrane Stroke Group, Remke Albers from Amsterdam Rehabilitation Research Centre Reade and the Dutch Cochrane Centre for their help in preparing the protocol and the assistance in developing the search strategies. In addition, we wish to acknowledge all external peer reviewers, with special thanks to the consumer reviewer Marion Foreman.

Version history

Published

Title

Stage

Authors

Version

2016 Dec 21

Caregiver‐mediated exercises for improving outcomes after stroke

Review

Judith DM Vloothuis, Marijn Mulder, Janne M Veerbeek, Manin Konijnenbelt, Johanna MA Visser‐Meily, Johannes CF Ket, Gert Kwakkel, Erwin EH van Wegen

https://doi.org/10.1002/14651858.CD011058.pub2

2014 Apr 02

Caregiver‐mediated exercises for improving outcomes after stroke

Protocol

Judith DM Vloothuis, Erwin EH van Wegen, Janne M Veerbeek, Manin Konijnenbelt, Johanna MA Visser‐Meily, Gert Kwakkel

https://doi.org/10.1002/14651858.CD011058

Differences between protocol and review

The second review author who also did the search and cross‐checked data extraction changed from Janne Veerbeek to Marijn Mulder.
Added Johannes Ket to the review team.
Updated 'Description of the intervention' section. Whereby we made clearer that we included interventions which were aimed at improving activities of daily living including mobility (review: 'Hereby, the exercises are aimed at improving activities of daily living including mobility, such as making transfers, standing and walking'), instead of only interventions to improve function (protocol: 'main aim to improve motor function').
Described the definition of 'caregiver' in more detail in the 'Types of interventions' section: a caregiver or carer as an unpaid or partially paid person who voluntarily helps an impaired individual with his or her activities of daily living. In other words, the mediated services were not applied by a professional in health care but in most cases, someone who was close to the patient and voluntarily offered his or her services. This may have been a partner, family member, or friend, but it could have also have been a volunteer. We argued that this person is 'not a professional' such as a 'therapy assistant'.
Included trials that combined caregiver‐mediated exercises (CME) with another intervention in contrary to our description in the protocol ('Types of interventions'). We included these trials because during search and data analysis two forms of CME came forward: trials in which CME was the only intervention (CME‐core) and trials in which caregivers provided an existing intervention. We differentiated between those trials in a sensitivity analysis ('CME‐core').
Changed primary outcome measure 'Caregiver: measures of mood, burden and quality of life' to 'Caregiver: measures of burden. Our primary objective was to learn the effect of CME on caregiver burden. Especially because one can argue that CME gives a caregiver influence and knowledge and, therefore, can lessen caregiver burden, but one can also argue that CME are yet another task for the caregiver in these stressful times and will increase caregiver burden. Moved mood and quality of life to secondary outcomes.
Changed the order of the secondary outcome measures to a more logical order (from impairment to participation).
Renamed the secondary outcome measure 'measures of upper limb activities of function' to 'measures of upper limb activities or function'
Added a sentence under 'Selection of studies' about the screening of abstracts, after the screening of titles.
In the protocol, we proposed under 'Subgroup analysis and investigation of heterogeneity' to do a subgroup analysis of interventions in addition to usual care versus control and interventions instead of usual care versus control. We did not do this subgroup analysis, but a subgroup analysis of interventions with a higher dose of training in the intervention group than the control group versus interventions with a same dose of training in intervention and control group. We changed this because we experienced the importance of difference of dose of training. We noticed that in the group 'interventions instead of usual care' dose of training could still be higher.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Adult; Humans;

PICO

Population

Intervention

Comparison

Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Figure 1

Study flow diagram.

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Figure 2

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

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 1 Patient: activities of daily living (ADL) measures: combined.

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Analysis 1.2

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 2 Patient: ADL measures: extended ADL: combined.

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Analysis 1.3

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 3 Caregiver: burden: combined.

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Analysis 1.4

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 4 Measures of motor impairment: Fugl‐Meyer Assessment lower extremity.

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Analysis 1.5

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 5 Measures of motor impairment: Fugl‐Meyer Assessment upper extremity.

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Analysis 1.6

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 6 Gait and gait‐related measures: balance: combined.

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Analysis 1.7

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 7 Gait and gait‐related measures: Six‐Minute Walk Test.

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Analysis 1.8

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 8 Gait and gait‐related measures: walking speed.

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Analysis 1.9

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 9 Measures of upper limb activities or function: Wolf Motor Function test ‐ functional ability.

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Analysis 1.10

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 10 Measures of upper limb activities or function: Wolf Motor Function Test ‐ performance time.

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Analysis 1.11

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 11 Measures of upper limb activities or function: Motor Activity Log (MAL) ‐ amount of use.

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Analysis 1.12

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 12 Measures of upper limb activities or function: MAL ‐ quality of movement.

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Analysis 1.13

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 13 Measures of upper limb activities or function: Nine Hole Peg test.

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Analysis 1.14

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 14 Measures of mood and quality of life (QoL) of the patient: Stroke Impact Scale (SIS) ‐ composite physical.

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Analysis 1.15

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 15 Measures of mood and QoL of the patient: SIS ‐ strength.

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Analysis 1.16

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 16 Measures of mood and QoL of the patient: SIS ‐ ADL/IADL.

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Analysis 1.17

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 17 Measures of mood and QoL of the patient: SIS ‐ mobility.

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Analysis 1.18

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 18 Measures of mood and QoL of the patient: SIS ‐ hand function.

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Analysis 1.19

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 19 Measures of mood and QoL of the patient: SIS ‐ memory.

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Analysis 1.20

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 20 Measures of mood and QoL of the patient: SIS ‐ communication.

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Analysis 1.21

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 21 Measures of mood and QoL of the patient: SIS ‐ emotion.

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Analysis 1.22

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 22 Measures of mood and QoL of the patient: SIS ‐ social participation.

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Analysis 1.23

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 23 Measures of mood and QoL of the patient: SIS ‐ general recovery.

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Analysis 1.24

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 24 Length of stay ‐ hospital.

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Analysis 1.25

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 25 Length of stay ‐ rehabilitation unit.

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Analysis 1.26

Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 26 Adverse outcomes: falls.

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Analysis 2.1

Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 1 Patient: activities of daily living (ADL) measures: ADL.

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Analysis 2.2

Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 2 Patient: ADL measures: extended ADL: combined.

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Analysis 2.3

Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 3 Caregiver: burden.

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Analysis 2.4

Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 4 Measures of motor impairment: Fugl‐Meyer Assessment lower extremity.

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Analysis 2.5

Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 5 Measures of motor impairment: Fugl‐Meyer Assessment upper extremity.

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Analysis 2.6

Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 6 Gait and gait‐related measures: balance.

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Analysis 2.7

Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 7 Gait and gait‐related measures: Six‐Minute Walking Test.

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Analysis 2.8

Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 8 Gait and gait‐related measures: walking speed.

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Analysis 2.9

Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 9 Measures of upper limb activities or function: Wolf Motor Function test ‐ functional ability.

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Analysis 2.10

Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 10 Measures of upper limb activities or function: Wolf Motor Function test ‐ performance time.

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Analysis 2.11

Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 11 Measures of upper limb activities or function: Motor Activity Log ‐ amount of use.

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Analysis 2.12

Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 12 Measures of upper limb activities or function: Motor Activity Log ‐ quality of movement.

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Analysis 2.13

Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 13 Measures of upper limb activities or function: Nine Hole Peg test.

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Analysis 2.14

Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 14 Measures of mood and quality of life of the patient: Stroke Impact Scale (SIS) ‐ hand function.

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Analysis 3.1

Comparison 3 Timing post stroke ‐ end of intervention, Outcome 1 Patient: activities of daily living measures: combined.

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Analysis 4.1

Comparison 4 Mean change from post intervention ‐ end of follow‐up, Outcome 1 Patient: activities of daily living (ADL) measures: Barthel Index.

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Analysis 4.2

Comparison 4 Mean change from post intervention ‐ end of follow‐up, Outcome 2 Patient: ADL measures: extended ADL ‐ Nottingham Extended Activities of Daily Living Index.

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Analysis 4.3

Comparison 4 Mean change from post intervention ‐ end of follow‐up, Outcome 3 Patient: ADL measures: extended ADL ‐ reintegration to normal living index.

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Analysis 4.4

Comparison 4 Mean change from post intervention ‐ end of follow‐up, Outcome 4 Caregiver: Caregiver Strain Index.

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Analysis 4.5

Comparison 4 Mean change from post intervention ‐ end of follow‐up, Outcome 5 Measures of motor impairment: Fugl‐Meyer Assessment lower extremity.

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Analysis 4.6

Comparison 4 Mean change from post intervention ‐ end of follow‐up, Outcome 6 Gait and gait‐related measures: balance: Berg Balance Scale.

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Analysis 4.7

Comparison 4 Mean change from post intervention ‐ end of follow‐up, Outcome 7 Gait and gait‐related measures: Six‐Minute Walking Test.

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Analysis 4.8

Comparison 4 Mean change from post intervention ‐ end of follow‐up, Outcome 8 Other outcomes: Motor Assessment Scale.

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Analysis 5.1

Comparison 5 Sensitivity analysis ‐ caregiver‐mediated exercise (CME)‐core ‐ end of intervention, Outcome 1 Patient: activities of daily living (ADL) measures: Barthel Index.

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Analysis 5.2

Comparison 5 Sensitivity analysis ‐ caregiver‐mediated exercise (CME)‐core ‐ end of intervention, Outcome 2 Patient: ADL measures: extended ADL ‐ Nottingham Extended Activities of Daily Living Index.

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Analysis 5.3

Comparison 5 Sensitivity analysis ‐ caregiver‐mediated exercise (CME)‐core ‐ end of intervention, Outcome 3 Gait and gait‐related measures: balance: Berg Balance Scale.

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Analysis 6.1

Comparison 6 Sensitivity analysis ‐ caregiver‐mediated exercise (CME)‐core ‐ end of follow‐up, Outcome 1 Patient: activities of daily living (ADL) measures: Barthel Index.

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Analysis 6.2

Comparison 6 Sensitivity analysis ‐ caregiver‐mediated exercise (CME)‐core ‐ end of follow‐up, Outcome 2 Patient: ADL measures: extended ADL ‐ Nottingham Extended Activities of Daily Living Index.

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Analysis 7.1

Comparison 7 Walking speed, different possibilities study of Wall, Outcome 1 Walking speed ‐ caregiver‐mediated exercises (CME) vs physiotherapy ‐ end of intervention.

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Analysis 7.2

Comparison 7 Walking speed, different possibilities study of Wall, Outcome 2 Walking speed ‐ CME vs physiotherapy ‐ end of follow‐up.

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Analysis 7.3

Comparison 7 Walking speed, different possibilities study of Wall, Outcome 3 Walking speed ‐ CME vs no intervention ‐ end of intervention.

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Analysis 7.4

Comparison 7 Walking speed, different possibilities study of Wall, Outcome 4 Walking speed ‐ CME vs no intervention ‐ end of follow‐up.

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Analysis 7.5

Comparison 7 Walking speed, different possibilities study of Wall, Outcome 5 Walking speed ‐ CME and physiotherapy vs physiotherapy ‐ end of intervention.

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Analysis 7.6

Comparison 7 Walking speed, different possibilities study of Wall, Outcome 6 Walking speed ‐ CME and physiotherapy vs physiotherapy ‐ end of follow‐up.

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Analysis 7.7

Comparison 7 Walking speed, different possibilities study of Wall, Outcome 7 Walking speed ‐ CME and physiotherapy vs no intervention ‐ end of intervention.

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Analysis 7.8

Comparison 7 Walking speed, different possibilities study of Wall, Outcome 8 Walking speed ‐ CME and physiotherapy vs no intervention ‐ end of follow‐up.

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Analysis 8.1

Comparison 8 Extended activities of daily living (ADL) ‐ analyses with Reintegration to Normal Living Index (RNLI), Outcome 1 Patient: ADL measures: extended ADL ‐ combined ‐ end of intervention.

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Analysis 8.2

Comparison 8 Extended activities of daily living (ADL) ‐ analyses with Reintegration to Normal Living Index (RNLI), Outcome 2 Patient: ADL measures: extended ADL ‐ combined ‐ end of follow‐up.

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Summary of findings for the main comparison. Caregiver‐mediated exercises compared with control intervention for people with stroke

Caregiver‐mediated exercises compared with control intervention for people with stroke
Patient or population: people with stroke Settings: inpatient and outpatient settings Intervention: caregiver‐mediated exercises Comparison: control, i.e. usual care, other intervention, no intervention
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control intervention	Caregiver‐mediated intervention
Patient: ADL measures Barthel Index. Scale 0 to 100 (follow‐up: 2 studies; 3/6 months) FIM. Scale 7 to 126 (no follow‐up)	The mean Barthel Index score ranged across control groups from 78 to 84 1 study: The mean FIM score in the control group was 65	The mean Barthel Index score in the intervention groups was 5.09 higher (‐2.88 to 13.07 higher) 1 study: The mean FIM score in the intervention group was 11 higher (‐1.59 to 23.67 higher)	‐	Barthel Index: 247 (3) FIM: 48 (1) Total: 295	⊕⊕⊕⊝ Moderate	Higher scores are better More than half of the studies at low risk of bias (3 low risk of bias, 1 at unclear risk of bias) There was clinical heterogeneity SMD 0.21 (‐0.02 to 0.44)
Caregiver: measures of mood, burden and QoL: burden Caregiver Strain Index Scale. 0 to 13 (follow‐up 3 months) Caregiver Burden Scale. 22 to 88 (no follow‐up)	The mean Caregiver Strain Index score in the control group was 3.4 The mean Caregiver Burden Scale score in the control group was 46.6	The mean Caregiver Strain Index score in the intervention group was 0.50 higher (‐0.81 to 1.81 higher) The mean Caregiver Burden Scale score in the intervention group was 1.30 lower (‐4.88 to 7.48 lower)	‐	Caregiver Strain Index: 40 (1) Caregiver Burden Scale: 51 (1) Total: 91	⊕⊕⊕⊝ Moderate	Lower scores are better Both studies at low risk of bias Small total number of participants SMD ‐0.04 (‐0.45 to 0.37)
Gait and gait‐related measures: walking speed in m/s (follow‐up: 1 study, 9 months)	The mean walking speed ranged across control groups from 0.26 m/s to 0.46 m/s	The mean walking speed in the intervention group was 0.08 m/s higher (‐0.03 to 0.18)	‐	71 (2)	⊕⊝⊝⊝ Very low
Gait and gait‐related measures: walking distance measured with the Six‐Minute Walk Test in metres walked in 6 minutes (follow‐up: 1 study, 3 months)	The mean distance walked ranged across control groups from 157 m to 166 m	The mean distance walked in the intervention groups was 30.98 m higher (‐20.22 to 82.19 higher)	‐	91 (2)	⊕⊕⊕⊝ moderate	Lower scores are better 1 study at unclear risk of bias Small total number of participants MD 0.04 (‐0.10 to 0.18)
Measures of mood and QoL of the patient: Stroke Impact Scale Stroke Impact Scale mobility scale. Scale 9 to 45. (no follow‐up)	The mean Stroke Impact Scale mobility score in the control group was 66.8	The mean Stroke Impact Scale mobility score in the intervention group was 18.2 higher (7.54 to 28.86 higher)	‐	51 (1)	⊕⊝⊝⊝ Very low	Higher scores are better 1 study at low risk of bias Small total number of participants MD 18.2 (7.54 to 28.86)
Length of stay: length of stay in rehabilitation unit in days	The mean length of stay in a rehabilitation unit in the control group was 52.3 days	The mean length of stay in a rehabilitation unit in the intervention group was 12 days lower (‐10.88 to 34.88)	‐	20 (1)	⊕⊝⊝⊝ very low	Higher scores are better 1 study at low risk of bias and 1 at unclear or high risk of bias Small total number of participants There was clinical heterogeneity MD 0.08 m/s (‐0.03 to 0.18)
Adverse outcomes: falls number of falls/patient (no follow‐up)	1 study: the mean number of falls/patient in the control group was 0.08	1 study: the mean number of falls/ patient in the intervention group was 0.04 lower (‐0.10 to 0.18 lower)	‐	48 (1)	⊕⊝⊝⊝ Very low	Higher scores are better Both studies at low risk of bias Small total number of participants MD 30.98 m (‐20.22 to 82.19)
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). ADL: activities of daily living; CI: confidence interval; FIM: Functional Independence Measure; MD: mean difference; QoL: quality of life; RR: risk ratio; SD: standard deviation; SMD: standardised mean difference.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.

Summary of findings for the main comparison. Caregiver‐mediated exercises compared with control intervention for people with stroke

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Table 1. Outline of included studies

Study ID	Form of training	Upper or lower body	Timing since stroke	Task caregiver	Routine care continued	Control group	Programme (length ‐frequency‐ duration)	Contact with therapist	Place
Abu Tariah 2010	CIMT	Upper	> 2 months	Carried out the intervention with support of therapists	No	Neurodevelopmental training, same intensity	2 months ‐ daily ‐ 2 hours	3 or 4 sessions	Home
Agrawal 2013	Exercise therapy	Upper	"Sub‐acute stroke"	Encouragement, participating, and help	Yes	Usual care	4 weeks ‐5 days/week ‐ 60 to 90 minutes	Weekly	Inpatient?
Barzel 2015	CIMT	Upper	> 6 months	Supervision, help, and maintaining training diary	No	Usual care, frequency of seeing a therapist was the same	4 weeks ‐ Every weekday (not weekend) ‐ 2 hours	5 x 60 minutes	Home
Dai 2013	Vestibular rehabilitation	Both	< 6 months	Guidance and supervision (in third and fourth week)	Yes	Usual care	4 weeks ‐ 10 sessions per 2 weeks ‐ 30 minutes	2 to 4 sessions in first 2 weeks	Inpatient?
Galvin 2011	Exercise therapy	Lower	Assessment 2 weeks after stroke onset	Encouragement and help	Yes	Usual care	8 weeks ‐every day ‐ 35 minutes	Weekly	Inpatient or at home
Gómez 2014	CIMT	Upper	< 6 months	Monitoring and supervising	Yes	Usual care	14 days ‐ every day* ‐ 5.5 hours*	1.5 hours per day*	Inpatient
Souza 2015	CIMT: 1.5 hours with therapist and 1.5 hours with caregiver	Upper	< 24 months**	Supervision and making notes	No	CIMT: 3 hours with therapist	22 days ‐ 10 sessions ‐ 3 hours	10 x 90 minutes	Outpatient and home
Wall 1987	Exercise therapy	Lower	After discharge of rehabilitation	Supervision	No	No intervention	6 months ‐ twice a week ‐ 1 hour	1 group: twice a week 1 group: once a week 1 group: 'monitoring'	Outpatient or at home
Wang 2015	Exercise programme aimed at body functions, activities, and participation	Both	> 6 months	Encouragement and help	No	Usual care	12 weeks ‐ minimal twice a week, if possible every day ‐ minimal 50 to 60 minutes	Weekly 90 minutes	Home
CIMT: constraint‐induced movement therapy. * Details of the intervention are not completely clear, contact with the authors was not successful. ** But mean time since stroke was 27 and 35 months since stroke, unclear why.

Table 1. Outline of included studies

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Table 2. (Standard) Mean differences which are not reported in section 'data and analysis'

Outcome	Outcome measure	Fixed‐effect or random‐effects model	Mean difference	Confidence interval	Heterogeneity	P value
1.1 Patient: ADL measures ‐ Combined	1.1.1 Barthel Index	Random‐effects	5.09	‐2.88 to 13.07	58%	0.21
1.1 Patient: ADL measures ‐ Combined	1.1.2 Functional Independence Measure	Fixed‐effect	11.04	‐1.59 to 23.67	‐	0.09
1.2 Patient: ADL measures ‐ extended ADL	1.2.1 Nottingham Extended Activities of Daily Living Index	Fixed‐effect	5.50	‐5.83 to 16.83	‐	0.34
1.2 Patient: ADL measures ‐ extended ADL	1.2.2 IADL	Fixed‐effect	0.02	‐0.72 to 0.76	‐	0.96
1.3 Caregiver: burden	1.3.1 Caregiver Strain Index	Fixed‐effect	‐0.50	‐1.81 to 0.81	‐	0.46
1.3 Caregiver: burden	1.3.2 Caregiver Burden Scale	Fixed‐effect	1.30	‐4.88 to 7.48	‐	0.68
1.6 Gait and gait‐related measures: balance	1.6.1 Berg Balance Scale	Fixed‐effect	6.35	1.64 to 11.06	0%	0.008
1.6 Gait and gait‐related measures: balance	1.6.2 Postural Assessment for Stroke patients	Fixed‐effect	3.50	‐0.52 to 7.52	‐	0.09
2.2 Patient: ADL measures ‐ extended ADL	2.2.1 Nottingham Extended Activities of Daily Living Index	Fixed‐effect	9.50	‐1.83 to 20.83	‐	0.10
2.2 Patient: ADL measures ‐ extended ADL	2.2.2 IADL	Fixed‐effect	0.02	‐0.77 to 0.81	‐	0.96
3.1 Patient: ADL measures ‐ combined	3.1.1 < 6 months	Fixed‐effect	0.44*	0.01 to 0.86	0%	0.04
3.1 Patient: ADL measures ‐ combined	3.1.2 > 6 months	Random‐effects	4.90	‐7.56 to 17.36	77%	0.44
8.1 Patient ADL measures ‐ extended ADL ‐ end of intervention	8.1.1 Reintegration to normal living Index	Fixed‐effect	0.20	‐3.76 to 4.16	‐	0.92
	8.1.2 IADL	Fixed‐effect	0.02	‐0.72 to 0.76	‐	0.96
8.2 Patient ADL measures ‐ extended ADL ‐ end of follow‐up	8.2.1 Reintegration to normal living Index	Fixed‐effect	4.50	0.54 to 8.46	‐	0.03
8.2 Patient ADL measures ‐ extended ADL ‐ end of follow‐up	8.2.2 IADL	Fixed‐effect	0.02	‐0.77 to 0.81	‐	0.96
ADL: activities of daily living; IADL: instrumental activities of daily living. *Standardised mean difference.

Table 2. (Standard) Mean differences which are not reported in section 'data and analysis'

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Table 3. Results 'other outcomes' (not included in meta‐analysis)

Outcome	Control group (mean (SD))			Intervention group (mean (SD))
Outcome	Baseline	Post intervention	Follow‐up	Baseline	Post intervention	Follow‐up
Behavioural Inattention Test Conventional (Dai 2013)	48.79 (44.64)	68.83 (44.72)	‐	49.71 (39.63)	88.71 (44.56)	‐
Motor Assessment Scale (Galvin 2011)	29.7 (12.9)	34.5 (11.6)	35.2 (10.8)	24.3 (11.1)	36.1 (10.2)	37.9 (9.7)
SD: standard deviation.

Table 3. Results 'other outcomes' (not included in meta‐analysis)

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Table 4. Results Agrawal 2013 (study not included in meta‐analysis)

Outcome	Control group (mean scores)		GRASP 60 group (mean scores)		GRASP 90 group (mean scores)
Outcome	Baseline	Post intervention	Baseline	Post intervention	Baseline	Post intervention
Fugl‐Meyer Assessment upper extremity	31.3	37.0	32.9	44.0	34.7	48.2
Chedoke Arm and Hand Activities Inventory	20.3	26.8	21.0	30.0	24.4	37.0

Table 4. Results Agrawal 2013 (study not included in meta‐analysis)

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Comparison 1. Caregiver‐mediated exercises versus control ‐ end of intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patient: activities of daily living (ADL) measures: combined Show forest plot	4	295	Std. Mean Difference (IV, Fixed, 95% CI)	0.21 [‐0.02, 0.44]

1.1 Barthel Index	3	247	Std. Mean Difference (IV, Fixed, 95% CI)	0.16 [‐0.09, 0.41]
1.2 Functional Independence Measure	1	48	Std. Mean Difference (IV, Fixed, 95% CI)	0.49 [‐0.09, 1.06]
2 Patient: ADL measures: extended ADL: combined Show forest plot	2	196	Std. Mean Difference (IV, Fixed, 95% CI)	0.07 [‐0.21, 0.35]

2.1 Nottingham Extended Activities of Daily Living Index	1	40	Std. Mean Difference (IV, Fixed, 95% CI)	0.29 [‐0.33, 0.92]
2.2 Instrumental Activities of Daily Living (IADL)	1	156	Std. Mean Difference (IV, Fixed, 95% CI)	0.01 [‐0.31, 0.32]
3 Caregiver: burden: combined Show forest plot	2	91	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.04 [‐0.45, 0.37]

3.1 Caregiver Strain Index	1	40	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.23 [‐0.85, 0.39]
3.2 Caregiver Burden Scale	1	51	Std. Mean Difference (IV, Fixed, 95% CI)	0.11 [‐0.44, 0.66]
4 Measures of motor impairment: Fugl‐Meyer Assessment lower extremity Show forest plot	1	40	Mean Difference (IV, Fixed, 95% CI)	3.10 [‐2.02, 8.22]

5 Measures of motor impairment: Fugl‐Meyer Assessment upper extremity Show forest plot	1	18	Mean Difference (IV, Fixed, 95% CI)	4.43 [‐2.09, 10.95]

6 Gait and gait‐related measures: balance: combined Show forest plot	3	139	Std. Mean Difference (IV, Fixed, 95% CI)	0.53 [0.19, 0.87]

6.1 Berg Balance Scale	2	91	Std. Mean Difference (IV, Fixed, 95% CI)	0.56 [0.14, 0.98]
6.2 Postural Assessment Scale for Stroke Patients	1	48	Std. Mean Difference (IV, Fixed, 95% CI)	0.48 [‐0.09, 1.06]
7 Gait and gait‐related measures: Six‐Minute Walk Test Show forest plot	2	91	Mean Difference (IV, Fixed, 95% CI)	30.98 [‐20.22, 82.19]

8 Gait and gait‐related measures: walking speed Show forest plot	2	71	Mean Difference (IV, Fixed, 95% CI)	0.08 [‐0.03, 0.18]

9 Measures of upper limb activities or function: Wolf Motor Function test ‐ functional ability Show forest plot	2	174	Mean Difference (IV, Random, 95% CI)	0.02 [‐0.52, 0.55]

10 Measures of upper limb activities or function: Wolf Motor Function Test ‐ performance time Show forest plot	2	174	Mean Difference (IV, Fixed, 95% CI)	‐1.72 [‐2.23, ‐1.21]

11 Measures of upper limb activities or function: Motor Activity Log (MAL) ‐ amount of use Show forest plot	2	174	Mean Difference (IV, Fixed, 95% CI)	0.01 [‐0.36, 0.38]

12 Measures of upper limb activities or function: MAL ‐ quality of movement Show forest plot	2	174	Mean Difference (IV, Fixed, 95% CI)	0.08 [‐0.26, 0.42]

13 Measures of upper limb activities or function: Nine Hole Peg test Show forest plot	1	156	Mean Difference (IV, Fixed, 95% CI)	‐0.04 [‐0.11, 0.03]

14 Measures of mood and quality of life (QoL) of the patient: Stroke Impact Scale (SIS) ‐ composite physical Show forest plot	1	51	Mean Difference (IV, Fixed, 95% CI)	12.40 [1.67, 23.13]

15 Measures of mood and QoL of the patient: SIS ‐ strength Show forest plot	1	51	Mean Difference (IV, Fixed, 95% CI)	12.20 [‐0.08, 24.48]

16 Measures of mood and QoL of the patient: SIS ‐ ADL/IADL Show forest plot	1	51	Mean Difference (IV, Fixed, 95% CI)	11.4 [‐1.11, 23.91]

17 Measures of mood and QoL of the patient: SIS ‐ mobility Show forest plot	1	51	Mean Difference (IV, Fixed, 95% CI)	18.20 [7.54, 28.86]

18 Measures of mood and QoL of the patient: SIS ‐ hand function Show forest plot	2	207	Mean Difference (IV, Fixed, 95% CI)	2.64 [‐5.87, 11.15]

19 Measures of mood and QoL of the patient: SIS ‐ memory Show forest plot	1	51	Mean Difference (IV, Fixed, 95% CI)	6.30 [‐1.65, 14.25]

20 Measures of mood and QoL of the patient: SIS ‐ communication Show forest plot	1	51	Mean Difference (IV, Fixed, 95% CI)	3.0 [‐2.34, 8.34]

21 Measures of mood and QoL of the patient: SIS ‐ emotion Show forest plot	1	51	Mean Difference (IV, Fixed, 95% CI)	2.10 [‐4.35, 8.55]

22 Measures of mood and QoL of the patient: SIS ‐ social participation Show forest plot	1	51	Mean Difference (IV, Fixed, 95% CI)	6.70 [‐1.69, 15.09]

23 Measures of mood and QoL of the patient: SIS ‐ general recovery Show forest plot	1	51	Mean Difference (IV, Fixed, 95% CI)	15.10 [8.44, 21.76]

24 Length of stay ‐ hospital Show forest plot	1	37	Mean Difference (IV, Fixed, 95% CI)	4.40 [‐3.91, 12.71]

25 Length of stay ‐ rehabilitation unit Show forest plot	1	20	Mean Difference (IV, Fixed, 95% CI)	12.0 [‐10.88, 34.88]

26 Adverse outcomes: falls Show forest plot	1	48	Mean Difference (IV, Fixed, 95% CI)	0.04 [‐0.10, 0.18]

Comparison 1. Caregiver‐mediated exercises versus control ‐ end of intervention

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Comparison 2. Caregiver‐mediated exercises versus control ‐ end of follow‐up

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patient: activities of daily living (ADL) measures: ADL Show forest plot	2	196	Mean Difference (IV, Random, 95% CI)	2.69 [‐8.18, 13.55]

1.1 Barthel Index	2	196	Mean Difference (IV, Random, 95% CI)	2.69 [‐8.18, 13.55]
2 Patient: ADL measures: extended ADL: combined Show forest plot	2	196	Std. Mean Difference (IV, Fixed, 95% CI)	0.11 [‐0.17, 0.39]

2.1 Nottingham Extended Activities of Daily Living Index	1	40	Std. Mean Difference (IV, Fixed, 95% CI)	0.51 [‐0.12, 1.14]
2.2 IADL	1	156	Std. Mean Difference (IV, Fixed, 95% CI)	0.01 [‐0.31, 0.32]
3 Caregiver: burden Show forest plot	1	40	Mean Difference (IV, Fixed, 95% CI)	0.60 [‐0.71, 1.91]

3.1 Caregiver Strain Index	1	40	Mean Difference (IV, Fixed, 95% CI)	0.60 [‐0.71, 1.91]
4 Measures of motor impairment: Fugl‐Meyer Assessment lower extremity Show forest plot	1	40	Mean Difference (IV, Fixed, 95% CI)	3.40 [‐1.74, 8.54]

5 Measures of motor impairment: Fugl‐Meyer Assessment upper extremity Show forest plot	1	18	Mean Difference (IV, Fixed, 95% CI)	2.75 [‐8.24, 13.74]

6 Gait and gait‐related measures: balance Show forest plot	1	40	Mean Difference (IV, Fixed, 95% CI)	8.40 [‐1.04, 17.84]

6.1 Berg Balance Scale	1	40	Mean Difference (IV, Fixed, 95% CI)	8.40 [‐1.04, 17.84]
7 Gait and gait‐related measures: Six‐Minute Walking Test Show forest plot	1	40	Mean Difference (IV, Fixed, 95% CI)	109.50 [17.12, 201.88]

8 Gait and gait‐related measures: walking speed Show forest plot	1	20	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐0.02, 0.22]

9 Measures of upper limb activities or function: Wolf Motor Function test ‐ functional ability Show forest plot	2	174	Mean Difference (IV, Random, 95% CI)	0.08 [‐0.46, 0.61]

10 Measures of upper limb activities or function: Wolf Motor Function test ‐ performance time Show forest plot	2	174	Mean Difference (IV, Random, 95% CI)	1.85 [‐8.78, 12.48]

11 Measures of upper limb activities or function: Motor Activity Log ‐ amount of use Show forest plot	2	174	Mean Difference (IV, Random, 95% CI)	0.21 [‐0.65, 1.08]

12 Measures of upper limb activities or function: Motor Activity Log ‐ quality of movement Show forest plot	2	174	Mean Difference (IV, Fixed, 95% CI)	‐0.03 [‐0.43, 0.37]

13 Measures of upper limb activities or function: Nine Hole Peg test Show forest plot	1	156	Mean Difference (IV, Fixed, 95% CI)	‐0.05 [‐0.12, 0.02]

14 Measures of mood and quality of life of the patient: Stroke Impact Scale (SIS) ‐ hand function Show forest plot	1	156	Mean Difference (IV, Fixed, 95% CI)	‐2.20 [‐12.46, 8.06]

Comparison 2. Caregiver‐mediated exercises versus control ‐ end of follow‐up

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Comparison 3. Timing post stroke ‐ end of intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patient: activities of daily living measures: combined Show forest plot	4	295	Std. Mean Difference (IV, Fixed, 95% CI)	0.21 [‐0.02, 0.44]

1.1 < 6 months	2	88	Std. Mean Difference (IV, Fixed, 95% CI)	0.44 [0.01, 0.86]
1.2 > 6 months	2	207	Std. Mean Difference (IV, Fixed, 95% CI)	0.12 [‐0.16, 0.39]

Comparison 3. Timing post stroke ‐ end of intervention

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Comparison 4. Mean change from post intervention ‐ end of follow‐up

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patient: activities of daily living (ADL) measures: Barthel Index Show forest plot	1	40	Mean Difference (IV, Fixed, 95% CI)	2.3 [‐3.95, 8.55]

2 Patient: ADL measures: extended ADL ‐ Nottingham Extended Activities of Daily Living Index Show forest plot	1	40	Mean Difference (IV, Fixed, 95% CI)	4.00 [‐0.99, 8.99]

3 Patient: ADL measures: extended ADL ‐ reintegration to normal living index Show forest plot	1	40	Mean Difference (IV, Fixed, 95% CI)	4.3 [2.03, 6.57]

4 Caregiver: Caregiver Strain Index Show forest plot	1	40	Mean Difference (IV, Fixed, 95% CI)	1.1 [0.45, 1.75]

5 Measures of motor impairment: Fugl‐Meyer Assessment lower extremity Show forest plot	1	40	Mean Difference (IV, Fixed, 95% CI)	0.30 [‐2.21, 2.81]

6 Gait and gait‐related measures: balance: Berg Balance Scale Show forest plot	1	40	Mean Difference (IV, Fixed, 95% CI)	‐0.9 [‐4.78, 2.98]

7 Gait and gait‐related measures: Six‐Minute Walking Test Show forest plot	1	40	Mean Difference (IV, Fixed, 95% CI)	43.3 [15.11, 71.49]

8 Other outcomes: Motor Assessment Scale Show forest plot	1	40	Mean Difference (IV, Fixed, 95% CI)	1.1 [‐0.92, 3.12]

Comparison 4. Mean change from post intervention ‐ end of follow‐up

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Comparison 5. Sensitivity analysis ‐ caregiver‐mediated exercise (CME)‐core ‐ end of intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patient: activities of daily living (ADL) measures: Barthel Index Show forest plot	2	91	Mean Difference (IV, Fixed, 95% CI)	9.45 [2.11, 16.78]

2 Patient: ADL measures: extended ADL ‐ Nottingham Extended Activities of Daily Living Index Show forest plot	1	40	Mean Difference (IV, Fixed, 95% CI)	5.5 [‐5.83, 16.83]

3 Gait and gait‐related measures: balance: Berg Balance Scale Show forest plot	2	91	Mean Difference (IV, Fixed, 95% CI)	6.35 [1.64, 11.06]

Comparison 5. Sensitivity analysis ‐ caregiver‐mediated exercise (CME)‐core ‐ end of intervention

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Comparison 6. Sensitivity analysis ‐ caregiver‐mediated exercise (CME)‐core ‐ end of follow‐up

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patient: activities of daily living (ADL) measures: Barthel Index Show forest plot	1	40	Mean Difference (IV, Fixed, 95% CI)	9.0 [‐1.29, 19.29]

2 Patient: ADL measures: extended ADL ‐ Nottingham Extended Activities of Daily Living Index Show forest plot	1	40	Mean Difference (IV, Fixed, 95% CI)	9.5 [‐1.83, 20.83]

Comparison 6. Sensitivity analysis ‐ caregiver‐mediated exercise (CME)‐core ‐ end of follow‐up

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Comparison 7. Walking speed, different possibilities study of Wall

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Walking speed ‐ caregiver‐mediated exercises (CME) vs physiotherapy ‐ end of intervention Show forest plot	2	61	Mean Difference (IV, Fixed, 95% CI)	0.06 [‐0.07, 0.20]

2 Walking speed ‐ CME vs physiotherapy ‐ end of follow‐up Show forest plot	1	10	Mean Difference (IV, Fixed, 95% CI)	0.11 [‐0.04, 0.26]

3 Walking speed ‐ CME vs no intervention ‐ end of intervention Show forest plot	2	61	Mean Difference (IV, Fixed, 95% CI)	0.06 [‐0.08, 0.19]

4 Walking speed ‐ CME vs no intervention ‐ end of follow‐up Show forest plot	1	10	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐0.04, 0.24]

5 Walking speed ‐ CME and physiotherapy vs physiotherapy ‐ end of intervention Show forest plot	2	61	Mean Difference (IV, Fixed, 95% CI)	0.07 [‐0.06, 0.21]

6 Walking speed ‐ CME and physiotherapy vs physiotherapy ‐ end of follow‐up Show forest plot	1	10	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐0.11, 0.31]

7 Walking speed ‐ CME and physiotherapy vs no intervention ‐ end of intervention Show forest plot	2	61	Mean Difference (IV, Fixed, 95% CI)	0.07 [‐0.07, 0.20]

8 Walking speed ‐ CME and physiotherapy vs no intervention ‐ end of follow‐up Show forest plot	1	10	Mean Difference (IV, Fixed, 95% CI)	0.09 [‐0.11, 0.29]

Comparison 7. Walking speed, different possibilities study of Wall

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Comparison 8. Extended activities of daily living (ADL) ‐ analyses with Reintegration to Normal Living Index (RNLI)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patient: ADL measures: extended ADL ‐ combined ‐ end of intervention Show forest plot	2	196	Std. Mean Difference (IV, Fixed, 95% CI)	0.01 [‐0.27, 0.29]

1.1 RNLI	1	40	Std. Mean Difference (IV, Fixed, 95% CI)	0.03 [‐0.59, 0.65]
1.2 Instrumental Activities of Daily Living (IADL)	1	156	Std. Mean Difference (IV, Fixed, 95% CI)	0.01 [‐0.31, 0.32]
2 Patient: ADL measures: extended ADL ‐ combined ‐ end of follow‐up Show forest plot	2	196	Std. Mean Difference (IV, Random, 95% CI)	0.29 [‐0.37, 0.95]

2.1 RNLI	1	40	Std. Mean Difference (IV, Random, 95% CI)	0.69 [0.05, 1.33]
2.2 IADL	1	156	Std. Mean Difference (IV, Random, 95% CI)	0.01 [‐0.31, 0.32]

Comparison 8. Extended activities of daily living (ADL) ‐ analyses with Reintegration to Normal Living Index (RNLI)

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