NationalClinicalGuidelineCentre

FinalFullGuideline

StrokeRehabilitation
Longtermrehabilitationafterstroke

Clinicalguideline162
Methods,evidenceandrecommendations

29May2013

FinalDraft

CommissionedbytheNationalInstitutefor
HealthandCareExcellence

StrokeRehabilitation
Contents

Disclaimer
HealthcareprofessionalsareexpectedtotakeNICEclinicalguidelinesfullyintoaccountwhen
exercisingtheirclinicaljudgement.However,theguidancedoesnotoverridetheresponsibilityof
healthcareprofessionalstomakedecisionsappropriatetothecircumstancesofeachpatient,in
consultationwiththepatientand/ortheirguardianorcarer.
Copyright
NationalClinicalGuidelineCentre,2013.
Funding
NationalInstituteforHealthandCareExcellence

NationalClinicalGuidelineCentre,2013.

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Contents

Contents
Guidelinedevelopmentgroupmembers.......................................................................................11
Acknowledgments......................................................................................................................13
1

Introduction..........................................................................................................................14

Developmentoftheguideline...............................................................................................16

2.1

WhatisaNICEclinicalguideline?.......................................................................................16

2.2

Remit...................................................................................................................................16

2.3

Whodevelopedthisguideline?..........................................................................................17

2.4

Whatthisguidelinecovers..................................................................................................17

2.5

Whatthisguidelinedoesnotcover....................................................................................17

2.6

RelationshipsbetweentheguidelineandotherNICEguidance.........................................17

Guidelinesummary...............................................................................................................20
3.1

Keyprioritiesforimplementation.......................................................................................20
3.1.1 Strokeunits............................................................................................................20
3.1.2 Thecoremultidisciplinarystroketeam..................................................................20
3.1.3 Healthandsocialcareinterface.............................................................................20
3.1.4 Transferofcarefromhospitaltocommunity........................................................20
3.1.5 Settinggoalsforrehabilitation...............................................................................21
3.1.6 Intensityofstrokerehabilitation............................................................................21
3.1.7 Cognitivefunctioning.............................................................................................21
3.1.8 Emotionalfunctioning............................................................................................21
3.1.9 Swallowing.............................................................................................................21
3.1.10 Returntowork.......................................................................................................21
3.1.11 Longtermhealthandsocialsupport.....................................................................22

3.2

Fulllistofrecommendations..............................................................................................22

3.3

Keyresearchrecommendations.........................................................................................34

Methods................................................................................................................................35
4.1

Developingthereviewquestionsandoutcomes................................................................35

4.2

Searchingforevidence........................................................................................................41
4.2.1 Clinicalliteraturesearch.........................................................................................41
4.2.2 Healtheconomicliteraturesearch.........................................................................42

4.3

Evidenceofeffectiveness....................................................................................................42
4.3.1 Inclusion/exclusioncriteria....................................................................................42
4.3.2 Methodsofcombiningclinicalstudies...................................................................43
4.3.3 Typeofstudies.......................................................................................................44
4.3.4 Typeofanalysis......................................................................................................44
4.3.5 Appraisingthequalityofevidencebyoutcomes...................................................44

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4.3.6 Gradingthequalityofclinicalevidence.................................................................46
4.3.7 Studylimitations....................................................................................................46
4.3.8 Inconsistency..........................................................................................................47
4.3.9 Indirectness............................................................................................................47
4.3.10 Imprecision.............................................................................................................47
4.4

Evidenceofcosteffectiveness............................................................................................50
4.4.1 Literaturereview....................................................................................................51
4.4.2 Undertakingnewhealtheconomicanalysis..........................................................52
4.4.3 Costeffectivenesscriteria......................................................................................53

4.5

PostconsultationprotocolincludingmodifiedDelphimethodology.................................53

4.6

Developingrecommendations............................................................................................57
4.6.1 Researchrecommendations..................................................................................57
4.6.2 Validationprocess..................................................................................................57
4.6.3 Updatingtheguideline...........................................................................................58
4.6.4 Disclaimer...............................................................................................................58
4.6.5 Funding...................................................................................................................58

Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke..................59
5.1

Strokeunits.........................................................................................................................59
5.1.1 EvidenceReview:Inpeopleafterstroke,doesorganisedrehabilitationcare
(comprehensive,rehabilitationandmixedrehabilitationstrokeunits)
improveoutcome(mortality,dependency,requirementforinstitutionalcare
andlengthofhospitalstay)?..................................................................................59
5.1.2 Recommendationsandlinkstoevidence..............................................................77

5.2

Thecoremultidisciplinarystroketeam..............................................................................78
5.2.1 EvidenceReview:Whatshouldbetheconstituencyofamultidisciplinary
rehabilitationteamandhowshouldtheteamworktogethertoensurethe
bestoutcomesforpeoplewhohavehadastroke?...............................................78
5.2.2 Delphistatementswhereconsensuswasachieved...............................................79
5.2.3 Delphistatementwhereconsensuswasnotreached...........................................80
5.2.4 RecommendationsandlinkstoDelphiconsensussurvey.....................................82

5.3

Healthandsocialcareinterface..........................................................................................84
5.3.1 Delphistatementswhereconsensuswasachieved...............................................84
5.3.2 RecommendationsandlinkstoDelphiconsensussurvey.....................................85

5.4

Transferofcarefromhospitaltocommunity.....................................................................87
5.4.1 Earlysupporteddischarge......................................................................................87
5.4.2 EvidenceReview:Inpeopleafterstrokewhatistheclinicalandcost
effectivenessofearlysupporteddischargeversususualcare?.............................87
5.4.3 Recommendationsandlinktoevidence..............................................................113
5.4.4 Transferofcarefromhospitaltocommunity......................................................115
5.4.5 EvidenceReview:Whatplanningandsupportshouldbeundertakenbythe

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multidisciplinaryrehabilitationteambeforeapersonwhohadastrokeis
dischargedfromhospitalortransferstoanotherteam/settingtoensurea
successfultransitionofcare?...............................................................................115
5.4.6 Delphistatementswhereconsensuswasachieved.............................................116
5.4.7 Delphistatementwhereconsensuswasnotreached.........................................117
5.4.8 RecommendationsandlinkstoDelphiconsensussurvey...................................119
6

Planninganddeliveringstrokerehabilitation......................................................................123
6.1

Screeningandassessment................................................................................................123
6.1.1 EvidenceReview:Inplanningrehabilitationforapersonafterstrokewhat
assessmentsandmonitoringshouldbeundertakentooptimisethebest
outcomes?............................................................................................................123
6.1.2 Delphistatementswhereconsensuswasachieved.............................................123
6.1.3 Delphistatementwhereconsensuswasnotreached.........................................126
6.1.4 RecommendationsandlinkstoDelphiconsensussurvey...................................127

6.2

Settinggoalsforrehabilitation..........................................................................................130
6.2.1 EvidenceReview:Doestheapplicationofpatientgoalsettingaspartof
planningstrokerehabilitationactivitiesleadtoanimprovementin
psychologicalwellbeing,functioningandactivity?..............................................130
6.2.2 Economicevidencesummary...............................................................................140
6.2.3 Evidencestatements............................................................................................141
6.2.4 Economicevidencestatements...........................................................................142
6.2.5 Recommendationsandlinkstoevidence............................................................142
6.2.6 Delphistatementswhereconsensuswasachieved.............................................144
6.2.7 Delphistatementswhereconsensuswasnotachieved......................................145
6.2.8 RecommendationsandlinkstoDelphiconsensussurvey...................................147

6.3

Planningrehabilitation......................................................................................................148
6.3.1 Delphistatementswhereconsensuswasachieved.............................................148
6.3.2 Delphistatementwhereconsensuswasnotreached.........................................150
6.3.3 RecommendationsandlinkstoDelphiconsensussurvey...................................151

6.4

Intensityofstrokerehabilitation......................................................................................153
6.4.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcost
effectivenessofintensiverehabilitationversusstandardrehabilitation?...........153
6.4.2 Recommendationsandlinktoevidence..............................................................166

Supportandinformation.....................................................................................................170
7.1

Providingsupportandinformation...................................................................................170
7.1.1 Evidencereview:Whatistheclinicalandcosteffectivenessofsupported
informationprovisionversusunsupportedinformationprovisiononmood
anddepressioninpeoplewithstroke?................................................................170
7.1.2 Recommendationsandlinktoevidence..............................................................179

Cognitivefunctioning..........................................................................................................181
8.1

Visualneglect....................................................................................................................181

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8.1.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcost
effectivenessofcognitiverehabilitationversususualcaretoimprovespatial
awarenessand/orvisualneglect?.......................................................................181
8.1.2 Recommendationsandlinktoevidence..............................................................194
8.2

Memoryfunction..............................................................................................................195
8.2.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcost
effectivenessofmemorystrategiesversususualcaretoimprovememory.......196
8.2.2 Recommendationsandlinktoevidence..............................................................201

8.3

Attentionfunction.............................................................................................................202
8.3.2 Recommendationsandlinktoevidence..............................................................210

Emotionalfunctioning.........................................................................................................213
9.1

Psychologicaltherapies.....................................................................................................213
9.1.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcost
effectivenessofpsychologicaltherapiesprovidedtothefamily(includingthe
patient)?...............................................................................................................213
9.1.2 Recommendationsandlinktoevidence..............................................................222

10 Vision..................................................................................................................................225
10.1 Eyemovementtherapy.....................................................................................................225
10.1.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcost
effectivenessofeyemovementtherapyforvisualfieldlossversususualcare? 225
10.1.2 Recommendationsandlinktoevidence..............................................................233
10.2 Diplopiaorotherongoingvisualsymptomsafterstroke.................................................234
10.2.1 Evidencereview:Howshouldpeoplewithvisualimpairmentsincluding
diplopiabebestmanagedafterastroke?...........................................................235
10.2.2 Delphistatementswhereconsensuswasachieved.............................................235
10.2.3 Delphistatementwhereconsensuswasnotreached.........................................235
10.2.4 RecommendationsandlinkstoDelphiconsensussurvey...................................237
11 Swallowing..........................................................................................................................238
11.1.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcost
effectivenessofinterventionsforswallowingversusalternativeinterventions
/usualcaretoimprovedifficultyswallowing(dysphagia)?.................................238
11.1.2 EconomicLiteraturereview.................................................................................245
11.1.3 Evidencestatements............................................................................................245
11.1.4 Recommendationsandlinktoevidence..............................................................247
12 Communication...................................................................................................................249
12.1 Aphasia..............................................................................................................................249
12.1.1 EvidenceReview:Inpeoplewhohaveaphasiaafterstrokeisspeechand
languagetherapycomparedtonospeechandlanguagetherapyorplacebo
(socialsupportandstimulation)effectiveinimproving
language/communicationabilitiesand/orpsychologicalwellbeing?..................249
12.2 Dysarthria..........................................................................................................................279
12.2.1 EvidenceReview:Inpeopleafterstrokeisspeechandlanguagetherapy

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comparedtosocialsupportandstimulationeffectiveinimproving
dysarthria?...........................................................................................................279
12.2.2 Recommendationsandinktoevidence...............................................................282
12.3 Speechandlanguagetherapiesfordysarthriaandapraxiaofspeech.............................286
12.3.1 Whatinterventionsimprovecommunicationinpeopledysphasia,dysarthria
andapraxiaofspeech?.........................................................................................286
12.3.2 Delphistatementswhereconsensuswasachieved.............................................286
12.3.3 Delphistatementwhereconsensuswasnotreached.........................................287
12.3.4 RecommendationsandlinkstoDelphiconsensussurvey...................................291
12.4 Intensityofspeechandlanguagetherapy........................................................................292
12.4.1 Evidencereview:Inpeopleafterstrokewithcommunicationdifficultieswhat
istheclinicalandcosteffectivenessofintensivespeechtherapyversus
standardspeechtherapy?....................................................................................292
12.4.2 Recommendationsandlinktoevidence..............................................................305
12.5 Listeneradvice..................................................................................................................307
12.5.1 Whatlisteneradviceskills/trainingorinformationwouldhelpfamily
members/carersimprovecommunicationinpeoplewithaphasiaafter
stroke?..................................................................................................................307
12.5.2 Recommendationsandlinktoevidence..............................................................312
13 Movement..........................................................................................................................313
13.1 Strengthtraining...............................................................................................................313
13.1.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcost
effectivenessofstrengthtrainingversususualcareonimprovingfunction
andreducingdisability?.......................................................................................314
13.1.2 Recommendationsandlinktoevidence..............................................................336
13.2 FitnessTraining.................................................................................................................338
13.2.1 Inpeopleafterstroke,doescardiorespiratoryorresistancefitnesstraining
improveoutcome(fitness,function,qualityoflife,mood)andreduce
disability?.............................................................................................................338
13.2.2 Recommendationsandlinkstoevidence............................................................395
13.3 Handandarmtherapies:orthosesfortheupperlimb.....................................................397
13.3.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcost
effectivenessoforthosesforpreventionoflossofrangeofmovementinthe
upperlimbversususualcare?..............................................................................397
13.3.2 Recommendationsandlinktoevidence..............................................................403
13.4 Electricalstimulation:upperlimb....................................................................................404
13.4.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcost
effectivenessofelectricalstimulation(ES)forhandfunctionversususual
care?.....................................................................................................................404
13.4.2 Recommendationsandlinktoevidence..............................................................437
13.5 Constraintinducedmovementtherapy............................................................................438
13.5.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcost
effectivenessofconstraintinducedtherapyversususualcareonimproving

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functionandreducingdisability?.........................................................................438
13.5.2 Recommendationsandlinktoevidence..............................................................456
13.6 Shoulderpain....................................................................................................................458
13.6.1 Howshouldpeoplewithshoulderpainafterstrokebemanagedtoreduce
pain?.....................................................................................................................458
13.6.2 Delphistatementswhereconsensuswasachieved.............................................458
13.6.3 Delphistatementwhereconsensuswasnotreached.........................................459
13.6.4 RecommendationsandlinkstoDelphiconsensussurvey...................................460
13.7 Repetitivetasktraining.....................................................................................................461
13.7.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcost
effectivenessofrepetitivetasktrainingversususualcareonimproving
functionandreducingdisability?.........................................................................461
13.7.2 Recommendationsandlinktoevidence..............................................................472
13.8 Walkingtherapies:treadmillandtreadmillwithbodyweightsupport...........................473
13.8.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcost
effectivenessofalltreadmillversususualcareonimprovingwalking?..............474
13.8.2 Evidencereview:Inpeopleafterstrokewhocanwalk,whatistheclinicaland
costeffectivenessoftreadmillplusbodysupportversustreadmillonlyon
improvingwalking?..............................................................................................474
13.8.3 Recommendationsandlinktoevidence..............................................................496
13.9 Electromechanicalgaittraining........................................................................................498
13.9.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcost
effectivenessofelectromechanicalgaittrainingversususualcareon
improvingfunctionandreducingdisability?........................................................498
13.9.2 Recommendationsandlinktoevidence..............................................................517
13.10Anklefootorthoses..........................................................................................................518
13.10.1Evidencereview:Inpeopleafterstrokewhatistheclinicalandcost
effectivenessofAnkleFootorthosesofalltypestoimprovewalkingfunction
versususualcare?................................................................................................518
13.10.2Recommendationsandlinktoevidence..............................................................527
14 Selfcare..............................................................................................................................530
14.1 Intensityofoccupationaltherapyforpersonalactivitiesofdailyliving...........................530
14.1.1 Evidencereview:Inpeopleafterstrokewhatistheclinicalandcost
effectivenessofintensiveoccupationaltherapyfocusedspecificallyon
personalactivitiesofdailyliving(dressing/others)versususualcare?.............530
14.1.2 RecommendationsandLinktoEvidence.............................................................540
15 Communityparticipationandlongtermrecovery................................................................543
15.1 Returntowork..................................................................................................................543
15.1.1 EvidenceReview:Inpeopleafterstrokewhatistheclinicalandcost
effectivenessofinterventionstoaidreturntoworkversususualcare?.............543
15.1.2 Clinicalevidence...................................................................................................544
15.1.3 Recommendationsandlinktoevidence..............................................................548

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15.2 Longtermhealthandsocialsupport................................................................................551
15.2.1 Whatongoinghealthandsocialsupportdothepersonafterstrokeandtheir
carer(s)requiretomaximisesocialparticipationandlongtermrecovery?........551
15.2.2 Delphistatementswhereconsensuswasachieved.............................................551
15.2.3 Delphistatementwhereconsensuswasnotreached.........................................553
15.2.4 RecommendationsandlinkstoDelphiconsensussurvey...................................555
16 Acronymsandabbreviations...............................................................................................558
17 Glossary..............................................................................................................................560
18 Referencelist......................................................................................................................573

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StrokeRehabilitation
Guidelinedevelopmentgroupmembers

Guidelinedevelopmentgroupmembers
Name

Organisation

Dr.DianePlayford(Chair)

Readerinneurologicalrehabilitation
UCLInstituteofNeurology
HonoraryConsultantNeurologist
NationalHospitalforNeurologyandNeurosurgery,UCLHNHSFoundation
Trust

Dr.KhalidAli

SeniorLecturerinGeriatrics
BrightonandSussexMedicalSchool

Mr.MartinBird

Carermember

Mr.RobinCant

Patientmember

Ms.SandraChambers

ClinicalSpecialist
StrokeandNeurorehabilitation,PhysiotherapyDepartment,GuysandSt.
ThomasHospitalNHSFoundationTrust

Ms.LouiseClark

TraineeConsultantPractitionerinNeurology(Stroke)
NHSSouthCentral
SeniorOccupationalTherapistspecialisinginStroke

Dr.AvrilDrummond

DeputyDirector,
TrentLocalResearchNetworkforStroke
(ResignedfromtheGuidelineDevelopmentGroupinOctober2012)

Prof.AnneForster

ProfessorofStrokeRehabilitation
InstituteofHealthSciences,UniversityofLeedsandBradford
InstituteforHealthResearch
(ResignedfromtheGuidelineDevelopmentGroupinMarch2013)

Dr.KathrynHead

PrincipalSpeechandLanguageTherapist
Strokeservice,CwmTafHealthBoard,SouthWales

Ms.PamelaHolmes

Representative
SocialCareInstituteforExcellence

Ms.HelenE.Hunter

ClinicalSpecialistNeurophysiotherapist
NorthumberlandCareTrust

Dr.NajmaKhanBourne

ConsultantClinicalNeuropsychologist
ClinicalLeadforNeuropsychologicalNeurorehabilitation
KingsCollegeHospital,KingsCollegeHospitalNHSFoundationTrust

Dr.KeithMacDermott

GeneralPractitioner(RetiredfromGeneralPracticeinApril2010)
Drs.Priceandpartners,York

Dr.RoryOConnor

HonoraryConsultantinRehabilitationMedicine
CommunityRehabilitationUnit,LeedsCommunityHealthcareNHSTrust
LeedsHonoraryConsultantinRehabilitationMedicine
NationalDemonstrationCentreinRehabilitation,LeedsTeachingHospitals
NHSTrust,Leeds

Ms.SueThelwell

StrokeServicesCoordinator
UniversityHospitalsCoventryandWarwickshireNHSTrust

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StrokeRehabilitation
Guidelinedevelopmentgroupmembers
Cooptees/ExpertAdvisors

Name

Organisation

Dr.CharlieDavie

ConsultantNeurologistattheRoyalFreeLondonNHSFoundationTrust
ProgrammeDirectorforNeuroscienceatUniversityCollegeLondon
Partners

Ms.JuliaParnaby

HeadofStrokeInformationServices
StrokeAssociation

Ms.CarolePound

Researcheraphasiatherapyandsupportservices
CentreforResearchandRehabilitation,
BrunelUniversity

Dr.FionaRowe

SeniorLecturerinOrthoptics
UniversityofLiverpool

Mr.MirekSkrypak

ClinicalCoordinatorandManager,CamdenEarlySupportedDischargeand
StrokeNavigationServices

Mr.RonaldBarneyWhite

SeniorOrthotist
SandwellandWestBirminghamHospitalsNHSTrust

NCGCStaffmembersontheguidelinedevelopmentgroup

Name

Role

Ms.GillRitchie

GuidelineLead

Ms.TamaraDiaz

ProjectManager

Dr.KatharinaDworzynski

SeniorResearchFellow

Ms.ElisabettaFenu

SeniorHealthEconomist

Ms.LinaGulhane

JointHeadofInformationScience

Dr.JonathanNyong

ResearchFellow

Dr.AngelaCooper

SeniorResearchFellow untilJuly2010

Dr.PaulineTurner

ResearchFellow

untilAugust2010

Dr.AntoniaMorga

HealthEconomist

untilApril2011

Ms.LolaAdedokun

HealthEconomist

untilJune2012

Dr.GrammatiSarri

SeniorResearchFellow untilJuly2012

Ms.KateLovibond

SeniorHealthEconomist untilAugust2012

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StrokeRehabilitation
Acknowledgments

Acknowledgments
Thedevelopmentofthisguidelinewasgreatlyassistedbythefollowingpeople:

NCGC:

Role

IanBullock

ChiefOperatingOfficer

SerenaCarville

SeniorResearchFellow/ProjectManager

RalphHughes

HealthEconomist

RosaLau

ResearchFellow

SharanginiRajesh

ResearchFellow

JaymeeniSolanki

Projectcoordinator

PhilippeLaramee

HealthEconomist

RichardWhitome

InformationScientist

DavidWonderling

HeadofHealthEconomics

HatiZorba

Projectcoordinator

External

Role

JacobyPatterson

ResearchFellow

ClaireTurner

NICECommissioningManagerfromJuly2010

SarahWillett

NICECommissioningmanageruntilJuly2010

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StrokeRehabilitation
Introduction

1 Introduction
StrokeisamajorhealthproblemintheUK.EachyearinEngland,approximately110,000people230,
inWales11,000andinNorthernIreland4,000peoplehaveafirstorrecurrentstroke250.Most
peoplesurviveafirststroke,butoftenhavesignificantmorbidity.Morethan900,000peoplein
Englandarelivingwiththeeffectsofstroke.StrokemortalityratesintheUKhavebeenfalling
steadilysincethelate1960s25.Thedevelopmentofstrokeunitsfollowingthepublicationofthe
StrokeUnitTrialistsCollaborationmetaanalysisofstrokeunitcare1,andthefurtherreorganisation
ofservicesfollowingtheadventofthrombolysishaveresultedinfurthersignificantimprovementsin
mortalityandmorbidityfromstroke(asdocumentedintheNationalSentinelAuditforStroke123).
However,theburdenofstrokemayincreaseinthefutureasaconsequenceoftheageing
population.
Despiteimprovementsinmortalityandmorbidity,strokesurvivorsneedaccesstoeffective
rehabilitationservices.Over30%ofpeoplehavepersistingdisabilityandtheyneedaccesstostroke
serviceslongterm.Strokerehabilitationisamultidimensionalprocess,whichisdesignedtofacilitate
restorationof,oradaptationto,thelossofphysiologicalorpsychologicalfunctionwhenreversalof
theunderlyingpathologicalprocessisincomplete.Rehabilitationaimstoenhancefunctional
activitiesandparticipationinsocietyandthusimprovequalityoflife.
Astrokerehabilitationservicecomprisesamultidisciplinaryteamofpeoplewhoworktogether
towardsgoalsforeachpatient,involveandeducatethepatientandfamily,haverelevantknowledge
andskillstohelpaddressmostcommonproblemsfacedbytheirpatients276Keyaspectsof
rehabilitationcareincludemultidisciplinaryassessment,identificationoffunctionaldifficultiesand
theirmeasurement,treatmentplanningthroughgoalsetting,deliveryofinterventionswhichmay
eithereffectchangeorsupporttheindividualinmanagingpersistingchange,andevaluationof
effectiveness.
AssessmentistypicallyundertakenusingtheWorldHealthOrganisation(WHO)International
ClassificationofFunctioning,DisabilityandHealth(ICF)whichprovidesabiopsychosocialmodelof
disability.AswellassupportingcomprehensiveassessmenttheICFcanbeusedingoalsetting&
treatmentplanningandmonitoring,aswellasoutcomemeasurement.Treatmentsarelargely
deliveredviaphysiotherapists,occupationaltherapists,speechandlanguagetherapists,nursesand
psychologists.Othercomponentsofrehabilitationincludethelearningofnewskillstocircumvent
thoselost;adaptationtolossbyboththepatientandfamily;theapplicationofnewtechnologies,
appliancesandenvironmentalmodifications;andthedevelopmentofnewservicedeliverysystems.
Therehabilitationprocessaimstomaximisetheparticipationofthepatientinhisorhersocial
setting,includingsupportingpeopletoestablishrolesandoccupations,andminimisethepainand
distressexperiencedbythepatientandtheirfamilycarers276.
Clearstandardsexistforstrokerehabilitation,forinstanceasdescribedbothintheNationalClinical
GuidelineforStrokedevelopedbytheIntercollegiateStrokeWorkingParty122.Thesearereflectedin
theNICEqualitystandards189andtheNationalStrokeStrategy61.Overallthereislittledoubtthat
therehabilitationapproachiseffective;whatindividualinterventionsshouldtakeplacewithinthis
structureislessclear.
Advancesintheneurosciencesincludinggreaterunderstandingofthemechanismsofimpairment
willleadtonoveltreatments.Thereisawealthofevidencesuggestingthatcentralnervoussystem
reorganisationunderliesmuchoftheimprovementinimpairmentthatisfrequentlyseen.
Experimentsshowthatsomeregionsinthenormaladultbrain,particularlythecortex,havethe
capacitytochangestructureandconsequentlyfunctioninresponsetoenvironmentalchange,a
processdescribedasplasticity.Inadditionfunctionallyrelevantadaptivechangeshavebeen
demonstratedfollowingfocaldamagetothebrain.Itissuggestedthatrehabilitationtherapies
interactswiththeseplasticchanges,thusreducingimpairmentviaactivitydependentplastic

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Introduction
change.280Examplesofsuchtherapiesalreadyexistinrehabilitationpracticesuchasupperorlower
limbsensorimotorfunctionbytaskrelatedtrainingusingconstraintinducedtherapy173,treadmill
training109,andprismadaptation(toreversevisualneglect)87,109.
Theaimofthisguidelinedevelopmentgroupwastoreviewthestructure,processesand
interventionscurrentlyusedinrehabilitationcare,andtoevaluatewhethertheyimproveoutcomes
forpeoplewithstroke.Suchstudiesarecomplexandresearchmethodologiesneedtoberobust.
Evaluationofclinicaleffectivenessneedsstudiesthathaverobusttheoreticalunderpinnings,capture
changesthatarerelevanttothetreatmentevaluatedandreflectwhatisimportanttopatients,and
belargeenoughtoallowreliabledatainterpretation.Thisguidelinereviewssomeoftheavailable
interventionsthatcanbeusedinstrokerehabilitation,andhighlightswheretherearegapsinthe
evidence.Itisnotintendedtobecomprehensive.
Allinterventionsshouldtakeplaceinthecontextofacomprehensivestrokepathwaywhich
recognisesthatearlymanagement,whilecritical,isacomponentofaprocesswhichaimsto
amelioratethelongtermconsequencesoflivingwithstrokeforindividualsandtheirfamiliesandto
enablethemtoliveathome,abletoparticipateinasmanyactivitiesastheyareable.Atthepointof
dischargethepersonwhohashadastrokemayneedsupportfromarangeofotheragenciessuchas
housing,JobcentrePlus,socialservicesandstrokevoluntaryorganisations.Randomisedcontrolled
trialevidence,althoughthegoldstandardforinterventionstudiesmaynotbeavailableor
appropriateforexaminingrehabilitationprocesses.AmodifiedDelphisurveywasconductedto
obtainformalconsensusaroundareassuchasservicedeliveryandcareplanning.Itneedstobe
recognisedthatevenwheretheevidencebaseisclear,rehabilitationinterventionsneedtobe
targetedandrelevanttotheindividual.Someindividualsmaydeclinetreatmentwhichhealthcare
professionalsseeasimportant.Insuchcircumstancesissuessuchascapacityandconsentneedtobe
considered108.

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StrokeRehabilitation
Developmentoftheguideline

2 Developmentoftheguideline
2.1 WhatisaNICEclinicalguideline?
NICEclinicalguidelinesarerecommendationsforthecareofindividualsinspecificclinicalconditions
orcircumstanceswithintheNHSfrompreventionandselfcarethroughprimaryandsecondary
caretomorespecialisedservices.Webaseourclinicalguidelinesonthebestavailableresearch
evidence,withtheaimofimprovingthequalityofhealthcare.Weusepredeterminedand
systematicmethodstoidentifyandevaluatetheevidencerelatingtospecificreviewquestions.
NICEclinicalguidelinescan:
providerecommendationsforthetreatmentandcareofpeoplebyhealthprofessionals
beusedtodevelopstandardstoassesstheclinicalpracticeofindividualhealthprofessionals
beusedintheeducationandtrainingofhealthprofessionals
helppatientstomakeinformeddecisions
improvecommunicationbetweenpatientandhealthprofessional
Whileguidelinesassistthepracticeofhealthcareprofessionals,theydonotreplacetheirknowledge
andskills.
Weproduceourguidelinesusingthefollowingsteps:
GuidelinetopicisreferredtoNICEfromtheDepartmentofHealth
Stakeholdersregisteraninterestintheguidelineandareconsultedthroughoutthedevelopment
process
ThescopeispreparedbytheNationalClinicalGuidelineCentre(NCGC)
TheNCGCestablishesaguidelinedevelopmentgroup
Adraftguidelineisproducedafterthegroupassessestheavailableevidenceandmakes
recommendations
Thereisaconsultationonthedraftguideline
Thefinalguidelineisproduced
TheNCGCandNICEproduceanumberofversionsofthisguideline:
thefullguidelinecontainsalltherecommendations,plusdetailsofthemethodsusedandthe
underpinningevidence
theNICEguidelineliststherecommendations
theNICEPathwayisanonlinetoolforhealthprofessionalsthatbringstogetherthe
recommendationsfromthisguidanceandallrelatedNICEguidance.
informationforthepublic(understandingNICEguidanceorUNG)iswrittenusingsuitable
languageforpeoplewithoutspecialistmedicalknowledge
Thisversionisthefullversion.TheotherversionscanbedownloadedfromNICEatwww.nice.org.uk

2.2 Remit
NICEreceivedtheremitforthisguidelinefromtheDepartmentofHealth.Theycommissionedthe
NCGCtoproducetheguideline.
Theremitforthisguidelineis:toproduceajointclinicalandsocialcareguidelineonthelongterm
rehabilitationandsupportofstrokepatients.

NationalClinicalGuidelineCentre,2013.
16

StrokeRehabilitation
Developmentoftheguideline

2.3 Whodevelopedthisguideline?
AmultidisciplinaryGuidelineDevelopmentGroup(GDG)comprisingprofessionalgroupmembersand
consumerrepresentativesofthemainstakeholdersdevelopedthisguideline(seesectionon
GuidelineDevelopmentGroupMembershipandacknowledgements).
TheNationalInstituteforHealthandClinicalExcellencefundstheNationalClinicalGuidelineCentre
(NCGC)andthussupportedthedevelopmentofthisguideline.TheGDGwasconvenedbytheNCGC
andchairedbyDrDianePlayfordinaccordancewithguidancefromtheNationalInstituteforHealth
andClinicalExcellence(NICE).
Thegroupmetapproximatelyevery5weeksduringthedevelopmentoftheguideline.Atthestartof
theguidelinedevelopmentprocessallGDGmembersdeclaredinterestsincludingconsultancies,fee
paidwork,shareholdings,fellowshipsandsupportfromthehealthcareindustry.Atallsubsequent
GDGmeetings,membersdeclaredarisingconflictsofinterest,whichwerealsorecorded(Appendix
[C]).
Memberswereeitherrequiredtowithdrawcompletelyorforpartofthediscussioniftheirdeclared
interestmadeitappropriate.Thedetailsofdeclaredinterestsandtheactionstakenareshownin
Appendix[C].
StafffromtheNCGCprovidedmethodologicalsupportandguidanceforthedevelopmentprocess.
Theteamworkingontheguidelineincludedaprojectmanager,systematicreviewers,health
economistsandinformationscientists.Theyundertooksystematicsearchesoftheliterature,
appraisedtheevidence,conductedmetaanalysisandcosteffectivenessanalysiswhereappropriate
anddraftedtheguidelineincollaborationwiththeGDG.

2.4 Whatthisguidelinecovers
Theguidelinecoversadultsandyoungpeople16orolderwhohavehadastrokeandhavecontinuing
impairment(2weeksormorepoststroke),limitedactivityorparticipationrestriction.
Theclinicalareascoveredincluded:therapiestoimprovephysical,cognitiveandspeechfunctions,
activitiesofdailylivingandvocationalrehabilitation,interventionstoaddressdysphagiaandvisual
fieldloss,informationandsupportforpatientsandcarers,earlysupporteddischargeandintensityof
rehabilitationtherapy.Theinterventionsconsideredandthesubsequentrecommendationsmade
arenotsettingspecificandincludehealthorsocialcareservices.
ForfurtherdetailspleaserefertothescopeinAppendixAandreviewquestionsinAppendixE.

2.5 Whatthisguidelinedoesnotcover
Childrenunder16yearsandpeoplewhohadhadatransientischaemicattackwerenotincluded.The
guidelinedidnotconsiderprimaryorsecondarypreventionofstroke,acutestrokeorassessmentfor
rehabilitation.

2.6 RelationshipsbetweentheguidelineandotherNICEguidance
RelatedNICEInterventionalProcedures:
Electricalstimulationfordropfootofcentralneurologicalorigin.NICEinterventionalprocedure
guidance278(2009).Availablefromwww.nice.org.uk/guidance/IPG278

NationalClinicalGuidelineCentre,2013.
17

StrokeRehabilitation
Developmentoftheguideline
RelatedNICEClinicalGuidelines:
Depressioninadults(update).NICEclinicalguidelineCG90(2009).Availablefrom:
http://publications.nice.org.uk/depressioninadultscg90.
Depressioninadultswithachronicphysicalhealthproblem:Treatmentandmanagement.NICE
clinicalguidelineCG91(2009).Availablefrom:http://publications.nice.org.uk/depressioninadults
withachronicphysicalhealthproblemcg91.
Faecalincontinence:ThemanagementoffaecalincontinenceinadultsNICEclinicalguidelineCG49
(2007).Availablefrom:http://publications.nice.org.uk/faecalincontinencecg49.
Falls:theassessmentandpreventionoffallsinolderpeople.NICEclinicalguidelineCG21(2004)
http://publications.nice.org.uk/fallscg21.
Generalisedanxietydisorderandpanicdisorder(withorwithoutagoraphobia)inadults:
Managementinprimary,secondaryandcommunitycare.NICEclinicalguidelineCG113(2011).
Availablefrom:http://publications.nice.org.uk/generalisedanxietydisorderandpanicdisorder
withorwithoutagoraphobiainadultscg113.
Neuropathicpain:Thepharmacologicalmanagementofneuropathicpaininadultsinnonspecialist
settingsNICEclinicalguidelineCG96(2010).http://publications.nice.org.uk/neuropathicpaincg96.
Nutritionsupportinadults:Oralnutritionsupport,enteraltubefeedingandparenteralnutrition.
NICEclinicalguidelineCG32(2006).Availablefrom:http://publications.nice.org.uk/nutrition
supportinadultscg32.
PatientexperienceinadultNHSservices:improvingtheexperienceofcareforpeopleusingadult
NHSservices.NICEclinicalguidelineCG138(2012)http://publications.nice.org.uk/patient
experienceinadultnhsservicesimprovingtheexperienceofcareforpeopleusingadultcg138.
Stroke:Diagnosisandinitialmanagementofacutestrokeandtransientischaemicattack(TIA).NICE
clinicalguidelineCG68(2008).Availablefrom:http://publications.nice.org.uk/strokecg68.
Urinaryincontinenceinneurologicaldisease:managementoflowerurinarytractdysfunctionin
neurologicaldisease.NICEclinicalguidelineCG148(2012).Availablefrom:
http://guidance.nice.org.uk/CG148.
Medicinesadherence:involvingpatientsindecisionsaboutprescribedmedicinesandsupporting
adherence.NICEclinicalguidelineCG76(2009).Availablefrom:http://www.nice.org.uk/CG76
Lipidmodification:Cardiovascularriskassessmentandthemodificationofbloodlipidsforthe
primaryandsecondarypreventionofcardiovasculardisease.NICEclinicalguidelineCG67(2008).
Availablefrom:http://www.nice.org.uk/CG67.
Hypertension:clinicalmanagementofprimaryhypertensioninadults.NICEclinicalguidelineCG127
(2011):Availablefrom:http://guidance.nice.org.uk/CG127.
Type2Diabetes:themanagementoftype2diabetes(update).NICEclinicalguidelineCG87(2009):
Availablefrom:http://www.nice.org.uk/CG87.
Atrialfibrillation.NICEclinicalguidelineCG36(2006):Availablefrom:http://www.nice.org.uk/CG36
RelatedNICEPublicHealthGuidance:
Managementoflongtermsicknessandincapacityforwork:Guidanceforprimarycareand
employersonthemanagementoflongtermsicknessandincapacity.NICEpublichealthguidance19
(2009).Availablefrom:www.nice.org.uk/guidance/PH19.

NationalClinicalGuidelineCentre,2013.
18

StrokeRehabilitation
Developmentoftheguideline
NICERelatedGuidancecurrentlyindevelopment:
Falls(update)NICEclinicalguideline(publicationexpectedJune2013).
Lipidmodification(update).NICEclinicalguideline(publicationTBC).
Neuropathicpain:pharmacologicalmanagementinadultsinnonspecialistsettings.NICEclinical
guideline(publicationexpectedAugust2013).
Type2diabetesNICEclinicalguideline(publicationTBC).
Oralhealth:innursingandresidentialcareNICEpublichealthguidance(publicationTBC).
Workplacehealth:employeeswithchronicdiseasesandlongtermconditionsNICEpublichealth
guidance(publicationTBC).

NationalClinicalGuidelineCentre,2013.
19

StrokeRehabilitation
Guidelinesummary

3 Guidelinesummary
3.1 Keyprioritiesforimplementation
TheGDGidentifiedkeyprioritiesforimplementation.Theyselectedrecommendationsthatwould:
Haveahighimpactonoutcomesthatareimportanttopatients
Haveahighimpactonreducingvariationincareandoutcomes
LeadtoamoreefficientuseofNHSresources
Promotepatientchoice
IndoingthistheGDGalsoconsideredwhichrecommendationswereparticularlylikelytobenefit
fromimplementationsupport.Theconsideredwhetherarecommendation:
Requireschangesinservicedelivery
Requiresretrainingofprofessionalsorthedevelopmentofnewskillsandcompetencies
Affectsandneedstobeimplementedacrossvariousagenciesorsettings
Maybeviewedaspotentiallycontentiousordifficulttoimplementforotherreasons
Thefollowingrecommendationshavebeenidentifiedasprioritiesforimplementation.

3.1.1

Strokeunits
1. Peoplewithdisabilityafterstrokeshouldreceiverehabilitationinadedicatedstrokeinpatient
unitandsubsequentlyfromaspecialiststroketeamwithinthecommunity.

3.1.2

Thecoremultidisciplinarystroketeam
2. Acoremultidisciplinarystrokerehabilitationteamshouldcomprisethefollowingprofessionals
withexpertiseinstrokerehabilitation:
o consultantphysicians
o nurses
o physiotherapists
o occupationaltherapists
o speechandlanguagetherapists
o clinicalpsychologists
o rehabilitationassistants
o socialworkers.

3.1.3

Healthandsocialcareinterface
3. Healthandsocialcareprofessionalsshouldworkcollaborativelytoensureasocialcare
assessmentiscarriedoutpromptly,whereneeded,beforethepersonwithstrokeistransferred
fromhospitaltothecommunity.Theassessmentshould:
o identifyanyongoingneedsofthepersonandtheirfamilyorcarer,forexample,accessto
benefits,careneeds,housing,communityparticipation,returntowork,transportandaccess
tovoluntaryservices
o bedocumentedandallneedsrecordedinthepersonshealthandsocialcareplan,withacopy
providedtothepersonwithstroke.

3.1.4

Transferofcarefromhospitaltocommunity
4. Offerearlysupporteddischargetopeoplewithstrokewhoareabletotransferfrombedtochair
independentlyorwithassistance,aslongasasafeandsecureenvironmentcanbeprovided.

NationalClinicalGuidelineCentre,2013.
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StrokeRehabilitation
Guidelinesummary

3.1.5

Settinggoalsforrehabilitation
5. Ensurethatgoalsettingmeetingsduringstrokerehabilitation:
o aretimetabledintotheworkingweek
o involvethepersonwithstrokeand,whereappropriate,theirfamilyorcarerinthediscussion.

3.1.6

Intensityofstrokerehabilitation
6. Offerinitiallyatleast45minutesofeachrelevantstrokerehabilitationtherapyforaminimumof
5daysperweektopeoplewhohavetheabilitytoparticipate,andwherefunctionalgoalscanbe
achieved.Ifmorerehabilitationisneededatalaterstage,tailortheintensitytothepersons
needsatthattimea.

3.1.7

Cognitivefunctioning
7. Screenpeopleafterstrokeforcognitivedeficits.Whereacognitivedeficitisidentified,carryouta
detailedassessmentusingvalid,reliableandresponsivetoolsbeforedesigningatreatment
programme.

3.1.8

Emotionalfunctioning
8. Assessemotionalfunctioninginthecontextofcognitivedifficultiesinpeopleafterstroke.Any
interventionchosenshouldtakeintoconsiderationthetypeorcomplexityofthepersons
neuropsychologicalpresentationandrelevantpersonalhistory.

3.1.9

Swallowing
9. Offerswallowingtherapyatleast3timesaweektopeoplewithdysphagiaafterstrokewhoare
abletoparticipate,foraslongastheycontinuetomakefunctionalgains.Swallowingtherapy
couldincludecompensatorystrategies,exercisesandposturaladvice.

3.1.10

Returntowork
10.Returntoworkissuesshouldbeidentifiedassoonaspossibleafterthepersonsstroke,reviewed
regularlyandmanagedactively.Activemanagementshouldinclude:
o identifyingthephysical,cognitive,communicationandpsychologicaldemandsofthejob(for
example,multitaskingbyansweringemailsandtelephonecallsinabusyoffice)
o identifyinganyimpairmentsonworkperformance(forexample,physicallimitations,anxiety,
fatiguepreventingattendanceforafulldayatwork,cognitiveimpairmentspreventingmulti
tasking,andcommunicationdeficits)
o tailoringanintervention(forexample,teachingstrategiestosupportmultitaskingormemory
difficulties,teachingtheuseofvoiceactivatedsoftwareforpeoplewithdifficultytyping,and
deliveryofworksimulations)
o educatingabouttheEqualityAct2010bandsupportavailable(forexample,anaccesstowork
scheme)
o workplacevisitsandliaisonwithemployerstoestablishreasonableaccommodations,suchas
provisionofequipmentandgradedreturntowork.

Intensityoftherapyfordysphagia,providedaspartofspeechandlanguagetherapyisaddressedin
recommendation58.

HMGovernment(2010)EqualityAct[online]

NationalClinicalGuidelineCentre,2013.
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StrokeRehabilitation
Guidelinesummary

3.1.11

Longtermhealthandsocialsupport
o Reviewthehealthandsocialcareneedsofpeopleafterstrokeandtheneedsoftheircarersat
6monthsandannuallythereafter.Thesereviewsshouldcoverparticipationandcommunity
rolestoensurethatpeoplesgoalsareaddressed.

3.2 Fulllistofrecommendations

1.

Peoplewithdisabilityafterstrokeshouldreceiverehabilitationinadedicated
strokeinpatientunitandsubsequentlyfromaspecialiststroketeamwithin
thecommunity.

2.

Aninpatientstrokerehabilitationserviceshouldconsistofthefollowing:

3.

4.

adedicatedstrokerehabilitationenvironment

acoremultidisciplinaryteam(seerecommendation3)whohavethe
knowledge,skillsandbehaviourstoworkinpartnershipwithpeople
withstrokeandtheirfamiliesandcarerstomanagethechanges
experiencedasaresultofastroke.

accesstootherservicesthatmaybeneeded,forexample:

continenceadvice

dietetics

electronicaids(forexample,remotecontrolsfordoors,lightsand
heating,andcommunicationaids)

liaisonpsychiatry

orthoptics

orthotics

pharmacy

podiatry

wheelchairservices

amultidisciplinaryeducationprogramme.

Acoremultidisciplinarystrokerehabilitationteamshouldcomprisethe
followingprofessionalswithexpertiseinstrokerehabilitation:

consultantphysicians

nurses

physiotherapists

occupationaltherapists

speechandlanguagetherapists

clinicalpsychologists

rehabilitationassistants

socialworkers.

Throughoutthecarepathway,therolesandresponsibilitiesofthecore
multidisciplinarystrokerehabilitationteamshouldbeclearlydocumented
andcommunicatedtothepersonandtheirfamilyorcarer.

NationalClinicalGuidelineCentre,2013.
22

StrokeRehabilitation
Guidelinesummary
5.

Membersofthecoremultidisciplinarystroketeamshouldscreentheperson
withstrokeforarangeofimpairmentsanddisabilities,inordertoinformand
directfurtherassessmentandtreatment.

6.

Healthandsocialcareprofessionalsshouldworkcollaborativelytoensurea
socialcareassessmentiscarriedoutpromptly,whereneeded,beforethe
personwithstrokeistransferredfromhospitaltothecommunity.The
assessmentshould:

7.

identifyanyongoingneedsofthepersonandtheirfamilyorcarer,for
example,accesstobenefits,careneeds,housing,community
participation,returntowork,transportandaccesstovoluntary
services.

bedocumentedandallneedsrecordedinthepersonshealthandsocial
careplan,withacopyprovidedtothepersonwithstroke.

Offertrainingincare(forexample,inmovingandhandlingandhelpingwith
dressing)tofamilymembersorcarerswhoarewillingandabletobeinvolved
insupportingthepersonaftertheirstroke.

Reviewfamilymembersandcarerstrainingandsupportneedsregularly
(asaminimumatthepersons6monthandannualreviews),
acknowledgingthattheseneedsmaychangeovertime.

8.

Offerearlysupporteddischargetopeoplewithstrokewhoareableto
transferfrombedtochairindependentlyorwithassistance,aslongasasafe
andsecureenvironmentcanbeprovided.

9.

Earlysupporteddischargeshouldbepartofaskilledstrokerehabilitation
serviceandshouldconsistofthesameintensityoftherapyandrangeof
multidisciplinaryskillsavailableinhospital.Itshouldnotresultinadelayin
deliveryofcare.

10.

Hospitalsshouldhavesystemsinplacetoensurethat:

peopleafterstrokeandtheirfamiliesandcarers(asappropriate)are
involvedinplanningfortransferofcare,andcarersreceivetrainingin
care(forexample,inmovingandhandlingandhelpingwithdressing)

peopleafterstrokeandtheirfamiliesandcarersfeeladequately
informed,preparedandsupported

GPsandotherappropriatepeopleareinformedbeforetransferofcare

anagreedhealthandsocialcareplanisinplace,andthepersonknows
whomtocontactifdifficultiesarise

appropriateequipment(includingspecialistseatingandawheelchairif
needed)isinplaceatthepersonsresidence,regardlessofsetting.

11.

Beforetransferfromhospitaltohomeortoacaresetting,discussandagree
ahealthandsocialcareplanwiththepersonwithstrokeandtheirfamilyor
carer(asappropriate),andprovidethistoallrelevanthealthandsocialcare
providers.

12.

Beforetransferofcarefromhospitaltohomeforpeoplewithstroke:

establishthattheyhaveasafeandenablinghomeenvironment,for
example,checkthatappropriateequipmentandadaptationshave
beenprovidedandthatcarersaresupportedtofacilitate
independence,and

NationalClinicalGuidelineCentre,2013.
23

StrokeRehabilitation
Guidelinesummary

13.

undertakeahomevisitwiththemunlesstheirabilitiesandneedscanbe
identifiedinotherways,forexample,bydemonstrating
independenceinallselfcareactivities,includingmealpreparation,
whileintherehabilitationunit.

Ontransferofcarefromhospitaltothecommunity,provideinformationto
allrelevanthealthandsocialcareprofessionalsandthepersonwithstroke.
Thisshouldinclude:

asummaryofrehabilitationprogressandcurrentgoals

diagnosisandhealthstatus

functionalabilities(includingcommunicationneeds)

careneeds,includingwashing,dressing,helpwithgoingtothetoiletand
eating

psychological(cognitiveandemotional)needs

medicationneeds(includingthepersonsabilitytomanagetheir
prescribedmedicationsandanysupporttheyneedtodoso)

socialcircumstances,includingcarersneeds

mentalcapacityregardingthetransferdecision

managementofrisk,includingtheneedsofvulnerableadults

plansforfollowup,rehabilitationandaccesstohealthandsocialcare
andvoluntarysectorservices.

14.

Ensurethatpeoplewithstrokewhoaretransferredfromhospitaltocare
homesreceiveassessmentandtreatmentfromstrokerehabilitationand
socialcareservicestothesamestandardsastheywouldreceiveintheirown
homes.

15.

Localhealthandsocialcareprovidersshouldhavestandardoperating
procedurestoensurethesafetransferandlongtermcareofpeopleafter
stroke,includingthoseincarehomes.Thisshouldincludetimelyexchangeof
informationbetweendifferentprovidersusinglocalprotocols.

16.

Aftertransferofcarefromhospital,peoplewithdisabilitiesafterstroke
(includingpeopleincarehomes)shouldbefollowedupwithin72hoursby
thespecialiststrokerehabilitationteamforassessmentofpatientidentified
needsandthedevelopmentofsharedmanagementplans.

17.

Provideadviceonprescribedmedicationsforpeopleafterstrokeinlinewith
recommendationsinMedicinesadherence(NICEclinicalguideline76).

18.

Onadmissiontohospital,toensuretheimmediatesafetyandcomfortofthe
personwithstroke,screenthemforthefollowingand,ifproblemsare
identified,startmanagementassoonaspossible:

orientation

positioning,movingandhandling

swallowing

transfers(forexample,frombedtochair)

pressurearearisk

continence

NationalClinicalGuidelineCentre,2013.
24

StrokeRehabilitation
Guidelinesummary

communication,includingtheabilitytounderstandandfollow
instructionsandtoconveyneedsandwishes

nutritionalstatusandhydration(followtherecommendationsinStroke
[NICEclinicalguideline68]andNutritionsupportinadults[NICE
clinicalguideline32]).

19.

Performafullmedicalassessmentofthepersonwithstroke,including
cognition(attention,memory,spatialawareness,apraxia,perception),vision,
hearing,tone,strength,sensationandbalance.

20.

Acomprehensiveassessmentofapersonwithstrokeshouldtakeinto
account:

21.

theirpreviousfunctionalabilities

impairmentofpsychologicalfunctioning(cognitive,emotionaland
communication)

impairmentofbodyfunctions,includingpain

activitylimitationsandparticipationrestrictions

environmentalfactors(social,physicalandcultural).

Informationcollectedroutinelyfrompeoplewithstrokeusingvalid,reliable
andresponsivetoolsshouldincludethefollowingonadmissionand
discharge:

NationalInstitutesofHealthStrokeScale

BarthelIndex.

22.

Informationcollectedfrompeoplewithstrokeusingvalid,reliableand
responsivetoolsshouldbefedbacktothemultidisciplinaryteamregularly.

23.

Takeintoconsiderationtheimpactofthestrokeonthepersonsfamily,
friendsand/orcarersand,ifappropriate,identifysourcesofsupport.

24.

Informthefamilymembersandcarersofpeoplewithstrokeabouttheirright
tohaveacarersneedsassessment.

25.

Ensurethatpeoplewithstrokehavegoalsfortheirrehabilitationthat:

26.

27.

aremeaningfulandrelevanttothem

focusonactivityandparticipation

arechallengingbutachievable

includebothshorttermandlongtermelements.

Ensurethatgoalsettingmeetingsduringstrokerehabilitation:

aretimetabledintotheworkingweek

involvethepersonwithstrokeand,whereappropriate,theirfamilyor
carerinthediscussion.

Ensurethatduringgoalsettingmeetings,peoplewithstrokeareprovided
with:

anexplanationofthegoalsettingprocess

theinformationtheyneedinaformatthatisaccessibletothem

thesupporttheyneedtomakedecisionsandtakeanactivepartin
settinggoals.

NationalClinicalGuidelineCentre,2013.
25

StrokeRehabilitation
Guidelinesummary
28.

Givepeoplecopiesoftheiragreedgoalsforstrokerehabilitationaftereach
goalsettingmeeting.

29.

Reviewpeoplesgoalsatregularintervalsduringtheirstrokerehabilitation.

30.

Provideinformationandsupporttoenablethepersonwithstrokeandtheir
familyorcarer(asappropriate)toactivelyparticipateinthedevelopmentof
theirstrokerehabilitationplan.

31.

Strokerehabilitationplansshouldbereviewedregularlybythe
multidisciplinaryteam.Timethesereviewsaccordingtothestageof
rehabilitationandthepersonsneeds.

32.

Documentationaboutthepersonsstrokerehabilitationshouldbe
individualised,andshouldincludethefollowinginformationasaminimum:

basicdemographics,includingcontactdetailsandnextofkin

diagnosisandrelevantmedicalinformation

listofcurrentmedications,includingallergies

standardisedscreeningassessments(seerecommendation18)

thepersonsrehabilitationgoals

multidisciplinaryprogressnotes

akeycontactfromthestrokerehabilitationteam(includingtheircontact
details)tocoordinatethepersonshealthandsocialcareneeds

dischargeplanninginformation(includingaccommodationneeds,aids
andadaptations)

jointhealthandsocialcareplans,ifdeveloped

followupappointments.

33.

Offerinitiallyatleast45minutesofeachrelevantstrokerehabilitation
therapyforaminimumof5daysperweektopeoplewhohavetheabilityto
participate,andwherefunctionalgoalscanbeachieved.Ifmore
rehabilitationisneededatalaterstage,tailortheintensitytothepersons
needsatthattimec.

34.

Considermorethan45minutesofeachrelevantstrokerehabilitationtherapy
5daysperweekforpeoplewhohavetheabilitytoparticipateandcontinue
tomakefunctionalgains,andwherefunctionalgoalscanbeachieved.

35.

Ifpeoplewithstrokeareunabletoparticipatein45minutesofeach
rehabilitationtherapy,ensurethattherapyisstilloffered5daysperweekfor
ashortertimeatanintensitythatallowsthemtoactivelyparticipate.

36.

Workingwiththepersonwithstrokeandtheirfamilyorcarer,identifytheir
informationneedsandhowtodeliverthem,takingintoaccountspecific
impairmentssuchasaphasiaandcognitiveimpairments.Pacethe
informationtothepersonsemotionaladjustment.

37.

Provideinformationaboutlocalresources(forexample,leisure,housing,
socialservicesandthevoluntarysector)thatcanhelptosupporttheneeds
andprioritiesofthepersonwithstrokeandtheirfamilyorcarer.

Intensityoftherapyfordysphagia,providedaspartofspeechandlanguagetherapyisaddressedin
recommendation58.

NationalClinicalGuidelineCentre,2013.
26

StrokeRehabilitation
Guidelinesummary
38.

Reviewinformationneedsatthepersons6monthandannualstroke
reviewsandatthestartandcompletionofanyinterventionperiod.

39.

NICEhasproducedguidanceonthecomponentsofgoodpatientexperience
inadultNHSservices.FollowtherecommendationsinPatientexperiencein
adultNHSservices(NICEclinicalguideline138)d.

40.

Screenpeopleafterstrokeforcognitivedeficits.Whereacognitivedeficitis
identified,carryoutadetailedassessmentusingvalid,reliableand
responsivetoolsbeforedesigningatreatmentprogramme.

41.

Provideeducationandsupportforpeoplewithstrokeandtheirfamiliesand
carerstohelpthemunderstandtheextentandimpactofcognitivedeficits
afterstroke,recognisingthatthesemayvaryovertimeandindifferent
settings.

42.

Assesstheeffectofvisualneglectafterstrokeonfunctionaltaskssuchas
mobility,dressing,eatingandusingawheelchair,usingstandardised
assessmentsandbehaviouralobservation.

43.

Useinterventionsforvisualneglectafterstrokethatfocusontherelevant
functionaltasks,takingintoaccounttheunderlyingimpairment.Forexample:

interventionstohelppeoplescantotheneglectedside,suchasbrightly
colouredlinesorhighlighterontheedgeofthepage

alertingtechniquessuchasauditorycues

repetitivetaskperformancesuchasdressing

alteringtheperceptualinputusingprismglasses.

44.

Assessmemoryandotherrelevantdomainsofcognitivefunctioning(suchas
executivefunctions)inpeopleafterstroke,particularlywhereimpairmentsin
memoryaffecteverydayactivity.

45.

Useinterventionsformemoryandcognitivefunctionsafterstrokethatfocus
ontherelevantfunctionaltasks,takingintoaccounttheunderlying
impairment.Interventionscouldinclude:

increasingawarenessofthememorydeficit

enhancinglearningusingerrorlesslearningandelaborativetechniques
(makingassociations,useofmnemonics,internalstrategiesrelated
toencodinginformationsuchaspreview,question,read,state,test)

externalaids(forexample,diaries,lists,calendarsandalarms)

environmentalstrategies(routinesandenvironmentalprompts).

46.

Assessattentionandcognitivefunctionsinpeopleafterstrokeusing
standardisedassessments.Usebehaviouralobservationtoevaluatethe
impactoftheimpairmentonfunctionaltasks.

47.

Considerattentiontrainingforpeoplewithattentiondeficitsafterstroke.

48.

Useinterventionsforattentionandcognitivefunctionsafterstrokethatfocus
ontherelevantfunctionaltasks.Forexample,usegenerictechniquessuchas
managingtheenvironmentandprovidingpromptsrelevanttothefunctional
task.

Forrecommendationsoncontinuityofcareandrelationshipsseesection1.4andforrecommendationson

enablingpatientstoactivelyparticipateintheircareseesection1.5.

NationalClinicalGuidelineCentre,2013.
27

StrokeRehabilitation
Guidelinesummary
49.

Assessemotionalfunctioninginthecontextofcognitivedifficultiesinpeople
afterstroke.Anyinterventionchosenshouldtakeintoconsiderationthetype
orcomplexityofthepersonsneuropsychologicalpresentationandrelevant
personalhistory.

50.

Supportandeducatepeopleafterstrokeandtheirfamiliesandcarers,in
relationtoemotionaladjustmenttostroke,recognisingthatpsychological
needsmaychangeovertimeandindifferentsettings.

51.

Whenneworpersistingemotionaldifficultiesareidentifiedatthepersons6
monthorannualstrokereviews,referthemtoappropriateservicesfor
detailedassessmentandtreatment.

52.

Managedepressionoranxietyinpeopleafterstrokewhohavenocognitive
impairmentinlinewithrecommendationsinDepressioninadultswitha
chronicphysicalhealthproblem(NICEclinicalguideline91)andGeneralised
anxietydisorder(NICEclinicalguideline113).

53.

Screenpeopleafterstrokeforvisualdifficulties.

54.

Offereyemovementtherapytopeoplewhohavepersistinghemianopiaafter
strokeandwhoareawareofthecondition.

55.

Whenadvisingpeoplewithvisualproblemsafterstrokeaboutdriving,
consulttheDriverandVehicleLicensingAgency(DVLA)regulations.

56.

Referpeoplewithpersistingdoublevisionafterstrokeforformalorthoptic
assessment.

57.

Assessswallowinginpeopleafterstrokeinlinewithrecommendationsin
Stroke(NICEclinicalguideline68).

58.

Offerswallowingtherapyatleast3timesaweektopeoplewithdysphagia
afterstrokewhoareabletoparticipate,foraslongastheycontinuetomake
functionalgains.Swallowingtherapycouldincludecompensatorystrategies,
exercisesandposturaladvice.

59.

Ensurethateffectivemouthcareisgiventopeoplewithdifficultyswallowing
afterstroke,inordertodecreasetheriskofaspirationpneumonia.

60.

Healthcareprofessionalswithrelevantskillsandtraininginthediagnosis,
assessmentandmanagementofswallowingdisordersshouldregularly
monitorandreassesspeoplewithdysphagiaafterstrokewhoarehaving
modifiedfoodandliquiduntiltheyarestable(thisrecommendationisfrom
Nutritionsupportinadults[NICEclinicalguideline32]).

61.

Providenutritionsupporttopeoplewithdysphagiainlinewith
recommendationsinNutritionsupportinadults(NICEclinicalguideline32)
andStroke(NICEclinicalguideline68).

62.

Screenpeopleafterstrokeforcommunicationdifficultieswithin72hoursof
onsetofstrokesymptoms.

63.

Eachstrokerehabilitationserviceshoulddeviseastandardisedprotocolfor
screeningforcommunicationdifficultiesinpeopleafterstroke.

64.

Provideappropriateinformation,educationandtrainingtothe
multidisciplinarystroketeamtoenablethemtosupportandcommunicate
effectivelywiththepersonwithcommunicationdifficultiesandtheirfamily
orcarer.

65.

Speechandlanguagetherapyforpeoplewithstrokeshouldbeledand
supervisedbyaspecialistspeechandlanguagetherapistworking

NationalClinicalGuidelineCentre,2013.
28

StrokeRehabilitation
Guidelinesummary
collaborativelywithotherappropriatelytrainedpeopleforexample,speech
andlanguagetherapyassistants,carersanfriends,andmembersofthe
voluntarysector.
66.

Provideopportunitiesforpeoplewithcommunicationdifficultiesafterstroke
tohaveconversationandsocialenrichmentwithpeoplewhohavethe
training,knowledge,skillsandbehaviourstosupportcommunication.This
shouldbeinadditiontotheopportunitiesprovidedbyfamilies,carersand
friends.

67.

Speechandlanguagetherapistsshouldassesspeoplewithlimitedfunctional
communicationafterstrokefortheirpotentialtobenefitfromusinga
communicationaidorothertechnologies(forexample,homebased
computertherapiesorsmartphoneapplications).

68.

Providecommunicationaidsforthosepeopleafterstrokewhohavethe
potentialtobenefit,andoffertraininginhowtousethem.

69.

Tellthepersonwithcommunicationdifficultiesafterstrokeabout
communitybasedcommunicationandsupportgroups(suchasthose
providedbythevoluntarysector)andencouragethemtoparticipate.

70.

Whenpersistingcommunicationdifficultiesareidentifiedatthepersons6
monthorannualstrokereviews,referthembacktoaspeechandlanguage
therapistfordetailedassessment,andoffertreatmentifthereispotentialfor
functionalimprovement.

71.

Makesurethatallwritteninformation(includingthatrelatingtomedical
conditionsandtreatment)isadaptedforpeoplewithaphasiaafterstroke.
Thisshouldinclude,forexample,appointmentletters,rehabilitation
timetablesandmenus.

72.

Helpandenablepeoplewithcommunicationdifficultiesafterstroketo
communicatetheireverydayneedsandwishes,andsupportthemto
understandandparticipateinbotheverydayandmajorlifedecisions.

73.

Ensurethatenvironmentalbarrierstocommunicationareminimisedfor
peopleafterstroke.Forexample,makesuresignageisclearandbackground
noiseisminimised.

74.

Referpeoplewithsuspectedcommunicationdifficultiesafterstroketoa
speechandlanguagetherapistfordetailedanalysisofspeechandlanguage
impairmentsandassessmentoftheirimpact.

75.

Speechandlanguagetherapistsshould:

providedirectimpairmentbasedtherapyforcommunication
impairments(forexample,aphasiaordysarthria)

helpthepersonwithstroketouseandenhancetheirremaining
languageandcommunicationabilities

teachothermethodsofcommunicating,suchasgestures,writingand
usingcommunicationprops

coachpeoplearoundthepersonwithstroke(includingfamilymembers,
carersandhealthandsocialcarestaff)todevelopsupportive
communicationskillstomaximisethepersonscommunication
potential

helpthepersonwithaphasiaordysarthriaandtheirfamilyorcarerto
adjusttoacommunicationimpairment

NationalClinicalGuidelineCentre,2013.
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StrokeRehabilitation
Guidelinesummary

supportthepersonwithcommunicationdifficultiestorebuildtheir
identity

supportthepersontoaccessinformationthatenablesdecisionmaking.

76.

Offertrainingincommunicationskills(suchasslowingdown,not
interrupting,usingcommunicationprops,gestures,drawing)tothe
conversationpartnersofpeoplewithaphasiaafterstroke.

77.

Providephysiotherapyforpeoplewhohaveweaknessintheirtrunkorupper
orlowerlimb,sensorydisturbanceorbalancedifficultiesafterstrokethat
haveaneffectonfunction.

78.

Peoplewithmovementdifficultiesafterstrokeshouldbetreatedby
physiotherapistswhohavetherelevantskillsandtraininginthediagnosis,
assessmentandmanagementofmovementinpeoplewithstroke.

79.

Treatmentforpeoplewithmovementdifficultiesafterstrokeshould
continueuntilthepersonisabletomaintainorprogressfunctioneither
independentlyorwithassistancefromothers(forexample,rehabilitation
assistants,familymembers,carersorfitnessinstructors).

80.

Considerstrengthtrainingforpeoplewithmuscleweaknessafterstroke.This
couldincludeprogressivestrengthbuildingthroughincreasingrepetitionsof
bodyweightactivities(forexample,sittostandrepetitions),weights(for
example,progressiveresistanceexercise),orresistanceexerciseonmachines
suchasstationarycycles.

81.

Encouragepeopletoparticipateinphysicalactivityafterstroke.

82.

Assesspeoplewhoareabletowalkandaremedicallystableaftertheir
strokeforcardiorespiratoryandresistancetrainingappropriatetotheir
individualgoals.

83.

Cardiorespiratoryandresistancetrainingforpeoplewithstrokeshouldbe
startedbyaphysiotherapistwiththeaimthatthepersoncontinuesthe
programmeindependentlybasedonthephysiotherapistsinstructions(see
recommendation84).

84.

Forpeoplewithstrokewhoarecontinuinganexerciseprogramme
independently,physiotherapistsshouldsupplyanynecessaryinformation
aboutinterventionsandadaptationssothatwherethepersonisusingan
exerciseprovider,theprovidercanensuretheirprogrammeissafeand
tailoredtotheirneedsandgoals.Thisinformationmaytaketheformof
writteninstructions,telephoneconversationsorajointvisitwiththeprovider
andthepersonwithstroke,dependingontheneedsandabilitiesofthe
exerciseproviderandthepersonwithstroke.

85.

Tellpeoplewhoareparticipatinginfitnessactivitiesafterstrokeabout
commonpotentialproblems,suchasshoulderpain,andadvisethemtoseek
advicefromtheirGPortherapistiftheseoccur.

86.

Donotroutinelyofferwristandhandsplintstopeoplewithupperlimb
weaknessafterstroke.

87.

Considerwristandhandsplintsinpeopleatriskafterstroke(forexample,
peoplewhohaveimmobilehandsduetoweakness,andpeoplewithhigh
tone),to:

maintainjointrange,softtissuelengthandalignment

increasesofttissuelengthandpassiverangeofmovement

NationalClinicalGuidelineCentre,2013.
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StrokeRehabilitation
Guidelinesummary

facilitatefunction(forexample,ahandsplinttoassistgriporfunction)

aidcareorhygiene(forexample,byenablingaccesstothepalm)

increasecomfort(forexample,usingasheepskinpalmprotectortokeep
fingernailsawayfromthepalmofthehand).

88.

Wherewristandhandsplintsareusedinpeopleafterstroke,theyshouldbe
assessedandfittedbyappropriatelytrainedhealthcareprofessionalsanda
reviewplanshouldbeestablished.

89.

Teachthepersonwithstrokeandtheirfamilyorcarerhowtoputthesplint
onandtakeitoff,careforthesplintandmonitorforsignsofrednessand
skinbreakdown.Provideapointofcontactforthepersonifconcerned.

90.

Donotroutinelyofferpeoplewithstrokeelectricalstimulationfortheirhand
andarm.

91.

Consideratrialofelectricalstimulationinpeoplewhohaveevidenceof
musclecontractionafterstrokebutcannotmovetheirarmagainst
resistance.

92.

Ifatrialoftreatmentisconsideredappropriate,ensurethatelectrical
stimulationtherapyisguidedbyaqualifiedrehabilitationprofessional.

93.

Theaimofelectricalstimulationshouldbetoimprovestrengthwhile
practisingfunctionaltasksinthecontextofacomprehensivestroke
rehabilitationprogramme.

94.

Continueelectricalstimulationifprogresstowardsclearfunctionalgoalshas
beendemonstrated(forexample,maintainingrangeofmovement,or
improvinggraspandrelease).

95.

Considerconstraintinducedmovementtherapyforpeoplewithstrokewho
havemovementof20degreesofwristextensionand10degreesoffinger
extension.Beawareofpotentialadverseevents(suchasfalls,lowmoodand
fatigue).

96.

Provideinformationforpeoplewithstrokeandtheirfamiliesandcarerson
howtopreventpainortraumatotheshoulderiftheyareatriskof
developingshoulderpain(forexample,iftheyhaveupperlimbweaknessand
spasticity).

97.

Manageshoulderpainafterstrokeusingappropriatepositioningandother
treatmentsaccordingtoeachpersonsneed.

98.

ForguidanceonmanagingneuropathicpainfollowNeuropathicpain(NICE
clinicalguideline96).

99.

Offerpeoplerepetitivetasktrainingafterstrokeonarangeoftasksforupper
limbweakness(suchasreaching,grasping,pointing,movingand
manipulatingobjectsinfunctionaltasks)andlowerlimbweakness(suchas
sittostandtransfers,walkingandusingstairs).

100.

Offerwalkingtrainingtopeopleafterstrokewhoareabletowalk,withor
withoutassistance,tohelpthembuildenduranceandmovemorequickly.

101.

Considertreadmilltraining,withorwithoutbodyweightsupport,asone
optionofwalkingtrainingforpeopleafterstrokewhoareabletowalkwith
orwithoutassistance.

102.

Offerelectromechanicalgaittrainingtopeopleafterstrokeonlyinthe
contextofaresearchstudy.

NationalClinicalGuidelineCentre,2013.
31

StrokeRehabilitation
Guidelinesummary
103.

Consideranklefootorthosesforpeoplewhohavedifficultywithswing
phasefootclearanceafterstroke(forexample,trippingandfalling)and/or
stancephasecontrol(forexample,kneeandanklecollapseorkneehyper
extensions)thataffectswalking.

104.

Assesstheabilityofthepersonwithstroketoputontheanklefootorthosis
orensuretheyhavethesupportneededtodoso.

105.

Assesstheeffectivenessoftheanklefootorthosisforthepersonwith
stroke,intermsofcomfort,speedandeaseofwalking.

106.

Assessmentforandtreatmentwithanklefootorthosesshouldonlybe
carriedoutaspartofastrokerehabilitationprogrammeandperformedby
qualifiedprofessionals.

107.

Forguidanceonfunctionalelectricalstimulationforthelowerlimbsee
Functionalelectricalstimulationfordropfootofcentralneurologicalorigin
(NICEinterventionalprocedureguidance278).

108.

Provideoccupationaltherapyforpeopleafterstrokewhoarelikelyto
benefit,toaddressdifficultieswithpersonalactivitiesofdailyliving.Therapy
mayconsistofrestorativeorcompensatorystrategies.

Restorativestrategiesmayinclude:

encouragingpeoplewithneglecttoattendtotheneglectedside

encouragingpeoplewitharmweaknesstoincorporatebotharms

establishingadressingroutineforpeoplewithdifficultiessuchaspoor
concentration,neglectordyspraxiawhichmakedressing
problematic.

Compensatorystrategiesmayinclude:

teachingpeopletodressonehanded

teachingpeopletousedevicessuchasbathinganddressingaids.

109.

Peoplewhohavedifficultiesinactivitiesofdailylivingafterstrokeshould
haveregularmonitoringandtreatmentbyoccupationaltherapistswithcore
skillsandtrainingintheanalysisandmanagementofactivitiesofdailyliving.
Treatmentshouldcontinueuntilthepersonisstableorabletoprogress
independently.

110.

Assesspeopleafterstrokefortheirequipmentneedsandwhethertheir
familyorcarersneedtrainingtousetheequipment.Thisassessmentshould
becarriedoutbyanappropriatelyqualifiedprofessional.Equipmentmay
includehoists,chairraisersandsmallaidssuchaslonghandledsponges.

111.

Ensurethatappropriateequipmentisprovidedandavailableforuseby
peopleafterstrokewhentheyaretransferredfromhospital,whateverthe
setting(includingcarehomes).

112.

Returntoworkissuesshouldbeidentifiedassoonaspossibleafterthe
personsstroke,reviewedregularlyandmanagedactively.Active
managementshouldinclude:

identifyingthephysical,cognitive,communicationandpsychological
demandsofthejob(forexample,multitaskingbyansweringemails
andtelephonecallsinabusyoffice)

identifyinganyimpairmentsonworkperformance(forexample,physical
limitations,anxiety,fatiguepreventingattendanceforafulldayat

NationalClinicalGuidelineCentre,2013.
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StrokeRehabilitation
Guidelinesummary
work,cognitiveimpairmentspreventingmultitasking,and
communicationdeficits)

tailoringanintervention(forexample,teachingstrategiestosupport
multitaskingormemorydifficulties,teachingtheuseofvoice
activatedsoftwareforpeoplewithdifficultytyping,anddeliveryof
worksimulations)

educatingabouttheEqualityAct2010eandsupportavailable(for
example,anaccesstoworkscheme)

workplacevisitsandliaisonwithemployerstoestablishreasonable
accommodations,suchasprovisionofequipmentandgradedreturn
towork.

113.

Managereturntoworkorlongtermabsencefromworkforpeopleafter
strokeinlinewithrecommendationsinManaginglongtermsicknessand
incapacityforwork(NICEpublichealthguidance19).

114.

Informpeopleafterstrokethattheycanselfrefer,usuallywiththesupport
ofaGPornamedcontact,iftheyneedfurtherstrokerehabilitationservices.

115.

Provideinformationsothatpeopleafterstrokeareabletorecognisethe
developmentofcomplicationsofstroke,includingfrequentfalls,spasticity,
shoulderpainandincontinence.

116.

Encouragepeopletofocusonlifeafterstrokeandhelpthemtoachievetheir
goals.Thismayinclude:

facilitatingtheirparticipationincommunityactivities,suchasshopping,
civicengagement,sportsandleisurepursuits,visitingtheirplaceof
worshipandstrokesupportgroups

supportingtheirsocialroles,forexample,work,education,volunteering,
leisure,familyandsexualrelationships

providinginformationabouttransportanddriving(includingDVLA
requirements;seewww.dft.gov.uk/dvla/medical/aag).

117.

ManageincontinenceafterstrokeinlinewithrecommendationsinUrinary
incontinenceinneurologicaldisease(NICEclinicalguideline148)andFaecal
incontinence(NICEclinicalguideline49).

118.

Reviewthehealthandsocialcareneedsofpeopleafterstrokeandtheneeds
oftheircarersat6monthsandannuallythereafter.Thesereviewsshould
coverparticipationandcommunityrolestoensurethatpeoplesgoalsare
addressed.

119.

Forguidanceonsecondarypreventionofstroke,followrecommendationsin
Lipidmodification(NICEclinicalguideline67),Hypertension(NICEclinical
guideline127),Type2diabetes(NICEclinicalguideline87)andAtrial
fibrillation(NICEclinicalguideline36).

120.

Provideadviceonprescribedmedicationsinlinewithrecommendationsin
Medicinesadherence(NICEclinicalguideline76).

HM Government (2010) Equality Act [online]

NationalClinicalGuidelineCentre,2013.
33

StrokeRehabilitation
Guidelinesummary

3.3 Keyresearchrecommendations
3.3.1

Upperlimbelectricalstimulation(ES)
What is the clinical and cost effectiveness of electrical stimulation (ES) as an adjunct
to rehabilitation to improve hand and arm function in people after stroke, from early
rehabilitation through to use in the community?

3.3.2

Intensiverehabilitationafterstroke
In people after stroke what is the clinical and cost effectiveness of intensive
rehabilitation (6 hours per day) versus moderate rehabilitation (2 hours per day) on
activity, participation and quality of life outcomes?

3.3.3

Neuropsychologicaltherapies
Which cognitive and which emotional interventions provide better outcomes for
identified subgroups of people with stroke and their families and carers at different
stages of the stroke pathway?

3.3.4

Shoulderpain
Which people with a weak arm after stroke are at risk of developing shoulder pain?
What management strategies are effective in the prevention or management of
shoulder pain of different aetiologies?
ForfurtherdetailspleaserefertoAppendixL.

NationalClinicalGuidelineCentre,2013.
34

StrokeRehabilitation
Methods

4 Methods
Thischaptersetsoutindetailthemethodsusedtogeneratetherecommendationsthatare
presentedinsubsequentchapters.Thisguidancewasdevelopedinaccordancewiththemethods
outlinedintheNICEGuidelinesManual2009187.

4.1 Developingthereviewquestionsandoutcomes
ReviewquestionsweredevelopedinaPICOframework(patient,intervention,comparisonand
outcome)forinterventionreviews.Thiswastoguidetheliteraturesearchingprocess,appraisal,and
synthesisofevidenceandtofacilitatethedevelopmentofrecommendationsbytheguideline
developmentgroup(GDG).TheyweredraftedbytheNCGCtechnicalteamandrefinedandvalidated
bytheGDG.Thequestionswerebasedonthekeyclinicalareasidentifiedinthescope(AppendixA).
Atotalof22reviewquestionswereidentified.
Fullliteraturesearches,criticalappraisalsandevidencereviewswerecompletedforallthespecified
clinicalquestions.
Chapter

Reviewquestions

Outcomes

Structureand
settings:strokeunits

Inpeopleafterstroke,does
organisedrehabilitationcare
(comprehensive,rehabilitationand
mixedrehabilitationstrokeunits)
improveoutcome(mortality,
dependency,requirementfor
institutionalcareandlengthof
hospitalstay)?

Structureand
settings:early
supporteddischarge

Inpeopleafterstrokewhatisthe
clinicalandcosteffectivenessof
earlysupporteddischargeversus
usualcare?

Servicedelivery:goal
setting

Doestheapplicationofpatientgoal
settingaspartofplanningstroke
rehabilitationactivitiesleadtoan
improvementinpsychological
wellbeing,functioningandactivity?

Psychologicalwellbeing
viewsaboutthequalityofthegoalsetting
process
satisfactionwithoutcome
healthrelatedqualityoflife
physicalfunction
ActivitiesofDailyLiving(ADL)

Servicedelivery:
intensityof

Inpeopleafterstrokewhatisthe
clinicalandcosteffectivenessof

Lengthofstay
FunctionalIndependenceMeasure(FIM)

NationalClinicalGuidelineCentre,2013.
35

Death
Deathordependency
Deathorinstitutionalcare
Durationofstayinhospitalorinstitutionor
both
Qualityoflife
Patientandcarersatisfaction
BarthelIndex
Lengthofhospitalstay
FunctionalIndependenceMeasure(FIM)
Caregiverstrainindex
Falls
Readmissionstohospital
HospitalAnxietyandDepressionScale
(HADS)
Mortality
QualityOfLife
NottinghamExtendedActivitiesofDaily
Living

StrokeRehabilitation
Methods
Chapter
rehabilitation

Reviewquestions
intensiverehabilitationversus
standardrehabilitation?

Outcomes

Supportand
information:
supported
informationprovision

Whatistheclinicalandcost
effectivenessofsupported
informationprovisionversus
unsupportedinformationprovision
onmoodanddepressioninpeople
withstroke?

Impactonmood/depression:
HospitalAnxietyandDepressionScale
(HADS)
GeneralHealthQuestionnaire
VisualAnalogueMoodScale
StrokeAphasicDepressionQuestionnaire
(SADQ)
GeriatricDepressionScale
BeckDepressionInventory
Selfefficacy
GeneralSelfefficacyScale
StrokeSelfefficacyQuestionnaire
LocusofControlScale
Extendedactivitiesofdailyliving(EADL)
NottinghamextendedADL
FrenchayActivitiesIndex
Yalemoodquestion

Cognitivefunctions:
visualneglect

Inpeopleafterstrokewhatisthe
clinicalandcosteffectivenessof
cognitiverehabilitationversus
usualcaretoimprovespatial
awarenessand/orvisualneglect?

Cognitivefunctions:
memoryfunctions

Inpeopleafterstrokewhatisthe
clinicalandcosteffectivenessof
memorystrategiesversususual
caretoimprovememory?

WechslerMemoryScale,
Rivermeadbehaviouralmemory
assessment,
Minimentalstateexamination(MMSE),
AddenbrooksCognitiveExamination
Revised,
AbbreviatedMentalTestScore.

Cognitivefunctions:
attentionfunction

Inpeopleafterstrokewhatisthe
clinicalandcosteffectivenessof
sustainedattentiontrainingversus
usualcaretoimproveattention?

Minimentalstateexamination,Behavioural
inattentiontest,drawingtests,line
bisectiontest,cancellationtests,sentence
reading,targetscreenexaminations,
RivermeadPerceptualAssessmentBattery

Emotional
functioning

Inpeopleafterstrokewhatisthe
QualityofLife(forbothcarerandpatient)
clinicalandcosteffectivenessof
AnyQOLanddepressionoutcomes
psychologicaltherapiesprovidedto

NationalClinicalGuidelineCentre,2013.
36

BarthelIndex
QualityofLife(anymeasure)
NottinghamActivitiesofDailyLiving
Rankin
Rivermeadmobilityindex
FrenchayActivitiesIndex

Minimentalstateexamination(MMSE),
BehaviouralInattentionTest(BIT),
Drawingtests(forexample:clockdrawing),
LineBisectiontests,
Allcancellationtests(including:line
cancellation,bellcancellation),
Sentencereading,
Targetscreenexaminations(lumptogether
allcancellationtestsanddrawingtests),
RivermeadPerceptualAssessmentBattery
(RPAB)

StrokeRehabilitation
Methods
Chapter

Reviewquestions
thefamily(includingthepatients)?

Outcomes
includingthefollowing:strokeimpactscale,
EuroQoL,caregiverburdenscale,caregiver
strainindex,carerstrainindex,burdenof
strokescale,Strokeandaphasiaqualityof
lifescale,ASCOTscale.
Occurrenceofdepression/anxiety/moodin
carers
BeckDepressionInventory,Beck
DepressionInventory2,Geriatric
DepressionScale,neuropsychiatric
inventory,HospitalAnxietyandDepression
Scale(HADS),Generalhealthquestionnaire,
VisualAnalogueMoodScale,SADQ.

Vision:eye
movementtherapy

Inpeopleafterstrokewhatisthe
clinicalandcosteffectivenessof
eyemovementtherapyforvisual
fieldlossversususualcare?

Digestivesystems:
swallowing

Inpeopleafterstrokewhatisthe
Occurrenceofaspirationpneumonia
clinicalandcosteffectivenessof
Occurrenceofchestinfections
interventionsforswallowingversus
Reductioninhospitalstay
alternativeinterventions
Reductioninreadmission
Returntonormaldiet

Communication:
Aphasia

Inpeopleafterstrokeisspeechand Functionalcommunication(languageor
languagetherapycomparedtono
communicationskillssufficienttopermit
speechandlanguagetherapyor
thetransmissionofmessageviaspoken,
placebo(socialsupportand
writtenornonverbalmodalities,ora
stimulation)effectiveinimproving
combinationofthesechannels)
language/communicationabilities
Formalmeasuresofreceptivelanguage
and/orpsychologicalwellbeing?
skills(languageunderstanding)
Formalmeasuresofexpressivelanguage
skills(languageproduction)
Overalllevelofseverityofaphasiaas
measuredbyspecialisttestbatteries(may
includeWesternAphasiaBatteryorPorch
IndexofCommunicativeAbilities)
Psychologicalorsocialwellbeingincluding
depression,anxietyanddistress
Patientsatisfaction/carerandfamilyviews
Compliance/dropout

Communication:
Dysarthria

Inpeopleafterstrokeisspeechand Measuresoffunctionalcommunication
languagetherapycomparedto
Formalmeasuresofreceptivelanguage
socialsupportandstimulation
skills(languageunderstanding)
effectiveinimprovingdysarthria?
Formalmeasuresofexpressivelanguage
skills(languageproduction)
Psychologicalorsocialwellbeingincluding
depression,anxietyanddistress
FrenchayDysarthriaAssessment.

NationalClinicalGuidelineCentre,2013.
37

Reading(speedandaccuracy)
Eyemovementtasks
Scanning
LetterCancellationTest

StrokeRehabilitation
Methods
Chapter

Reviewquestions

Outcomes
Measuresofarticulation(range,speed,
strength,andcoordination)
Perceptualmeasuresofvoiceandprosody
(forexample,VocalProfileAnalysis)
Acousticmeasures(forexample,
fundamentalfrequency,pitchperturbation
(jitter),amplitudeperturbation(shimmer),
asmeasuredby,computerisedsoundor
spectrography)

Communication:
Inpeopleafterstrokewith
intensityofspeech
communicationdifficultieswhatis
andlanguagetherapy theclinicalandcosteffectiveness
ofintensivespeechtherapyversus
standardspeechtherapy?

Anyoutcomereportedinthepapers.
Examplesinclude:
FunctionalAssessmentofCommunication
SkillsforAdults(ASHAFACS)
BostonNamingTest
WesternAphasiaBattery
StrokeDysphasiaIndex
McKennaGradedNamingTest

Communication:
Listeneradvice

Whatlisteneradvice
skills/informationwouldhelp
familymembers/carersimprove
communicationinpeoplewith
aphasiaafterstroke?

Anyoutcome
Qualityoflife

Movementstrength
training

Inpeopleafterstrokewhatisthe
clinicalandcosteffectivenessof
strengthtrainingversususualcare
onimprovingfunctionand
reducingdisability?

Movement:fitness
training

Inpeopleafterstroke,does
cardiorespiratoryorresistance
fitnesstrainingimproveoutcome
(fitness,function,qualityoflife,
andmood)andreducedisability?

NationalClinicalGuidelineCentre,2013.
38

UpperLimb
MRCScale
NewtonMetres
Fuglmeyer
ActionResearchArmTest(ARAT)
FunctionalIndependenceMeasurement
(FIM)
BarthelIndex
Adverseeventspainorspasticity
LowerLimb/Trunk
TimedUpandGoTest
Anytimedwalk
Walkingdistance
Functional;IndependenceMeasure(FIM)
BarthelIndex
Adverseeventsfalls,painorspasticity

Mortalityrate
Dependenceorlevelofdisability
Physicalfitness
Mobility
Physicalfunction
Qualityoflife
Mood

StrokeRehabilitation
Methods
Chapter

Reviewquestions

Outcomes

Movement:hand
andarm:orthoses
upperlimb

Inpeopleafterstrokewhatisthe
clinicalandcosteffectivenessof
orthosesforpreventionoflossof
rangeoftheupperlimbversus
usualcare?

Rangeofmovementassessedby
goniometry

Movement:handand Inpeopleafterstrokewhatisthe
arm:electrical
clinicalandcosteffectivenessof
stimulation
ElectricalStimulationforhand
functionversususualcare?

Anyoutcomereportedinthepaper.
UpperLimboutcomesincluding:
o ActionResearchArmTest(ARAT)
o FuglMeyerAssessment(FMA)
o 9holepegtest
o gripstrength.

Movement:Hand
andarm:constraint
inducedmovement
therapy

Inpeopleafterstrokewhatisthe
clinicalandcosteffectivenessof
constraintinducedtherapyversus
usualcareonimprovingfunction
andreducingdisability?

Movement:
Repetitivetask
training

Inpeopleafterstrokewhatisthe
clinicalandcosteffectivenessof
repetitivetasktrainingversususual
careonimprovingfunctionand
reducingdisability?

Lowerlimb
Anytimedwalk,6m,5m,10mwalk
Changeinwalkingdistance
Rivermeadmobilityindex
Upperlimb
Arm:
FuglMeyerAssessment,
ActionResearchArmTest(ARAT)
Hand:
Anypegholetest,
FrenchayArmTest,
MotorAssessmentScale(MAS)

Movement:walking
therapy:treadmill
training

Inpeopleafterstrokewhatisthe
clinicalandcosteffectivenessofall
treadmillversususualcareon
improvingwalking?

Inpeopleafterstrokewhocan
walk,whatistheclinicalandcost
effectivenessoftreadmillplusbody
supportversustreadmillonlyon
improvingwalking?

Movement:walking
therapy:
electromechanical

Inpeopleafterstrokewhatisthe
clinicalandcosteffectivenessof
electromechanicalgaittraining

Walkingspeeds(5metres/10metres/30
metres)
Anytimedwalk

NationalClinicalGuidelineCentre,2013.
39

FunctionalIndependenceMeasure(FIM)
BarthelIndex
FuglMeyerAssessment
ActionResearchArmTest(ARAT)
WolfMotorFunctionTest(WMFT)
9holepegtest
Anyadverseevent

Walkingspeeds(5m/10m/30m)
Timedwalk
Walkingendurance
FunctionalIndependenceMeasure(FIM)
BarthelIndex
RivermeadMobilityIndex

StrokeRehabilitation
Methods
Chapter
gaittraining

Reviewquestions
versususualcareonimproving
functionandreducingdisability?

Outcomes

Walkingendurance
FunctionalIndependenceMeasure(FIM)
BarthelIndex
RivermeadMobilityIndex

Movement:walking
therapy:orthoses
anklefoot

Inpeopleafterstrokewhatisthe
clinicalandcosteffectivenessof
anklefootorthosesofalltypesto
improvewalkingfunctionversus
usualcare?

Gaitspeed:6minwalk,10mtimedwalk
LowerlimbMAS(stairs)
Timedwalk
Walkingendurance
FunctionalIndependence
Measure(FIM)/BarthelIndex
RivermeadMobilityIndex
Cadence
Gaitsymmetry(stancetime,steplength)
QualityofLifeoutcomes

Selfcare

Inpeopleafterstrokewhatisthe
clinicalandcosteffectivenessof
intensiveoccupationaltherapy
focusedspecificallyonpersonal
activitiesofdailylivingversususual
care?

Longtermhealthand Inpeopleafterstrokewhatisthe
socialsupport
clinicalandcosteffectivenessof
interventionstoaidreturntowork
versususualcare?

NottinghamExtendedActivitiesofDaily
Living(NEADL)
ExtendedActivitiesofDailyLiving(EADL)
FunctionalIndependenceMeasure(FIM)
BarthelIndex
NottinghamStrokeDressingAssessment
NorthwickParkNursingDependencyScale
RivermeadMobilityIndex

Samejobsameemployer
Samejobdifferentemployer
Differentjobsameemployer
Differentjobdifferentemployer
Unemployment
Retiredduetoillhealth
Voluntarywork
Benefitclaims

Duringthedevelopmentofquestionsconcerningemploymentandreturntowork,provisionof
information,deliveryofpsychologicaltherapiesandearlysupporteddischarge,theGDGtookthe
followingissuesintoconsideration:
WhentheGDGformulatedthequestionaboutaidstoreturntowork,theyacknowledgedthe
universalconsensusintheliteratureaboutthepredictivefactorsrestrictingpeopleafterstroketo
returntowork.Forthisreason,theybelievedthatthereviewofobservationalorcohortstudies
investigatingthisissuewouldnotprovideanyaddedvalueintheformulationof
recommendationsforthisguideline.TheGDGbelievedthatrandomisedtrialsinvestigatingthe
impactofanytypeofinterventionthatcouldfacilitatepeopletoreturntoemployment(either
formerornewemployment)wasahigherpriorityforthepurposesofthisguideline.Inaddition,
theGDGnotedthatthenatureofvocationalinterventionswouldbeverydiverseandtailoredto
individualcircumstances(typeofdisability,natureofemployment).

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StrokeRehabilitation
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Duringtheformulationofaquestionrelatedtoprovisionofinformationforpeopleafterstroke

andtheircarers,theGDGhadafulldiscussionwithregardtothelargeandheterogeneousareaof
informationprovision.Wewereclearlyunabletoaddressallinformationaspectswithinthe
timelineavailable.TheGDGagreedthatpeopleafterstrokeliveinarichinformation
environment,althoughitisnotalwaystailoredtothepatientsneeds.TheGDGfeltitwas
particularlyimportanttolookattheevidencepertainingtotheprovisionofsupported
information(informationgivenwithadditionalsupportofsomekindsuchastheactiveprovision
ofinformation,theencouragementoffeedback,availabilityofpeersupportoruseofinteractive
computerprogrammeasopposedtotheprovisionofleaflets/bookletsinisolation)inorderto
investigateitsimpactonmoodanddepressioninpeopleafterstrokeandpotentiallydirectthe
developmentofrecommendationsinthisarea.
Forthepsychologicalsupportquestion,theGDGthoughtthatthisshouldinvestigatethe
effectivenessofthepsychologicaltherapiessuchasfamilytherapy,cognitivebehaviourtherapy
andrelationshipcounsellingprovidedtothefamily(includingthepersonwithstroke)onthe
qualityoflifeofpeopleswithstrokeandtheircarers.Thegroupacknowledgedthatitwasnot
usualtohaveapsychologicaltherapyinisolationandthereforeallofthesetherapiesmayalso
includesomeformofeducationincombination.InlightofthepublicationofthePatient
experienceinadultNHSservices(NICEclinicalguideline138)theGDGagreedthatthisguidance
couldbecrossreferencedwhereappropriate
Whenformulatingthequestiononearlysupporteddischarge,theGDGagreedtoinvestigatethe
effectivenessofearlysupporteddischargeonimprovingspecificpatientandhospitalrelated
outcomes(suchasmortality,qualityoflife,readmissionsandlengthofstayinthehospital).The
GDGdidnotconsiderthatpatientswouldhaveanydifferentinformationneedsafterearly
supporteddischargetootherpatientsbeingdischargedfromhospital.
Duringthedevelopmentofquestionsforthisguidelinescopingsearchesforcohortstudieswere
undertakenandweconsultedwiththeGDGonwhethertheywereawareofanylargecohortstudies
intheseareasthatwouldjustifyincludingstudiesotherthanrandomisedtrials.Nonewere
identified.

4.2 Searchingforevidence
4.2.1

Clinicalliteraturesearch
Theaimoftheliteraturereviewwastoidentifyallavailable,relevantpublishedevidenceinrelation
tothekeyclinicalquestionsgeneratedbytheGDG.Systematicliteraturesearcheswereundertaken
toidentifyevidencewithinpublishedliteratureinordertoanswerthereviewquestionsasperThe
GuidelinesManual[2009]187.Clinicaldatabasesweresearchedusingrelevantmedicalsubject
headings,freetexttermsandstudytypefilterswhereappropriate.Studiespublishedinlanguages
otherthanEnglishwerenotreviewed.Wherepossible,searcheswererestrictedtoarticlespublished
inEnglishlanguage.Allsearcheswereconductedoncoredatabases,MEDLINE,Embase,Cinahland
TheCochraneLibrary.Additionalsubjectspecificdatabaseswereusedforsomequestions:PsycInfo
forpatientviews,allsearcheswereupdatedon5thOct2012.Nopapersafterthisdatewere
considered.
Searchstrategieswerecheckedbylookingatreferencelistsofrelevantkeypapers,checkingsearch
strategiesinothersystematicreviewsandaskingtheGDGforknownstudiesinaspecificarea.The
questions,thestudytypesapplied,thedatabasessearchedandtheyearscoveredcanbefoundin
Appendix[D].
Duringthescopingstage,asearchwasconductedforguidelinesandreportsonthewebsiteslisted
belowandonorganisationsrelevanttothetopic.Searchingforgreyliteratureorunpublished
literaturewasnotundertaken.Allreferencessentbystakeholderswereconsidered.

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StrokeRehabilitation
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GuidelinesInternationalNetworkdatabase(www.gin.net)
NationalGuidelineClearingHouse(www.guideline.gov/)
NationalInstituteforHealthandClinicalExcellence(NICE)(www.nice.org.uk)
NationalInstitutesofHealthConsensusDevelopmentProgram(consensus.nih.gov/)
HealthInformationResources,NHSEvidence(www.library.nhs.uk/)

ThetitlesandabstractsofrecordsretrievedbythesearcheswerescannedforrelevancetotheGDGs
clinicalquestions.Anypotentiallyrelevantpublicationswereobtainedinfulltext.Thesewere
assessedagainsttheinclusioncriteriaandthereferencelistswerescannedforanyarticlesnot
previouslyidentified.FurtherreferenceswerealsosuggestedbytheGDG.

4.2.2

Healtheconomicliteraturesearch
Systematicliteraturesearcheswerealsoundertakentoidentifyhealtheconomicevidencewithin
publishedliteraturerelevanttothereviewquestions.Theevidencewasidentifiedbyconductinga
broadsearchrelatingtotheguidelinepopulationintheNHSeconomicevaluationdatabase(NHS
EED),theHealthEconomicEvaluationsDatabase(HEED)andhealthtechnologyassessment(HTA)
databaseswithnodaterestrictions.Additionally,thesearchwasrunonMEDLINEandEmbase,witha
specificeconomicfilter,toensurerecentpublicationsthathadnotyetbeenindexedbythese
databaseswereidentified.StudiespublishedinlanguagesotherthanEnglishwerenotreviewed.
Wherepossible,searcheswererestrictedtoarticlespublishedinEnglishlanguage.
ThesearchstrategiesforhealtheconomicsareincludedinAppendix[D].Allsearcheswereupdated
on5thOct2012.Nopaperspublishedafterthisdatewereconsidered.

4.3 Evidenceofeffectiveness
TheResearchFellow:
Identifiedpotentiallyrelevantstudiesforeachreviewquestionfromtherelevantsearchresults
byreviewingtitlesandabstracts.Twentypercentofthesiftandselectionofpaperswasquality
assuredbyasecondreviewertoeliminateanypotentialofselectionbiasorerror.Fullpapers
werethenobtained.
Reviewedfullpapersagainstprespecifiedinclusion/exclusioncriteriatoidentifystudiesthat
addressedthereviewquestionintheappropriatepopulationandreportedonoutcomesof
interest(reviewprotocolsareincludedinAppendix[D]).
CriticallyappraisedrelevantstudiesusingtheappropriatechecklistasspecifiedinTheGuidelines
Manual187
Extractedkeyinformationaboutthestudysmethodsandresultsintoevidencetables(evidence
tablesareincludedinAppendix[H]).
Generatedsummariesoftheevidencebyoutcome(includedintherelevantchapterwriteups):
o Randomisedstudies:metaanalysed,whereappropriateandreportedinGRADEprofiles(for
clinicalstudies)seebelowfordetails.

4.3.1

Inclusion/exclusioncriteria
Theinclusion/exclusionofstudieswasbasedonthereviewprotocols.TheGDGwereconsulted
aboutanyuncertaintyregardinginclusion/exclusionofselectedstudies.Minimumsamplesizeand
theproportionofparticipantswithstrokewereamongtheinclusion/exclusioncriteriausedforthe
selectionofstudiesintheevidencereviews.TheGDGagreedthat(withtheexceptionofreview
questionsoncognitivefunctionsandFunctionalElectricalStimulation)thesamplesizeof20
participants(10ineacharm)wouldbetheminimumrequirementforastudytobeincluded.Forthe
reviewquestionsoncognitivefunctions,theminimumsamplesizewouldbesetat10participantsin

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totalduetothenatureofinterventionsandtheavailabilityofstudiesintheliterature.Thisdecision
onstudiessamplesizecutoffpointswasmadeforpragmaticreasons.
Wehaveincludedanystudyonstrokepopulationatleast2weekspoststroke.Wedidntapplyany
restrictiononselectionofstudieswithpopulationsonlongtermrehabilitation.
Duetothenatureofinterventionsinvestigatedinthefollowingevidencereviews;memory
strategies,eyemovementtherapy,swallowing,constraintinducedmovementtherapy,treadmill,
electromechanicalgaittraining,anklefoot,aidstoreturntowork,whichaimedultimatelytoreduce
disabilityandwouldbeapplicabletootherpopulations(whohavenotexperiencedstroke),theGDG
decidedthatwecouldusemixedpopulationsforreviewingthesequestions,aslongastheminimum
proportionofparticipantswithstrokeinthesestudieswassetat50%.Seethereviewprotocolsin
AppendixEandexcludedstudiesbythereviewquestions(withtheirexclusionreasons)inAppendix
Mforfulldetails.

4.3.2

Methodsofcombiningclinicalstudies
Datasynthesisforinterventionreviews
Wherepossible,metaanalyseswereconductedtocombinetheresultsofstudiesforeachreview
questionusingCochraneReviewManager(RevMan5)software.Fixedeffects(MantelHaenszel)
techniqueswereusedtocalculateriskratios(relativerisk)forthebinaryoutcomes.Theoutcome(s)
was(were)analysedusinganinversevariancemethodforpoolingweightedmeandifferencesand
wherethestudieshaddifferentscales,standardisedmeandifferenceswereused.
Statisticalheterogeneitywasassessedbyconsideringthechisquaredtestforsignificanceatp<0.1or
anIsquaredinconsistencystatisticof>50%toindicatesignificantheterogeneity.Wheresignificant
heterogeneitywaspresent,wecarriedoutasensitivityanalysiswithparticularattentionpaidto
allocationconcealment,blindingandlosstofollowup(missingdata).Incaseswheretherewas
inadequateallocationconcealment,unclearblindingordifferentialmissingdatamorethan20%in
thetwogroups,thiswasexaminedinasensitivityanalysis.Forthelatter,thedurationoffollowup
wasalsotakenintoconsiderationpriortoincludinginasensitivityanalysis.Nosubgroupanalyses
werepredefinedwiththeexceptionoftheclinicalquestionforconstraintinducedtherapyforwhich
asubgroupanalysisondurationofintervention(moreorlessthan5hours)wasprespecified(see
AppendixEforfurtherdetails).
Ifnosensitivityanalysiswasfoundtocompletelyresolvestatisticalheterogeneitythenarandom
effects(DerSimonianandLaird)modelwasemployedtoprovideamoreconservativeestimateofthe
effect.
Forcontinuousoutcomes,themeansandstandarddeviationswererequiredformetaanalysis.
However,incaseswherestandarddeviationswerenotreported,thestandarderrorwascalculatedif
thepvaluesor95%confidenceintervalswerereportedandmetaanalysiswasundertakenwiththe
meanandstandarderrorusingthegenericinversevariancemethodinCochraneReviewManager
(RevMan5)software.Whentheonlyevidencewasbasedonstudiessummarisedresultsbyonly
presentingmedians(andinterquartilerange),oronlypvaluesthisinformationwasincludedinthe
GRADEtableswithoutcalculatingtherelativeandabsoluteeffect.Consequently,imprecisionof
effectcouldnotbeassessedwhenresultswerenotpresentedinthestudiesbymeansandstandard
deviations.
Forbinaryoutcomes,absoluteeventrateswerealsocalculatedusingtheGRADEprosoftwareusing
eventrateinthecontrolarmofthepooledresults.

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Theresultsfromcrossoverstudieswerecombinedinametaanalysiswiththosefromparallel
randomisedtrials,onlyaftercorrectionshavebeenmadetothestandarderrorforthecrossover
trials.

4.3.3

Typeofstudies
Systematicreviews,doubleblinded,singleblindedandunblindedparallelrandomisedcontrolled
trials(RCTs)andcrossoverrandomizedstudieswereincludedintheevidencereviewsforthis
guideline.
Weincludedrandomisedtrials,astheyareconsideredthemostrobusttypeofstudydesignthat
couldproduceanunbiasedestimateoftheinterventioneffects.TheGDGbelievedthatthereason
whynolargetrialswerefoundforthispopulationwaslargelybecausestrokeunitsarerelativelynew
andpriortotheirformationithasnotbeenpossibletoconductlargemulticentreRCTs.
Wealsosearchedforsystematicreviewsofcohortstudies,howevernonewasfoundinanyreview
question.TheGDGdecidednottoincludeindividualcohortstudies.Cohortstudieshavebeenbased
inrehabilitationunitswheretherearemixedpopulationgroupsandextractingstrokedatafrom
thosemixedpopulationswouldbechallenging.Preliminarysearchesundertakendidnotfindany
largecohortstudies;thereforetheGDGagreedthatindividualcohortstudieswouldnotprovideany
addedvaluetothereviewsofindividualinterventions.
Formostofthereviewsthecontentofinterventionsandthereferredpopulationswithinthe
includedstudieswasfoundtobeverydiverse,makingtheextractionofrelevantdatachallengingand
timeconsuming.Inaddition,theGDGhaddifficultiesindrawingoverallconclusionsonthebodyof
evidencepresentedanditwasoftennotpossibletomakerecommendationsspecifyingwhat
interventionsshouldcompriseof.Intheseinstances,theGDGdecidedthattheresultsofeach
outcomeshouldbepresentedseparatelyforeachstudyandametaanalysiscouldnotbeconducted.
Duetothediversityofinterventions,itwasdecidedtoincludeasummarytableofstudiesincluded
withindividualcharacteristics(population,intervention,control,outcomes)atthebeginningofeach
evidencereview.

4.3.4

Typeofanalysis
EstimatesofeffectfromindividualstudieswerebasedonIntentionToTreat(ITT)analysiswiththe
exceptionoftheoutcomeofexperienceofadverseeventswhereasweusedAvailableCaseAnalysis
(ACA).ITTanalysisiswhereallparticipantsincludedintherandomisationprocesswereconsideredin
thefinalanalysisbasedontheinterventionandcontrolgroupstowhichtheywereoriginally
assigned.Weassumedthatparticipantsinthetrialslosttofollowupdidnotexperiencetheoutcome
ofinterest(forcategoricaloutcomes)andtheywouldnotconsiderablychangetheaveragescoresof
theirassignedgroups(forcontinuousoutcomes).
ItisimportanttonotethatITTanalysestendtobiastheresultstowardsnodifference.ITTanalysisis
aconservativeapproachtoanalysethedata,andthereforetheeffectmaybesmallerthaninreality.
However,themajorityofoutcomesselectedtobereviewedwerecontinuousoutcomes,veryfew
peopledroppedoutandmostofthestudiesreporteddataonanITTbasis.

4.3.5

Appraisingthequalityofevidencebyoutcomes
TheevidenceforoutcomesfromtheincludedRCTswasevaluatedandpresentedusinganadaptation
oftheGradingofRecommendationsAssessment,DevelopmentandEvaluation(GRADE)toolbox
developedbytheinternationalGRADEworkinggroup(http://www.gradeworkinggroup.org/).The
software(GRADEpro)developedbytheGRADEworkinggroupwasusedtoassessthequalityofeach
outcome,takingintoaccountindividualstudyqualityandthemetaanalysisresults.Thesummaryof

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studiescharacteristicsandfindingswaspresentedinonetableinthisguideline.The
Clinical/EconomicStudyCharacteristicstableincludesdetailsofthequalityassessmentwhilethe
Clinical/EconomicSummaryofFindingstableincludespooledoutcomedataandwhere
appropriate,anabsolutemeasureofinterventioneffectandthesummaryofqualityofevidencefor
thatoutcome.Inthistable,thecolumnsforinterventionandcontrolindicatesummariesofthesum
ofthesamplesizeforcontinuousoutcomes.Forbinaryoutcomessuchasnumberofpatientswithan
adverseevent,theeventrates(n/N:numberofpatientswitheventsdividedbysumofnumberof
patients)areshownwithpercentages.Reportingorpublicationbiaswasonlytakeninto
considerationinthequalityassessmentandincludedintheClinicalStudyCharacteristicstableifit
wasapparent.
EachoutcomewasexaminedseparatelyforthequalityelementslistedanddefinedinTable1and
eachgradedusingthequalitylevelslistedinTable2.Themaincriteriaconsideredintheratingof
theseelementsarediscussedbelow(seesection4.3.6GradingofEvidence).Footnoteswereusedto
describereasonsforgradingaqualityelementashavingseriousorveryseriousproblems.The
ratingsforeachcomponentweresummedtoobtainanoverallassessmentforeachoutcome.
Table3:TheGRADEtoolboxiscurrentlydesignedonlyforrandomisedtrialsandobservational
studies
Table1:DescriptionsofqualityelementsinGRADEforinterventionstudies
Table1:

DescriptionofqualityelementsinGRADEforinterventionstudies

Qualityelement

Description

Limitations

Limitationsinthestudydesignandimplementationmaybiastheestimatesofthe
treatmenteffect.Majorlimitationsinstudiesdecreasetheconfidenceintheestimate
oftheeffect.

Inconsistency

Inconsistencyreferstoanunexplainedheterogeneityofresults.

Indirectness

Indirectnessreferstodifferencesinstudypopulation,intervention,comparatorand
outcomesbetweentheavailableevidenceandthereviewquestion,or
recommendationmade.

Imprecision

Resultsareimprecisewhenstudiesincluderelativelyfewpatientsandfeweventsand
thushavewideconfidenceintervalsaroundtheestimateoftheeffectrelativetothe
clinicallyimportantthreshold.

Publicationbias

Publicationbiasisasystematicunderestimateoranoverestimateoftheunderlying
beneficialorharmfuleffectduetotheselectivepublicationofstudies.

Table2:

LevelsofqualityelementsinGRADE

Level

Description

None

Therearenoseriousissueswiththeevidence

Serious

Theissuesareseriousenoughtodowngradetheoutcomeevidencebyonelevel

Veryserious

Theissuesareseriousenoughtodowngradetheoutcomeevidencebytwolevels

Table3:

OverallqualityofoutcomeevidenceinGRADE

Level

Description

High

Furtherresearchisveryunlikelytochangeourconfidenceintheestimateofeffect

Moderate

Furtherresearchislikelytohaveanimportantimpactonourconfidenceintheestimate
ofeffectandmaychangetheestimate

Low

Furtherresearchisverylikelytohaveanimportantimpactonourconfidenceinthe
estimateofeffectandislikelytochangetheestimate

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StrokeRehabilitation
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Level

Description

Verylow

Anyestimateofeffectisveryuncertain

4.3.6

Gradingthequalityofclinicalevidence
Afterresultswerepooled,theoverallqualityofevidenceforeachoutcomewasconsidered.The
followingprocedurewasadoptedwhenusingGRADE:
11.Aqualityratingwasassigned,basedonthestudydesign.RCTsstartHIGHandobservational
studiesasLOW,uncontrolledcaseseriesasLOWorVERYLOW.
12.Theratingwasthendowngradedforthespecifiedcriteria:Studylimitations,inconsistency,
indirectness,imprecisionandreportingbias.Thesecriteriaaredetailedbelow.Observational
studieswereupgradediftherewasalargemagnitudeofeffect,doseresponsegradient,andifall
plausibleconfoundingwouldreduceademonstratedeffectorsuggestaspuriouseffectwhen
resultsshowednoeffect.Eachqualityelementconsideredtohaveseriousorveryseriousrisk
ofbiaswasrateddown1or2pointsrespectively.
13.Thedowngraded/upgradedmarkswerethensummedandtheoverallqualityratingwasrevised.
Forexample,allRCTsstartedasHIGHandtheoverallqualitybecameMODERATE,LOWorVERY
LOWif1,2or3pointsweredeductedrespectively.
14.Thereasonsorcriteriausedfordowngradingwerespecifiedinthefootnotes.
Thedetailsofcriteriausedforeachofthemainqualityelementarediscussedfurtherinthefollowing
sections4.3.7to4.3.10.

4.3.7

Studylimitations
ThemainlimitationsforrandomisedcontrolledtrialsarelistedinTable4.
Outcomesfromstudieswhichwerenotdoubleblindedweredowngradedonstudylimitationsdueto
thehigherriskofbias.However,theGDGexpressedtheirconcernthatconductingdoubleblinded
trialsinstrokerehabilitationwasnotpracticalasitwouldbeimpossibletoblindthetrialparticipant
duetothenatureoftheinterventionsdeliveredinstrokerehabilitation.However,singleblindedand
unblindedtrialsweredowngradedtomaintainaconsistentapproachinqualityratingacrossthe
guidelinefollowingtheapplicationofGRADEsystem,recognisingthatadoubleblindedtrialwould
providetheleastbiasedoutcomesinaclinicalsetting.Table4listedthelimitationsconsideredfor
randomisedcontrolledtrials.
Table4:

Studylimitationsofrandomisedcontrolledtrials

Limitation

Explanation

Allocation
concealment

Thoseenrollingpatientsareawareofthegrouptowhichthenextenrolledpatient
willbeallocated(majorprobleminpseudoorquasirandomisedtrialswith
allocationbydayofweek,birthdate,chartnumber,etc.)

Lackofblinding

Patient,caregivers,thoserecordingoutcomes,thoseadjudicatingoutcomes,ordata
analystsareawareofthearmtowhichpatientsareallocated.Baselinedifferences
arealsoassessedinthiscategory.

Incomplete
accountingof
patientsand
outcomeevents

Losstofollowupnotaccountedandfailuretoadheretotheintentiontotreat
principlewhenindicated

Selectiveoutcome
reporting

Reportingofsomeoutcomesandnotothersonthebasisoftheresults

Otherlimitations

Forexample:

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StrokeRehabilitation
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Limitation

Explanation
Stoppingearlyforbenefitobservedinrandomisedtrials,inparticularintheabsence
ofadequatestoppingrules
Useofinvalidatedpatientreportedoutcomes
Carryovereffectsincrossovertrials
Recruitmentbiasinrandomisedtrials

4.3.8

Inconsistency
Inconsistencyreferstoanunexplainedheterogeneityofresults.Whenestimatesofthetreatment
effectacrossstudiesdifferwidely(i.e.heterogeneityorvariabilityinresults),thissuggeststrue
differencesinunderlyingtreatmenteffect.Whenheterogeneityexists(Chisquarep<0.1orIsquared
inconsistencystatisticof>50%),butnoplausibleexplanationcanbefound(forexampleacuteor
chronicstrokepopulations,durationofintervention,differentfollowupperiods),thequalityof
evidencewasdowngradedbyoneortwolevels,dependingontheextentofuncertaintytothe
resultscontributedbytheinconsistencyintheresults.Duetothediversityofinterventionsusedin
theincludedtrialsforthisguideline,therewerecaseswheretheGDGbelievedthepresentationof
evidenceshouldbekeptseparateandexplanatoryfootnotesweregiveninGRADEtableswhere
appropriate.InadditiontotheIsquareandChisquarevalues,thedecisionfordowngradingwas
alsodependentonfactorssuchaswhethertheinterventionisassociatedwithbenefitinallother
outcomesorwhethertheuncertaintyaboutthemagnitudeofbenefit(orharm)oftheoutcome
showingheterogeneitywouldinfluencetheoveralljudgmentaboutnetbenefitorharm(acrossall
outcomes).
Ifinconsistencycouldbeexplainedbasedonprespecifiedsubgroupanalysis,theGDGtookthisinto
accountandconsideredwhethertomakeseparaterecommendationsbasedontheidentified
explanatoryfactors,i.e.populationandintervention.Wheresubgroupanalysisgivesaplausible
explanationofheterogeneity,thequalityofevidencewouldnotbedowngraded.Themostcommon
factorofsubgroupanalysiswasthetimesincestrokeeventandtheGDGconsideredtheevidenceof
someoutcomesseparatelyforacuteandchronicstrokepatients.

4.3.9

Indirectness
Directnessreferstotheextenttowhichthepopulations,intervention,comparisonsandoutcome
measuresaresimilartothosedefinedintheinclusioncriteriaforthereviews.Indirectnessis
importantwhenthesedifferencesareexpectedtocontributetoadifferenceineffectsize,ormay
affectthebalanceofharmsandbenefitsconsideredforanintervention.TheGDGdecidedthatfor
specificquestions(forexamplethereviewofinterventionstoassessclinicalandcosteffectivenessof
interventionstoaidreturntowork)thereviewofevidencecouldincludemixedpopulationswithat
least50%strokepatients.

4.3.10

Imprecision
Thesamplesize,eventrates,theresultingwidthofconfidenceintervalsandtheminimalimportant
differenceintheoutcomebetweenthetwogroupswerethemaincriteriaconsidered.
Thethresholdsofimportantbenefitsorharms,ortheMID(minimalimportantdifference)foran
outcomeareimportantconsiderationsfordeterminingwhetherthereisaclinicallyimportant
differencebetweeninterventionandcontrolgroupsandinassessingimprecision.Forcontinuous
outcomes,theMIDisdefinedasthesmallestdifferenceinscoreintheoutcomeofinterestthat
informedpatientsorinformedproxiesperceiveasimportant,etherbeneficialorharmful,andthat
wouldleadthepatientorcliniciantoconsiderachangeinthemanagement(98124,231,232).Aneffect

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StrokeRehabilitation
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estimatelargerthantheMIDisconsideredtobeclinicallyimportant.Fordichotomousoutcomes,
theMIDisconsideredintermsofchangesofabsoluterisk.
Thedifferencebetweentwointerventions,asobservedinthestudies,wascomparedagainstthe
MIDwhenconsideringwhetherthefindingswereofclinicalimportance;thisisusefultoguide
decisions.Forexample,iftheeffectwassmall(lessthantheMID),thisfindingsuggeststhatthere
maynotbeenoughdifferencetostronglyrecommendoneinterventionovertheotherbasedonthat
outcome.
Wesearchedtheliteratureforpublishedstudieswhichgaveaminimalimportantdifferencepoint
estimatefortheoutcomesspecifiedintheprotocolandagreementwasobtainedfromtheGDGfor
theiruseinassessingimprecisionthroughoutthereviewsintheguideline.Table5presentstheMID
thresholdsusedforthespecifiedoutcomesandthesourceofbaseevidence.Wherenopublished
studieswerefoundonMIDsforoutcomes,thedefaultGRADEproMIDswasused.Forcategorical
data,wecheckedwhethertheconfidenceintervaloftheeffectcrossedoneortwoendsoftherange
of0.751.25.Forquantitativeoutcomestwoapproacheswereused.Whenonlyonetrialwas
includedastheevidencebaseforanoutcome,themeandifferencewasconvertedtothe
standardizedmeandifference(SMD)andcheckedtoseeiftheconfidenceintervalcrossed0.5.
However,themeandifference(95%confidenceinterval)wasstillpresentedintheGradetables.If
twoormoreincludedtrialsreportedaquantitativeoutcomethenthedefaultapproachof
multiplying0.5bystandarddeviation(takenasthemedianofthestandarddeviationsacrossthe
metaanalysedstudies)wasemployed.WhenthedefaultMIDswereused,theGDGwouldassessthe
estimateofeffectwithrespectstotheMID,andthentheimprecisionmaybereconsidered.
Theconfidenceintervalforthepooledorbestestimateofeffectwasconsideredinrelationtothe
MID,asillustratedinFigure1.Essentially,iftheconfidenceintervalcrossedtheMIDthreshold,there
wasuncertaintyintheeffectestimateinsupportingourrecommendation(becausetheCIwas
consistentwithtwodecisions)andtheeffectestimatewasratedasimprecise.
Table5:

AgreedMIDsfromtheliterature

Outcomes

AgreedMID

Evidencebase

Otherconsiderations

BarthelIndex

1.85points(SE1.45)

Hsieh,Wang,Wu,Chen,Sheu,
Hsieh2007.116

Taiwansetting(n=43)
Papersaimtoestimate
MID

ActionResearch 12and17pointsfor
ArmTest(ARAT) theaffecteddominant
andnondominant
sidesrespectively

Lang,Edwards,Birkenmeier,
Dromerick2008.141

Inpatientrehabilitation
hospitalsettingearly
afterstrokepatientswith
hemiparesis(N=52)
Papersaimtoestimate
MID.

FuglMeyer
Assessment
(FMA)

VanderLee,Beckerman,
LankhorstandBouter2001.269

Paperassessedsensitivityof
theresearcharmtestin22
chronicstrokepatients

Differenceby10%of
thetotalscale

WolfMotor
FunctionTest
(WMFT)

Animprovementof19 Lang,Edwards,Birkenmeier,
secondsonthe
Dromerick2008141
affecteddominantside
(16%ofthe120second
limit)

Inpatientrehabilitation
hospitalsettingearly
afterstrokepatientswith
hemiparesis(N=52)
Papersaimtoestimate
MID.

MotorActivity
Log(MAL)

Atleast1.0and1.1
points(1718%ofthe
scale)fortheaffected
dominantandnon

Inpatientrehabilitation
hospitalsettingearly
afterstrokepatientswith
hemiparesis(N=52)

Lang,Edwards,Birkenmeier,
Dromerick2008141

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StrokeRehabilitation
Methods
Outcomes

AgreedMID
dominantsides
respectively

Evidencebase

Otherconsiderations

Functional
Independence
Measure(FIM)

22pointsforthetotal
FIM,17points(onthe
105pointscale16%)
forthemotorFIMand
3pointsforthe
cognitiveFIM.

Beninato,GillBody,Salles,
Stark,BlackSchaffer,Stein.
2006.24

Patientswithstrokein
longtermacutehospital.
(N=113)
Papersaimtoestimate
MID

Walkingspeed
(forchronic
strokepatients)

20cm/sec

PerryJ,GarrettM,GronleyJK,
MulroySJ.Classificationof
walkinghandicapinstroke
population.Stroke1995;26:
98289.202

chronicstrokepatients
(over3monthspoststroke)

Walkingspeed
(foracute
strokepatients)

16cm/sec

TilsonJK,SullivanK,CenSY,
RoseD.K,CH.Koradia,SP.
Azen,PW.Duncan2010.258

Firsttimestrokepatients
(2060dayspoststroke)
withseveregait
impairments(N=283)
Papersaimtoestimate
MIDforgaitspeed

TimedUpand
Go

10sec

PerryJ,GarrettM,GronleyJK,
MulroySJ.Classificationof
walkinghandicapinstroke
population.Stroke1995;26:
98289.202

StairsTest

15sec

PodsiadloD,RichardsonS.The
timedUp&Go:atestofbasic
functionalmobilityforfrail
elderlypersons.JAmGeriatr
Soc1991;39:14248.207

6minutewalk
test

28m

DeanCM,RichardsCL,
MalouinF2000.58

Rangeof
movement
(wrist
extensibility)

5ochange(SD4.1o)

LanninNA,CusickA,McCluskey MIDtakenfromsamplesize
A,HerbertRD2007.144
calculation(N=63)

Papersaimtoestimate
MID.

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StrokeRehabilitation
Methods

Figure1: Illustrationofpreciseandimprecisionoutcomesbasedontheconfidenceintervalof
outcomesinaForrestplot

Source: FigureadaptedfromGRADEProsoftware.

MID=minimalimportantdifferencedeterminedforeachoutcome.TheMIDsarethethresholdfor
appreciablebenefitsandharms.Theconfidenceintervalsofthetopthreepointsofthediagramwere
consideredprecisebecausetheupperandlowerlimitsdidnotcrosstheMID.Conversely,thebottom
threepointsofthediagramwereconsideredimprecisebecauseallofthemcrossedtheMIDand
reducedourcertaintyoftheresults.

4.4 Evidenceofcosteffectiveness
TheGuidelineDevelopmentGroup(GDG)isrequiredtomakedecisionsbasedonthebestavailable
evidenceofbothclinicalandcosteffectiveness.Guidelinerecommendationsshouldbebasedonthe
estimatedcostsofthetreatmentoptionsinrelationtotheirexpectedhealthbenefits(thatis,their
costeffectiveness),ratherthanonthetotalcostorresourceimpactofimplementingthem.Thus,if
theevidencesuggeststhataninterventionprovidessignificanthealthbenefitsatanacceptablecost
perpatienttreated,itshouldberecommendedevenifitwouldbeexpensivetoimplementacross
thewholepopulation.
Evidenceoncosteffectivenessrelatedtothekeyclinicalissuesbeingaddressedintheguidelinewas
sought.Thehealtheconomistundertook:
Asystematicreviewofthepublishedeconomicliterature.
Newcosteffectivenessanalysisinpriorityareas.
Whennorelevantpublishedstudieswerefound,andanewanalysiswasnotprioritised,theGDG
madeaqualitativejudgementaboutcosteffectivenessbyconsideringexpecteddifferencesin
resourceusebetweencomparatorsandrelevantUKNHSunitcostsalongsidetheresultsofthe
clinicalreviewofeffectivenessevidence.Whereconsidereduseful,thisincludedcalculationof
expectedcostdifferencesandconsiderationoftheQALYgainthatwouldberequiredtojustifythe
expectedadditionalcostoftheinterventionbeingconsidered.Unitcostswerebasedonpublished
nationalsourcewhereavailable.Staffcostsarereportedusingthetypicalsalarybandofsomeone
deliveringtheinterventionasidentifiedbyclinicalGDGmembers.Itshouldbenotedhoweverthatin

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StrokeRehabilitation
Methods
practicestaffbandswillvaryduetotheneedforaskillmixacrossteams.Inputstocalculations
shouldnotbeinterpretedasrecommendationsaboutwhoshoulddelivercare.

4.4.1

Literaturereview
Thehealtheconomist:
Identifiedpotentiallyrelevantstudiesforeachreviewquestionfromtheeconomicsearchresults
byreviewingtitlesandabstractsfullpaperswerethenobtained.
Reviewedfullpapersagainstprespecifiedinclusion/exclusioncriteriatoidentifyrelevantstudies
(seebelowfordetails).
CriticallyappraisedrelevantstudiesusingtheeconomicevaluationschecklistasspecifiedinThe
GuidelinesManual187.
Extractedkeyinformationaboutthestudysmethodsandresultsintoevidencetables(evidence
tablesareincludedinAppendixH).
GeneratedsummariesoftheevidenceinNICEeconomicevidenceprofiles(includedinthe
relevantchapterwriteups)seebelowfordetails.

4.4.1.1

Inclusion/exclusion
Fulleconomicevaluations(studiescomparingcostsandhealthconsequencesofalternativecourses
ofaction:costutility,costeffectiveness,costbenefitandcostconsequenceanalyses)and
comparativecostingstudiesthataddressedthereviewquestionintherelevantpopulationwere
consideredpotentiallyapplicableaseconomicevidence.
Studiesthatonlyreportedcostperhospital(notperpatient),oronlyreportedaveragecost
effectiveness,withoutdisaggregatedcostsandeffects,wereexcluded.Abstracts,posters,reviews,
letters/editorials,foreignlanguagepublicationsandunpublishedstudieswereexcluded.Studies
judgedtohaveanapplicabilityratingofnotapplicablewereexcluded(thisincludedstudiesthat
tooktheperspectiveofanonOECDcountry).
Remainingstudieswereprioritisedforinclusionbasedontheirrelativeapplicabilitytothe
developmentofthisguidelineandthestudylimitations.Forexample,ifahighquality,directly
applicableUKanalysiswasavailableotherlessrelevantstudiesmaynothavebeenincluded.Where
exclusionsoccurredonthisbasis,thisisnotedintherelevantsection.
Formoredetailsabouttheassessmentofapplicabilityandmethodologicalqualityseetheeconomic
evaluationchecklist(TheGuidelinesManual,AppendixH187)andthehealtheconomicsresearch
protocolinAppendixE.

4.4.1.2

NICEeconomicevidenceprofiles
TheNICEeconomicevidenceprofilehasbeenusedtosummarisecostandcosteffectiveness
estimates.Theeconomicevidenceprofileshows,foreacheconomicstudy,anassessmentof
applicabilityandmethodologicalquality,withfootnotesindicatingthereasonsfortheassessment.
Theseassessmentsweremadebythehealtheconomistusingtheeconomicevaluationchecklistfrom
TheGuidelinesManual,AppendixH187.Italsoshowsincrementalcosts,incrementaleffects(for
example,QALYs)andtheincrementalcosteffectivenessratiofromtheprimaryanalysis,aswellas
informationabouttheassessmentofuncertaintyintheanalysis.SeeTable6formoredetails.
IfanonUKstudywasincludedintheprofile,theresultswereconvertedintopoundssterlingusing
theappropriatepurchasingpowerparity194.

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Table6:

ContentofNICEeconomicprofile

Item

Description

Study

Firstauthorname,reference,dateofstudypublicationandcountryperspective.

Limitations

Anassessmentofmethodologicalqualityofthestudy(a):
Minorlimitationsthestudymeetsallqualitycriteria,orthestudyfailstomeetone
ormorequalitycriteria,butthisisunlikelytochangetheconclusionsaboutcost
effectiveness.
Potentiallyseriouslimitationsthestudyfailstomeetoneormorequalitycriteria,
andthiscouldchangetheconclusionaboutcosteffectiveness
Veryseriouslimitationsthestudyfailstomeetoneormorequalitycriteriaand
thisisverylikelytochangetheconclusionsaboutcosteffectiveness.Studieswith
veryseriouslimitationswouldusuallybeexcludedfromtheeconomicprofiletable.

Applicability

Anassessmentofapplicabilityofthestudytotheclinicalguideline,thecurrentNHS
situationandNICEdecisionmaking(a):
Directlyapplicabletheapplicabilitycriteriaaremet,oroneormorecriteriaare
notmetbutthisisnotlikelytochangetheconclusionsaboutcosteffectiveness.
Partiallyapplicableoneormoreoftheapplicabilitycriteriaarenotmet,andthis
mightpossiblychangetheconclusionsaboutcosteffectiveness.
Notapplicableoneormoreoftheapplicabilitycriteriaarenotmet,andthisis
likelytochangetheconclusionsaboutcosteffectiveness.

Othercomments

Particularissuesthatshouldbeconsideredwheninterpretingthestudy.

Incrementalcost

Themeancostassociatedwithonestrategyminusthemeancostofacomparator
strategy.

Incrementaleffects

ThemeanQALYs(orotherselectedmeasureofhealthoutcome)associatedwith
onestrategyminusthemeanQALYsofacomparatorstrategy.

ICER

Incrementalcosteffectivenessratio:theincrementalcostdividedbytherespective
QALYsgained.

Uncertainty

AsummaryoftheextentofuncertaintyabouttheICERreflectingtheresultsof
deterministicorprobabilisticsensitivityanalyses,orstochasticanalysesoftrialdata,
asappropriate.

(a) LimitationsandapplicabilitywereassessedusingtheeconomicevaluationchecklistfromTheGuidelinesManual,
AppendixH187

4.4.2

Undertakingnewhealtheconomicanalysis
Aswellasreviewingthepublishedeconomicliteratureforeachreviewquestion,asdescribedabove,
neweconomicanalysiswasundertakenbythehealtheconomistinselectedareas.Priorityareasfor
newhealtheconomicanalysiswereagreedbytheGDGafterformationofthereviewquestionsand
considerationoftheavailablehealtheconomicevidence.
TheGDGidentifiedintensityofrehabilitationasthehighestpriorityareaforanoriginaleconomic
model.Thisissueimpactsthelargestgroupofpeopleintheguidelineasitrelatestothewhole
populationratherthanaspecificsubset.Inaddition,theGDGconsideredthattheintensityof
rehabilitationprovidedcurrentlyvariesconsiderablyfromservicetoserviceintermsofhoursperday
anddurationoftherapy,anditisgenerallylowerthanthatcurrentlyrecommendedintheNICE
qualitystandardforongoingrehabilitation.Thereforerecommendationsinthisareawereconsidered
likelytohavethebiggestimpactonNHSresourcesandpatientoutcomes.
Thefollowinggeneralprincipleswereadheredtoindevelopingthecosteffectivenessanalysis:
MethodswereconsistentwiththeNICEreferencecase185.
TheGDGwasconsultedduringtheconstructionandinterpretationofthemodel.

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StrokeRehabilitation
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Modelinputswerebasedonthesystematicreviewoftheclinicalliteraturesupplementedwith

otherpublisheddatasourceswherepossible.
Whenpublisheddatawasnotavailableexpertopinionwasusedtopopulatethemodel.
Modelinputsandassumptionswerereportedfullyandtransparently.
Theresultsweresubjecttosensitivityanalysisandlimitationswerediscussed.
ThemodelwaspeerreviewedbyanotherhealtheconomistattheNCGC.

FullmethodsfortheintensityofrehabilitationcosteffectivenessanalysisaredescribedinAppendix
K.

4.4.3

Costeffectivenesscriteria
NICEsreportSocialvaluejudgements:principlesforthedevelopmentofNICEguidancesetsoutthe
principlesthatGDGsshouldconsiderwhenjudgingwhetheraninterventionoffersgoodvaluefor
money186,187.
Ingeneral,aninterventionwasconsideredtobecosteffectiveifeitherofthefollowingcriteria
applied(giventhattheestimatewasconsideredplausible):
a. Theinterventiondominatedotherrelevantstrategies(thatis,itwasbothlesscostlyintermsof
resourceuseandmoreclinicallyeffectivecomparedwithalltheotherrelevantalternative
strategies),or
b. Theinterventioncostlessthan20,000perqualityadjustedlifeyear(QALY)gainedcompared
withthenextbeststrategy.
IftheGDGrecommendedaninterventionthatwasestimatedtocostmorethan20,000perQALY
gained,ordidnotrecommendonethatwasestimatedtocostlessthan20,000perQALYgained,
thereasonsforthisdecisionarediscussedexplicitlyinthefromevidencetorecommendations
sectionoftherelevantchapterwithreferencetoissuesregardingtheplausibilityoftheestimateor
tothefactorssetoutintheSocialvaluejudgements:principlesforthedevelopmentofNICE
guidance186.
IfastudyreportedthecostperlifeyeargainedbutnotQALYs,thecostperQALYgainedwas
estimatedbymultiplyingbyanappropriateutilityestimatetoaidinterpretation.Theestimatedcost
perQALYgainedisreportedintheeconomicevidenceprofilewithafootnotedetailingthelifeyears
gainedandtheutilityvalueused.WhenQALYsorlifeyearsgainedarenotusedintheanalysis,
resultsaredifficulttointerpretunlessonestrategydominatestheotherswithrespecttoevery
relevanthealthoutcomeandcost.

4.5 PostconsultationprotocolincludingmodifiedDelphimethodology
Duringconsultation,substantialstakeholdercommentswerereceivedwhichhighlightedanumberof
significantissuesinrelationtotheguidelinescopeandrecommendationsdevelopedintheguideline.
Stakeholdersraisedconcernsthattheguidelinewasincompletebecauseofthenumberofareasin
therehabilitationpatientcarepathwaythattheguidelinehadnotcovered,andthismayresultin
therapiesandservicesforthestrokepopulationbeingreducedorevenwithdrawn.Theareas
identifiedintheconsultationperiodincluded:
servicedelivery,rolesandresponsibilityofthemultidisciplinaryteam/strokerehabilitation
services
holisticassessment,careplanning,goalsetting,ongoingreviewandmonitoring
transferofcare/dischargeplanningandinterfacewithsocialcare
longtermhealthandsocialsupportforpeopleafterstrokeandpatientinformationneeds

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StrokeRehabilitation
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Stakeholdersalsoconsideredthatsometopicsincludedinthescopehadnotbeenaddressed
adequately,includingmooddisorders(depressionandanxiety),physicalfitnessandexercise,other
speechandlanguagetherapiesanddiplopia.
Thefocusoftheoutcomesfortheinterventionsincludedintheguidelinehasbeenonfunctionand
mobilityasthesewereconsideredbytheGuidelineDevelopmentGroup(GDG)tohavethebiggest
impactonpatientslives.Howevermanystakeholdersconsideredthatthepatientexperienceand
holisticapproachestocarehadbeenneglectedandrepresentedamajorgapintheguidance.Inlight
ofthecommentsreceivedfromstakeholders,theGDGagreedthatadditionalworkshouldbecarried
outforsomeoftheseareasorreferencemadetootherNICEguidance,inordertoproduceamore
completepieceofguidancethatwouldbeusefultohealthprofessionalsdeliveringrehabilitationtoa
strokepopulation.ThecurrentguidancehasfollowedstandardNICEmethodologyandtheGDGwere
inagreementthatforthoseareaswhereeitherweakornoevidencewasavailablearobustprocess
neededtobefollowed.
InconsultationwithNICEandtheGDGtheNCGCtechnicalteamconductedadditionalworkto
addresstheareasidentifiedbystakeholdersandnotcoveredintheoriginalscope.Comprehensive
searchesofdatabaseswithtermsdesignedtoidentifyevidencerelatedtothetopicsoutlinedabove
wereundertakenfollowingtheNICEprocessbutrestrictedtoretrieveotherguidelinesand
systematicreviewsonly.Inadditionasimilarscopingsearchwasdoneforeconomicevidence
relatingtothesameareas.Thesearchstrategywaslimitedtocaptureonlyeconomicevaluations.A
firstsiftwasundertakentoidentifypotentiallyrelevanteconomicpapersrelatedtothetopicslisted
above.
ReviewsoftheclinicalandeconomicliteraturewereundertakenfollowingtheusualNICEprocess
andpresentedtotheGDGwhousedthisevidenceasabasistomakefurtherrecommendations.
WheretherewererecommendationsinotherNICEguidancerelevanttothestrokepopulationand
addressedcommentshighlightedbystakeholders,crossreferencetothesewasmaderatherthan
undertakingfurtheroriginalwork.
RelevantguidelinesidentifiedfromthecomprehensivesearchwerequalityassessedusingtheAGREE
IItoolchecklist.Thoseofsufficientqualitywerereviewedforrecommendationsrelatingtothetopics
identifiedinthestakeholderconsultation.
ThefullprotocolcanbefoundinAppendixB.
ModifiedDelphiconsensusmethodology
Astheevidencebasewasweakorabsentformanyoftheareasstakeholderswishedtheguidelineto
includeadifferentmethodology.Thiswasseenasnecessarysinceitwouldprovidearobustprocess
toenabletheGDGtomakefurtherrecommendations.Wheretherewasalackofpublishedevidence
theNCGCtechnicalteamusedamodifiedDelphimethod(anonymous,multiround,consensus
buildingtechnique)basedonotheravailableguidelinesorexpertopinion.Thistypeofsurveyhas
beenusedsuccessfullyforgenerating,analysingandsynthesisingexpertviewtoreachagroup
consensusposition.Thetechniqueusessequentialquestionnairestosolicitindividualresponses,
withthepotentialthreatofpeerpressureremoved95.Thisisanimportantconsiderationandisakey
strengthofthetechnique.StraussandZieglers249(1975)seminalworkonthetechniquehighlights
thefeaturesofthetechnique:
Enablestheeffectiveuseofapanelofexperts
Dataisgeneratedthroughsequentialquestioning
Highlightsconsensusanddivergentopinion
Anonymityisguaranteed
Ithandlesjudgementaldataeffectively

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StrokeRehabilitation
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InNICEprocesses,littleornoevidenceforreviewsisanexceptionalcircumstancewhenformal
consensustechniques(suchastheDelphimethod)canbeadopted187.Themethodsandprocess
proposedwasdiscussedwithmethodologicaladviserswithinNICEandtheprotocolwasagreedand
signedoffbythempriortoworkbeingcarriedout.
Delphistatementsweredistilledfromthecontentofexistingnationalandinternationalstroke
rehabilitationguidelines.Theidentifiedguidelineswerequalityassuredbytworesearchfellowsusing
theAppraisalofGuidelinesforResearchandEvaluation(AGREEII)instrumentasdescribedinthe
AppendixFTherelevantsectionsoftheguidelinesweresummarised(andnotedwhetherthe
recommendationswerebasedonconsensusorevidence)andthesesummarieswereusedasthe
basisfordraftstatements.Statementswerethendiscussedandrevisedwithtwoexternalexperts
recruitedtoactasconsultantsinthedevelopmentofthesurveystatements.Atablewiththe
relevantguidelinesectionsandfirstdraftstatementcanbefoundinAppendixF.
TheDelphipanelcomprisedofstrokerehabilitationcliniciansandotherprofessionalswithsignificant
experienceinstrokerehabilitation(referredtoastheDelphipanel)coveringawiderangeof
disciplinesinvolvedinstrokecare.Membersofthepanelwereidentifiedbymeansofnominationby
theGDG,andthesewerethencollatedandreviewedbythechairoftheGDGandtheRCP
IntercollegiateStrokeWorkingPartyand,afterremovalofduplicates,inspectedfor
representativeness.Inthefirstinstance164expertswerecontactedandinvitedtoparticipate.The
professionscomprisedof:geriatricians,neurologists,nurses,occupationaltherapists,peoplefrom
patientrepresentation/organisations,physiotherapists,psychologists,research/policymakers,
socialworkers,speechandlanguagetherapists,strokephysiciansandotherhealthcare
professionals(forexampleorthoptists,dieticians,GPsandpharmacists).
Asurvey,consistingof68statementsplus3demographicquestions(profession,setting,and
geographicarea),wasthencirculatedtotheDelphipanel.Freetextboxeswereavailableforpanel
comments,thesewerethenevaluatedandusedtoreviseandrefinestatementsifnecessary.This
processwascarriedoutinconjunctionwiththeconsultantexpertsaswellastheChairofthe
guideline.Theresultsfromeachroundwassummarisedandthencommunicatedtoparticipants.
Fourroundsofthesurveywereundertakenintotal.Forthemajorityofstatements(plus
demographics),aLikertscalewasappliedtoindicatethelevelofagreement.Somestatements
employedmultiplechoiceoptions.AfouroptionLikertscalewasused:stronglydisagree,disagree,
agreeandstronglyagree.ThepurposeofusingafourpointscalewastobeconsistentforDelphi
panelmemberswhomayhavebeenfamiliarwithboththesizeofscaleandtermsusedtosupport
DelphiprocessesfrompreviousconsensusworkinStrokeCare.InpublishedliteratureaboutDelphi
methodologytherehasbeenmuchdebateaboutwhatpercentageofagreementamongDelphipanel
membersconstitutesconsensus(seeMurphyetals1998HealthTechnologyAssessment)181onthis
subject).Whilethereisnouniversalagreementorguidelinesonthelevelofconsensus,Keeneyetal.
(2011)135suggestedthatresearchersshoulddecideontheconsensuslevelbeforecommencingthe
studyandconsiderusingahighlevelofconsensus,suchas70%.
InlinewithKeeneyetal(2011)135alevelof70%orhigherofparticipantsstronglyagreeingwasset
forrounds1and2,withthisthresholdforconsensusbeingreviewedinrounds3and4.Inanalysing
thedata,andinunderstandingthedifficultyofreachingconsensusinthelatterroundswhere
iterationhadfeatured,adecisionwasreachedbythetechnicalteamtolowerthethreshold
marginallyto67%stronglyagreeaslongasthemajorityofotherparticipantresponseswere
agree.Theanalysisofthisineveryitemadoptingthisapproachinthelatterroundswasthatthe
combinedDelphipanelresponsewasinexcessof90%ofparticipantseitherrespondingstrongly
agree(atleast67%oftotalparticipantresponse)oragree.Thiswasapragmaticresponsebythe
technicalteamandmeetspublishedcriteriathatconsensusisachievedwhen66.6%ofaDelphipanel
agrees.Statementsthatreachedtheselevelswouldnotfeatureinthenextround.Statementsthat
didnotreachthislevelwerereviewedbythetechnicalteamwiththeGDGchairandexpert
consultantsandwereamendedbasedonthepanelscommentsinthesurvey.Whentherewerelow

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StrokeRehabilitation
Methods
levelsofdisagreement,somestatementswerenoteditedandreincludedinthenextround.With
alreadylowlevelsofdisagreementitwasfeltthatreinclusionofthesestatementswouldencourage
panelmemberswhoagreedtoshifttoastronglyagreeresponse.Thisprocedureofreevaluation
continueduntileithertheconsensusratewasachievedoruntiltheDelphipanelmembersnolonger
modifiedtheirpreviousestimates/responses(orcomments).Insummary,whenboththelevelof
agreementandthetypeofcommentsnolongerchangeditwasagreedthatafurtherroundwould
notachieveconsensus.Thecommentsthatillustratedthesedifferencesinopinionsorcomments
thatshowedagreementbutnolongerchangedwerethenhighlightedinthefinalDelphireport.
ThereisnocompleteagreementaboutwhentoterminateaDelphisurvey,andoneresearcherhas
statedifnoconsensusemerges,atleastacrystallizingofthedisparatepositionsusuallybecomes
apparent(Gordon,1971)97.

SincetherewasanoverrepresentationofphysiotherapistsintheDelphipanelresponseswere
inspectedbyprofessionintheanalysis.Therewerenosystematicdifferencesinphysiotherapists
responsescomparedtothoseofotherprofessions.Hencefurtherdetailsofresponsesperprofession
werenotincludedinthereport.However,intheGDGmeetinginwhichrecommendationswere
draftedfromtheDelphistatementsGDGmemberswereinformedabouttheDelphicompositionand
askedtoconsiderthisintheirdiscussionofthestatements.
ThefullreportwascirculatedtotheGDG.Theconsensusstatementsemergingfromtheiterative
modifiedDelphitechniquewerepresentedtotheGDGandformedthebasisofdiscussion.The
economicsearchresultswererecheckedtoseeiftherewereanyeconomicanalysesrelatingtoareas
wherenewrecommendationshadbeenmade.Sincenoeconomicevaluationswasfoundonthenew
areasoftheguideline,theGDGmadeaqualitativejudgementaboutthecosteffectivenessofthe
interventionstheywantedtorecommendbasedontheDelphistatements.Economicconsiderations
weredraftedforallthosenewrecommendationswhereeconomicimplicationsweredeemed
important.
Asummaryoftheareasthatareaddressedinthepostconsultationprocessandthetypeofevidence
identifiedisprovidedinTable7below.
Table7:

Summaryofpostconsultationtopicsandlevelofevidenceidentified(consensusrefers
tothoseareasthatwillbecoveredbythemodifiedDelphi.

Areastoaddress

Evidence

servicedelivery
multidisciplinaryteams
strokeunits

consensus
systematicreviewidentified

assessmentforrehab
careplans
goalsetting
ongoingmonitoring

consensus
consensus
systematicreviewidentified
consensus

dischargeplanning/transferofcare
interfacewithsocialcare

consensus

consensus

longtermhealthandsocialsupport

consensus

visualimpairment(diplopia)

consensus

physicalfitness

systematicreviewidentified

speechandlanguagetherapies
aphasia

systematicreviewidentified

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StrokeRehabilitation
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Areastoaddress
apraxia
dysarthria

Evidence
consensus
consensus

shoulderpain

consensus

patientinformation

crossrefertoNICEguidance
consensus

TheGDGformulatednewrecommendationsbasedontheconsensusstatements.ThefullDelphi
reportisinAppendixF

4.6 Developingrecommendations
Overthecourseoftheguidelinedevelopmentprocess,theGDGwaspresentedwith:
Evidencetablesoftheclinicalandeconomicevidencereviewedfromtheliterature.Allevidence
tablesareinAppendicesHandI.
Summaryofclinicalandeconomicevidenceandquality(aspresentedinchapters717).
Forestplots(AppendixJ).
Adescriptionofthemethodsandresultsofthecosteffectivenessanalysisundertakenforthe
guideline(AppendixK).
RecommendationsweredraftedonthebasisoftheGDGinterpretationoftheavailableevidence,
takingintoaccountthebalanceofbenefits,harmsandcosts.Whenclinicalandeconomicevidence
wasofpoorquality,conflictingorabsent,theGDGdraftedrecommendationsbasedontheirexpert
opinion.Theconsiderationsformakinginformalconsensusbasedrecommendationsincludethe
balancebetweenpotentialharmsandbenefits,economicorimplicationscomparedtothebenefits,
currentpractices,recommendationsmadeinotherrelevantguidelines,patientpreferencesand
equalityissues.Theinformalconsensusrecommendationsweredonethroughdiscussionsinthe
GDG.TheGDGmayalsoconsiderwhethertheuncertaintyissufficienttojustifydelayingmakinga
recommendationtoawaitfurtherresearch,takingintoaccountthepotentialharmoffailingtomake
aclearrecommendation(SeeAppendixL).
ThemainconsiderationsspecifictoeachrecommendationareoutlinedintheRecommendations
andlinktoevidencesectionswithineachchapter.

4.6.1

Researchrecommendations
Whenareaswereidentifiedforwhichgoodevidencewaslacking,theguidelinedevelopmentgroup
consideredmakingrecommendationsforfutureresearch.Decisionsaboutinclusionwerebasedon
factorssuchas:
theimportancetopatientsorthepopulation
nationalpriorities
potentialimpactontheNHSandfutureNICEguidance
ethicalandtechnicalfeasibility

4.6.2

Validationprocess
Theguidanceissubjecttoaneightweekpublicconsultationandfeedbackaspartofthequality
assuranceandpeerreviewthedocument.Allcommentsreceivedfromregisteredstakeholdersare
respondedtointurnandpostedontheNICEwebsitewhentheprepublicationcheckofthefull

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StrokeRehabilitation
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guidelineoccurs.Basedoncommentsfromthestakeholdersduringthisconsultationfurtherareas
wereidentifiedwhereguidanceneededinordertoaddressthepatientpathwaymore
comprehensively.ForthisreasonapostconsultationprotocolwasdrawnupandagreedwithNICE
(seesection4.5).Asecondconsultationwasthenheldafterthisextendeddevelopmentperiod.

4.6.3

Updatingtheguideline
Followingpublication,andinaccordancewiththeNICEguidelinesmanual,NICEwillaskaNational
CollaboratingCentreortheNationalClinicalGuidelineCentretoadviseNICEsGuidanceexecutiveon
whethertheevidencebasehasprogressedsignificantlytoaltertheguidelinerecommendationsand
warrantanupdate.

4.6.4

Disclaimer
Healthcareprovidersneedtouseclinicaljudgement,knowledgeandexpertisewhendeciding
whetheritisappropriatetoapplyguidelines.Therecommendationscitedhereareaguideandmay
notbeappropriateforuseinallsituations.Thedecisiontoadoptanyoftherecommendationscited
heremustbemadebythepractitionersinlightofindividualpatientcircumstances,thewishesofthe
patient,clinicalexpertiseandresources.
TheNationalClinicalGuidelineCentredisclaimsanyresponsibilityfordamagesarisingoutoftheuse
ornonuseoftheseguidelinesandtheliteratureusedinsupportoftheseguidelines.

4.6.5

Funding
TheNationalClinicalGuidelineCentrewascommissionedbytheNationalInstituteforHealthand
ClinicalExcellencetoundertaketheworkonthisguideline.

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StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

5 Organisinghealthandsocialcareforpeople
needingrehabilitationafterstroke
Rehabilitationmaytakeplaceinavarietyofsettings,bothinhospitalandinthecommunity,inout
patientsandintheindividualsownhome.Whatiscriticalisthatwhateverthesetting,peoplewith
strokegetaccesstothelevelofrehabilitationthatmeetstheirneeds.Thischapterconsidersthe
evidenceforthestructureofmultidisciplinarystroketeams,rehabilitationunits,earlysupported
dischargeandtheintensityorrehabilitation.
Asearchforsystematicreviewswascarriedoutforstrokerehabilitationunits,dischargeplanning,
interfacewithsocialcareandmultidisciplinaryteamworking.AnupdateofaCochranesystematic
review251formsthebasisoftherecommendationsregardingstrokerehabilitationservices.Therewas
alackofdirectevidenceformultidisciplinaryteamwork,interfacewithsocialcareanddischarge
planning(seesections5.2,5.3,5.4.4).Thereforerecommendationsinthesesectionswerebasedon
modifiedDelphiconsensusstatementsthatweredrawnupfromexistingnationalandinternational
publishedguidelines.InthesesectionswewillprovidetablesofDelphistatementsthatreached
consensusandstatementsthatdidnotreachconsensusandgiveasummaryofhowtheywereused
todrawuptherecommendations.Fordetailsontheprocessandmethodologyusedforthemodified
DelphisurveyseeAppendixF.

5.1 Strokeunits
5.1.1

EvidenceReview:Inpeopleafterstroke,doesorganisedrehabilitationcare
(comprehensive,rehabilitationandmixedrehabilitationstrokeunits)improveoutcome
(mortality,dependency,requirementforinstitutionalcareandlengthofhospitalstay)?
ClinicalMethodologicalIntroduction
Population

Adultsandyoungpeople16orolderwhohavehadastroke.

Intervention

Organisedstrokeunitssuchas:
Strokeward(includingamultidisciplinaryteaminadiscretearea
caringexclusivelyforstrokepatients).Subdividedinto:
o Rehabilitationstrokeunits(acceptingpatientsafteracute
management)
o Comprehensivestrokeunits(combinedacuteaswellas
rehabilitation)
Mixedrehabilitationward(amultidisciplinaryteamincluding
specialistnursingstaffprovidingrehabilitationservices)

Comparison

Generalmedicalward:careinanacutemedicalorneurologyward
withoutroutinemultidisciplinaryinput.

Outcomes

Death
Deathordependency
Deathorinstitutionalcare
Durationofstayinhospitalorinstitutionorboth
Qualityoflife
Patientandcarersatisfaction

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StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke
5.1.1.1

ClinicalEvidenceReview
Asearchwasconductedforsystematicreviewscomparingtheclinicaleffectivenessoforganised
strokeunits(comprehensivestrokeunits,rehabilitationstrokeunits,andmixedrehabilitationward)
withgeneralmedicalwardstoimprovehealthoutcomesforadultsandyoungpeople16orolder
whohavehadastroke.
OneCochranesystematicreview251wasidentified.TheCochranerevieworiginallyincluded31trials
(RCTs).Fromthesetrials,weexcludedthosethataddressedanacutepopulation(2weekspost
stroke)andthatcomparedmobilestroketeamtogeneralmedicalwardleaving20trialsthat
matchedourprotocol.These(20)trialswereincludedforthisreview.
AfurthersystematicsearchwasconductedforanytrialpublishedsinceApril2006whichwasthe
searchcutoffdateoftheincludedCochranereview,butnostudieswereidentified.
IntheCochranesystematicreviewthefollowingstrategyofanalysiswasadopted:
Differenttypesoforganisedstrokeunitswerecomparedtogeneralmedicalwards.Thesewere:
o Comprehensivestrokeward
o rehabilitationstrokeward
o mixedrehabilitationstrokeward
Subgroupanalyseswerecarriedoutcomparingcomprehensive,rehabilitation,andmixed
rehabilitationstrokewardstogeneralmedicalwardsfordeath,deathordependency,deathor
institutionalcare(median12months;range6to12months)anddurationofstayinhospitalor
institutionorboth(Table10)
Sensitivityanalysiswasconductedbyexcludingtrialswithahighriskofbias.Thisdidnotaffect
theestimateofeffect
Lengthofstaywascalculatedindifferentways(forexampleacutehospitalstay,totalstayin
hospitalorinstitution).Thesecalculationsweresubjecttomethodologicallimitations
Twotrials126120extendedfollowuptofiveandtenyearspoststroke(Table11)
Patientcarersatisfactionandqualityoflifeoutcomeswereintendedassecondaryoutcomesbuta
metaanalysiswasnotreported

Totalmortalityanddurationofstayinhospitalorinstitutionacrossalltrialsaswellaswithinthe
differentsettingsoforganisedstrokeunitswereanalysed.Forthisreason,intheGRADEtableswe
haveonerowforthetotaleffectaswellasthreeotherrowsforthesubgroups(differentsettingsof
organisedstrokeunit).
Theevidencestatementsalsoreflectthetotaleffectsaswellasthesubgroupanalysis.
PleaseseeAppendixMforexcludedtrials.
Table8:

OverviewofstrokeunitscomparedintheCochranereview

STUDIES
162

Beijing ;
Edinburgh90;
GoteborgOstra253;
GoteborgSahlgren78;
Joinville35;Perth103;
Stockholm273;
Svendborg148;
Trondheim120;Umea
248

NUMBEROF
PARTICIPANTS
2574participants

INTERVENTION

COMPARISON

OUTCOMES

Comprehensive
strokeward

Generalmedical
ward

Death(median
followupof12
months;range
from6weeksto
12months)
*Deathor
dependency
**Deathor

NationalClinicalGuidelineCentre,2013.
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StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke
NUMBEROF
PARTICIPANTS

STUDIES

INTERVENTION

COMPARISON

Dover ;Nottingham 535participants

126
;Orpington1993128;
Orpington1995129

Rehabilitation
strokeward

Generalmedical
ward

Birmingham201;
Helsinki132;Illinois96;
Kuopio239;;NewYork
81
;Newcastle4

Mixed
rehabilitation
ward

247

Table9:

630participants

Generalmedical
ward

OUTCOMES
institutional
care
Durationof
stayinhospital
orinstitutionor
both

Death;deathordependency;deathorinstitutionalcareatfiveand10yearfollowup
NUMBEROF
PARTICIPANTS

STUDIES
126

Nottingham ;
Trondheim120

535participants

INTERVENTION

COMPARISON

OUTCOMES

Rehabilitation
strokeward

Generalmedical
ward

Death

Comprehensive
strokeward

*Deathor
dependency
**Deathor
institutional
care

Note.GMW=GeneralMedicalWard;MRW=MixedRehabilitationWard;inbothTable8andTable9*Dependencyis
definedasarequirementforphysicalattentionsuchasassistancefortransfers,mobility,dressing,feedingor
toileting(andwherecriteriaforindependencewereapproximatelyequivalenttoamodifiedRankinscoreof0
to2,aBarthelIndexofmorethan18outof20oranActivityIndex(AI)ofmorethan83);**Requirementfor
longterminstitutionalcareistakentomeancareinaresidentialhome,nursinghome,orhospitalattheendof
scheduledfollowup.

NationalClinicalGuidelineCentre,2013.
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StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

Comparison:Organisedstrokeunitcareversusgeneralmedicalward(medianfollowup12months)
Table10: Organisedstrokeunitcare(comprehensivestrokeward,rehabilitationstrokewardand,mixedrehabilitationward)versusgeneralmedical
wardStudyreferencesandsummaryoffindings
Qualityassessment

Summaryoffindings
Effect

Noof
studies

Design

Limitations

Inconsistency

Indirectness

Imprecision

Deathbytheendofscheduledfollowup
20
Seesub
group
below
(next6
rows)

RCTsingle
blinded

Serious
limitation(a)

Organised
strokeunit
care
Mean(SD)/
Frequency
(%)

Risk
ratio(RR)/
General
Standardise
medical
dMean
wards
Difference
Mean(SD)/ (SMD)/
Frequency Relative
(95%CI)
(%)

Absolute
effect(95%
CI)

Confidenc
e(in
effect)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

374/1932
(19.40%)

410/1807
(24.10%)

RR0.9(0.79 23fewer
to1.01)
per1000
(from48
fewerto2
more)

Moderat
e

291/1259
(23.10%)

RR0.92(0.8 18fewer
to1.06)
per1000
(from46
fewerto14
more)

Moderat
e

DeathbytheendofscheduledfollowupComprehensivestrokewardversusgeneralmedicalward
10
Beijing162;
Edinburgh
90
;
Goteborg
Ostra253;
Goteberg
Sahlgren
78
;Joinville
35
;Perth

RCTsingle
blinded

Serious
Noserious
limitation(a) inconsistency

Noserious
indirectness

Noserious
imprecision

267/1315
(20.30%)

NationalClinicalGuidelineCentre,2013.

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StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

Qualityassessment

Summaryoffindings
Effect

Noof
studies
103
;
Stockholm
273
;
Svendborg
148
;
Trondheim
120
;Umea
248

Design

Limitations

Inconsistency

Indirectness

Imprecision

Organised
strokeunit
care
Mean(SD)/
Frequency
(%)

Risk
ratio(RR)/
General
Standardise
medical
dMean
wards
Difference
Mean(SD)/ (SMD)/
Frequency Relative
(%)
(95%CI)

Absolute
effect(95%
CI)

Confidenc
e(in
effect)

DeathbytheendofscheduledfollowupRehabilitationstrokewardversusgeneralmedicalward
4
Dover
GMW247;
Nottingha
mGMW
126
;
Orpington
1993
GMW128;
Orpington
1995129

RCTsingle
blinded

Serious
limitation(a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
b)

58/285
(20.40%)

68/250
(27.20%)

RR0.77
(0.57to
1.03)

63fewer
per1000
(from117
fewerto8
more)

Low

51/298
(17.10%)

RR0.93
(0.66to

12fewer
per1000
(from58

Low

DeathbytheendofscheduledfollowupMixedrehabilitationwardversusgeneralmedicalward
6
Birmingha

RCTsingle
blinded

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision(f

49/332
(14.80%)

NationalClinicalGuidelineCentre,2013.

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StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

Qualityassessment

Summaryoffindings
Effect

Noof
studies
Design
201
m ;
Helsinki132;
Illinois96;
Kuopio239;
NewYork
81
;
Newcastle
4

Limitations

Inconsistency

Indirectness

Imprecision
)

Noserious
indirectness

Noserious
imprecision

Organised
strokeunit
care
Mean(SD)/
Frequency
(%)

Risk
ratio(RR)/
General
Standardise
medical
dMean
wards
Difference
Mean(SD)/ (SMD)/
Frequency Relative
(%)
(95%CI)
1.31)

Absolute
effect(95%
CI)
fewerto53
more)

Confidenc
e(in
effect)

50fewer
per1000
(from21
fewerto79
fewer)

Moderate

RR0.9(0.82 41fewer
to0.99)
per1000
(from4
fewerto73
fewer)

Moderate

Deathorinstitutionalcarebytheendofscheduledfollowup
19
Seesub
group
below
(next6
rows)

RCTsingle
blinded

Serious
limitation(a)

Noserious
inconsistency

695/1901
(36.60%)

746/1784
(41.80%)

RR0.88
(0.81to
0.95)

DeathorinstitutionalcarebytheendofscheduledfollowupComprehensivestrokewardversusgeneralmedicalward
10
Beijing162;
Edinburgh
90
;
Goteborg
Ostra253;
Goteberg

RCTsingle
blinded

Serious
limitation(a)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

477/1315
(36.30%)

511/1259
(40.60%)

NationalClinicalGuidelineCentre,2013.

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StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

Qualityassessment

Summaryoffindings
Effect

Noof
studies
Sahlgren
78
;Joinville
35
;Perth
103
;
Stockholm
273
;
Svendborg
148
;
Trondheim
120
;Umea
248

Design

Limitations

Inconsistency

Indirectness

Imprecision

Organised
strokeunit
care
Mean(SD)/
Frequency
(%)

Risk
ratio(RR)/
General
Standardise
medical
dMean
wards
Difference
Mean(SD)/ (SMD)/
Frequency Relative
(%)
(95%CI)

Absolute
effect(95%
CI)

Confidenc
e(in
effect)

62fewer
per1000
(from129
fewerto22
more)

Low

DeathorinstitutionalcarebytheendofscheduledfollowupRehabilitationstrokewardversusgeneralmedicalward
4
Dover
GMW247;
Nottingha
mGMW
126
;
Orpington
1993
GMW128;
Orpington
1995129

RCTsingle
blinded

Serious
limitation(a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
b)

105/283
(37.10%)

111/250
(44.40%)

DeathorinstitutionalcarebytheendofscheduledfollowupMixedrehabilitationwardversusgeneralmedicalward

NationalClinicalGuidelineCentre,2013.

65

RR0.86
(0.71to
1.05)

StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

Qualityassessment

Summaryoffindings
Effect

Noof
studies

Design

5
RCTsingle
132
Helsinki ; blinded
Illinois96;
Kuopio239;
NewYork
81
;
Newcastle
4

Organised
strokeunit
care
Mean(SD)/
Frequency
(%)

Risk
ratio(RR)/
General
Standardise
medical
dMean
wards
Difference
Mean(SD)/ (SMD)/
Frequency Relative
(%)
(95%CI)

Absolute
effect(95%
CI)

Confidenc
e(in
effect)

Limitations

Inconsistency

Indirectness

Imprecision

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
b)

113/303
(37.30%)

124/275
(45.10%)

RR0.82
(0.68to
0.99)

81fewer
per1000
(from5
fewerto
144fewer)

Moderat
e

Noserious
indirectness

Noserious
imprecision

792/1415
(56%)

836/1346
(62.10%)

RR0.89
(0.84to
0.95)

68fewer
per1000
(from31
fewerto99
fewer)

Moderat
e

RR0.89
(0.82to
0.97)

67fewer
per1000
(from18
fewerto
110fewer)

Moderate

Deathordependencybytheendofscheduledfollowup
17
Seesub
group
below
(next6
rows)

RCTsingle
blinded

Serious
limitation(a)

Noserious
inconsistency

DeathordependencybytheendofscheduledfollowupComprehensivestrokewardversusgeneralmedicalward
7
Beijing162;
Edinburgh
90
;
Goteberg
Sahlgren
78
;Joinville

RCTsingle
blinded

Serious
limitation(a)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

448/800
(56%)

487/798
(61%)

NationalClinicalGuidelineCentre,2013.

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StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

Qualityassessment

Summaryoffindings
Effect

Noof
studies
35
;Perth
103
;
Trondheim
120
;Umea
248

Design

Limitations

Inconsistency

Indirectness

Imprecision

Organised
strokeunit
care
Mean(SD)/
Frequency
(%)

Risk
ratio(RR)/
General
Standardise
medical
dMean
wards
Difference
Mean(SD)/ (SMD)/
Frequency Relative
(%)
(95%CI)

Absolute
effect(95%
CI)

Confidenc
e(in
effect)

RR0.95
(0.85to
1.06)

36fewer
per1000
(from107
fewerto43
more)

Moderat
e

RR0.83
(0.71to
0.96)

98fewer
per1000
(from23
fewerto

Moderat
e

DeathordependencybytheendofscheduledfollowupRehabilitationstrokewardversusgeneralmedicalward
4
RCTsingle
blinded
Dover
GMW247;
Nottingha
mGMW
126
;
Orpington
1993
GMW128;
Orpington
1995(Kalra
1995)129

Serious
limitation(a)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

189/283
(66.80%)

178/250
(71.20%)

DeathordependencybytheendofscheduledfollowupMixedrehabilitationwardversusgeneralmedicalward
6
RCTsingle
blinded
Birmingha
201
m ;
Helsinki132;

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
b)

155/332
(46.70%)

171/298
(57.40%)

NationalClinicalGuidelineCentre,2013.

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StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

Qualityassessment

Summaryoffindings
Effect

Noof
studies
Illinois96;
Kuopio239;
NewYork
81
;
Newcastle
4

Design

Limitations

Inconsistency

Indirectness

Imprecision

Organised
strokeunit
care
Mean(SD)/
Frequency
(%)

Risk
ratio(RR)/
General
Standardise
medical
dMean
wards
Difference
Mean(SD)/ (SMD)/
Frequency Relative
(%)
(95%CI)

SeeForest
plotsfor
study
meansand
SDs

SeeForest
plotsfor
study
meansand
SDs

Absolute
effect(95%
CI)
166fewer)

Confidenc
e(in
effect)

Lengthofstay(days)inahospitalorinstitution(Betterindicatedbylowervalues)
16
Seesub
group
below
(next6
rows)

RCTsingle
blinded

Serious
limitation(a)

Serious
inconsistency(c
)

Noserious
indirectness

Noserious
imprecision

0.09(
0.24,0.05)

SMD0.09
Low
lower(0.24
lowerto
0.05higher)

Lengthofstay(days)inahospitalorinstitutionComprehensivestrokewardversusgeneralmedicalward(Betterindicatedbylowervalues)
10
Beijing162;
Edinburgh
90
;
Goteborg
Ostra253;
Goteberg
Sahlgren
78
;Joinville

RCTsingle
blinded

Serious
limitation(a)

Serious
inconsistency(d
)

Noserious
indirectness

Noserious
imprecision

SeeForest
plotsfor
study
meansand
SDs

SeeForest
plotsfor
study
meansand
SDs

NationalClinicalGuidelineCentre,2013.

68

0.19(
0.35,0.02)

SMD0.19
lower(0.35
to0.02
lower)

Low

StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

Qualityassessment

Summaryoffindings
Effect

Noof
studies
35
;Perth
103
;
Stockholm
273
;
Svendborg
148
;
Trondheim
120
;Umea
248

Design

Limitations

Inconsistency

Indirectness

Imprecision

Organised
strokeunit
care
Mean(SD)/
Frequency
(%)

Risk
ratio(RR)/
General
Standardise
medical
dMean
wards
Difference
Mean(SD)/ (SMD)/
Frequency Relative
(%)
(95%CI)

Absolute
effect(95%
CI)

Confidenc
e(in
effect)

Lengthofstay(days)inahospitalorinstitutionRehabilitationstrokewardversusgeneralmedicalward(Betterindicatedbylowervalues)
3
Dover
GMW247;
Nottingha
mGMW
126
;
Orpington
1993
GMW128

RCTsingle
blinded

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(e
)

Dover
GMW:0(0)
Nottingham
GMW:
76.72
(39.37)
Orpington
1993GMW:
0(0)

Dover
GMW:0(0)
Nottingham
GMW:
60.38
(48.91)
Orpington
1993
GMW:0(0)

0.37(0.07,
0.67)

SMD0.37
Moderat
higher(0.07 e
to0.67
higher)

Lengthofstay(days)inahospitalorinstitutionMixedrehabilitationwardversusgeneralward(Betterindicatedbylowervalues)
3
RCTsingle
132
Helsinki ; blinded
Kuopio239;

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

Helsinki:
23.6(38.8)
Kuopio:

Helsinki:
30.5(70.6)
Kuopio:

NationalClinicalGuidelineCentre,2013.

69

0.08(0.21,
0.37)

SMD0.08
High
higher(0.21
lowerto

StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

Qualityassessment

Summaryoffindings
Effect

Noof
studies
Newcastle
4

Design

Limitations

Inconsistency

Indirectness

Imprecision

Organised
strokeunit
care
Mean(SD)/
Frequency
(%)
162.5(125)
Newcastle:
52(45)

Risk
ratio(RR)/
General
Standardise
medical
dMean
wards
Difference
Mean(SD)/ (SMD)/
Frequency Relative
(%)
(95%CI)
129.5(119)
Newcastle:
41(34)

Absolute
effect(95%
CI)
0.37higher)

Confidenc
e(in
effect)

(a)
(b)
(c)
(d)
(e)
(f)

Unclearrandomisation;unclearallocationconcealment.Limitationswereconsideredbystudyweightsinthemetaanalysis
ConfidenceintervalcrossesoneendofdefaultMID(0.75)
Heterogeneity;I2=73%
Heterogeneity;I2=74%
ConfidenceintervalcrossesoneendofdefaultMID(0.5)
ConfidenceintervalcrossesbothendsofdefaultMID(0.75;1.25)

Comparison:Comprehensive/rehabilitationstrokeunitversusgeneralmedicalward(longtermfollowup)
Table11: Comprehensive/rehabilitationstrokeunitversusgeneralmedicalwardClinicalstudycharacteristicsandclinicalsummaryoffindings

Qualityassessment
Noof

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Organised

General

NationalClinicalGuidelineCentre,2013.

70

Effect

Confidence
(ineffect)

StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

studies

strokeunit

Mean(SD)/
Frequency
(%)

medical
ward
Mean
(SD)/
Frequency
(%)

Riskratio(RR)/
Standardised
Mean
Difference
(SMD)/
(95%CI)

Absolute
effect/
Standardis
edMean
Difference
(SMD)
(95%CI)

Deathatfiveyearfollowup
2
Nottingh
am126;
Trondhei
m120

RCTsingle
blinded

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
a)

144/286
(50.30%)

155/249
(62.20%)

RR0.82(0.71
to0.95)

112fewer Moderate
per1000
(from31
fewerto
181fewer)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

172/286
(60.10%)

178/249
(71.50%)

RR0.85(0.75
to0.96)

107fewer High
per1000
(from29
fewerto
179fewer)

Noserious
limitation

Serious
inconsistency(b
)

Noserious
indirectness

Noserious
imprecision

223/286
(78%)

214/249
(85.90%)

RR0.91(0.84
to0.99)

77fewer
Moderate
per1000
(from9
fewerto
138fewer)

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

205/286
(71.70%)

207/249
(83.10%)

RR0.87(0.79
to0.95)

108fewer High
per1000
(from42
fewerto
175fewer)

Deathorinstitutionalcareatfiveyearfollowup
2
Nottingh
am126;
Trondhei
m120

RCTsingle
blinded

Noserious
limitation

Deathordependencyatfiveyearfollowup
2
Nottingh
am126;
Trondhei
m120

RCTsingle
blinded

Deathat10yearfollowup
2
Nottingh
am126;
Trondhei
m120

RCTsingle
blinded

Deathorinstitutionalcareat10yearfollowup

NationalClinicalGuidelineCentre,2013.

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StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

Qualityassessment

Summaryoffindings
Effect

Noof
studies
2
Nottingh
am126;
Trondhei
m120

Organised
strokeunit

Mean(SD)/
Frequency
(%)

General
medical
ward
Mean
(SD)/
Frequency
(%)

Riskratio(RR)/
Standardised
Mean
Difference
(SMD)/
(95%CI)

Absolute
effect/
Standardis
edMean
Difference
(SMD)
(95%CI)

Confidence
(ineffect)

Design

Limitations

Inconsistency

Indirectness

Imprecision

RCTsingle
blinded

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

220/286
(76.90%)

214/249
(85.90%)

RR0.9(0.83to
0.98)

86fewer
High
per1000
(from17
fewerto
146fewer)

Serious
inconsistency(c
)

Noserious
indirectness

Noserious
imprecision

249/286
(87.10%)

224/249
(90%)

RR0.97(0.91
to1.03)

27fewer
per1000
(from81
fewerto
27more)

Deathordependencyat10yearfollowup
2
Nottingh
am126;
Trondhei
m120

RCTsingle
blinded

Noserious
limitation

(a) ConfidenceintervalcrossesoneendofdefaultMID(0.75)
(b) Heterogeneity;I2=64%
(c) Heterogeneity;I2=51%

NationalClinicalGuidelineCentre,2013.

72

Moderate

StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

5.1.1.2

Economicevidence
Twostudiesthatincludedtherelevantcomparisonarereviewed44,176.Thesearesummarisedinthe
economicevidenceprofilebelow(Table12andQALYsnotused
(a)
(b)
(c)
(d)
(e)
(f)

SomeuncertaintyaboutapplicabilityofnonUKresourceuseandunitcosts
Someuncertaintyaboutapplicabilityofresourceuseandunitcostsfromover10yearsago
Someuncertaintyininterpretingtheresultsoftheanalysisintermsofthehealthoutcomes
Nosensitivityanalysis
Costingisbasedonthepracticeofonehospitalsouncertaintyastowhetheritreflectsnationalcosts
Someuncertaintyaboutthecomparabilityofthehealthoutcomesintheanalysistothosespecifiedinthereview
protocol

Table13).SeealsothefullstudyevidencetablesinAppendixI.
Onestudy(Major,1996165)thatmettheinclusioncriteriawasselectivelyexcludeddueto
methodologicallimitations.
Table12: StrokeunitsversusgeneralmedicalwardcareEconomicstudycharacteristics
Study
44

Claesson2000
(Sweden)

Applicability Limitations

Othercomments

Partially
applicable
(a)(b)(c)

Costconsequenceanalysis(varioushealthoutcomes)
Acutestrokeunitswerelinkedtoageriatricwardfor
longertermrehabilitation
Withintrialanalysis,clinicaleffectivenessdatareported
separatelyinFagerberg200078(includedinclinical
review)

Potentially
serious
limitations
(e)(f)

Moodie2006176
(Australia)

Partially
applicable
(a)(b)(d)

Veryserious
limitations
(e)(g)

Costeffectivenessanalysis(healthoutcomes=
thoroughadherencetodefinedprocessofcare
measuresandratesofseveremedicalcomplications)
Strokecareunitvs.generalmedicalward
Withintrialanalysis

(g) QALYsnotused
(h) SomeuncertaintyaboutapplicabilityofnonUKresourceuseandunitcosts
(i) Someuncertaintyaboutapplicabilityofresourceuseandunitcostsfromover10yearsago
(j) Someuncertaintyininterpretingtheresultsoftheanalysisintermsofthehealthoutcomes
(k) Nosensitivityanalysis
(l) Costingisbasedonthepracticeofonehospitalsouncertaintyastowhetheritreflectsnationalcosts
(m) Someuncertaintyaboutthecomparabilityofthehealthoutcomesintheanalysistothosespecifiedinthereview
protocol

Table13: StrokeunitsversusgeneralmedicalwardcareEconomicsummaryoffindings
Incremental
cost

Study
44

Incrementaleffects

Costeffectiveness

Uncertainty

Claesson2000
(Sweden)

Saves845
(a)

Nosignificantdifference

N/A

NR

Moodie2006176
(Australia)

1553
(b)

Higheradherencetoprocess
indicatorsandreducedrate
ofseveremedical
complicationswasobserved
onstrokeunits

4891perpatientwith
thoroughadherence
gained
8116perpatientwith
severecomplications
avoided

NR

N/A=notapplicable;NR=notreported
(a) ConvertedtoUKpoundsusingexchangeratequotedinthestudy

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(b) ConvertedtoUKpoundsusingrelevantpurchasingpowerparities194

5.1.1.3

Evidencestatements
Clinicalevidencestatements
Deathbytheendofscheduledfollowup
Twentystudiescomprising3739participantsfoundnosignificantdifferenceinrateofmortality
betweenorganisedstrokeunits(comprehensive,rehabilitationand,mixedrehabilitationwards)and
generalmedicalwardbytheendofscheduledfollowup(MODERATECONFIDENCEINEFFECT).
Tenstudies162902537835103273148120248comprising2574participantsfoundnosignificant
differenceinrateofmortalitybetweencomprehensivestrokewardandgeneralmedical
wardbytheendofscheduledfollowup(MODERATECONFIDENCEINEFFECT).
Fourstudies247126128129comprising535participantsfoundnosignificantdifferenceinrate
ofmortalitybetweenrehabilitationstrokewardandgeneralmedicalwardbytheendof
scheduledfollowup(LOWCONFIDENCEINEFFECT).
Sixstudies20113296239814comprising630participantsfoundnosignificantdifferenceinrate
ofmortalitybetweenmixedrehabilitationwardandgeneralmedicalwardbytheendof
scheduledfollowup(LOWCONFIDENCEINEFFECT).
Deathorinstitutionalcarebytheendofscheduledfollowup
Nineteenstudiescomprising3685participantsfoundthatsignificantlyfewerpeopleintheorganised
strokeunit(comprehensive,rehabilitationand,mixedrehabilitationwards)diedorrequired
institutionalcarebytheendofscheduledfollowupcomparedtogeneralmedicalward(MODERATE
CONFIDENCEINEFFECT).
Tenstudies162902537835103273148120248comprising2574participantsfoundthatsignificantly
fewerpeopleincomprehensivestrokewarddiedorrequiredinstitutionalcarebytheendof
scheduledfollowupcomparedtogeneralmedicalward(MODERATECONFIDENCEIN
EFFECT).
Fourstudies247126128129comprising533participantsfoundnosignificantdifferenceinrate
ofmortalityorinstitutionalcarebetweenrehabilitationstrokewardandgeneralmedical
wardbytheendofscheduledfollowup(LOWCONFIDENCEINEFFECT).
Fivestudies13296239814comprising578participantsfoundthatsignificantlyfewerpeoplein
themixedrehabilitationwarddiedorrequiredinstitutionalcarebytheendofscheduled
followupcomparedtogeneralmedicalward(MODERATECONFIDENCEINEFFECT).
Deathordependencybytheendofscheduledfollowup
Seventeenstudiescomprising2763participantsfoundthatsignificantlyfewerpeopleinorganised
strokeunit(comprehensive,rehabilitationand,mixedrehabilitationwards)diedorweredependent
bytheendofscheduledfollowupcomparedtogeneralmedicalward(MODERATECONFIDENCEIN
EFFECT).
Sevenstudies162907835103120248comprising1598participantsfoundthatsignificantlyfewer
peopleincomprehensivestrokewarddiedorweredependentbytheendofscheduled
followupcomparedtogeneralmedicalward(MODERATECONFIDENCEINEFFECT).

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Fourstudies247126128129comprising535participantsfoundnosignificantdifferenceinrate
ofmortalityordependencybetweentherehabilitationstrokewardandgeneralmedical
wardbytheendofscheduledfollowup(MODERATECONFIDENCEINEFFECT).
Sixstudies20113296239814comprising630participantsfoundthatsignificantlyfewerpeoplein
themixedrehabilitationwarddiedorweredependentbytheendofscheduledfollowup
comparedtogeneralmedicalward(MODERATECONFIDENCEINEFFECT).
Lengthofstay(days)inhospitalorinstitution
Sixteenstudiescomprising3121participantsfoundnosignificantdifferenceinlengthofstay(days)in
hospitalorinstitutionorbothbetweenorganisedstrokeunits(comprehensive,rehabilitation,and
mixedrehabilitationstrokewards)andgeneralmedicalwards(LOWCONFIDENCEINEFFECT).
Tenstudies162902537835103273148120248comprising2556participantsfoundastatistically
significantdifferenceinlengthofstay(days)inhospitalorinstitutioninfavourof
comprehensivestrokewardcomparedtogeneralmedicalward(LOWCONFIDENCEIN
EFFECT).
Threestudies247126128comprising178participantsfoundastatisticallysignificantdifference
inlengthofstay(days)inahospitalorinstitutioninfavourofgeneralmedicalward
comparedtorehabilitationstrokeward(MODERATECONFIDENCEINEFFECT).
Threestudies1324,239comprising387participantsfoundnosignificantdifferenceinlengthof
stay(days)inhospitalorinstitutionbetweenmixedrehabilitationwardandgeneralmedical
ward(HIGHCONFIDENCEINEFFECT).
Deathatfiveyearfollowup
Twostudies126120comprising535participantsfoundthatsignificantlyfewerpeopleintheorganised
strokeunit(comprehensiveandrehabilitationstrokewards)diedatfiveyearfollowupcomparedto
generalmedicalward(MODERATECONFIDENCEINEFFECT).
Deathorinstitutionalcareatfiveyearfollowup
Twostudies126120comprising535participantsfoundthatsignificantlyfewerpeopleintheorganised
strokeunit(comprehensiveandrehabilitationstrokeward)diedorrequiredinstitutionalcareatfive
yearfollowupcomparedtogeneralmedicalward(HIGHCONFIDENCEINEFFECT).
Deathordependencyatfiveyearfollowup
Twostudies126120comprising535participantsfoundthatsignificantlyfewerpeopleintheorganised
strokeunit(comprehensiveandrehabilitationstrokeward)diedorweredependentatfiveyear
followupcomparedtogeneralmedicalward(MODERATECONFIDENCEINEFFECT).
Deathat10yearfollowup
Twostudies126120comprising535participantsfoundthatsignificantlyfewerpeopleintheorganised
strokeunit(comprehensiveandrehabilitationstrokeward)diedat10yearfollowupcomparedto
generalmedicalward(HIGHCONFIDENCEINEFFECT).
Deathorinstitutionalcareat10yearfollowup
Twostudies126120comprising535participantsfoundthatsignificantlyfewerpeopleintheorganised
strokeunit(comprehensiveandrehabilitationstrokeward)diedorrequiredinstitutionalcareat10
yearfollowupcomparedtogeneralmedicalward(HIGHCONFIDENCEINEFFECT).
Deathordependencyat10yearfollowup

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Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke
Twostudies126120comprising535participantsfoundnosignificantdifferenceinrateofmortalityor
dependencybetweentheorganisedstrokeunit(comprehensiveandrehabilitationstrokeward)and
generalmedicalwardat10yearfollowup(MODERATECONFIDENCEINEFFECT).
Economicevidencestatements
Onepartiallyapplicablestudywithpotentiallyseriouslimitationsshowedthatthecostsper
patientinastrokeunitwaslowercomparedtoageneralmedicalwardwithnosignificant
differenceintermsofhealthoutcomes.
Onepartiallyapplicablestudywithveryseriouslimitationsshowedthatcareonstokeunitscost
morethancareongeneralmedicalwards.However,thequalityofcaredeliveredonstrokeunits
wasmuchhigher.

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5.1.2

Recommendationsandlinkstoevidence
1. Peoplewithdisabilityafterstrokeshouldreceive
rehabilitationinadedicatedstrokeinpatientunitand
subsequentlyfromaspecialiststroketeamwithinthe
community.
2. Aninpatientstrokerehabilitationserviceshouldconsistof
thefollowing:
adedicatedstrokerehabilitationenvironment
acoremultidisciplinaryteam(seerecommendation3)
whohavetheknowledge,skillsandbehaviourstoworkin
partnershipwithpeoplewithstrokeandtheirfamiliesand
carerstomanagethechangesexperiencedasaresultofa
stroke.
accesstootherservicesthatmaybeneeded,forexample:
- continenceadvice
- dietetics
- electronicaids(forexample,remotecontrolsfor
doors,lightsandheating,andcommunicationaids)
- liaisonpsychiatry
- orthoptics
- orthotics
- pharmacy
- podiatry
- wheelchairservices
amultidisciplinaryeducationprogramme.
Recommendation

Relativevaluesofdifferent
outcomes

DeathordependencyorinstitutionalcarewereconsideredbytheGDG
tobethemostcriticaloutcomesqualityoflifeandpatientandcarer
satisfactionwerealsoimportantoutcomes.Durationofstayinhospital
orinstitutionorboth,wasseenaslessimportantoutcomessincesuch
measuresareoftenveryvariableandoftenaffectedbyoutliers.The
Cochranereviewreporteddeath,admittancetoinstitutionalcareand
lengthofhospitalstayasoutcomes.

Tradeoffbetweenclinical
benefitsandharms

TheGDGagreedthatthereisclearevidencethatoutcomesforpatients
withresidualdisabilityarebetterwhenmanagedinadedicatedstroke
rehabilitationunitattheposttwoweekperiodafterstroke.Thishas
beendemonstratedbothinthepapersconsideredbutalsofrom
experienceinclinicalpractice.TheGDGacknowledgedthatfromthe
rehabilitationunitpeoplewouldbeassessedforsuitabilityforearly
supporteddischargeortoremainonthestrokerehabilitationunit.No
harmswereassociatedwithcareintheseunits.

Economicconsiderations

TheGDGrecognisedthattheavailabilityofstrokeunitsisstandard.
Strokeunitsareexpectedtobemoreexpensivethangeneralmedical
wardduetoprovisionofmorespecialisedservicesandincreased

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resourceuseforexample theuseofmorespecialisedstaff.
Aneconomicstudyshowedthatthecostsperpatientinastrokeunit
waslowercomparedtoageneralmedicalwardwithnosignificant
differenceintermsofhealthoutcomes,whileanothereconomicstudy
showedthatcareonstokeunitscostmorethancareongeneralmedical
wardsbutthequalityofcaredeliveredonstrokeunitswasmuchhigher.
Theeconomicstudiesincludedintheeconomicliteraturerevieware
basedonsingletrials,whereastheNCGCclinicalreviewpoolstheoverall
effectivenessofstrokeunitsfromseveralRCTs.Thepotentialbenefits
(decreasedmortality,decreaseddependencyandneedfor
institutionalisedcare)ofdedicatedstrokeunitsarethoughttobelikely
tooffsetthecosts.
Qualityofevidence

Theveryacutestrokepopulation(2weekspoststoke)wasexcluded
fromthisreviewbecausethispopulationhasalreadybeenaddressedin
theStrokeguideline(CG68).Thosestudiesthataddressedmobilestroke
unitswerealsoexcludedastheGDGagreedtreatmentwouldnotbe
providedviathismeansanymore.
TheincludedstudiesintheCochranereviewhadlargenumbersof
participants.Theconfidenceintheeffectofspecifiedoutcomesranged
fromlowtohighwiththemajoritybeingmoderate.
Organisedstrokeunitsshowedasignificantreductionindeathor
institutionalcareanddeathordependencyattheendofscheduled
followup.
Oftheorganisedstrokeunits,thecomprehensiveandrehabilitation
strokewardshowedasignificantreductionindeath;deathor
institutionalcareatfiveandtenyearfollowup;andareductionindeath
ordependencyatfiveyearfollowup.
Theevidencewasfoundtobeveryrobustforstrokerehabilitationunits
andmustremainamajorcomponentforstrokecarepathway.

Otherconsiderations

Strokerehabilitationunitsprovideanenvironmentforappropriate
assessmentforongoingcareandsupportforpeopleafterstroke.
Thedefinitionofwhataspecialiststrokerehabilitationserviceshould
consistofwastakenfromtheStrokeUnitTrialistsCollaboration
outlinedintheCochranereview251.TheGDGagreedthatthiswas
universallyacceptedandalthoughtheevidencecomesfrominpatient
strokeunitsitisequallyappropriateforearlysupporteddischarge
communityteams.TheGDGrecognisedthatstrokeisamultifaceted
conditionandthataccesstoservicesoutsidethosethatcanbeprovided
byacoremultidisciplinaryteamisimportant.ThereforetheGDG
specifiedtheseinthedescriptionoftheinpatientstrokerehabilitation
service.

5.2 Thecoremultidisciplinarystroketeam
5.2.1

EvidenceReview:Whatshouldbetheconstituencyofamultidisciplinaryrehabilitation
teamandhowshouldtheteamworktogethertoensurethebestoutcomesforpeople
whohavehadastroke?
Population

Adultsandyoungpeople16orolderwhohavehadastroke

Components

Constituencyofamultidisciplinaryrehabilitationteam
Workingpractices,suchascommunicationandcoordinationofservices(teamand
familymeetings,coordinationofcarebetweenrehabilitationspecialtiesandother
agencies)

Outcomes

Patientandcarersatisfaction

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5.2.2

Optimisedstrategiestominimiseimpairmentandmaximiseactivity/participation

Delphistatementswhereconsensuswasachieved
Table14: Tableofconsensusstatements,resultsandcomments(percentageintheresultscolumn
indicatestheoverallrateofresponderswhostronglyagreedwithastatementand
amountofcommentsinthefinalcolumnreferstorateofresponderswhousedthe
openendedcommentsboxes,i.e.No.peoplecommented/No.peoplewhoresponded
tothestatement)
Results
%

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes

Number

Statement

Acorestrokerehabilitationteam
shouldcompriseofmembershipfrom
thefollowingdisciplines:
Consultantneurology/strokemedicine
Nursing
Physiotherapy
Occupationaltherapy
SpeechandLanguageTherapy
ClinicalNeuropsychology
RehabilitationAssistant
Socialwork

81.0

89.1
99.0
99.0
99.0
74.0
72.2
71.2

28/101(28%)panelmembers
commented

Pharmacistsand
Nutritionist/Dieticiandidnotreach
consensus

Someotheroptionalteam
membersweresuggestedin
comments,forinstance:
Orthoptists
Counsellor
Familyorpatientsupportworker
Accesstorelevantotherssuchas
peerswithstroke,information
navigators,voluntarysector
organisations
Anopinionwasexpressedthat
differentspecialistsarerequiredat
differentstagesofrehabilitation
(Thecoreteamshouldbeavailable
althoughitisrecognisedthatat
differentstagesoftherehabilitation
pathwayanddependingonthe
needsofthepatientthelevelof
theseinputsmayvary.)

Theimportanceofvoluntarysector
involvementwasstatedwithregards
totheroleofacoordinator(This
rolecouldbeprovidedbythe
voluntarysector,thebestexample
beingtheStrokeAssociations
information,adviceandsupportco
ordinators.).

Throughoutthecarepathwayroles
andresponsibilitiesofthemulti
disciplinarystrokerehabilitationteam
servicesshouldbeclearlyoutlined,
documentedandcommunicatedto
thepatientandtheirfamily.

72.7

18/99(18%)panelmembers
commented

Informationtothefamilyofthe
personwhohashadastrokeshould

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5.2.3

Number

Statement

Inordertoinformanddirectfurther
assessment,membersoftheMDT
shouldscreenthepersonwhohashad
astrokeforarangeofimpairments
anddisabilities.

Results
%

81.0

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes
onlybegivenwithpatientsconsent

Communicationwasviewedas
integralinrehabilitationprocess

Extracts:
Verbalcommunicationshouldbe
supportedbyclear,unambiguous
writteninformationtoavoidany
subsequentdisputes/confusion.

Ithinkithelpscommunicationfor
patientsandstaff,howeverthe
frequencyandprocessofthishasto
berealisticinitsdelivery.
9/100(9%)commented:
Reliabilityandvalidityofscreening
instrumentswashighlighted

Reasonforscreening:
Screeningtoinformtreatment/
furtherassessmentratherthan
screeningforscreeningssake

Treatment:
Somepeoplecommentedthatthe
focusinstrokerehabilitationshould
beontreatmentratherthan
measurement.

Delphistatementwhereconsensuswasnotreached
Table15: Tableofnonconsensusstatementswithqualitativethemesofpanelcomments
Number
1.

Statement

Results

Thepersonwhohashadastrokeis
integratedinthestrokerehabilitation
team.

62.9

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Amountandcontentofpanel
commentsorthemes
26/100(26%)panelmembers
commentedinround2;29/84(35%)
commentedinround3and24/70
(34%)commentedinround4:

Impairmentsofthepersonswho
havehadastrokethataffect
participationshouldbeconsidered
forthisstatement.(Some
individualscaneasilymakeavery
activeandsubstantialcontribution
totheworkoftheteamwhereas
othersbecauseoftheseverityofthe
strokeorofanycommunication

StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

Number

2.

Statement

Results

Amemberofthemultidisciplinary
strokerehabilitationteamshouldbe
taskedwithcoordinationandsteering
(forexamplecommunication,family
liaisonandgoalplanning)ofthe
rehabilitationofthepersonwhohas
hadastrokeateachstageofthecare
pathway.

62.5

NationalClinicalGuidelineCentre,2013.
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Amountandcontentofpanel
commentsorthemes
difficultieswouldbemuchmore
limited.)

Patientpreference:
Itmaynotbethewishoftheperson
whohashadastroketoparticipate
intheteam(WhenIneedcareor
helpIwishtobetreatedwith
respect,dignityandasanequal,butI
viewtheMDTaspeoplewhosupport
me,advisemeandhaveclinical
expertise,theyaretheteamwho
helpme.).

Betweenrounds3and4the
statementwaschangedfrom:
isamemberof
to
isintegratedinthestroke
rehabilitationteam.

Mostpanelmembersobjectedto
theconceptofteammembership.

Theconceptofmembershipas
opposedtopartnershipwas
highlighted

Twopanelmembersexpressedthe
opinionthatthisstatementwas
redundant.
Adirectpromptwasgivenforthis
question(tolisttheroles).Inround2
61/100(61%)panelmembers
commented;48/85(56%)inround3
and34/72(47%)inround4:

Therewasalistofpossiblerolesfor
acoordinator:
Communication
Goalplanning
Familyliaison
Keyworking
Dischargeplanning
Singlepointofcontact

fewteamscoverthewholeofthe
strokecarepathwayandthiswould
notworkpractically.

whereamemberoftheteamis

StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

Number

5.2.4

Statement

Results

Amountandcontentofpanel
commentsorthemes
responsible,theprocessbecomes
sloweddown.

RecommendationsandlinkstoDelphiconsensussurvey
Statements

Recommendations

1. Acorestrokerehabilitationteamshouldcompriseofmembership
fromthefollowingdisciplines:
Consultantneurology/strokemedicine
Nursing
Physiotherapy
Occupationaltherapy
SpeechandLanguageTherapy
ClinicalNeuropsychology
Rehabilitationassistant
Socialworker
2. Throughoutthecarepathwayrolesandresponsibilitiesofthemulti
disciplinarystrokerehabilitationteamservicesshouldbeclearly
outlined,documentedandcommunicatedtothepatientandtheir
family.

3. Inordertoinformanddirectfurtherassessment,membersofthe
MDTshouldscreenthepersonwhohashadastrokeforarangeof
impairmentsanddisabilities.
3. Acoremultidisciplinarystrokerehabilitationteamshouldcomprise
thefollowingprofessionalswithexpertiseinstrokerehabilitation:
consultantphysicians
nurses
physiotherapists
occupationaltherapists
speechandlanguagetherapists
clinicalpsychologists
rehabilitationassistants
socialworkers.
4. Throughoutthecarepathway,therolesandresponsibilitiesofthe
coremultidisciplinarystrokerehabilitationteamshouldbeclearly
documentedandcommunicatedtothepersonandtheirfamilyor
carer.
5. Membersofthecoremultidisciplinarystroketeamshouldscreenthe
personwithstrokeforarangeofimpairmentsanddisabilities,in
ordertoinformanddirectfurtherassessmentandtreatment.

Otherconsiderations

SomeconcernwasexpressedthatasaresultoftheDelphisurvey
thepatientandfamilymemberswerenotpartoftheMDT(oneof

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thestatementsthatdidnotreachconsensus).Alotofcomments
hadbeenmadeonthiswithinthesurvey,andtheGDGthoughtit
maybebecauseofdifferentinterpretationsofthemeaningofthe
termteam.TheMDTismadeupofagroupofprofessionalswho
areemployedtodeliveraservice,andalthoughthepatientand
familymemberswouldbeinvolvedtheywouldnotbeconsidered
asanintrinsicpartoftheteamdeliveringarehabilitationservice.It
wasagreedthatitwasimportantthatthepatientisclearwhatthe
teamsfunctionisandwhateachindividualroledoes.TheGDG
acknowledgedthatthereisalackofinformationforpatientsand
theirfamiliesonthestructureofthestrokepathway,andon
individualteammembersresponsibilities.Itisoftenjustassumed
patientsalreadyhaveanunderstandingofwhatrehabilitation
servicesare.
Itwasthereforefeltthatdocumentingandcommunicatingthiswas
veryimportant.Therewasadiscussionofwhetheritwaspossible
toprovideaclearerdescriptionofhowthiswouldtakeplacein
practice.However,theGDGcametotheconclusionthatthere
wouldbeawidevariationdependingonwhereinthecarepathway
peoplewouldbe,andaccordingtoindividualdifficultiesand
priorities.TheGDGthereforedidnotwanttobetooprescriptive
aboutthisprocess.
Thegroupacknowledgedthatwhilststatingaclinicalneuro
psychologistwouldbetheideal,itwasnotrealisticastherewere
notenoughoftheseprofessionalscurrentlyavailable.Thereforea
recommendationforaclinicalpsychologistwasmade.Howeverthe
groupwereinstrongagreementthatpsychologicalservicesshould
beacorepartoftheMDTandthiswasnotalwaysthecaseat
present.Althoughconsensuswasreachedforaconsultant
neurologist/strokemedicinethiswasmodifiedbythegroupin
recognitionthatstrokemedicineinthiscountryisoneyeartraining
andphysicianscomefromavarietyofdifferenthostroutes.
TheGDGrecognisedthattherewerearangeofotherservicesthat
peoplemayrequireafterastroke,notcoveredbythecoreMDT,
butvitalinprovidingacomprehensiveservice.TheGDGalsoraised
theimportanceofprovidingguidanceonaccesstoarangeof
servicesthatmayberequiredandtheimportanceofspeedy
referraltootherhealthprofessionalexpertisesuchasdieticians,
continenceadvisors,orthoptists,orthotistsorpharmacy.A
recommendationwasthereforeincludedprovidingguidanceon
accesstoservicesoutsidethecoreteambasedoncommentsfrom
theDelphipanel(seerecommendation2).

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5.3 Healthandsocialcareinterface
5.3.1

Delphistatementswhereconsensuswasachieved
Table16: Tableofconsensusstatements,resultsandcomments(percentageintheresultscolumn
indicatestheoverallrateofresponderswhostronglyagreedwithastatementand
amountofcommentsinthefinalcolumnreferstorateofresponderswhousedthe
openendedcommentsboxes,i.e.No.peoplecommented/No.peoplewhoresponded
tothestatement)
Results
%

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes

Number

Statement

1.

Whereappropriate,socialworkers
shouldbeinvolvedwiththestroke
rehabilitationteamintheassessment
ofposthospitalcareneeds.

2.

Theroleofsocialcareandanyservice 72.7
provisionrequiredshouldbediscussed
withthepersonwhohashadastroke
anddocumentedwithinthesocialcare
plan.

10/99(10%)panelmembers
commented

Afewpanelmembershighlighted
therelationshipbetweenthis
statementandthejointcareplan
andthatthereshouldbeaccessto
onesetofnotes.

Acoupleofpeoplethoughtthatthis
shouldbediscussedfullywiththe
personwhohashadastrokeand
withthecarerornearestrelative.

Inanothercommentitwasstated
thatitisnotnecessarytodiscussthe
wholeplanwiththepersonwhohas
hadastrokeincasetheamountof
informationwasoverwhelming

3.

Whensocialneedsareidentifiedthere
needstobetimelyinvolvementof
socialservicestoensureseamless
transferfromprimarytocommunity
care.

11/100(11%)panelmembers
commented

Severalpanelmemberscommented
thatasocialworkershouldbepartof
theMDT.

Onepersoncommentedwhetherthe
statementshouldreadfrom
secondarytocommunitycarerather
thanfromprimarytocommunity
care.

72.0

76.8

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11/100(11%)panelmembers
commented

Thepanelassumedthatasocial
workerwouldbepartoftheMDT

Somepeoplethoughtthattheterm
appropriateneededtobedefined.

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Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

Results
%

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes
Anothercommentwasregardingthe
conceptsoftimelyandseamless
whichwerenotdefinedandthe
statementshouldbesetoutto
describeminimumstandards.

Number

Statement

4.

Coordinationbetweenhealthand
77.8
socialcareshouldincludeatimely,
accurateassessment(including
documentationandcommunication)
tofacilitatethetransitionalprocessfor
admission/returntocareornursing
homes.

10/99(10%)panelmembers
commented

Thisshouldalsoincludethe
managementstaffofthecarehome.

Socialworkershouldbepartofthe
MDT.

Therewouldbenoneedforthis
sinceintegratedhealthandsocial
careteamswoulddealwiththis.

Thetermtimelywasquestioned.

5.

Shouldfamilymemberswishto
participateinthecareoftheperson
whohashadastroketheyshouldbe
offeredtraininginassistingtheperson
whohashadastrokeintheiractivities
ofdailylivingpriortodischarge.

18/99(18%)panelmembers
commented

Thereweresomecommentsabout
theneedforconsentfromthe
personwhohashadastroke.

Thedifficultyofarrangingthisprior
todischargewasmentionedand
whetherthiscouldbedoneatthe
personshomewasraised.

Itwasalsostatedthatthereshould
notbeanassumptionthatpeople
arewillingtoprovidehighlevelsof
care.

Respitecareandcarersupport
optionsshouldalsobeidentifiedand
putinplace.

79.8

5.3.2

RecommendationsandlinkstoDelphiconsensussurvey
Statements

4. Whereappropriate,socialworkersshouldbeinvolvedwiththestroke
rehabilitationteamintheassessmentofposthospitalcareneeds.
5. Theroleofsocialcareandanyserviceprovisionrequiredshouldbe
discussedwiththepersonwhohashadastrokeanddocumented
withinthesocialcareplan.

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6. Whensocialneedsareidentifiedthereneedstobetimely
involvementofsocialservicestoensureseamlesstransferfrom
primarytocommunitycare.
7. Coordinationbetweenhealthandsocialcareshouldincludeatimely,
accurateassessment(includingdocumentationandcommunication)
tofacilitatethetransitionalprocessforadmission/returntocareor
nursinghomes.
8. Shouldfamilymemberswishtoparticipateinthecareoftheperson
whohashadastroketheyshouldbeofferedtraininginassistingthe
personwhohashadastrokeintheiractivitiesofdailylivingpriorto
discharge.Ifthereisanewidentifiedneedforfurtherstroke
rehabilitationservices,thepersonwhohashadastrokeshouldbe
abletoselfreferwiththesupportofaGPorspecialistcommunity
services.

Recommendations

Forrecommendationsonlongtermhealthandsocialsupportsee15.2.4.

6. Healthandsocialcareprofessionalsshouldworkcollaborativelyto
ensureasocialcareassessmentiscarriedoutpromptly,where
needed,beforethepersonwithstrokeistransferredfromhospital
tothecommunity.Theassessmentshould:
identifyanyongoingneedsofthepersonandtheirfamilyor
carer,forexample,accesstobenefits,careneeds,housing,
communityparticipation,returntowork,transportandaccessto
voluntaryservices.
bedocumentedandallneedsrecordedinthepersonshealthand
socialcareplan,withacopyprovidedtothepersonwithstroke.
7. Offertrainingincare(forexample,inmovingandhandlingand
helpingwithdressing)tofamilymembersorcarerswhoarewilling
andabletobeinvolvedinsupportingthepersonaftertheirstroke.
Reviewfamilymembersandcarerstrainingandsupportneeds
regularly(asaminimumatthepersons6monthandannual
reviews),acknowledgingthattheseneedsmaychangeovertime.

Economicconsiderations Therearesomecostsassociatedwiththesocialcareassessmentandwith
thetrainingforfamilymembers(stafftimecost).TheGDGhasconsidered
theeconomicimplicationsandconcludedthattheseinterventionswill
improvethequalityoflifeofthepersonwithstroke;theimprovementin
qualityoflifewasconsideredlikelytooutweighthecosts.
Otherconsiderations

Asocialcareassessmenttoidentifyneedstosupportthepersonand
carersfollowingdischargeisessential,andthebenefitsofhavingasocial
workeraspartofthemultidisciplinarystrokerehabilitationteamhas
beenacknowledged.Itwasagreedhavingsocialcarefullyintegrated
withintheMDThelpstoensureinformationiscommunicatedand
planningsupportfordischargeisconductedadequately.Itwas
recognisedthatthereisoftenadeficiencyintheprovisionofaco

NationalClinicalGuidelineCentre,2013.
86

StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke
ordinatedapproachtodeliveryofservicesincurrentpractice.An
assessmentmayberequiredatdifferentpointsofthecarepathwayand
includeothersettingssuchascarehomes.Thediscussionalsohighlighted
aneedformorejoinedupserviceprovisionandneedforspeedy
distributionofinformation/documentationbetweenservices.
Communicationiscurrentlycommonlyslowwhichthenleadstodelays
andintherehabilitationprocess.TheGDGalsoagreedthattheperson
whohashadastrokeandtheirfamily/carerneedtobefullyintegrated
inthisprocessandassuchreceiveacopyofthehealthandsocialcare
plan.
Provisionoftrainingforthecarerwhoiswillingandabletoprovide
supporthasbeenhighlighted.Itwasagreedthattheseneedswouldvary
atdifferentstagesofthepersonsrecovery,andthereforeshouldbe
reviewedatregularintervals.TheGDGagreedthattrainingandsupport
forcarerswasextremelyimportant.

5.4 Transferofcarefromhospitaltocommunity
Rehabilitation can take place in either the hospital or at home. There are potential advantages to
rehabilitationathomeincludinginterventionstargetedmoreaccuratelyatthepatientsneedswithin
their own environment, better patient and carer outcomes in terms of wellbeing and mood, and
greater costeffectiveness. There are also potential disadvantages, for example, delivering high
intensitytherapymaybemoredifficulttoorganiseinacommunitysetting.

5.4.1

Earlysupporteddischarge
Early supported discharge is an approach that promotes discharge from hospital for community
based rehabilitation as soon as possible once appropriate support is in place for both patient and
carer.ItislikelythatsomestrokepatientswillbeunsuitableforthisESDapproachbecauseoftheir
level of physical disability or because of significant prior morbidity. The components of early
supported discharge vary from service to service, the integrated health and social care inputs
offered, and varying skill mix and number. Identifying the clinical and cost effectiveness of ESD is
thuscomplexandmultifaceted.

5.4.2

EvidenceReview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofearly
supporteddischargeversususualcare?
ClinicalMethodologicalIntroduction

Population

Adultsandyoungpeople16orolderwhohavehadastroke

Intervention

Earlysupporteddischargeforstroke

Comparison

Usualcare;strokehospitalunits

Outcomes

BarthelIndex
Lengthofhospitalstay
FunctionalIndependenceMeasure(FIM)
Caregiverstrainindex
Falls
Readmissionstohospital
HospitalAnxietyandDepressionScale(HADS)

NationalClinicalGuidelineCentre,2013.
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StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke
ClinicalMethodologicalIntroduction

Mortality
QualityOfLife(anyoutcome)
NottinghamExtendedActivitiesofDailyLiving(NEADL)

5.4.2.1

Clinicalevidencereview
SearcheswereconductedforsystematicreviewsandRCTscomparingtheeffectivenessofearly
supporteddischargeversususualcareforpatientswithstroke.Onlystudieswithaminimumsample
sizeof20participants(10ineacharm)wereselected.Ten(10)RCTswereidentified.Table17
summarisesthepopulation,intervention,comparisonandoutcomesforeachofthestudies.
Table17: Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
STUDY

POPULATION

INTERVENTION

COMPARISON

OUTCOME

Anderson,
200010

Acutestroke
patientsthat
were
medically
stableand
suitabletobe
discharged
earlyfrom
hospitaltoa
community
rehabilitation
schemeand
hadsufficient
physicaland
cognitive
function.
Patients
includedin
thisstudy
weremildly
disabled277

Earlyhospital
dischargeand
individuallytailored
home
based/community
rehabilitation
(medianduration,5
weeks)byafulltime
occupational
therapist,a
consultantin
rehabilitation,
physiotherapists,
occupational
therapists,social
workers,speech
therapists,and
rehabilitationnurses.
Effortsweremadeso
thatdischargefrom
hospitalcouldoccur
within48hoursof
randomisation.
(N=42)
BarthelIndexat
randomisation
[median(IQR)]:85
(8097)

Conventionalcareand
rehabilitationinhospital,
eitheronanacutecare
medicalgeriatricwardorin
amultidisciplinarystroke
rehabilitationunitrunby
specialistsinrehabilitation
orgeriatricmedicine.
(N=44)
BarthelIndexat
randomisation[median
(IQR)]:86(7795)

Askim,
200412

Acutestroke
patientswith
a
Scandinavian
StrokeScale
(SSS)score
greaterthan2
pointsand
lessthan58
points.Iscore
suchasthis
indicatesthat

Extendedservice
consistingofstroke
unittreatment
combinedwitha
homebased
programmeoffollow
upcarecoordinated
byamobilestroke
teamthatoffersearly
supporteddischarge
andworksinclose
cooperationwiththe

Ordinaryservicedefinedas
thestrokeunittreatmentof
choiceaccordingto
evidencebased
recommendations.
(N=31)
Barthelindex,
mean/median:54.0/55.0

BarthelIndex
CaregiverStrain
index
Mortality
Lengthofhospital
stay

NationalClinicalGuidelineCentre,2013.
88

SF36
Mortality
Falls
Barthelindex
Caregiverstrain
index
Readmissionto
hospital
Lengthofhospital
stay

StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke
STUDY

POPULATION
patientswere
moderately
disabled277

INTERVENTION
COMPARISON
primaryhealthcare
systemduringthe
firstfourweeksafter
discharge.Themobile
teamconsistedofa
nurse,a
physiotherapist,an
occupational
therapistandthe
consultingphysician.
(N=31)
Barthelindex,
mean/median:
57.7/55.0

Bautz
Holtert,
200220

Acutestroke
patients;not
severely
disabledprior
tostroke;had
noother
medical
condition
likelyto
preclude
rehabilitation
andwere
medically
stable.
Patients
includedwere
moderatelyto
mildly
disabled277

Earlysupported
dischargewitha
multidisciplinary
teamforeachstroke
patientwasoffered
andsupportand
supervisionwas
providedfromthe
projectteam
wheneverneeded.
Fourweeksafter
discharge,the
patientsintheESD
groupwereseenat
theoutpatientclinic.
(N=42)
BarthelIndexsum
scoreatday7:
[median(IQR)]:16.5
(1219)

Conventionalproceduresfor Lengthofhospital
dischargeandcontinued
stay
rehabilitation,whichwere
Nottingham
anticipatedtobelesswell
ExtendedActivities
organized.
ofDailyLiving
(N=40)
Mortality
BarthelIndexsumscoreat
day7:[median(IQR)]:14
(1118)

Donnelly,
200469

Acutestroke
patientswith
nopre
existing
physicalor
mental
disabilitythat
wasjudgedto
makefurther
rehabilitation
inappropriate.
Patients
includedwere
moderately
(1014)to
mildly
disabled(15
19)277

Earlierhospital
dischargecombined
withcommunity
based
multidisciplinary
stroketeam
rehabilitation
comprising0.33
coordinator,1
occupational
therapist,1.5
physiotherapists,1
speechandlanguage
therapist,and2
rehabilitation
assistants.On
averagethenumber
ofhomevisitsovera
3monthperiodwas
2.5perweekeach
lasting45minutes.

Usualhospitalrehabilitation
comprisinginpatient
rehabilitationinastroke
unitandfollowup
rehabilitationinaday
hospital
(N=54)
BarthelIndexatbaseline:
mean(SD):13.89(3.93);
Median(range):15(16)

NationalClinicalGuidelineCentre,2013.
89

OUTCOME

BarthelIndex
Nottingham
ActivitiesofDaily
Living
SF36
EuroQoL
CaregiverStrain
index
Lengthofstay

StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke
STUDY

POPULATION

INTERVENTION
COMPARISON
PatientsintheCST
groupweretobe
dischargedassoonas
theirhomewas
assessed.
(N=59)
BarthelIndexat
baseline:mean(SD):
14.14(3.38);
Median(range):14
(13)

OUTCOME

Fjaeartoft, Acutestroke
200482
patientswith
a
Scandinavian
StrokeScale
(SSS)score
greaterthan2
pointsand
lessthan57
points(i.e.
moderately
disabled).

ExtendedStrokeUnit
Service(ESUS)
definedasstrokeunit
treatmentsimilarto
OSUScombinedwith
servicefromamobile
teamthatoffersearly
supporteddischarge
andcoordinates
furtherrehabilitation
andfollowupinclose
cooperationwiththe
primaryhealthcare
system.Theteam
consistedofanurse,
aphysiotherapist,an
occupational
therapist,anda
physician.
(N=160)

OrdinaryStrokeUnitService
(OSUS)consistingof
treatmentinacombined
acuteandrehabilitation
strokeunitand/orthe
primaryhealthcaresystem.
Alsodefinedasstrokeunit
treatmentaccordingto
evidencebased
recommendations.
(N=160)

Caregiverstrain
index
GlobalNottingham
HealthProfile1&2

Indredavik, Acutestroke
patientswith
2000121
a
Scandinavian
StrokeScale
(SSS)score
greaterthan2
pointsand
lessthan57
points.
Patients
includedwere
moderately
disabled277

ExtendedStrokeUnit
Service(ESUS)
definedasstrokeunit
treatmentsimilarto
OSUScombinedwith
servicefromamobile
teamthatoffersearly
supporteddischarge
andcoordinates
furtherrehabilitation
andfollowupinclose
cooperationwiththe
primaryhealthcare
system.Theteam
consistedofanurse,
aphysiotherapist,an
occupational
therapist,anda
physician.
(N=160)
BarthelIndex,
mean/median:

OrdinaryStrokeUnitService
(OSUS)consistingof
treatmentinacombined
acuteandrehabilitation
strokeunitand/orthe
primaryhealthcaresystem.
Alsodefinedasstrokeunit
treatmentaccordingto
evidencebased
recommendations.
(N=160)
BarthelIndex,
mean/median:58.5/60

BarthelIndex
Mortality

12monthqualityoflifefollowuponIndredavikstudy

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STUDY

POPULATION

INTERVENTION
60.4/65.0

COMPARISON

Mayo,
2000170

Acutestroke
patientswith
motordeficits
afterstroke
whohad
caregivers
willingand
ableto
providelivein
careforthe
subjectovera
4weekperiod
after
discharge
fromthe
hospital.
Patients
includedwere
mildly
disabled277

Rehabilitationat
homeafterprompt
dischargefrom
hospitalwiththe
immediateprovision
offollowupservices
byamultidisciplinary
teamoffering
nursing,physical
therapy(PT),
occupationaltherapy
(OT),speechtherapy
(ST),anddietary
consultation.
Durationof
interventionwas4
weeksforall
participants.
(N=58)
BarthelIndex:
8414.4

Usualcarepracticesfor
SF36
dischargeplanningand
BarthelIndex
referralforfollowup
services.Theseincluded
physiotherapy,occupational
therapyandspeechtherapy,
asrequestedbythe
patient'scareproviderand
offeredthroughextended
acutecarehospitalstay;
inpatientoroutpatient
rehabilitation;orhomecare
vialocalcommunityhealth
clinics
(N=56)
BarthelIndex:82.713.9

Rodgers,
1997219

Acutestroke
patientsthat
werenot
severely
handicapped
priortothe
incident
strokewithno
other
condition
likelyto
preclude
rehabilitation.
Patients
includedwere
moderately
disabled277

EarlySupported
Dischargewithhome
carefromtheStroke
DischargeTeam
(communitybased).
Theteamconsisted
ofanoccupational
therapist,
physiotherapist,
speechandlanguage
therapist,social
workerand
occupationaltherapy
technician.The
strokedischarge
rehabilitationservice
wasavailablefive
daysperweekbut
thehomecare
componentofthe
servicewasavailable
24hperdayand
sevendaysperweek
ifrequired.The
strokedischarge
servicewas
withdrawngradually
andacontactname
andnumberwas
providedtopatients
incaseofsubsequent
queriesorproblems
(N=46)

Inpatientandoutpatient
carewasprovidedforthe
controlgroupby
conventionalhospitaland
communityservices.
Dischargeplanningand
servicespostdischargefor
patientsrandomizedto
conventionalcarewere
arrangedandprovided
accordingtotheusual
practiceofeach
participatingwardorunit.
(N=46)
BarthelIndexat7dayspost
stroke:[median(range)]:13
(220)

NationalClinicalGuidelineCentre,2013.
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OUTCOME

Lengthofhospital
stay
Mortality
Nottingham
ExtendedActivities
ofDailyLiving
Readmissionto
hospital

StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke
STUDY

POPULATION

INTERVENTION
BarthelIndexat7
dayspoststroke:
[median(range)]:15
(220)

COMPARISON

OUTCOME

Rudd,
1997224

Stroke
patientsable
toperform
functional
independent
transferor
ableto
perform
transferwith
assistance

Earlydischargewitha
plannedcourseof
domiciliary
physiotherapy,
occupationaltherapy,
andspeechtherapy,
withvisitsas
frequentlyas
considered
appropriate
(maximumoneday
visitfromeach
therapist)forupto3
monthsafter
randomization.
(N=167)
Barthelscoreat
randomisation
rangedfrom020

Usualcarewithno
augmentationofsocial
servicesresources.
(N=164)
Barthelscoreat
randomisationrangedfrom
020

BarthelIndex
HospitalAnxiety
andDepression
Scale(HADS),
Caregiverstrain
index
Mortality

vonKoch
2000275

Stroke
patientswith
moderateto
severe
impairment

Earlysupported
Routinerehabilitation.
dischargeand
(N=41)
continued
rehabilitationat
homebyaspecialised
team.The
rehabilitation
programmewas
tailormadeforeach
patient,continuedin
theirhomesfor3to4
months(meanof12
visits(range331)by
ahomerehabilitation
teamtherapist).
(N=42)

NationalClinicalGuidelineCentre,2013.
92

BarthelIndex
Falls
Lengthofhospital
stay
Readmissionto
hospital

StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

Comparisonofearlysupporteddischargeversususualcare
Table18: Earlysupporteddischargeversususualcareclinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings
Qualityassessment

Effect

Author(s)

Absolute
effect/
Mean
Differenc
e(MD)
or
Standard
ised
Mean
Mean
difference/
Differenc
Median
e(SMD)
difference/
(95%CI)
SMD/Risk
orP
Ratio(95%CI) value

Design

Limitations

Inconsistency

Indirectness

Imprecision

Early
Supported
Discharge
Mean
(SD)/
Median
(range)/fr
equency
(%)

Usualcare
Mean
(SD)/
Median
(range)/
Frequency
(%)

Confidence
(ineffect)

BarthelIndex(6weeksfollowup)(Betterindicatedbyhighervalues)
Askim,200412

RCT

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(d)

75.2(30.6) 74(31.2)

1.20(14.71
to17.11)

MD1.20
higher
(14.71
lowerto
17.11
higher)

Moderate

Serious
imprecision
(d)

97.1(6.9)

95.1(10.6) 2.0(1.72to
5.72)

MD2.0
higher
(1.72
lowerto

Low

BarthelIndex(12weeksfollowup)(Betterindicatedbyhighervalues)
Mayo,2000170

RCT

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

NationalClinicalGuidelineCentre,2013.

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Summaryoffindings
Qualityassessment

Author(s)

Design

Effect

Limitations

Inconsistency

Indirectness

Early
Supported
Discharge
Mean
(SD)/
Median
(range)/fr
equency
(%)

Usualcare
Mean
(SD)/
Median
(range)/
Frequency
(%)

(m)

96.0(88.3
100)(h)

98.0(85.5
100)(h)

Serious
imprecision
(d)

75(32.9)

Serious
imprecision

Askim:
71.7

Imprecision

Absolute
effect/
Mean
Differenc
e(MD)
or
Standard
ised
Mean
Mean
difference/
Differenc
Median
e(SMD)
difference/
(95%CI)
orP
SMD/Risk
Ratio(95%CI) value
5.72
higher)

Confidence
(ineffect)

BarthelIndex(26weeksfollowup)(Betterindicatedbyhighervalues)
Anderson,
200010,

RCT

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

0(2.0to
2.0)(h)

(n)

Moderate
(m)

77.7(27.6) 2.70(19.59
to14.19)

MD2.70
lower
(19.59
lowerto
14.19
higher)

Moderate

Askim:
79.0

SMD
0.03

Low

BarthelIndex(26weeksfollowup)(Betterindicatedbyhighervalues)
Askim,200412

RCT

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

BarthelIndex(52weeksfollowup)(Betterindicatedbyhighervalues)
Askim,200412;
RCTs
Donnelly,200469;

Serious
limitations(

Noserious
inconsistency

Noserious
indirectness

NationalClinicalGuidelineCentre,2013.

94

0.03(0.16to
0.22)

StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

Summaryoffindings
Qualityassessment

Author(s)
Rudd,1997224

Design

Effect

Limitations
b)

Inconsistency

Indirectness

Imprecision
(d)

Absolute
effect/
Mean
Differenc
e(MD)
Early
or
Supported
Standard
Discharge Usualcare
ised
Mean
Mean
Mean
Mean
(SD)/
difference/
(SD)/
Differenc
Median
Median
e(SMD)
Median
difference/
(range)/fr (range)/
(95%CI)
equency
orP
Frequency SMD/Risk
(%)
(%)
Ratio(95%CI) value
(34.7);
(28.7);
higher
(0.16
Donnelly: Donnelly:
lowerto
17.98
17.15
0.22
(3.1);
(3.81);
higher)
Rudd:16.0 Rudd:16.0
(4.0)
(4.0)

Confidence
(ineffect)

BarthelIndex(26weeksfollowup)(Betterindicatedbyhighervalues)
Indredavik,
2000121

RCT

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

(f)

(g)

(g)

1.72(1.10
2.70)(h)

(g)

Moderate
(f)

(f)

(g)

(g)

2.75(0.77
9.77)(h)

(g)

Moderate
(f)

BarthelIndex(52weeksfollowup)(Betterindicatedbyhighervalues)
vonKoch,
2000275

RCT

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

NationalClinicalGuidelineCentre,2013.

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Summaryoffindings
Qualityassessment

Author(s)

Design

Effect

Limitations

Inconsistency

Early
Supported
Discharge
Mean
(SD)/
Median
(range)/fr
equency
(%)

Usualcare
Mean
(SD)/
Median
(range)/
Frequency
(%)

Absolute
effect/
Mean
Differenc
e(MD)
or
Standard
ised
Mean
Mean
difference/
Differenc
Median
e(SMD)
difference/
(95%CI)
orP
SMD/Risk
Ratio(95%CI) value

Indirectness

Imprecision

noserious
indirectness

Veryserious
imprecision
(e)

31/84
(36.9%)

32/85
(37.6%)

RR0.96(0.68
to1.35)

(m)

15.0(8.0
22.0)

30.0(17.3
48.5)

13.0(22.0to <0.001(h
6.0)
)

Confidence
(ineffect)

Falls(24and52weeksfollowup)(Betterindicatedbylowervalues)
Anderson,
200010;von,
2000275

RCT

Serious
limitations(c
)

noserious
inconsistency

15fewer Verylow
per1000
(from
120
fewerto
132
more)

Lengthofhospitalstay(6monthsfollowup)(Betterindicatedbylowervalues)
Anderson,
200010

RCT

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

NationalClinicalGuidelineCentre,2013.

96

Moderate
(m)

StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

Summaryoffindings
Qualityassessment

Effect

Author(s)

Design

Limitations

Inconsistency

Indirectness

Imprecision

Early
Supported
Discharge
Mean
(SD)/
Median
(range)/fr
equency
(%)

Usualcare
Mean
(SD)/
Median
(range)/
Frequency
(%)

Absolute
effect/
Mean
Differenc
e(MD)
or
Standard
ised
Mean
Mean
difference/
Differenc
Median
e(SMD)
difference/
(95%CI)
orP
SMD/Risk
Ratio(95%CI) value

(m)

22(h)

31(h)

(n)

(n)

Moderate
(m)

(o)

6(h)

6(h)

(o)

(o)

Moderate
(o)

Noserious
imprecision

Askim:
23.5
(30.5);
Mayo:9.8
(5.3);

Askim:
30.5
(44.8);
Mayo:
12.4(7.4);

3.34(5.44,
1.24)

MD3.34
lower
(5.44to
1.24
lower)

Moderate

Confidence
(ineffect)

Lengthofhospitalstay(6monthsfollowup)(Betterindicatedbylowervalues)
BautzHoltert,
200220

RCT

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Lengthofhospitalstay(6monthsfollowup)(Betterindicatedbylowervalues)
vonKoch
2000275

RCT

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Lengthofhospitalstay(52weeksfollowup)(Betterindicatedbylowervalues)
Askim,200412;
Mayo,2000170;
Rudd,1997224

RCT

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

NationalClinicalGuidelineCentre,2013.

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Summaryoffindings
Qualityassessment

Author(s)

Design

Effect

Limitations

Inconsistency

Indirectness

Absolute
effect/
Mean
Differenc
e(MD)
or
Standard
ised
Mean
Mean
difference/
Differenc
Median
e(SMD)
difference/
(95%CI)
orP
SMD/Risk
Ratio(95%CI) value

Early
Supported
Discharge
Mean
(SD)/
Median
(range)/fr
equency
(%)
Rudd:12
(19)

Usualcare
Mean
(SD)/
Median
(range)/
Frequency
(%)
Rudd:18
(24)

Veryserious
imprecision
(k)

(l)

(l)

8.00(23.25,
7.25)

MD8
lower
(23.25
lowerto
7.25
higher)

Verylow

Moderate
(m)

Imprecision

Confidence
(ineffect)

Lengthofhospitalstay(52weeksfollowup)(Betterindicatedbylowervalues)
Donnelly,
200469

RCT

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Lengthofhospitalstay(52weeksfollowup)(Betterindicatedbylowervalues)
Rodgers,1997219

RCT

Serious
limitations(
q)

Noserious
inconsistency

Noserious
indirectness

(m)

14(8
31)(h)

23(1158)
(h)

(n)

0.03(h)

Noserious

Noserious

Serious

49/444

65/482

RR0.75(0.53

34fewer Low

Mortality(1252weeksfollowup)
Anderson,

RCT

Serious

NationalClinicalGuidelineCentre,2013.

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Summaryoffindings
Qualityassessment

Author(s)
Design
10
2000 ,Askim,
200412;
BautzHolter,
200220;
Indredavik,
2000121;Rodgers,
1997219;Rudd,
1997224

Effect

Limitations
limitations(
b)

Inconsistency
inconsistency

Indirectness
indirectness

Imprecision
imprecision
(i)

Early
Supported
Discharge
Mean
(SD)/
Median
(range)/fr
equency
(%)
(10.1%)

Usualcare
Mean
(SD)/
Median
(range)/
Frequency
(%)
(10.1%)

Absolute
effect/
Mean
Differenc
e(MD)
or
Standard
ised
Mean
Mean
difference/
Differenc
Median
e(SMD)
difference/
(95%CI)
orP
SMD/Risk
Ratio(95%CI) value
to1.05)
per1000
(from63
fewerto
7more)

Confidence
(ineffect)

NottinghamADL(3monthsfollowup)(Betterindicatedbyhighervalues)
BautzHoltert,
200220

RCT

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

(m)

34.5(28
44)

30(1446)

(8to7)(h)

0.78(h)

Moderate(
m)

(m)

40(29
45)(h)

37(20
46)(h)

(8to7)(h)

0.93(h)

Moderate(
m)

NottinghamADL(6monthsfollowup)(Betterindicatedbyhighervalues)
BautzHoltert,
200220

RCT

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

NationalClinicalGuidelineCentre,2013.

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Summaryoffindings
Qualityassessment

Effect

Author(s)

Absolute
effect/
Mean
Differenc
e(MD)
or
Standard
ised
Mean
Mean
difference/
Differenc
Median
e(SMD)
difference/
(95%CI)
orP
SMD/Risk
Ratio(95%CI) value

Design

Limitations

Inconsistency

Indirectness

Imprecision

Early
Supported
Discharge
Mean
(SD)/
Median
(range)/fr
equency
(%)

Usualcare
Mean
(SD)/
Median
(range)/
Frequency
(%)

Confidence
(ineffect)

NottinghamADL(52weeksfollowup)(Betterindicatedbyhighervalues)
Donnelly,200469 RCT

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(j)

12.0(6.34) 10.43
(5.92)

1.57(0.87to
4.01)

MD1.57
higher
(0.87
lowerto
4.01
higher)

Moderate

(m)

10.0(018) 7.0(021)

(n)

(n)

Moderate(
m)

30/128
(23.4%)

RR1.16(0.73
to1.82)

32more Verylow
per1000
(from55
fewerto

NottinghamADL(52weeksfollowup)(Betterindicatedbyhighervalues)
Rodgers,1997219

RCT

Serious
limitations(
q)

Noserious
inconsistency

Noserious
indirectness

Readmissiontohospital(24&52weeksfollowup)(Betterindicatedbylowervalues)
Anderson,
200010;Rodgers,
1997219;von
Koch

RCT

Serious
limitations
(c,q)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision
(e)

26/128
(17.8%)

NationalClinicalGuidelineCentre,2013.

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Summaryoffindings
Qualityassessment

Author(s)
2000275

Design

Effect

Limitations

Inconsistency

Indirectness

Imprecision

Early
Supported
Discharge
Mean
(SD)/
Median
(range)/fr
equency
(%)

Usualcare
Mean
(SD)/
Median
(range)/
Frequency
(%)

Absolute
effect/
Mean
Differenc
e(MD)
or
Standard
ised
Mean
Mean
difference/
Differenc
Median
e(SMD)
difference/
(95%CI)
orP
SMD/Risk
Ratio(95%CI) value
167
more)

Confidence
(ineffect)

SF36AndersonPhysicalfunctioning(24weeksfollowup)(Betterindicatedbyhighervalues)
Anderson,
200010

RCT

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

41.3(29.1) 42.5(28.1) 1.2(13.3to

10.9)

MD1.2
lower
(13.3
lowerto
10.9
higher)

Moderate

SF36AndersonSocialfunctioning(24weeksfollowup)(Betterindicatedbyhighervalues)
Anderson,200010 RCT

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
j)

74.7(31.3) 82.8(23.8) 8.1(19.89to MD8.1

3.69)
lower
(19.89
lowerto
3.69
higher)

NationalClinicalGuidelineCentre,2013.

101

Low

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Summaryoffindings
Qualityassessment

Author(s)

Design

Effect

Limitations

Inconsistency

Indirectness

Imprecision

Early
Supported
Discharge
Mean
(SD)/
Median
(range)/fr
equency
(%)

Usualcare
Mean
(SD)/
Median
(range)/
Frequency
(%)

Absolute
effect/
Mean
Differenc
e(MD)
or
Standard
ised
Mean
Mean
difference/
Differenc
Median
e(SMD)
difference/
(95%CI)
orP
SMD/Risk
Ratio(95%CI) value

Confidence
(ineffect)

SF36Physicalhealth(12weeksfollowup)(Betterindicatedbyhighervalues)
Mayo,2000170

RCT

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(j)

42.9(10.1) 37.9(10.6) 5(0.82to

9.18)

MD5
higher
(0.82to
9.18
higher)

Low

Noserious
imprecision

46.5(11.7) 46.7(10.8) 0.2(4.73to

4.33)

MD0.2
lower
(4.73
lowerto
4.33
higher)

Moderate

Noserious

35.59

MD0.92

High

SF36Mentalhealth(12weeksfollowup)(Betterindicatedbyhighervalues)
Mayo,2000170

RCT

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

SF36Physicalhealth(52weeksfollowup)(Betterindicatedbyhighervalues)
Donnelly,200469 RCT

Noserious

Noserious

Noserious

34.67

NationalClinicalGuidelineCentre,2013.

102

0.92(11.71

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Summaryoffindings
Qualityassessment

Author(s)

Design

Effect

Limitations
limitations

Inconsistency
inconsistency

Indirectness
indirectness

Imprecision
imprecision

Early
Supported
Discharge
Mean
(SD)/
Median
(range)/fr
equency
(%)
(31.32)

Usualcare
Mean
(SD)/
Median
(range)/
Frequency
(%)
(32.01)

Absolute
effect/
Mean
Differenc
e(MD)
or
Standard
ised
Mean
Mean
difference/
Differenc
Median
e(SMD)
difference/
(95%CI)
orP
SMD/Risk
Ratio(95%CI) value
to13.55)
higher
(11.71
lowerto
13.55
higher)

Confidence
(ineffect)

SF36Mentalhealth(52weeksfollowup)(Betterindicatedbyhighervalues)
Donnelly,2004
69

RCT

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(j)

69.49
(18.26)

67.3
(20.07)

2.19(5.48to
9.86)

MD2.19
higher
(5.48
lowerto
9.86
higher)

Noserious
indirectness

Noserious
imprecision

66.36
(18.45)

68.21
(20.31)

1.85(9.60to MD1.85
5.90)
lower
(9.60
lowerto

Moderate

EuroQol(52weeksfollowup)(Betterindicatedbyhighervalues)
Donnelly,2004
69

RCT

Noserious
limitations

Noserious
inconsistency

NationalClinicalGuidelineCentre,2013.

103

High

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Summaryoffindings
Qualityassessment

Author(s)

Design

Effect

Limitations

Inconsistency

Indirectness

Imprecision

Absolute
effect/
Mean
Differenc
e(MD)
or
Standard
ised
Mean
Mean
difference/
Differenc
Median
e(SMD)
difference/
(95%CI)
orP
SMD/Risk
Ratio(95%CI) value
5.90
higher)

Early
Supported
Discharge
Mean
(SD)/
Median
(range)/fr
equency
(%)

Usualcare
Mean
(SD)/
Median
(range)/
Frequency
(%)

(l)

(l)

2.70(0.02to
5.38)

MD2.70 Moderate
higher
(0.02
higherto
5.38
higher)

(l)

(l)

4.90(0.46to
10.26)

MD4.90
higher(
0.46
lowerto
10.26
higher)

Confidence
(ineffect)

GlobalNottinghamHealthProfile1(52weeksfollowup)(Betterindicatedbyhighervalues)
Fjaeartoft,
200482

RCT

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(j)

GlobalNottinghamHealthProfile2(52weeksfollowup)(Betterindicatedbyhighervalues)
Fjaeartoft,
200482

RCT

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(j)

NationalClinicalGuidelineCentre,2013.

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Moderate

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Summaryoffindings
Qualityassessment

Effect

Author(s)

Usualcare
Mean
(SD)/
Median
(range)/
Frequency
(%)

Absolute
effect/
Mean
Differenc
e(MD)
or
Standard
ised
Mean
Mean
difference/
Differenc
Median
e(SMD)
difference/
(95%CI)
orP
SMD/Risk
Ratio(95%CI) value

7/126
(5.6%)

RR2.65(1.16
to6.05)

92more Low
per1000
(from9
moreto
281
more)

Design

Limitations

Inconsistency

Indirectness

Imprecision

Early
Supported
Discharge
Mean
(SD)/
Median
(range)/fr
equency
(%)

Confidence
(ineffect)

HospitalAnxietyandDepressionScaleAnxiety(52weeksfollowup)(Betterindicatedbylowervalues)
Rudd,1997224

RCT

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(i)

20/136
(14.7%)

HospitalAnxietyandDepressionScaleDepression(52weeksfollowup)(Betterindicatedbylowervalues)
Rudd,1997224

RCT

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision
(e)

24/136
(17.6%)

21/126
(16.7%)

RR1.06(0.62
to1.8)

10more Verylow
per1000
(from63
fewerto
133
more)

Serious

1.5(2.3)

2.2(2.4)

0.70(1.91,

MD0.7

CaregiverStrainIndex(6weeksfollowup)(Betterindicatedbylowervalues)
Askim,200412

RCT

Noserious

Noserious

Noserious

NationalClinicalGuidelineCentre,2013.

105

Moderate

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Summaryoffindings
Qualityassessment

Author(s)

Design

Effect

Limitations
limitations

Inconsistency
inconsistency

Indirectness
indirectness

Absolute
effect/
Mean
Differenc
e(MD)
or
Standard
ised
Mean
Mean
difference/
Differenc
Median
e(SMD)
difference/
(95%CI)
orP
SMD/Risk
Ratio(95%CI) value
0.51)
lower
(1.91
lowerto
0.51
higher)

Early
Supported
Discharge
Mean
(SD)/
Median
(range)/fr
equency
(%)

Usualcare
Mean
(SD)/
Median
(range)/
Frequency
(%)

Serious
imprecision
(j)

Anderson:
0.2(0.4);
Askim:1.0
(1.6)

Anderson:
0.2(0.4);
Askim:1.8
(2.5)

0.03(0.26,
0.20)

MD0.03
lower
(0.26
lowerto
0.20
higher)

Low

Noserious
imprecision

Askim:1.2
(1.9);
Donnelly:

Askim:1.7
(2.7);
Donnelly:

0.13(0.98,
0.72)

MD0.13
lower
(0.98
lowerto

Moderate

Imprecision
imprecision
(j)

Confidence
(ineffect)

CaregiverStrainIndex(24&26weeksfollowup)(Betterindicatedbylowervalues)
Anderson,
200010;Askim,
200412

RCT

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

CaregiverStrainIndex(52weekfollowup)(Betterindicatedbylowervalues)
Askim,200412;
RCT
Donnelly,200469;
Fjaertoft,200482;

Serious
limitations(b
)

Noserious
inconsistency

Noserious
indirectness

NationalClinicalGuidelineCentre,2013.

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Summaryoffindings
Qualityassessment

Author(s)
Rudd,1997224

(a)

Effect

Design

Limitations

Inconsistency

Indirectness

Imprecision

Early
Supported
Discharge
Mean
(SD)/
Median
(range)/fr
equency
(%)
5.9(2.9);
Fjaertoft:
15.7(2.7);
Rudd:5(4)

Usualcare
Mean
(SD)/
Median
(range)/
Frequency
(%)
6(4.2);
Fjaertoft:
16.4(3.1);
Rudd:4(3)

Blindingnotdoneforoutcomeassessment.

BlindingofoutcomeassessmentnotdoneforRudd,1997.

(c)
Blindingnotdoneforoutcomeassessment(Anderson,2000).
(d)
ConfidenceintervalcrossedoneendofagreedMID.
(e)
.
ConfidenceintervalcrossedbothendsofthedefaultMID

(f)
Imprecisioncouldnotbeassessedbecauseonlyoddsratiowasreported.

(g)
Relativeandabsoluteeffectcouldnotbeassessedbecauseoddsratiowasreported.
(h)

Dataasreportedbytheauthor(s).

(i)
ConfidenceintervalcrossedoneendofthedefaultMID.

(j)
ConfidenceintervalcrossedoneendofdefaultMID.

(k)
ConfidenceintervalcrossedbothendsofdefaultMID.
(l)
Meandifferencereported.GenericInverseVarianceused.
(m)
Imprecisioncouldnotbeassessedbecauseonlymedianandinterquartilevaluesreported.
(n)
Meandifferencecouldnotbeassessedbecausemedianandinterquartilevaluesreported.
(o)
Imprecision/Relativeandabsoluteeffectcouldnotbeassessedbecauseonlythemeannumberofdayswasreported.
(b)

NationalClinicalGuidelineCentre,2013.

107

Absolute
effect/
Mean
Differenc
e(MD)
or
Standard
ised
Mean
Mean
difference/
Differenc
Median
e(SMD)
difference/
(95%CI)
orP
SMD/Risk
Ratio(95%CI) value
0.72
higher)

Confidence
(ineffect)

StrokeRehabilitation
Organisinghealthandsocialcareforpeopleneedingrehabilitationafterstroke

5.4.2.2

Economicevidence
Eightanalyseswereincludedthatcomparedearlysupporteddischargewithusualcare:onemodelledcostutilityanalysis183andsevencostconsequence
analysesthatreportedananalysisofcostsalongsideclinicaloutcomesfromarandomisedclinicaltrialincludedintheclinicalreview8,22,69,83,172,255,274.These
aresummarisedintheeconomicevidenceprofilebelow(Table19).FurtherdetailsoneachstudyareavailablefromtheevidencetablesinAppendixI.
ThreeidentifiedanalysescomparingESDwithusualcarewereexcludedformethodologicalreasons(Anderson20029,Larsen2006146,Saka2009228).
Table19: Economicevidenceprofile:earlysupporteddischarge(ESD)versususualcare
Study

Applicabilit
y

Anderson
20008
(Australia)

Partially
applicable
(b)(c)(d)

Potentially
serious
limitations
(g)(h)(l)

Costconsequenceanalysis
WithinRCTanalysisRCT
includedinclinicalreview
(Anderson200010)
Followup:6months

Beech
199922
(UK)

Partially
applicable
(b)(d)

Potentially
serious
limitations
(g)(i)(h)(j)

Donnelly
200469
(UK)

Partially
applicable
(e)(d)

Potentially
serious
Limitations
(g)(i)(h)(l)

Limitations Othercomments

Incremental
cost

Incrementaleffect(a)

ICER

Uncertainty

1217(m)
(ESDcost
saving)

FromclinicalreviewAnderson
200010
SF36(MD):physicalfunctioning
1.2(13.3,10.9);social
functioning8,1(19.89,3.69)
Barthel(MD):0(2.0,2.0)
Falls(RR):0.75(0.26,2.17)
Caregiverstrain(MD):0.00
(0.23,0.23)

N/A

IncrementalcostCI:2306
to127(o)
DSA:hospitalbasedcare
becamelesscostlythanESD
whenhospitalcostswere
reducedby50%

Costconsequenceanalysis
WithinRCTanalysisRCT
includedinclinicalreview
(Rudd1997224)
Followup:12months.

632(ESD
costsaving)

FromclinicalreviewRudd
1997224
Mortality(RR):0.75(0.47,1.19)
Barthel(SMD):0.0(0.24,0.24)
HADS(RR):2.65(1.16,6.05)
Caregiverstrain(SMD):1.00(
0.19,2.19)

N/A

IncrementalcostCI:NR;
p=NR
DSA:conclusionsnot
impactedunderplausible
variationsinlengthofstay
andoverheadrates

Costconsequencesanalysis
WithinRCTanalysisRCT
includedinclinicalreview
(Donnelly200469).
Followup:12months

1578(ESD
costsaving)

SeeclinicalreviewDonnelly
200469
Barthel020:0.24(0.16,0.64)
NottinghamADL(MD):1.57
(0.87,4.01)

N/A

IncrementalcostCI:
12,115,4851(o)
NoSA

NationalClinicalGuidelineCentre,2013.

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Study

Applicabilit
y

Limitations Othercomments

Incremental
cost

Incrementaleffect(a)

ICER

Uncertainty

SF36(MD):physicalfunctioning
0.92(11.71,13.55);mental
health2.19(5.48,9.86)
EuroQolVAS(e):1.85(9.60,
5.90)
Caregiverstrain(SMD):0.03
(0.52,0.57)
Fjaertoft
200583
(Norway)

Partially
applicable
(b)(c)(d)

Potentially
serious
limitations
(g)(h)(l)

Costconsequenceanalysis
WithinRCTanalysisRCT
includedinclinicalreview
(Indredavik2000121and
Fjaetoft200482)
Followup:12months

1491(m)
(ESDcost
saving)

FromclinicalreviewIndredavik
2000121andFjaetoft200482
Barthel(MD):1.72(1.102.70)
Mortality(RR):0.87(0.43,1.76)
Caregiverstrainindex(SMD):
0.24(0.00,0.49)

N/A

IncrementalcostCI:NR;
p=0.127
Stratificationbyfunctional
impairmentlevel:ESDnot
costsavingintheleast
severegroup(1477,CINR,
p=0.200)
DSA:varyingcostsdidnot
impactconclusions

McNamee
1998172
(UK)

Partially
applicable
(b)(d)

Potentially
serious
limitations
(g)(i)(h)(j)

Costconsequenceanalysis
WithinRCTanalysisRCT
includedinclinicalreview
(Rodgers1997219)
Followup:6months

325(ESD
costsaving)

FromclinicalreviewRodgers
1997219
Mortality(RR):0.25(0.03,2.15)

N/A

IncrementalcostCI:NR;
p=NR
Stratificationbyfunctional
impairment:ESDnotcost
savingintheleastsevere
group(2400,CINR,
p=0.001)
DSA:ESDnotcostsaving
whenthelowerrangeofthe
costofbeddayswasused
(578)

National
Audit
Office

Partially
applicable
(f)

Potentially
serious
limitations

Costutilityanalysis
Discreteeventsimulation
model

804

0.13QALYs

6184
(n)

UncertaintyaroundICERnot
reported
DSA:conclusionsnot

NationalClinicalGuidelineCentre,2013.

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Study
2010183
(NAO)
(UK)

Applicabilit
y

Limitations Othercomments
(k)
Timehorizon:10years
Healthstates:severe,
moderateandmild
disabilitydefinedbyBarthel
score
Treatmenteffects
(probabilityofbeingmild,
moderateorsevere)were
determinedat1year(data
fromRuddetal1997224)

Incremental
cost

Incrementaleffect(a)

ICER

Uncertainty
sensitivetodiscountrateor
extentofcoverageofESD

VonKoch
2001274
(Sweden)

Partially
applicable
(b)(c)(d)

Potentially Costconsequencesanalysis
serious
WithinRCTanalysisRCT
limitations
includedinclinicalreview
(g)(i)(h)(j)(l)
(vonKoch2000,2001274,275
Followup:12months

1333(m)
(ESDcost
saving)

FromclinicalreviewvonKoch
2000,2001274,275.
BarthelADL(MD):2.75(0.77,
9.77)
Falls(RR):1.02(0.72,1.43)

N/A

IncrementalcostCI:NR;
p=NR
NoSA

Teng
2003255
(Canada)

Partially
applicable
(b)(c)(d)

Potentially
serious
limitations
(g)(h)(i)

Costconsequenceanalysis
WithinRCTanalysisbased
onRCTincludedinclinical
review(Mayo2000170)
Followup:3months

1695(m)
(ESDcost
saving)

FromclinicalreviewMayo
2000170
SF36(MD):physicalcomponent
5.00(0.82,9.18);mentalhealth
0.20(4.73,4.33)
Barthel0100(MD):2.0(1.72,
5.72)

N/A

IncrementalcostCI:NR;
p=NR
DSA:conclusionsnot
sensitivetovaryingoverhead
rate

CI:confidenceinterval;DSA=deterministicsensitivityanalysis;ICER=incrementalcosteffectivenessratio;MD=meandifference;NR=notreported;RR=relativerisk;SA=sensitivity
analysis;SMD=standardisedmeandifference.
(a) ForwithinRCTcostconsequenceanalysesthehealthoutcomesreportedinclinicalreviewareincludedintableasreportedaspartofclinicalreview.
(b) QALYsnotused.
(c) SomeuncertaintyaboutapplicabilityofnonUKresourceuseandunitcosts.
(d) Someuncertaintyaboutapplicabilityofresourceuseandunitcostsfromover10yearsago.
(e) EuroQolreportedbutunclearifEQ5Dorvisualanaloguescalepartoftoolused.AssumedVASasreportsonscale0100.
(f) DiscountingnotinlinewithNICEmethodologicalguidance.
(g) RCTbasedanalysissofromonestudybydefinitionthereforenotreflectingallevidenceinarea.

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Someuncertaintyaboutwhethertimehorizonissufficient.
Somelocalcostsused;someuncertaintyastowhetherthesewillreflectnationalcosts.
Doesn'treportifresidentialcarehasbeenconsideredinanalysis.
Unclearhowthehealthoutcomes,healthandsocialcarecostsofeachhealthstateswerecalculated.Notclearwhetherthestudyconsideredthecostsoflongtermcaresuchas
residentialcare(nursinghomesandresidentialhomes).Unitcostsourcesunclear.
(l) Limited/nosensitivityanalysis.
194
(m) ConvertedtoUKpoundsusingrelevantpurchasingpowerparities .
(n) ICERcalculatedbytheNCGChealtheconomistusingtheincrementalcostsof804and0.13QALYs.TheactualNAOstudyreportedanICERof2,881butisunclearhowthisfigurewas
obtained.Theauthorofthereportwascontactedoverthisspecificissuebutnofeedbackwasreceivedatthetimeofwriting.
(o) Totalmeancosts,differenceinmeantotalcostsandconfidenceintervalfordifferencecalculatedbyNCGChealtheconomistbysummingcostcategories.Standarderrorofdifferencewas
calculatedassumingindependenceofcostcategoriesascovariancewasnotavailable;thisisjudgedlikelytounderestimateuncertainty.
(h)
(i)
(j)
(k)

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5.4.2.3

Evidencestatements
Clinicalevidencestatements
Onestudy12comprising62participantsfoundnosignificantdifferenceintheBarthelindexat6and
26followupbetweentheEarlySupportedDischargegroupandtheusualcaregroup(MODERATE
CONFIDENCEINEFFECT).
Onestudy170comprising114participantsfoundnosignificantdifferenceintheBarthelindexat12
weeksfollowupbetweentheEarlySupportedDischargegroupandtheusualcaregroup(LOW
CONFIDENCEINEFFECT).
Threestudies12,69,224comprising506participantsfoundnosignificantdifferenceintheBarthelindex
at52followupbetweentheEarlySupportedDischargegroupandtheusualcaregroup(LOW
CONFIDENCEINEFFECT).
Twostudies10,275comprising169participantsfoundnosignificantdifferenceinfallsexperiencedin
theEarlySupportedDischargegroupcomparedtotheusualcaregroupat24and52weeksfollowup
(VERYLOWCONFIDENCEINEFFECT).
Threestudies12,170,224comprising507participantsfoundasignificantdifferenceinlengthofhospital
stayat52weeksfollowup(measuredbyinpatientstay)infavouroftheEarlySupportedDischarge
groupcomparedtotheusualcaregroup(MODERATECONFIDENCEINEFFECT).
Onestudy69comprising113participantsfoundnosignificantdifferenceinlengthofhospitalstayat
52weeksfollowupbetweentheEarlySupporteddischargegroupandtheusualcaregroup(VERY
LOWCONFIDENCEINEFFECT)
Sixstudies10,12,20,121,219,224comprising968participantsfoundnosignificantdifferenceinmortality
betweentheEarlySupportedDischargegroupandtheusualcareat12to52weeksfollowup(LOW
CONFIDENCEINEFFECT)
Onestudy69comprising113participantsfoundnosignificantdifferenceintheNottinghamADLat52
weeksfollowupbetweentheEarlySupportedDischargegroupandtheusualcaregroup(MODERATE
CONFIDENCEINEFFECT).
Threestudies10,219,275comprising356participantsfoundnosignificantdifferenceinreadmissionsto
hospitalat24and52weeksfollowupbetweentheEarlySupportedDischargegroupandtheusual
caregroup(VERYLOWCONFIDENCEINEFFECT).
Onestudy10comprising86participantsfoundnosignificantdifferenceinthephysicalfunctionofthe
SF36at24weeksfollowupbetweentheEarlySupportedDischargegroupandtheusualcaregroup
(MODERATECONFIDENCEINEFFECT).
Onestudy10comprising86participantsfoundnosignificantdifferenceinthesocialfunctionoftheSF
36at24weeksfollowupbetweentheEarlySupportedDischargegroupandtheusualcaregroup
(LOWCONFIDENCEINEFFECT).
Onestudy170comprising114participantsfoundasignificantdifferenceinthephysicalhealthofthe
SF36at12weeksfollowupinfavouroftheEarlySupportedDischargegroupcomparedtotheusual
caregroup(LOWCONFIDENCEINEFFECT).
Onestudy170comprising114participantsfoundnosignificantdifferenceinthementalhealthofthe
SF36at12weeksbetweentheEarlySupportedDischargegroupandtheusualcaregroup
(MODERATECONFIDENCEINEFFECT).

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Onestudy69comprising113participantsfoundnosignificantdifferenceinphysicalhealthoftheSF
36at52weeksfollowupbetweentheEarlySupportedDischargegroupandtheusualcaregroup
(HIGHCONFIDENCEINEFFECT).
Onestudy69comprising113participantsfoundnosignificantdifferenceinmentalhealthoftheSF36
at52weeksfollowupbetweentheEarlySupportedDischargegroupandtheusualcaregroup
(MODERATECONFIDENCEINEFFECT).
Onestudy69comprising113participantsfoundnosignificantdifferenceintheEuroQolat52follow
upbetweentheEarlySupportedDischargegroupandtheusualcaregroup(HIGHCONFIDENCEIN
EFFECT).
Onestudy82comprising320participantsfoundnosignificantdifferenceintheGlobalNottingham
HealthProfile1at52weeksbetweentheEarlySupportedDischargegroupandtheusualcaregroup
(MODERATECONFIDENCEINEFFECT).
Onestudy82comprising320participantsfoundnosignificantdifferenceintheGlobalNottingham
HealthProfile2at52weeksbetweentheEarlySupportedDischargegroupandtheusualcaregroup
(MODERATECONFIDENCEINEFFECT).
Onestudy224comprising262participantsfoundthatsignificantlylessproportionofpeopleinthe
usualcareexperiencedanxietyat52weeksfollowupcomparedtotheearlysupporteddischarge
group(LOWCONFIDENCEINEFFECT)
Onestudy224comprising262participantsfoundnosignificantdifferenceindepressionat52weeks
followupbetweentheearlysupporteddischargegroupandtheusualcaregroup(VERYLOW
CONFIDENCEINEFFECT)
Onestudy12comprising62participantsfoundnosignificantdifferenceincaregiverstrainat6weeks
followupbetweentheEarlySupportedDischargegroupandtheusualcaregroup(MODERATE
CONFIDENCEINEFFECT).
Twostudies10,12comprising148participantsfoundnosignificantdifferenceincaregiverstrainat24
and26weeksfollowupbetweentheEarlySupportedDischargegroupandtheusualcaregroup
(LOWCONFIDENCEINEFFECT).
Fourstudies12,69,82,224comprising826participantsfoundnosignificantdifferenceincaregiverstrain
at52weeksfollowupbetweentheEarlySupportedDischargegroupandtheusualcaregroup
(MODERATECONFIDENCEINEFFECT).
Economicevidencestatements
AUKcostutilitymodelfoundESDtobecosteffectivecomparedtousualcare(directlyapplicable,
potentiallyseriouslimitation)183.
SevenwithinRCTcostconsequenceanalyses(partiallyapplicable,potentiallyseriouslimitations)
foundcostswithESDtobesimilarorlowerthanusualcaretakingintoaccounthospitaland
communitycostswithfollowupover312months8,22,69,172,255,274.Thesestudiesalsogenerallyfound
healthoutcomestobeequivalentorimprovedwithESD.

5.4.3

Recommendationsandlinktoevidence

Recommendations

8. Offerearlysupporteddischargetopeoplewithstrokewhoareable
totransferfrombedtochairindependentlyorwithassistance,as
longasasafeandsecureenvironmentcanbeprovided.

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9. Earlysupporteddischargeshouldbepartofaskilledstroke
rehabilitationserviceandshouldconsistofthesameintensityof
therapyandrangeofmultidisciplinaryskillsavailableinhospital.It
shouldnotresultinadelayindeliveryofcare.
10.Hospitalsshouldhavesystemsinplacetoensurethat:
peopleafterstrokeandtheirfamiliesandcarers(as
appropriate)areinvolvedinplanningfortransferofcare,and
carersreceivetrainingincare(forexample,inmovingand
handlingandhelpingwithdressing)
peopleafterstrokeandtheirfamiliesandcarersfeeladequately
informed,preparedandsupported
GPsandotherappropriatepeopleareinformedbeforetransfer
ofcare
anagreedhealthandsocialcareplanisinplace,andtheperson
knowswhomtocontactifdifficultiesarise
appropriateequipment(includingspecialistseatinganda
wheelchairifneeded)isinplaceatthepersonsresidence,
regardlessofsetting.

Relativevaluesofdifferent Thereviewoftheevidenceincludedthefollowingoutcomes:disability,quality
outcomes
oflife,andcarerstrainaswellasfalls,mortalityandlengthofstay.
TherewasconcernthatmeasuresofdisabilityusedintheBarthelindexwere
limitedbytheceilingeffectandthatmeasuresofqualityoflifedidnotcapture
thedomainsimportanttopatientssuchascognitiveandcommunication
difficulties.
DefinitionsoftheBarthelindexclassificationgiveninthesummarytableswere
takenfromthepaperbyDWadeasagreedwiththeGDG277.TheGDGnoted
thatpatientsrecruitedtostudieswereonaverageinthemildtomoderate
rangeoftheBarthelindex(1014moderate,1519mild)10,12,20,69,121,170,219.
TheGDGnotedthattheresultsshowninthemortalityoutcomesweredifficult
tointerpretduetoimprovementsinstrokecareandmortalityoutcomesover
thelastfewyearswhichwouldnotbereflectedinthestudiesincludedinthe
analysisofevidence(studiesrangedfrom1997to2004).
Tradeoffbetweenclinical
benefitsandharms

TheGDGstressedtheimportanceofdevelopingaconsensusonwhatearly
supporteddischargeshouldcompriseof,asthiswasvariableatpresent.The
GDGnotedthatearlysupporteddischargeservicesshouldbeabletooffer
similarintensityandskillmixavailableinhospitalwithoutadelayofdelivery.
TheGDGalsohighlightedthatthisinterventioncouldplaceaburdenonthe
carerandnotedtheimportanceoftheintegrationofhealthandsocialcareto
enableanadequateassessmentincludingequipmentneedsandacareneeds
assessmentundertakenandcareplanagreedforthepatientandtheirfamily.
TheGDGnotedtheimportanceofpatientsandtheirfamilieshavingapointof
contactifneeded.Existingcommunityrehabilitationteamsshouldalsobe
engagedinthisprocessandthepatientsGPkeptfullyinformed.

Economicconsiderations

TheGDGconsideredtheevidencetosuggestthatESDiscosteffective
comparedtousualcare.AllofsevenwithinRCTanalysesfoundthatESDwas
costsavingcomparedtousualcaretakingintoaccounthospitaland
communitycosts(whichoftenincludedsocialcarecosts)uptoayear;they
alsofoundthatitwasatleastaseffective.Amodelledcostutilityanalysis

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foundESDtobecosteffectivecomparedtousualcare,withanincremental
costeffectivenessratiowellbelowthethresholdadoptedbyNICE.TheGDG
agreedthat,sincetheclinicalevidencesuggeststhatESDisatleastaseffective
asusualcare,andsincethereisevidencethatitisalsolikelytohavelower
costs,ESDrepresentsacosteffectiveinterventionforstrokepatients.
TheGDGnotedthatthemaincostsavingsofESDarelinkedtoapotentially
shorterlengthofhospitalstayandthatthisalsohasthepotentialtofreeup
acutecarehospitalbedsforotherstrokepatients.TheGDGalsonotedthat
ESDprogrammesarealreadycommonlyimplementedthroughouttheUKNHS
forappropriatepatients.
Qualityofevidence

ThreeofthestudiesshowedthatEarlySupportedDischargereducedlength
ofstayinhospital12,170,224.Theassessmentofconfidenceintheresultsforthis
outcomewasmoderate.Theredidnotappeartobeanysignificantdifference
inoutcomesthatrelatetodisability,qualityoflife,orcarerstrain.Confidence
intheresultsforotheroutcomeswaslimitedduetothestudydesignorto
variationsinhowtheresultswerereported.
TheGDGconsideredthatanecdotallyitwouldbeexpectedthatearly
supporteddischargewouldputagreaterburdenonthecarerbutthiswasnot
showninthestudiesbyAskimandAnderson10,12.TheGDGagreedwiththe
findingsofnodifferencebetweengroupsatoneyear12,69,82,224.

Otherconsiderations

TheGDGnotedthattherewasnoadequatedescriptionofthecompositionof
usualcareorearlysupporteddischargeinthestudiesanalysed.Thereforeit
wasnotpossibletospecifythecomponentsofESDwithinthe
recommendation.Whilstthismethodofdeliverywouldbesuitableformany
patients,theGDGagreedthatitwasnotsuitableforallandforsomepatients
rehabilitationwithinahospitalsettingwouldbemoreappropriate.Thisis
reflectedbythepatientsrecruitedintothetrialswhowerelessseverely
affectedaftertheirstroke.
TheGDGnotedthatoftenpatientsexperiencedistressatthepointof
discharge,feelingservicesaredisjointedandprovisionisinadequate.Inorder
toaddresstheseconcerns,consensusrecommendationsweremadeindicating
theplanning,supplyofequipmentandsupportforthepatientandtheircarers
thatneedtobeprovidedbythemultiagenciesinvolvedinthedeliveryofcare.

ESDteamswithinthestudiesvariedbutincluded:specialistphysiotherapists,
occupationaltherapists,speechandlanguagetherapists,rehabilitationnurses,
consultantsinrehabilitation,dieticiansandsocialworkers.Thegroupnoted
thatthestudiesdidnotincludeclinicalneuropsychologyinputandthismay
reflectpracticeatthetimeofthestudies.Theconsensusofthegroupwasthat
neuropsychologyshouldbeconsideredpartoftherehabilitationteam.
TheGDGthoughtitimportantthatfuturestudiesrecognisecarerandpatient
perspectivesandqualityoflifewereimportantoutcomestobemeasuredfor
bothgroups.

5.4.4

Transferofcarefromhospitaltocommunity

5.4.5

EvidenceReview:Whatplanningandsupportshouldbeundertakenbythe
multidisciplinaryrehabilitationteambeforeapersonwhohadastrokeisdischarged
fromhospitalortransferstoanotherteam/settingtoensureasuccessfultransitionof
care?
Population

Adultsandyoungpeople16orolderwhohavehadastroke

Components

1. Dischargeplanning
2. Emotional/educationalsupport
3. Coordinationandresourcesofotherservices/agencies(suchassocialcare)

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Outcomes

5.4.6

4.
5.
6.
7.

Patientandcarersatisfaction
Successfuldischarge
Qualityoflife
optimisedstrategiestominimiseimpairmentandmaximiseactivity/participation

Delphistatementswhereconsensuswasachieved
Table20: Tableofconsensusstatements,resultsandcomments(percentageintheresultscolumn
indicatestheoverallrateofresponderswhostronglyagreedwithastatementand
amountofcommentsinthefinalcolumnreferstorateofresponderswhousedthe
openendedcommentsboxes,i.e.No.peoplecommented/No.peoplewhoresponded
tothestatement)

Number

Results
%

Statement

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes

Eachpatientshouldhavea
documenteddischargereportwhich
hasbeendiscussedwiththeperson
whohashadastrokeandtheircarer/s
priortotransferofcare,including
dischargestoresidentialsettings.

75.5

14/98(14%)panelmembers
commented

Thiswasseenasimportant,butit
wasquestionedwhetherthiswould
bedifferenttotheGPreport,acopy
ofwhichwouldbegiventothe
personwhohashadastroke.

Thisshouldbewritteninan
accessibleway.

Adischargereport(informingongoing
rehabilitationplanning)shouldcontain
informationaboutthefollowing:
Diagnosisandhealthstatus
Mentalcapacity
Functionalabilities
Transfersandmobility
Careneedsforwashing,dressing,
toiletingandfeeding
Psychologicalandemotionalneeds
Medicationneeds
Socialcircumstances
Managementofriskincludingthe
needsofvulnerableadults
Ongoinggoals
Waysofaccessingrehabilitation
services

86.8
69.7
86.8
82.8
82.8

77.7
84.8
76.7
74.7

76.5
74.4

31/99(31%)panelmembers
commented

Afewfurthersuggestionsand
commentsweremade:
Theindividualsnamedpointof
contact.
Jointhealthandsocialcareplan.
StrokeAssociationInformation

Furthercomments:
Thetermsmentalcapacitywas
queriedi.e.capacityforwhat,and
whethercognitivestatusmaybea
betterterm
Itwasfeltnotnecessarytohaveall
theseforallpeople.

Ahomevisit(withthepersonwhohas 69.8
hadastrokepresent)mayberequired
whensimulationofthehome
environmentsetupintheinpatient
settinghasbeeninconclusiveorthere
isanindicationforfurtherassessment.

14/96(14%)panelmembers
commented

Alimitednumberofpanelmembers
providedcommentsforthis
statement:
Onepersonfeltthattherewere
limitsonstafftimeandresources

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5.4.7

Results
%

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes
Anotherpersonstatedthatthis
dependedonwhetheranearly
supporteddischargeteamwas
available.
Thiscoulddelaydischargefrom
hospitalwasmentioned.
Thetermmaywasqueried.

Number

Statement

4.

Localsystemswithopen
communicationchannelsandtimely
exchangeofinformationshouldbe
establishedtoensurethattheperson
whohashadastrokeisableto
transfertotheirplaceofresidenceina
welltimedmanner.

71.7

10/99(10%)panelmembers
commented

Ofthetenpeoplewhocommented
onthisstatementsevenindicated
thatthephrasingofthestatement
wasconfusingandcontainedjargon.

Oftheotherthree,onecommented
ontheroleofthekeyworker,
anotherpersoncommentedthatthis
shouldminimiseduplicationand
administrationandthethirdperson
statedthatthisshouldbedoneas
soonasitissafetodoso.

5.

Localhealthandsocialcareproviders
shouldhaveestablishedstandard
operatingprocedurestoensureasafe
dischargeprocess.

74.0

11/100(11%)panelmembers
commented

Individualissueswereraisedinthe
comments:
Anychangestoproceduresneedto
becommunicatedintimelyfashion
Takeintoaccountpersonswishes
andbeawareofcarerstressand
vulnerableadultprocedures
Ideallyjointstandardprocedures
Aneedforflexibilityandbroad
guidancethatcanbeeasily
individualised,ratherthan
prescriptiveprocedures.

Delphistatementwhereconsensuswasnotreached
Results
Number
1.

Statement

Anaccessvisit(withouttheperson 36.6
present)canascertainsuitabilityof
accessto,fromandwithinthe
propertyinrespecttotheperson's
functional,cognitivestatusand
managingrisk.

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Amountandcontentofpanel
commentsorthemes
Inround220/98(20%)panel
memberscommented;
15/84(18%)inround3and13/71
(18%)inround4:

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Results
Number

Statement

Amountandcontentofpanel
commentsorthemes
Themajorityofcomments
expressedthatthestatementwas
unspecificanddidnotsay
whetheritshouldbedoneorin
whatcircumstances(Theissueis
whenalways,sometimes,why,
howtodecide.).

Severalpeopleexpressedthe
opinionthatthisstatementwas
tooobvious,sinceitincludedthe
wordmayorlatertheword
can.

2.

Ahomevisitcanascertaina
person'spotentialformanaging
riskandcognitive/functional
impairmentwithinafamiliar
environment.

56.8

Inround211/99(11%)panel
memberscommented;
13/84(15%)inround3and8/70
(11%)inround4:

Themajorityofcomments
expressedthatthestatementwas
unspecificanddidnotsay
whetheritshouldbedoneorin
whatcircumstances.
(guidelinesshouldbegiven
guidanceabouttowhomand
underwhatcircumstancesavisit
eitheraccessorwiththepatient
shouldbedone.
usuallynotrequiredifESDteam
involvedincare.)

Severalpeopleexpressedthe
opinionthatthisstatementwas
tooobvious,sinceitincludedthe
wordmayorlatertheword
can.

3.

Bothaccessandhomevisitsshould 19.4
becoordinatedbyanoccupational
therapistandifthisisnotpossible
theyshouldhaveclinicaloversight
fromanoccupationaltherapist.

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Inround238/95(40%)panel
memberscommented;
34/83(41%)inround3and15/72
(21%)inround4:

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Results
Number

Statement

Amountandcontentofpanel
commentsorthemes
Themainpointofcontentionwas
whetherornotanOTshould
overseethis.

althoughtheOTwouldusually
beinvolved,thisdoesnotneedto
bethecaseanditmaybe
appropriateforanothermember
oftheteamtoco
ordinate/conductthisdepending
onwhatlimitationsthept
presentedwith.

4.

Aspartofrehabilitationcare
52.1
planning,bothaccessandhome
visitscanbeusedseparatelyor
sequentially,toascertainsuitability
forrehabilitation,managementof
riskandmanagementoflifeafter
strokewithinthepersonshome
environment.

Inround29/99(9%)panel
memberscommented;9/83(11%)
inround3and11/71(15%)in
round4:

Itwasfeltthatthisstatement
wasvagueanddidnotdefinethe
circumstancesofwhenandhow
thisshouldhappen.

Therewasalsoacommentthat
thisshouldnotdelaydischarge
andthatthisissomethingthe
communitystroketeamcould
undertake.

5.4.8

RecommendationsandlinkstoDelphiconsensussurvey
Statements

9. Eachpatientshouldhaveadocumenteddischargereportwhichhas
beendiscussedwiththepersonwhohashadastrokeandtheircarer/s
priortotransferofcare,includingdischargestoresidentialsettings.
10.Adischargereport(informingongoingrehabilitationplanning)should
containinformationaboutthefollowing:
Diagnosisandhealthstatus
Mentalcapacity
Functionalabilities
Transfersandmobility
Careneedsforwashing,dressing,toiletingandfeeding
Psychologicalandemotionalneeds
Medicationneeds

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Socialcircumstances
Managementofriskincludingtheneedsofvulnerableadults
Ongoinggoals
Waysofaccessingrehabilitationservices

11.Ahomevisit(withthepersonwhohashadastrokepresent)maybe
requiredwhensimulationofthehomeenvironmentsetupinthe
inpatientsettinghasbeeninconclusiveorthereisanindicationfor
furtherassessment.
12.Localsystemswithopencommunicationchannelsandtimely
exchangeofinformationshouldbeestablishedtoensurethatthe
personwhohashadastrokeisabletotransfertotheirplaceof
residenceinawelltimedmanner.
13.Localhealthandsocialcareprovidersshouldhaveestablished
standardoperatingprocedurestoensureasafedischargeprocess.
Recommendations

11.Beforetransferfromhospitaltohomeortoacaresetting,discuss
andagreeahealthandsocialcareplanwiththepersonwithstroke
andtheirfamilyorcarer(asappropriate),andprovidethistoall
relevanthealthandsocialcareproviders.
12.Beforetransferofcarefromhospitaltohomeforpeoplewithstroke:
establishthattheyhaveasafeandenablinghomeenvironment,
forexample,checkthatappropriateequipmentandadaptations
havebeenprovidedandthatcarersaresupportedtofacilitate
independence,and
undertakeahomevisitwiththemunlesstheirabilitiesandneeds
canbeidentifiedinotherways,forexample,bydemonstrating
independenceinallselfcareactivities,includingmeal
preparation,whileintherehabilitationunit.
13.Ontransferofcarefromhospitaltothecommunity,provide
informationtoallrelevanthealthandsocialcareprofessionalsand
thepersonwithstroke.Thisshouldinclude:
asummaryofrehabilitationprogressandcurrentgoals
diagnosisandhealthstatus
functionalabilities(includingcommunicationneeds)
careneeds,includingwashing,dressing,helpwithgoingtothe
toiletandeating
psychological(cognitiveandemotional)needs
medicationneeds(includingthepersonsabilitytomanagetheir
prescribedmedicationsandanysupporttheyneedtodoso)
socialcircumstances,includingcarersneeds
mentalcapacityregardingthetransferdecision
managementofrisk,includingtheneedsofvulnerableadults
plansforfollowup,rehabilitationandaccesstohealthandsocial
careandvoluntarysectorservices.

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14.Ensurethatpeoplewithstrokewhoaretransferredfromhospitalto
carehomesreceiveassessmentandtreatmentfromstroke
rehabilitationandsocialcareservicestothesamestandardsasthey
wouldreceiveintheirownhomes.
15.Localhealthandsocialcareprovidersshouldhavestandard
operatingprocedurestoensurethesafetransferandlongtermcare
ofpeopleafterstroke,includingthoseincarehomes.Thisshould
includetimelyexchangeofinformationbetweendifferentproviders
usinglocalprotocols.
16.Aftertransferofcarefromhospital,peoplewithdisabilitiesafter
stroke(includingpeopleincarehomes)shouldbefollowedupwithin
72hoursbythespecialiststrokerehabilitationteamforassessment
ofpatientidentifiedneedsandthedevelopmentofshared
managementplans.
17.Provideadviceonprescribedmedicationsforpeopleafterstrokein
linewithrecommendationsinMedicinesadherence(NICEclinical
guideline76).

Economicconsiderations Noeconomicevidencewasfoundondischargeofpeopleafterstroke.
Therearesomecostsassociatedwiththeassessmentandfollowupvisits
(stafftimeandtravel/transportcost);theGDGhasconsideredthe
economicimplicationsandconcludedthatinsomecircumstancesthe
benefitoftheinterventionislikelytooutweighthecosts.
Otherconsiderations

Boththehealthandsocialcareplanoutliningrequirementsgoing
forwardaswellasasummaryofinformationontheadmissionand
treatmentsgiveninhospitalneedstobeprovidedtoappropriatepeople
(includingtheGP)andthepersonwhohadthestroke.Aspartofthe
dischargedocumentation,asummaryofrehabilitationactivitieswouldbe
includedasusualpractise.Havingalocalprotocoldrawnupbetween
healthandsocialcareproviderstoensureinformationisbeingrelayed
betweenbothagenciespriortodischargeisveryimportantinensuringa
smoothdischargeforthepersonandtheirfamilies.Itwasnotedthat
thereisoftenalackofinformationprovidedtofamilieswhentheperson
isgoingtoresidentialcare.TheGDGnotedthatitwasveryimportant
thatpeoplewhotransferfromhospitaltoacarehomeshouldreceivethe
samelevelofcareandtreatmentasthosewhoareabletoreturnhome.
TheGDGagreedthatthiswasaneglectedareaandfeltaconsensus
recommendationwaswarrantedtoinitiateanimprovementincurrent
practice.
Consensuswasnotreachedregardinghomevisitsthroughthemodified
Delphi.TheGDGrecognisethathomevisitsarenotrequiredinallcases;
howeverthereareacceptedsituationswhereahomevisitisindicated.
Clinicalindicationsforhomevisitsbeingcarriedoutmayincludetheneed
toassesswhetherthepersonisabletomobilisearoundtheirown
environment,andmanagenecessarytransferswithorwithout
equipment.Patientswithcognitiveorperceptualimpairmentsmayneed

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tobeassessedintheirownenvironmenttoaiddecisionmakingregarding
whetherthepatientisabletosafelyreturnhome.Homevisitsorward
leavemayberequiredtoaidthepatientsacceptanceandtransitionback
homewithalteredabilitiesfollowingtheirstroke.
Whensufficientinformation(measurements,photographs)canbegained
andmockupcanbeachievedtofullyassessapatientsabilityinthe
hospitalsetting,visitsmaybeunnecessary.Thereshouldbelocally
agreedsituationswherehomevisitswouldandwouldn'tbeconducted,
andinwhatsituationsprofessionsotherthananOccupationaltherapist
couldconductthem.Onesuchexamplemaybeapatientwithminor
equipmentneedswhoismobilisingwithonepersononthewardmaynot
requireahomevisitiftheyarebeingdischargedwithimmediateESD
involvement.
Itiscurrentpracticethattheseareusuallycarriedoutbyoccupational
therapists,butattimesmaybeperformedbyotherappropriate
membersoftheMDT(forexamplephysiotherapist),dependingonthe
reasonforthehomevisit,andwouldbeoverseenbyanoccupational
therapistwithknowledgeofenvironmentalriskassessment,equipment
provisionandadaptation.TheGDGnotedalargetrial(HOVIS)whichis
soontobepublishedonthisarea.
Theneedforafollowuptobeundertakenbythestrokerehabilitation
teamoncethepersonhadtransferredtothecommunitywasviewedto
beimportanttoensuremanagementplanshavebeenfollowedandto
identifyanyfurthersupport.TheGDGnotedthiswasalready
documentedintheStrokeQualityStandardandagreedthisshouldbe
reinforcedbyaconsensusrecommendationfollowingcomments
receivedbystakeholders.

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

6 Planninganddeliveringstrokerehabilitation
Toensurethesafetyofthepersonwithstrokewhilemaintainingapatientcentredapproach,key
processesneedtobeinplace.Theseprocessesincludeassessmentonadmissiontothe
rehabilitationservice,individualisedgoalsettingandpatientcentredcareplanning.Thischapter
reviewsthoseprocesses.
Asearchforsystematicreviewswascarriedoutforassessmentforrehabilitation,goalsettingand
rehabilitationplanning.Directevidencefromsystematicreviewswasnotidentifiedforassessment
forrehabilitation(6.1)andrecommendationswerethereforedrawnfromthemodifiedDelphi
consensusstatement.Asystematicreviewforgoalsetting(6.2)wasidentifiedandupdated
(Rosewilliam2011221).Notallaspectsofgoalsettingwerecoveredbytheincludedsystematicreview
andthereforeadditionalDelphistatementsweredraftedfrompublishednationalandinternational
guidelinesandrecommendationsweremadebasedonboththereviewandtheDelphiconsensus
statements.Directevidencefromsystematicreviewswasnotidentifiedforrehabilitationplanning
(section6.3)andrecommendationswerethereforedrawnfromthemodifiedDelphiconsensus
statement.

6.1 Screeningandassessment
6.1.1

6.1.2

EvidenceReview:Inplanningrehabilitationforapersonafterstrokewhatassessments
andmonitoringshouldbeundertakentooptimisethebestoutcomes?
Population

Adultsandyoungpeople16orolderwhohavehadastroke

Components

assessment
careplans
monitoring

Outcomes

Patientandcarersatisfaction
optimisedstrategiestominimiseimpairmentandmaximiseactivity/participation

Delphistatementswhereconsensuswasachieved
Table21: Tableofconsensusstatements,resultsandcomments(percentageintheresultscolumn
indicatestheoverallrateofresponderswhostronglyagreedwithastatementand
amountofcommentsinthefinalcolumnreferstorateofresponderswhousedthe
openendedcommentsboxes,i.e.No.peoplecommented/No.peoplewhoresponded
tothestatement)

Number

Results
%

Statement

Afteradmissiontohospitaltheperson
whohashadastrokeshouldhavethe
followingassessedassoonaspossible:
Positioning
Movingandhandling
Swallowing
Transfers
Pressurearearisk
Continence
Communication

82.0
92.0
94.9
79.5
90.0
86.8

NationalClinicalGuidelineCentre,2013.
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Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes
34/100(34%)panelmembers
commented:

Anumberofadditional
assessments/measurementswere
suggested(alotofthesearecovered
inothersections):
Activitiesofdailyliving
Mood
Pain

StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

Number

Results
%
80.0
77.7

Statement

Nutritionalstatus

86.1
81.1

81.1

84.1
75.2

76.2

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes
Motorcontrol
Cognition

Anumberofpeoplecommentedthat
theterminologysensory
registration[theoneoptionthatdid
notreachconsensus]wasunclear.

1.

Comprehensiveassessmenttakesinto
account:
Previousfunctionalstatus
Impairmentofpsychological
functioning
Impairmentofphysiologicalbody
functionsandstructures
Activitylimitationsduetostroke
Participationrestrictionsinlifeare
stroke
Environmentalfactors(social
physicalandcultural)

2.

Familymembersand/orcarersshould 71.7
beinformedoftheirrightsforacarers
needsassessment.

11/99(11%)panelmembers
commented:

Thiswasgenerallyviewedasan
importantissue.
Extracts:
Thosecarerswhoarepassiveneed
tobeinformedthatthisisavailable
andmanymaybetootimidtoknow
theycanrequestthisassessment.

3.

Theimpactofthestrokeonthe
personsfamily,friendsand/orcarers
shouldbeconsideredandif
appropriatetheycanbereferredfor
support.

78.0

11/100(13%)panelmembers
commented:

Commentsweredivided:
Somethoughtthatthiswas
obvious
Othersthoughtthatinreality
thereisalackofavailable
supportmechanisms.

4.

Peoplewhohavehadastrokeshould
haveafullneurologicalassessment
includingcognition,vision,hearing,
power,sensationandbalance.

69.0

19/84(23%)panelmembers
commented:

Thiswasastatementthatwasadded
inRound3basedoncommentsin
Round2.
Commentstothisstatementwere
moreindividualthaninthemes:
Thephrasefullassessment

NationalClinicalGuidelineCentre,2013.
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25/100(25%)panelmembers
commented:

Additionalissuestotakeinto
account:
Patientandcarerviews
Motivation
Comorbidities

StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

Number

Statement

Results
%

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes
wasqueriedbyone(Ifyou
meanthatafullneurological
assessmentincludesascreening
processthatcanleadtoamore
detailedassessmentasneeded
thenIstronglyagree)
Somepeoplewantedadditional
assessments(swallow,
coordination,movement
control,shouldersubluxationfor
instance)
Itwasmentionedthatthis
shouldbedoneaccordingto
needandthatpeopleshouldnot
beoverassessed.
Theneedtohaveaneurologist
doingthiswasquestioned.

5.

Delphipanelmembersagreedwith
screeningforthefollowing:
Mood

Pain

69.8
68.6

Inround2thiswasanopentext
questionand83peopleanswered;in
round3thiswasrephrasedintoa
statementwithmultipleoptions
formatand18/83(22%)commented:

Therewasconfusionaboutsomeof
theoptionsandadditionalscreening
toolsweresuggested:
Dysphagia/Swallowtests
Falls
CarersStrainIndex

6.

Routinecollectionandanalysisofa
rangeofmeasuresshouldinclude:
NationalInstituteofHealthStroke
Scale
BarthelIndex
HospitalAnxietyDepressionScale
(HADS)

74.0(of50)
selectedas
firstoption
46.5(of43)
assecond
option
56.3(of32)
asthird
option

Inround240/87(46%)panel
memberscommented;26/77(34%)
inround3.Thiswasincludedina
differentformatinRound3(toselect
thethreemain).

Thosethatdidnotreachconsensus
were:
ModifiedRankin
BergBalanceScale
EQ5D
GeneralHealthQuestionnaire
(GHQ)
GeriatricDepressionScale

Somepeopledislikedthefactthat
only3optionscouldbeselectedand
statedthatitdependsonthe
individualpatientswhichmeasures

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

Number

6.1.3

Statement

Results
%

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes
wouldbeselected.

Otherspanelmembershighlighted
thatmeasuresdependonthestage
ofrehabilitation(NIHSSisa
reasonablebaselinewhereasthe
Bergismostusefulbeyondtheacute
phase.Italsodependsonwhatsort
ofanalysisyouareexpectingtobe
done.Isthedataforunderstanding
theseverityofstrokeortheoutcome
ofrehab?)

Itwasquestionedwhetherthe
statementreferstooutcomeor
baselinemeasures(Itdepends
whatyouaretryingtoshow?Ifits
outcomesandservicedemands?
Mayberehabilitationcomplexity
scalestoshowthedemandsand
resourcesyouneed.FIMtoshow
functionaloutcomesperhapsinstead
ofBarthel.).

Additionalmeasureswerealso
suggested:
TOM
PHQ
NottinghamExtendedActivities
ofDailyLivingScale

Delphistatementwhereconsensuswasnotreached
Table22: Tableofnonconsensusstatementswithqualitativethemesofpanelcomments
Number
1.

Statement
Thespecificlistofprofessional
screeningtoolstobeincluded:
MontrealCognitiveAssessment
(MOCA)
FrenchayAphasiaScreeningTest
(FAST)
MalnutritionUniversalScreening
Tool(MUST)
TheWaterlowPressurescorerisk
assessmenttool(pressureulcers)

Results
%

Amountandcontentofpanel
commentsorthemes

25.4

22.5

42.6

44.9

Inround248/93(52%)panel
memberscommented;40/72(56%)
inround3theoptionschanged
betweenrounds2and3:

Anumberofadditionalscales/tools
werementioned[someofwhich
werealreadyincludedinother
statements]:
BergBalancescale
ModifiedRivermeadMobility
Index
Mood

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

Number

Results
%

Statement

Amountandcontentofpanel
commentsorthemes
Therapyoutcomemeasure
Screenformalnutrition

Validity,reliabilityandtrainingneed
tobetakenintoconsideration.(You
shouldstateusingarecognised
tool;
Thetoolisnotimportantsolongas
itisavalidatedtool.Thereisnoneed
todirectwhichtoolspeopleshould
use.)

Concernwasraisedaboutpossible
recommendationsbeingtoo
prescriptive(Thesetoolsshould
onlybesuggestedtoolsnot
prescriptiveastheclinicianshouldbe
abletomakethedecisionastothe
mostappropriatetool.
Thetoolisnotimportantaslongas
itisavalidatedtool.Thereisnoneed
todirectwhichtoolspeopleshould
use.)

Whetherthesewerescreeningtools
oroutcomemeasureswasalso
questioned.

2.

6.1.4

Datacollectionshouldbeoverseenby
anationalbody.

62.0

Inround227/97(28%)panel
memberscommented;21/81(26%)
inround3and16/71(23%)inround
4:

Itwashighlightedthatthisisalready
inexistenceinsomeplace(suchas
theRCPaudit,theScottishStroke
CareAuditortheNationalSentinel
StrokeAudit)

RecommendationsandlinkstoDelphiconsensussurvey
Statements

14.Afteradmissiontohospitalthepersonwhohashadastrokeshould
havethefollowingassessedassoonaspossible:
Positioning
Movingandhandling
Swallowing
Transfers
Pressurearearisk
Continence
Communication
Nutritionalstatus

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation
15.Comprehensiveassessmenttakesintoaccount:
Previousfunctionalstatus
Impairmentofpsychologicalfunctioning
Impairmentofphysiologicalbodyfunctionsandstructures
Activitylimitationsduetostroke
Participationrestrictionsinlifearestroke
Environmentalfactors(socialphysicalandcultural)
16.Familymembersand/orcarersshouldbeinformedoftheirrightsfora
carersneedsassessment.
17.Theimpactofthestrokeonthepersonsfamily,friendsand/orcarers
shouldbeconsideredandifappropriatetheycanbereferredfor
support.
18.Peoplewhohavehadastrokeshouldhaveafullneurological
assessmentincludingcognition,vision,hearing,power,sensationand
balance.
19.Delphipanelmembersagreedwithscreeningforthefollowing:
Mood
Pain
20.Routinecollectionandanalysisofarangeofmeasuresshouldinclude:
NationalInstituteofHealthStrokeScale
BarthelIndex
HospitalAnxietyDepressionScale(HADS)

Recommendations

18.Onadmissiontohospital,toensuretheimmediatesafetyand
comfortofthepersonwithstroke,screenthemforthefollowing
and,ifproblemsareidentified,startmanagementassoonas
possible:
orientation
positioning,movingandhandling
swallowing
transfers(forexample,frombedtochair)
pressurearearisk
continence
communication,includingtheabilitytounderstandandfollow
instructionsandtoconveyneedsandwishes
nutritionalstatusandhydration(followtherecommendationsin
Stroke[NICEclinicalguideline68]andNutritionsupportinadults
[NICEclinicalguideline32]).
19.Performafullmedicalassessmentofthepersonwithstroke,
includingcognition(attention,memory,spatialawareness,apraxia,
perception),vision,hearing,tone,strength,sensationandbalance.
20.Acomprehensiveassessmentofapersonwithstrokeshouldtake
intoaccount:
theirpreviousfunctionalabilities

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation
impairmentofpsychologicalfunctioning(cognitive,emotional
andcommunication)
impairmentofbodyfunctions,includingpain
activitylimitationsandparticipationrestrictions
environmentalfactors(social,physicalandcultural).
21.Informationcollectedroutinelyfrompeoplewithstrokeusingvalid,
reliableandresponsivetoolsshouldincludethefollowingon
admissionanddischarge:
NationalInstitutesofHealthStrokeScale
BarthelIndex.
22.Informationcollectedfrompeoplewithstrokeusingvalid,reliable
andresponsivetoolsshouldbefedbacktothemultidisciplinary
teamregularly.
23.Takeintoconsiderationtheimpactofthestrokeonthepersons
family,friendsand/orcarersand,ifappropriate,identifysourcesof
support.
24.Informthefamilymembersandcarersofpeoplewithstrokeabout
theirrighttohaveacarersneedsassessment.

Economic
considerations

Therearesomecostsassociatedwiththescreeningandfurther
assessment;theGDGhasconsideredtheeconomicimplications
andconcludedthattheseinterventionswillimprovethesafetyand
qualityoflifeofthepersonwithstroke;theimprovementinquality
oflifewasconsideredlikelytooutweighthecosts.

Otherconsiderations

TheGDGagreedthatinthiscontextscreeningisabriefevaluation
whichallowsthepatienttobetriagedandimmediatemanagement
tobeputinplacetoensurethepersonssafety.Wherethereis
evidenceoffunctionalimpairments,moredetailedassessmentwill
thenneedtotakeplace.Otherassessmentsshouldbeundertaken
wheretherearespecificneedsofthepatients.Itwasfeltthat
assessingformoodwasimportantandthiswasnotmadeexplicitin
thesurveyandshouldbeaddedintotherecommendation.The
GDGrecognisedthatsignsofimpairmentsinpsychological
functioning(includingmood)mightnotbedirectlyapparenttothe
personwhohashadthestrokeandthecliniciansonadmissionto
hospitalatthetimeofscreening.Thereforeitwasfeltthatthese
processesshouldbecomprehensivelyassessedatalaterstage.It
wasalsoagreedthatinadditiontolimitationsonactivity,an
assessmentofparticipationrestrictionsshouldalsobeundertaken.
Theanxietythatneurologicalassessmentimpliedthataneurologist
wouldhavetoundertaketheassessmentwasrecognisedby

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

substitutingthewordmedical.TheGDGfeltamedical
assessmentwasanintegralpartofacomprehensiverehabilitation
assessment.
ActivitylimitationsasdefinedbytheICFincludesocialattitudes,
architecturalcharacteristics,legalandsocialstructures,aswellas
climate,andterrain.TheGDGrecognisedthatarangeofadditional
measurestotheBarthel,andNationalInstituteofHealthStrokeScale
maybeused.Suchmeasuresshouldbeusedtocomparecohorts
ofdata,nottomonitorindividualprogressforrehabilitation.
Sincenoneofthespecificscreeningtoolsreachedconsensusthe
GDGwereunabletomakearecommendation.However,basedon
commentsofthenonconsensusstatementstheGDGrecognised
thatifmeasuresweretobecollectedtheyshouldbestandardised
measurementtoolswithpsychometricallyrobustproperties,and
staffshouldbetrainedintheiruseandfindingsshouldbefedback
totheteam.
TheGDGrecognisedthatthereisadistinctionbetweenmeasures
andscreeningtoolsthatshouldnotbeusedasoutcomes.
Opiniononsupportforfamilyandcarerswasdividedinthesurvey,
withsomethinkingthiswouldalwaysbedoneandothersthatin
realitythereisalackoforganisedmechanismstoprovidesupport.
TheGDGnotedthatitwouldbeusualtoreferthepersontotheir
GPifitwasfelttheyneededtobereferredforadditionalsupport.
TheMDTstroketeamwouldprovideinformationonwheresupport
couldbefound.

6.2 Settinggoalsforrehabilitation
6.2.1

EvidenceReview:Doestheapplicationofpatientgoalsettingaspartofplanningstroke
rehabilitationactivitiesleadtoanimprovementinpsychologicalwellbeing,functioning
andactivity?
ClinicalMethodologicalIntroduction
Population

Adultsandyoungpeople16orolderwhohavehadastroke.

Intervention

Anypatientgoalsettingapproach

Comparison

Alternativerehabilitationgoalsettingapproaches

Outcomes

Psychologicalmeasuresandhealthrelatedqualityoflife
Physicalfunction
ActivitiesofDailyLiving(ADL)
Thesemayinclude:Barthel,Nottinghamextendedactivitiesofdaily
living,FIM,ratingscales,surveydata(quantitative),themes
identifiedbyqualitativestudies

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation
6.2.1.1

ClinicalEvidenceReview
Asearchwasconductedforsystematicreviewscomparingtheclinicaleffectivenessofanypatient
goalsettingapproachestoalternativerehabilitationgoalsettingapproachestoimprove
psychologicalwellbeing,functionandactivityinadultsandyoungpeople16orolderwhohavehada
stroke.
Onesystematicreview(Rosewilliam2011221)matchingourprotocolwasidentified.Thisreview
includedtwentysevenstudies(eighteenqualitative,eightquantitativeandonemixedmethod
study).Weincludedtwentyonestudiesfromthisreviewmatchingourprotocol.Thesystematic
reviewexploredthenature,extentandeffectsofapplyingpatientcentredgoalsettinginstroke
rehabilitationpractice.
Afurthersystematicsearch(usingthesamesearchtermsasprovidedintheidentifiedsystematic
review)wasconductedforstudiespublishedsinceJune2010whichwasthesearchcutoffdateof
theincludedsystematicreview.Twostudies(Hale2010100;Worrall2011287)(Table23)matchingour
protocolwereidentifiedfromthisupdatesearchandwerealsoincludedforthisreview.
Table23: Overviewofthetwoadditionalstudiesfromthetopupsearchsincethesystematic
reviewsearchcutoffdate.SeeAppendixHforextraction
Studies
100

Hale2010

Worrall2011287

Population/setting
4communitybased
physiotherapistandseven
strokepatients(threemen,
fourwomen)

Aims

Reviewmethods

Toexplorethe
feasibilityand
acceptabilityofusing
*GoalAttainment
Scaling(GAS)inhome
basedstroke
rehabilitation(HBSR)

Qualitativedescriptive
studyinvolvingsemi
structuredindepth
interviews

50participantswith
aphasiapoststroke.All
participantshadtobeable
toparticipateinanin
depthinterviewinEnglish
usingspeech,gesture,
writing,pictures,and/or
drawings.

Todescribethegoals
ofpeoplewithaphasia
andtocodethegoals
accordingtothe
International
Classificationof
Functioning,Disability
andHealth(ICF)(WHO,
2001)

Qualitativedescriptive
studyinvolvingsemi
structured,indepth
interviews

*Astandardisedwayofscoringtheextenttowhichpatientsindividualgoalsisachievedinthecourseofintervention.

Intheincludedsystematicreview(Rosewilliam2011221)thefollowingmethodologywasadopted:
Bothqualitative(Table24)andquantitative(Table25)studydesignswereincludedinthereview
Qualityofincludedstudieswereassessedbyusingqualitycriteriaadaptedfrompublished
literatures256;106;184.Differentsetsofqualitycriteriawereusedforthequalitativeand
quantitativestudies
Studyqualityassessmentwasdoneinitiallybyoneresearcherandcrosscheckedbyoneofthe
twootherauthors
Themesfromallqualitativestudiesmatchingthereviewquestionswerepooled
Findingsweresynthesizedbyaggregatingthethemesfromthequalitativestudiesandrelating
themtofindingsfromquantitativestudies
Datafromthequantitativestudiescouldnotbemetaanalysedduetolackofrandomisedtrials
Effectsizes(forincludedquantitativestudies)werecalculatedwherepossible

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

Forthisreview,wehaveaddedqualityratings(ourconfidenceinthestudies)tothequalitativeand
quantitativestudiesincludedinthesystematicreview.Thequalityratingswerebasedonquality
characteristics(reportedintheincludedsystematicreview)thatwereassessedinthereview.
Studiesfromthesystematicreviewwereexcludediftheyaddressedmixedneurologicalpopulations,
iftheproportionofpatientswithstrokeis<50%orifthenumberofstrokeparticipantsisunclear
Fortheadditionalqualitativestudiesidentifiedinourupdatesearch:
o ThestudyqualitiesofHale2010100andWorrall2011287wereassessedandratedusingthe
qualitycriteriaadaptedfromtheincludedsystematicreview(Table26)
o WemergedfindingsfromthethemesthatHale2010100identified:enthusiasticallycautious,a
toolintheboxofinterventions,timeconsuming,noteasytosetgoals.Findingswithinthese
themesmatchingthequalitativethemesinthesystematicreviewarepresented(inbold)in
oursummaryoffindingstable(Table27)
o ItwasnotpossibletomergefindingsfromWorrall2011287asthisstudywasstrictlyonaphasic
strokepatientsdescribingtheirgoalsandhowthesegoalscanbecoded(byclinicians)
accordingtotheInternationalClassificationofFunctioning,DisabilityandHealth(ICF)(WHO,
2001).Wethereforereportedthisstudyseparately

Table24: Qualitativestudiesintheincludedsystematicreview(Rosewilliam2011221)

Study
Alaszewski20045

Andreassenand
Wyller200511
Bendz200323

Stroke
samples/settings
Strokepatients,
professionalsfrom
strokerehabilitation
services
Strokepatientsnot
specified
Strokeunit

BoutinLesterand
Gibson200228

Strokepatients

Cott200449

Strokepatients,
occupational
therapist,
neurological
rehabilitationunit
Occupational
therapists
Occupational
therapists

Daniels200255
Foye200285

Datacollection
Semistructured
interviews

*Quality
characteristics
assessed
1,2,3,4,5,6,7,8,9,12
,13,14

Confidence(in
study)
Moderate

Semistructured
interviews
Openinterviews
withpatientsand
notesfrom
professionals
Unstructured
interviewsby
phoneandin
person
Focusgroupsused
tocollectdata

1,2,3,4,6,8,9,11,12,
13,14
2,3,4,8,9,11,12,13,
14

Moderate

1,2,3,5,7,8,9

Verylow

1,2,3,4,5,6,8,9,11,1
2,13,14

Moderate

Focusgroupsand
casenotes
Surveystodescribe
ethicallydifficult
situationsinown
words

1,2,3,4,5,6,7,8,9,10
,11,12,13,14
1,2,3,4,6,7,8,9,11,1
2,13,14

High

NationalClinicalGuidelineCentre,2013.
132

Moderate

Moderate

StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

Stroke
samples/settings
Stroke
physiotherapist
Strokepatients,
carersandspecialist
nurses
Professionalsfrom
strokerehabilitation
services
Strokepatients

Study
HaleandPiggot
2005101
Lawler1999149

Leach2010150

McGrathand
Adams1999171
Parry2004200

Strokeinpatient
rehabilitation

SuddickandDe
souza2006252
Timmermans
2009259
Wressle1999290

Strokeunits
Strokepatients
Strokepatients,
carer,professional
andclinicians

Confidence(in
study)
Moderate

Datacollection
Semistructured
interviews
Semistructured
interviews

*Quality
characteristics
assessed
1,2,3,4,5,6,8,9,10,1
1,12,13,14
1,2,3,4,5,8,9,10,11,
14

Semistructured
interview

1,2,3,4,6,7,8,9,10,1
1,12,13,14

Moderate

Structured
interviews
Videorecordswere
analysedusing
conversational
analysis
Semistructured
interview
Semistructured
interview
Interviewsand
dailyrecords

1,2,4,6

Verylow

1,2,3,4,5,6,8,9,11,1
2,13,14

Moderate

1,2,3,4,5,6,8,9

Low

1,2,3,4,5,6,9,11,12,
13,14
1,2,3,4,6,9

Moderate

Low

Low

*Qualitycharacteristicsassessed:1.Clearaims2.Adequatebackground3.Appropriatemethodology4.Appropriatedesign
5.Appropriaterecruitmentstrategy(sampleandsampling)Appropriatedatacollection6.Reliabilityofdatacollectiontool
7.Validityofdatacollectiontool8.Datacollectionmethodsdescribedadequately9.Dataanalysismethodsdescribed
adequately10.Reflexivity11.Ethicalissues12.Rigorousdataanalysis13.Clearfindings14.Valueofresearch

Table25: Quantitativestudiesintheincludedsystematicreview(Rosewilliam2011221)
Participants
andsample
size

Study
46

Design

Intervention
used(if
present)

*Quality
characteristics
assessed

Confidence(in
study)

Combs2010

caseseries
design

Useof
Canadian
Occupational
Performance
Measure
(COPM)to
exploregoals

1,5,6,9,10,11

Verylow

Gilbertson
200091

138stroke
patients

Singleblind
randomized
controltrial

Clientcentred
occupational
therapy
tailoredto
patientgoals

1,2,3,4,9,10,11,
13

Low

Monaghan
2005175

75stroke
patients

Serial
comparison
design

AStandard
meetingform
BNewform
toenhance
documentation

1,2,3,4,5,6,7,8,
11,12

Moderate

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

Study

Participants
andsample
size

Design

*Quality
Intervention
characteristics
used(if
assessed
present)
ofpatient
needsgoalsand
involvement
CAboveform
andweekly
wardrounds
withpatients,
carersand
doctors

Confidence(in
study)

Phippsand
Richardson
2007205

CVApatients=
117

Retrospective
analysisof
records

Useof
Canadian
Occupational
Performance
Measure
(COPM)to
exploregoals

1,3,4,8,9,10,11,
13

Low

Roberts2005
214

9stroke
patients

preandpost
intervention
design

Useof
Canadian
Occupational
Performance
Measure
(COPM)to
exploregoals

1,2,4,5,6,9,11,1
2,13,14

Low

Timmermans
2009**259

40stroke
patents

Crosssectional
surveyusing
semistructured
interviews

1,2,9,11,13

Verylow

Wressle2002
289

206stroke
patients

Experimental
design

1,3,6,9,11

Verylow

Useof
Canadian
Occupational
Performance
Measure
(COPM)to
exploregoals

*Qualitycharacteristicsassessed1.Clearlyfocussedquestion2.Appropriatedesign3.Appropriatesamplesize4.Lackof
selectionbias5.Lackofperformancebias6.Appropriateintervention7.Lackofobserverbias8.LackofHawthorneeffect
9.Reliabilityofmeasures10.Validityofmeasures11.Appropriatestatistics12.Lackofconfoundingfactors13.Accurate
results
**Timmermans2009:acrosssectionalsurveyusingsemistructuredformatrequiringquantitativeandqualitativedata
(mixedmethodology)

Table26: Additionalqualitativestudiesfromtheupdatesearchsincesearchcutoffdateof
includedsystematicreviewherewithqualitycharacteristicsandratings

Study
Hale2010100

Stroke
samples/settings
4communitybased
physiotherapistand
sevenstrokepatients

Datacollection
semistructuredin
depthinterviews;
detailedclinicalcase
notesandresearcher

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Quality
characteristics
assessed
1,6,7,8,12,13

Confidence(in
study)
Low

StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

Study

Worrall2011287

Stroke
samples/settings

50participantswith
aphasiapoststroke

Datacollection
fieldnotes
Qualitative
descriptivestudy
involvingsemi
structured,indepth
interviews

Quality
characteristics
assessed

Confidence(in
study)

1,2,3,4,5,6,7,8,9,1
1,12,13,14

High

*Qualitycharacteristicsassessed:1.Clearaims2.Adequatebackground3.Appropriatemethodology4.Appropriatedesign
5.Appropriaterecruitmentstrategy(sampleandsampling)Appropriatedatacollection6.Reliabilityofdatacollectiontool
7.Validityofdatacollectiontool8.Datacollectionmethodsdescribedadequately9.Dataanalysismethodsdescribed
adequately10.Reflexivity11.Ethicalissues12.Rigorousdataanalysis13.Clearfindings14.Valueofresearch

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Table27: Summaryoffindingsfromthequalitativethemesandquantitativeevidencefromsystematicreview(Rosewilliam2011)221and
additionalqualitativestudy(Hale2010)100fromupdatesearch
QUALITATIVEANDQUANTITATIVEFINDINGS

MATCHINGQUALITATIVEANDQUANTITATIVE
EVIDENCE

Patientsperceivedthatmakingprogresstowardspersonally

Quantitativeevidence:MaitraandErway2006164;
Wressle2002289;Timmermans2009259

Qualitativeevidence:Cott200449;Bendz200323;
Andreassen200511;McGrath1999171;Young2008295;

QUALITATIVETHEMES
Perceptionsofpatientsregardingpersoncenteredness
ingoalsettingandfactorsinfluencingit

meaningfulgoalshadbeengoodfortheirselfimageand
helpedasacopingmechanism171(VERYLOWCONFIDENCEIN
STUDY)

Otherreasonscitedaretogetbacktowork,independence,
nottobeaburdentoothersandtoavoidembarrassmentin
public259(VERYLOWCONFIDENCEINSTUDY)

Patientsperceivedthattheywerenotincontroloftheirgoals
andtheirinvolvementwithgoalsettingwaspassive295
(MODERATECONFIDENCEINSTUDY)

Passivitywasattributedto:

Limitedaccesstoinformation49(MODERATE
CONFIDENCEINSTUDY)

Inabilitytoaccepttheirconditionespeciallyinthe
earlystagesofstroke49(MODERATECONFIDENCEIN
STUDY)

Participationingoalsettingcouldbeimprovedbyprocesses
suchasformaldocumentationofthepatientsviews,
empoweringkeyworkerstobeproactive,respondingflexibly
totheirchangingneedsandtheuseofgradingsystemsto
measuretheirgoalachievement29549(MODERATE
CONFIDENCEINSTUDIES)

Evidencesuggesttheuseofexplicitmethodstoimprove
patientsperceptionofactiveparticipationingoalsetting
practice289(VERYLOWCONFIDENCEINSTUDY)
Professionalsperceptionsconcerningperson
centerednessingoalsetting

Patientssocialandoccupationalneedswerenotexplicitly
incorporatedintothetreatmentgoals,therebyreflectinga
perceptualpracticegap150(MODERATECONFIDENCEIN
STUDY)

Qualitativeevidence:Leach2010150;Daniels200255;
Hale2010100

Patientcenterednessingoalsettingwouldimprovepatients

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QUALITATIVEANDQUANTITATIVEFINDINGS
QUALITATIVETHEMES

MATCHINGQUALITATIVEANDQUANTITATIVE
EVIDENCE

motivation,effectiveuseoftimeandcontributetoholistic
planning150(MODERATECONFIDENCEINSTUDY)

Professionalsascribedreasonsthatcouldlimitadoptionofa
patientcentredapproachsuchasconcernsaboutfuturerisks,
socioculturalbarriers,environmentalandresource
implications15055(MODERATETOHIGHCONFIDENCEIN
STUDIES)

*Setgoalsmightbeusedasameansofencouraging,

motivatingandpromptingpatient100(LOWCONFIDENCEIN
STUDIES)

*Ameasurementtool(GAS)wasfoundusefulinguiding
treatmentandassistingtherapiststosetpatientcentred
goals100(LOWCONFIDENCEINSTUDY)

*ProfessionalswereconcernedaboutthereliabilityofGoal
AttainmentScaling(GAS)inthatdifferenttherapistscould
setdifferentindicatorsforthesamepatient100(LOW
CONFIDENCEINSTUDY)
Statusofpatientcenterednessincurrentstroke
rehabilitationgoalsettingpractices

Evidencesuggeststhatcurrentgoalsettingpracticeisnot
largelypatientcentred
STUDIES)

150

Qualitativeevidence:Leach2010150;Hale2010100

(MODERATECONFIDENCEIN

*IndecisionbyprofessionalsabouttheuseofGASintheir
practice100(LOWCONFIDENCEINSTUDY)

Consequencesofdiscrepanciesinperceptionsand
practiceofgoalsettingprocess

Thereviewrevealeddiscrepanciesbetweenpatientand
professionalintheirperceptionsregardinglevelofpatient
involvementinthegoalsettingprocessandalsowithregard
torecoveryandfocusofrehabilitation164(LOWCONFIDENCE
INSTUDY)

Quantitativeevidence:MaitraandErway2006164;
Qualitativeevidence:Leach2010150;BoutinLester2002
28
;Alaszewski20045;Hale2005101

Thesediscrepanciesinperceptionofillnessandrecovery
betweenthepatientandprofessionalleadtoconflictsnotjust
inthegoalsettingprocessbutalsoimpactedonotherrealms
ofrehabilitationsuchasitsdeliveryandthetherapeutic
relationship150281015(VERYLOWtoMODERATECONFIDENCE
INSTUDIES)

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QUALITATIVEANDQUANTITATIVEFINDINGS

MATCHINGQUALITATIVEANDQUANTITATIVE
EVIDENCE

Conflictarisingduetoamismatchinvaluesandprioritieswas

Noquantitativeevaluation
Qualitativeevidence:Foye200285

QUALITATIVETHEMES
Ethicalconflict

highlightedasanimportantdilemmaencounteredinpractice
85
(MODERATECONFIDENCEINSTUDY)
Challengestopatientparticipationingoalsetting

Inhibitoryfactorssuchaslimitedtime,presidingprofessional
routinesandthesingleopportunitytomeetclinicianspost
dischargeforsecondaryriskmanagement150252200(LOWto
MODERATECONFIDENCEINSTUDIES)

Quantitativeevidence:Monaghan2005175
Qualitativeevidence:Leach2010150;Suddick2006252;
Parry2004200;Cott200449;Lawler1999149;Hale2010
100

Patientsparticipationingoalsettingwashinderedby
psychosocialfactorssuchinabilitytoaccepttheoccurrenceof
stroke,depression,patientsguardingagainstexposingtheir
incompetence15049200(VERYLOWtoMODERATE
CONFIDENCEINSTUDIES)

Standardgoalsettingmeetingwhichisheldawayfromthe
patientandwithstandarddocumentationisnotconduciveto
patientcentredgoalsetting175(MODERATECONFIDENCEIN
STUDY)

Thefactormentionedbybothprofessionalsandpatientswas
thestrokepathologywithitshighlyunpredictablerecovery
prognosisanditseffects,suchasaphasia150149(LOWand
MODERATECONFIDENCEINSTUDIES)

*Settinggoalsandindicatorscouldbetimeconsuming
especiallywithpatientswithsevereimpairment(for
example,cognitiveimpairment)100(LOWCONFIDENCEIN
STUDY)
Strategiestodeveloppersoncenterednessingoal
settingpractices

Amultidisciplinaryteamapproachinvolvingthepatientalong
withspecialistssuchasspeechpathologistsimproves
discussionanddocumentationofpatientgoals150175
(MODERATECONFIDENCEINSTUDY)

Setpatientcentredgoalsandthentraining,either

Quantitativeevidence:Monaghan2005175;Wressle
2002289;Roberts2005214;Phipps2007205;Combs2010
46
;Gilbertson200091
Qualitativeevidence:Leach2010150;Hale2005101;
Daniels200255;Cott200449;Lawler1999149

conventionalorinnovative,tailoredtothosegoalsledto
shorttermimprovementinactivitiesofdailyliving,better
globaloutcome,bettermotoroutcomesandbetterself
214 205 46 91
perceivedperformanceandsatisfaction (VERY

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QUALITATIVEANDQUANTITATIVEFINDINGS
QUALITATIVETHEMES

MATCHINGQUALITATIVEANDQUANTITATIVE
EVIDENCE

LOWtoLOWCONFIDENCEINSTUDIES)

Patientandfamilyeducationregardingthepathology,process

ofrehabilitationandgoalsetting150(MODERATECONFIDENCE
INSTUDY)

Encouragingpatientstoidentifygoalsthatareinlinewith
theirexpectation150(MODERATECONFIDENCEINSTUDY)

Activedecisionmakinginvolvingpatientsneededtobe
pitchedtotheirparticipatingability(gradeddecisionmaking)
49 55
(MODERATEtoHIGHCONFIDENCEINSTUDIES)

Theusestandardmeasurestoidentifyclientcentredgoals
improvedopportunityforpatientparticipationingoalsetting,
theirperceptionregardingparticipationandabilitytorecall
149 289 214 205 46
theirgoals (VERYLOWtoLOWCONFIDENCE
INSTUDIES)
*Findingsfromadditionalqualitativestudy(Hale2010)mergedherewithfindingsfromincludedsystematicreview

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Additionalqualitativestudyfromupdatesearchsincesearchcutoffdateofincludedsystematic
review
Summaryoffindings:
Worrall2011287(HIGHCONFIDENCEINEVIDENCEfromthisstudy):Describingthegoalsofpeople
withaphasiaandtocodethegoalsaccordingtotheICF
Returntoprestrokelife:
Participantsexpressedtheirdesiretobenormalagainandtoescapetheircurrentsituationand
returnhometothesecurityoftheiroldlife
Communication:
Participantswithaphasiaspokeoftheimportanceofrecoveringtheircommunicativefunction(for
example,communicationforbasicneedsaswellascommunicationtoexpresstheiropinions).
Theydescribedintensefeelingsoffrustration,hopelessness,isolation,anddepressionatnot
beingabletotalk
Manystressedthattheaphasiawasofhigherprioritytothemthantheirphysicalimpairments
Participantsspokeoftheneedforcommunicationrehabilitationtobeconnectedtoreallifeand
abouthowcommunicationgavethemconfidence
Information:
Participantswantedmoreinformationaboutaphasia,stroke,prognosis,andwhattoexpectat
differentstagesofrehabilitation
Havinginformationallowedpeopletostarttakingcontrolandtoparticipateindecisionsabout
theirowntherapyandtheirownrehabilitation
Speechtherapyandotherhealthservices:
Participantswantedspeechtherapythatmettheirneedsatdifferentstagesofrecovery,was
relevanttotheirlife,morefrequentandcontinuedforlonger.
Participantswantedpositiverelationshipsandinteractionswiththeirspeechtherapistsandother
healthserviceproviders
Controlandindependence:
Someexpressedfrustrationatnotbeingapartofthedecisionmakingintheircare,seeking
informationfromsourcesotherthanhealthprofessionals
Dignityandrespect:
Manypeoplereportedafeelingofbeingdisempoweredbytheiraphasia.Theywantedrespect,
statingthattheywerecompetentpeople,despitetheircommunicationdifficulties.
Social,leisure,andwork:
Tobeabletocarryoutsocialactivitiesandtofeelcomfortableinacrowd
Youngerpeoplewithaphasiawereparticularlyawareofthelossofworkandcareerandoften
helddeep,strongdesirestoreturntosomeemployment

6.2.2

Economicevidencesummary
Literaturereview
Norelevanteconomicevaluationswereidentified.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.

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Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
Basedonthedetailsoftheclinicalstudies,theresourcesassociatedwiththegoalsetting
interventionareequivalenttoanhourofmultidisciplinaryteamtimefortheinitialgoalsettingand
halfanhourforeachreview.ThesecostsaresummarisedinTable28.
Table28: Interventioncostsgoalsetting
Resources

Frequency

Unitcosts(a)

Costperpatient

Goalsettingwithmulti
disciplinaryteam

1hour

136perhourpsychologist
35perhournurse
45perhourphysiotherapist
45perhouroccupational
therapist
132perhourmedical
consultant

393

136perhourpsychologist
35perhournurse
45perhourphysiotherapist
45perhouroccupational
therapist
132perhourmedical
consultant

197

Reviewofgoalsettingwith 30minutes
multidisciplinaryteam

a)EstimatedbasedondataandmethodsfromPersonalSocialServicesResearchUnitUnitcostsofhealthandsocialcarereportandthe
51
followingAgendaforChangesalarybandspsychologist(band8),physiotherapistandoccupationaltherapist(band6),nurse(band5)
(typicalsalarybandsidentifiedbyclinicalGDGmembers).

6.2.3

Evidencestatements
ClinicalEvidencestatements
Perceptionsofpatientsregardingpersoncenterednessingoalsettingandfactorsinfluencingit
Twostudies171259foundthatpatientsperceivedthatmakingprogresstowardspersonally
meaningfulgoalshadbeengoodfortheirselfimage,gettingbacktowork,independence,avoiding
embarrassmentinpublicandhelpedasacopingmechanism(MODERATECONFIDENCEINSTUDIES)
Onestudy49foundthatpatientsperceivedtheywerenotincontroloftheirgoalsandtheir
involvementwithgoalsettingwaspassive(MODERATECONFIDENCEINSTUDY)
Twostudies29549foundthatparticipationingoalsettingcouldbeimprovedbyprocessessuchas
formaldocumentationofthepatientsviews,empoweringkeyworkerstobeproactive,responding
flexiblytotheirchangingneedsandtheuseofgradingsystemstomeasuretheirgoalachievement
(MODERATECONFIDENCEINSTUDIES)

Professionalsperceptionsconcerningpersoncenterednessingoalsetting
Onestudy150foundthatpatientssocialandoccupationalneedswerenotincorporatedintothe
treatmentgoals,andthatpatientcenterednessingoalsettingwouldimprovepatientsmotivation,
effectiveuseoftimeandcontributetoholisticplanning(MODERATECONFIDENCEINSTUDY)
Twostudies15055highlightedconcernsaboutfuturerisks,socioculturalbarriers,environmental
andresourceimplicationsasreasonsthatcouldlimitadoptionofapatientcentredapproachingoal
setting(MODERATEtoHIGHCONFIDENCEINSTUDIES)
Onestudy100foundthatameasurementtool(GAS)wasfoundusefulinguidingtreatmentand
assistingtherapiststosetpatientcentredgoalsbutconcernswereraisedaboutthereliabilityofthis
tool(LOWCONFIDENCEINSTUDY)

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Statusofpatientcenterednessincurrentstrokerehabilitationgoalsettingpractices
Onestudy150foundthatcurrentgoalsettingpracticeisnotlargelypatientcentred(MODERATE
CONFIDENCEINSTUDY)
Onestudy100foundthatprofessionals(physiotherapist)wereundecidedabouttheuseofGoal
AttainmentScaling(GAS)intheirpractice(LOWCONFIDENCEINSTUDY)

Consequencesofdiscrepanciesinperceptionsandpracticeofgoalsettingprocess
Fourstudies15028,1015foundthatdiscrepanciesinperceptionofillnessandrecoverybetweenthe
patientandprofessionalleadtoconflictsinthegoalsettingprocesswhichalsoimpactedonother
realmsofrehabilitation(VERYLOWtoMODERATECONFIDENCEINSTUDIES)
Challengestopatientparticipationingoalsetting
Fivestudies149150252200175highlightedfactorsinhibitingpatientsfromparticipatingingoalsettings.
Thesefactorsinclude:limitedtime,presidingprofessionalroutines,goalsettingmeetingwhichis
heldawayfromthepatient,singleopportunitytomeetclinicianspostdischargeforsecondaryrisk
management,strokepathologywithitshighlyunpredictablerecoveryprognosisanditseffectssuch
asaphasiaand(LOWtoMODERATECONFIDENCEINSTUDIES)
Threestudies15049200highlightedpsychosocialfactorsinhibitingpatientsfromparticipatingingoal
settings.Thesefactorsinclude:inabilitytoaccepttheoccurrenceofstroke,depression,patients
guardingagainstexposingtheirincompetence(MODERATECONFIDENCEINSTUDIES)
Strategiestodeveloppersoncenterednessingoalsettingpractices
Twostudies150175highlightedthatamultidisciplinaryteamapproachinvolvingthepatientalong
withspecialistssuchasspeechpathologistsimprovesdiscussionanddocumentationofpatientgoals
(MODERATECONFIDENCEINSTUDY)
Fourstudies2142054691showedthatpatientcentredgoalsledtoshorttermimprovementinactivities
ofdailyliving,betterglobaloutcome,bettermotoroutcomesandbetterselfperceivedperformance
andsatisfaction(VERYLOWtoLOWCONFIDENCEINSTUDIES)
Onestudy150mentionedthatpatientandfamilyshouldbeeducatedwithregardsthepathology,
processofrehabilitation,settinggoalsandpatientsshouldbeencouragedtoidentifygoalsthatarein
linewiththeirexpectation(MODERATECONFIDENCEINSTUDY)
Goalsofpeoplewithaphasiapoststroke
Onestudy287foundthatpeoplewithaphasiapoststrokewantedgreaterautonomydignityand
respect.Theyalsowantedmoreinformationaboutaphasia,stroketoreturntotheirprestrokelife
tocommunicatetheirbasicneedsandtheiropinions(HIGHCONFIDENCEINSTUDY)

6.2.4

Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

6.2.5

Recommendationsandlinkstoevidence
25.Ensurethatpeoplewithstrokehavegoalsfortheirrehabilitation
that:
aremeaningfulandrelevanttothem
focusonactivityandparticipation
Recommendations

arechallengingbutachievable

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includebothshorttermandlongtermelements.
26.Ensurethatgoalsettingmeetingsduringstrokerehabilitation:
aretimetabledintotheworkingweek
involvethepersonwithstrokeand,whereappropriate,their
familyorcarerinthediscussion.

Relativevaluesofdifferent
outcomes

Theoutcomesofinterestwerepsychologicalmeasuresandhealthrelated
qualityoflife,physicalfunctionandActivitiesofDailyLiving(ADL)
AnyimpactgoalsettinghasonactivityandparticipationisclearlyImportant
butotheroutcomesincludingpatientssenseofself,autonomy,copingand
selfimagewerealsofelttobeimportant.

Tradeoffbetweenclinical
benefitsandharms

TheGDGagreedthatgoalsettingthatwaspatientcentredandinvolved
sharinginformation,andidentifyingpatientsvalues,beliefsandpreferences
waslikelytohavesignificantbenefitstothepatient,beingbothencouraging
andmotivating.Howevergoalsettingthatisdominatedbyprofessionalsmay
bebothtimeconsuming,anddisempowerpatients,focussingonrehabilitation
interventionsthathavelittleapparentrelevance,althoughtheycanassist
therapistsindevelopingatreatmentplan.

Economicconsiderations

Nocosteffectivenessstudieswerefound.Personnelcostfordeliveringagoal
settinginterventionwasestimatedat393fortheinitialinterventionand197
forthereviewofthegoalssetbasedonGDGestimatesoftheresourceuse
involved.TheGDGconsideredthattheadditionalcostswouldpotentiallybe
offsetbythelongtermbenefittopatientsintermsofimprovedqualityoflife.

Qualityofevidence

Thesystematicreview(Rosewilliam,2011)ofbothquantitativeandqualitative
studiesincludedinthereviewexploredthenature,extentandeffectsof
applyingpatientcentredgoalsettinginstrokerehabilitationpractice.Inthe
qualitativestudiesdatahadbeencollectedbyinterviews,focusgroupsand
surveys.Thequantitativestudieshadusedrandomised,crosssectionalsurvey,
retrospectiveanalysisofrecordsandcaseseriesdesigns.

TwootherqualitativestudiesevaluatedtheGoalAttainmentScaling(GAS)in
homebasedstrokerehabilitation(Hale,2010),andgoalsofpeoplewith
aphasiaandhowthesegoalscanbecoded(byclinicians)accordingtothe
InternationalClassificationofFunctioning,DisabilityandHealth(ICF)(Worrall,
2011).Thesewerebothdescriptivestudiesusingsemistructured,indepth
interviews.
Thethemesexploredbythestudiesincludedperceptionsofpatientsregarding
personcenterednessingoalsettingandfactorsinfluencingit,professionals
perceptionsconcerningpersoncenterednessingoalsetting, challengesto
patientparticipationingoalsettingandstrategiestodevelopperson
centerednessingoalsettingpractices.

Thequalityofincludedstudies(Rosewilliam,2011)wereassessedbyusing
qualitycriteriaadaptedfrompublishedliteraturewithdifferentsetsofquality
criteriausedforthequalitativeandquantitativestudies.Themesfromall
qualitativestudiesmatchingthereviewquestionswerepooled.Thefindings
fromallofthestudiesweresynthesisedbyaggregatingthethemesfromthe
qualitativestudiesandrelatingthemtofindingsfromquantitativestudies.The
studyqualitiesofHale2010andWorrall2011wereassessedandratedusing
thequalitycriteriaadaptedfromtheincludedsystematicreviewandwe
mergedfindingsfromthethemesthatHale2010identified.Confidenceinthe
effectsreportedwithinthestudiesrangedfromverylowtohigh.TheGDG
notedthatthemajorityofstudiesweresmallqualitativestudiesfocussingon
patients'perceptions,professionalsperceptions,theneedforpatient

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centrednessandhowtodevelopthis.

Otherconsiderations

6.2.6

TheGDGnotedthatthefindingsfromthestudiesofgoalsettinginstrokewere
similartothosereportedingoalsettinginotherdisablingconditions.
Theimportanceofdevelopingstructurestosupportpatientinvolvementin
goalsettingincludingstafftrainingwashighlighted.Goalsettingneedstobe
adaptedaccordingtotheenvironmentandthestageofacceptancewiththe
individual.Thestudieshighlightedthatsettinggoalsattheveryacutestageis
notalwaysappropriate.Afterastroke,thepersonhasanenormous
adjustmenttomakeinacceptingandcomingtotermswithwhathas
happened.TheGDGagreedthatthereweredifferentlevelsofparticipationby
thepatientingoalsetting,andattheacutestagethismaybelimiteduntilthe
personfeelsreadyandmoreconfidentwhentheycanparticipatemore.

Delphistatementswhereconsensuswasachieved
Table29: Tableofconsensusstatements,resultsandcomments(percentageintheresultscolumn
indicatestheoverallrateofresponderswhostronglyagreedwithastatementand
amountofcommentsinthefinalcolumnreferstorateofresponderswhousedthe
openendedcommentsboxes,i.e.No.peoplecommented/No.peoplewhoresponded
tothestatement)
Results
%

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes

Number

Statement

Bothprofessionspecificaswellas
multidisciplinarystroketeams'goals
shouldbepersonfocused.

81.8

17/99(17%)panelmembers
commented

Thiswasseenimportantinthe
processofgoalplanningbysome
panelmembers(Absolutely.We
dontdothisenoughyetandwe
needtogetmuchbetteratthisto
useoutcomemeasuresproperlyand
reallyeffectively.)

Itwasseenasmostimportantthat
goalsshouldbesetbyorset
collaborativelywiththepersonwho
hashadastroke(Goalsneedtobe
genuinelypersongenerated.
Goalsettingshouldbe
collaborative,setwiththepatient,
andmultidisciplinaryratherthanuni
disciplinary
Thereshouldbeonesetofpatient
agreedpatientcentredgoals)

Fourpeopleexpressedtheopinion
thatthiswasnotasensible
statement.

Effortsshouldbemadetoestablish
thewishesandexpectationsofthe
personwhohashadastrokeandtheir
carer/family.

86.9

13/99(13%)panelmembers
commented

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6.2.7

Results
%

Number

Statement

Thefollowingcriteriashouldbeused
whensettinggoalswiththeperson
whohashadastroke:
Meaningfulandrelevant
Shouldbefocusedonactivitiesand
participation
Challengingbutachievable
Bothshortandlongtermtargets
MayinvolveoneMDTteammember
ormaybemultidisciplinary
Involvecarer/familywherepossible,
withconsentofpersonwhohashada
stroke
Usedtoguidetherapyandtreatment

92.0
69.7

76.0

70.1

76.0

81.0

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes
Itwashighlightedthatthese
expectationsneedtoberealistic.

Somepeoplequestionedtheterm
effortsandwhatthiswouldmeanin
realterms.

Onepersonindicatedtheopinion
thatthiswasaredundantstatement.
20/100(20%)panelmembers
commented

Ratherthanthemesindividualissues
werehighlighted:
Thetypeofgoaldependsonthe
stageandsettingofrehabilitation
(Initialgoalsintheacutesetting
maybelessfocussedonactivities
andparticipationasthetreatment
beginstodevelopabasefromwhich
furthergoalsmaybeset,forexample
increasingthelengthoftreatment
thatcanbetolerated.Notall
objectivescanbeidentifiedwithin
recognisedassessmenttoolsinthe
earlystages.)
Somegoalsmightnotbeeasily
measurable(Goalsdonothaveto
bemeasurableasimprovementin
engagementandmotivationcanbea
goalthatwillbedifficultto
quantify.)
Goalsshouldbejargonfree.

Onepersonindicatedtheopinion
thatthiswasaredundantstatement.

Delphistatementswhereconsensuswasnotachieved
Table30: Tableofnonconsensusstatementswithqualitativethemesofpanelcomments
Number

Statement

Goalsshouldhavepredicteddatesfor
completion.

Results
%

Amountandcontentofpanel
commentsorthemes

36.5

Inround224/98(24%)panel
memberscommented;19/85(22%)
inround3:

Themes:
Flexibilitytimingofgoalsshould
notbetoorigidandprescriptive.

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Results
%

Amountandcontentofpanel
commentsorthemes
Typeofgoalssomegoalsdont
lendthemselvestopredictanend
point
Effectonpatientsfocusondates
andfailurecanleadtodistressand
haveanimpactonconfidenceand
esteem
ProgressionRatherthangivingone
date,regularreviewsleadtoa
feelingofprogress

Number

Statement

Areviewofgoalsofthepersonwho
hashadastrokeshouldbeconducted
betweenthepersonandthe
multidisciplinaryteammember
deliveringtheinterventionatthe
expecteddateofcompletion.

42.4

Inround214/99(14%)panel
memberscommented;13/85(15%)
inround:

Thepanelscommentshavethe
followingthemessomeofthese
aremirroringthoseforexpected
datesofgoals:
Expecteddateitwasqueried
whethertherewouldbeanexpected
date(Idontagreethatgoalsalways
needtohaveanexpecteddateof
completion.)
Regularreviewsgoalsshouldbe
regularlyreviewedasanongoing
process(Butshouldbeconstantly
reviewedthroughouttherapy.).
Flexibilitywhenandhowthe
reviewwouldtakeplaceshouldbe
flexible(Thesepeopleshouldbe
involvedbuttheredoesneedtobe
someflexibility).
TeamorindividualmemberCould
involveanindividualteammember,
butsometimesalsothewholeteam
(Thisshouldbepartoftheweekly
MDTmeetingwhichthepatient
shouldtakepartin.).

Onepersonobjectedtothis
statementsinceitrepresentsand
idealscenarioratherthanwhatcan
beachievedinclinicalpractice(if
youdidallthesethings,youdnever
havetimetodoanyactual
therapy.).

Thereasonsforunattainedgoalsand
goalsthathavebeenreassessedneed
tobedocumented.

56.5

Inround211/99(11%)panel
memberscommented;6/85(7%)in
round3:

Generallythiswasseenaspositive,
butitwasstatedthatthismaybetoo
reflectiveforsomeandthatitneeds

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

6.2.8

Number

Statement

Patientsshouldhaveawrittencopyof
theirgoals.

Results
%

Amountandcontentofpanel
commentsorthemes
tobenefittheindividualratherthan
beameasureofoutcome.

Itishelpfultoknowwhyagoalis
notbeingmettolearnabout
patternsofrecoveryandwhat
affectsprogress.

52.4

Inround3(thisstatementwasfirst
introducedinround3)17/84(20%)
panelmemberscommented

Therewasafeelingthattheformat
ofthisdocumentationwouldnot
alwaysbeaccessibletotheperson
whohashadastroke(cognitiveor
languageimpairedpersonsfor
instance).

Itmightbehelpfulifthisstatedthat
thesegoalsshouldbeinlanguage
appropriatetothepatient(notMDT
language)andthatwherepossible,
theyshouldreflectthepatientsown
wordsinsettingthegoals.

Forpatientswithmemoryproblems
thisisparticularlyimportantbutalso
writtengoalsaidcommunication
betweenthepatient,teamand
family.

RecommendationsandlinkstoDelphiconsensussurvey
Statements

Recommendations

21.Bothprofessionspecificaswellasmultidisciplinarystroketeams'
goalsshouldbepersonfocused.
22.Effortsshouldbemadetoestablishthewishesandexpectationsof
thepersonwhohashadastrokeandtheircarer/family.
23.Thefollowingcriteriashouldbeusedwhensettinggoalswiththe
personwhohashadastroke:
Meaningfulandrelevant
Shouldbefocusedonactivitiesandparticipation
Challengingbutachievable
Bothshortandlongtermtargets
MayinvolveoneMDTteammemberormaybemultidisciplinary
Involvecarer/familywherepossible,withconsentofperson
whohashadastroke
Usedtoguidetherapyandtreatment
27.Ensurethatduringgoalsettingmeetings,peoplewithstrokeare
providedwith:

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation
anexplanationofthegoalsettingprocess
theinformationtheyneedinaformatthatisaccessibletothem
thesupporttheyneedtomakedecisionsandtakeanactivepart
insettinggoals.
28.Givepeoplecopiesoftheiragreedgoalsforstrokerehabilitation
aftereachgoalsettingmeeting.
29.Reviewpeoplesgoalsatregularintervalsduringtheirstroke
rehabilitation.

Otherconsiderations

TheDelphitechniquewasusedtoelucidatethestrokerehabilitation
community'sviewsofgoalsettingandconsensuswasachievedonthe
importanceofmeaningful,relevantachievablegoalsthatfocussedonactivity
andparticipationandincludedbothshorttermandlongtermtargets.
TheGDGconsideredtheareasthatachievedconsensusthatwouldsupplement
therecommendationsalreadymadebasedontheevidencereviewundertaken.
TheGDGnotedthosestatementsthatdidnotachieveconsensus,andagreed
thesedidnotseemtobeparticularlycontroversial.Itwasagreedthatemphasis
shouldbeplacedonhavinggoalsthataremeaningfulandrelevanttothe
patient.TheGDGagreedthatitwasveryimportantthatpatientsshouldreceive
acopyoftheirgoals,andarguedthatitwasnotpossibletoprovidepatient
centredgoalsiftheydidnothaveacopytheycouldreferto.Thegroupagreed
withmanyofthecommentsfromthesurveythatinformationongoalsshouldbe
inaformataccessibletothepatienttotakeintoaccountcognitiveor
languageimpairmentsAlthoughtherewasnoagreementaboutreviewing
goalsatspecifieddatestheGDGagreedthatareviewshouldbeconductedat
appropriatetimepointstomonitoranddiscussprogressandreassesstheneeds
andwishesofthepatient.

6.3 Planningrehabilitation
6.3.1

Delphistatementswhereconsensuswasachieved
Table31: Tableofconsensusstatements,resultsandcomments(percentageintheresultscolumn
indicatestheoverallrateofresponderswhostronglyagreedwithastatementand
amountofcommentsinthefinalcolumnreferstorateofresponderswhousedthe
openendedcommentsboxes,i.e.No.peoplecommented/No.peoplewhoresponded
tothestatement)

Number

Statement

Results
%

Documentationrelatedto
rehabilitationshouldbe
individualised,andcontainthe
followingminimuminformation:

Basicdemographicsincluding

92.9

93.9
96.9

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Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes

17/99(17%)panelmembers
commented:

Anumberofadditional

StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

Number

Results
%

Statement

contactdetailsandnexttokin

Diagnosisandrelevantmedical
information

78.7

Listofcurrentmedications
includingallergies

93.9

Standardisedscreening
assessmentstoincludethose
identifiedinearlierquestions

87.8

79.5

Personfocusedrehabilitationgoals 85.8
Multidisciplinaryprogressnotes

76.5

Keycontactfromthestroke
rehabilitationteamtocoordinate
healthandsocialcareneeds

79.5

Dischargeplanninginformation

Jointhealth/socialcareplansif
developed

Followupappointments

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes

documentsweresuggested:
Returntoworkinformationwas
mentionedmostfrequently
Informationonadditional
supportavailableafterdischarge
(forexample,carersupport
organisationsandstrokesupport
groups)
Strokeeducation/lifestyle
information

1.

Inthedevelopmentof
rehabilitationplans,effortsshould
bemadetoencouragetheperson
whohashadastrokeandcarersto
beinvolvedandactively
participate.

86.9

17/99(17%)panelmembers
commented:

Thiswasseenasimportantin
personcentredcare.

Itwasmentionedthatthewishes
ofthepersonwhohashada
strokeshouldbetakeninto
consideration.Somepeoplefind
thisastressfulexperience.

Threepeopleexpressedan
opinionthatthiswasaredundant
statement.

2.

Rehabilitationplansshouldbe
reviewedbythemultidisciplinary
teamatleastonceperweek.

71.4

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Inround241/95(43%)panel
memberscommented;
34/77(44%)inround3

StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

Number

Statement

Results
%

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes

Thephaseofrehabilitationwas
commentedon.Weeklyreviews
earlyonintheacutephase,or
whenthepersonwhohashada
strokeisaninpatient,reducingto
longerintervalsasthe
rehabilitationprogresses.
notsensible.Infirst6weeks
weeklyisneededthereaftertwo
weeklyisreasonableorlonger

inlightofthequickthroughput
ofhospitalstrokepatientsthe
reviewmayneedtobe
undertakentwiceaweek.

Therewasaconcernnottobe
tooprescriptiveabouttiming.
becauseeachpersonwhohas
hadastrokeisdifferent,the
reviewshouldtakeplace
accordingtoneedsofthe
individualandthiswillvary

Typeofplanandtypeofgoal
wasalsoseenasimportant:
Thisdependsonhowyoudefine
rehabilitationplans.Arethey
broad,forexampletogohome
independentlywalkingandself
careandreturningtoworkor
morespecifictothemomentfor
exampletobeabletostandfor5
minutesinastandingframe?

6.3.2

Delphistatementwhereconsensuswasnotreached
Table32:

Tableofnonconsensusstatementswithqualitativethemesofpanelcomments

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

Results
Number
1.

Statement

Whenthereisasignificantchange,
orwhenaplateau/potentialis
reached,orbeforedischarge,a
meetinginvolvingthestroke
rehabilitationteam,withan
invitationtothepersonandtheir
family/carer,shouldbeconducted
todiscussthesepoints.

63.4

Amountandcontentofpanel
commentsorthemes
Inround222/99(22%)panel
memberscommented;
16/85(19%)inround3and11/72
(15%)inround4:

Therewereseveralthemes:
MDTsomemembersofthe
panelthoughtthatthisdoesnot
havetoinvolvethewholeteam
(Themeetingsshouldhappen
butonlyincludetherelevant
staff,notthewholestroke
rehabilitationteam).
Beforedischargethiswasseen
asthemostimportantaspectof
thestatement.
Needforanadditionalmeeting
ifthereareregularreviewsthen
changes/plateaushouldnot
comeasasurprise
Meetingtypethisneedstobe
tailored(formalorinformal)to
theindividualandtheir
carer/family
Statementthestatementitself
wasseenashavingtoomany
differentcomponentstoanswer
withoneresponse.

Severalpeoplecommentedthat
thetermsplateauorpotential
wasunclear.(Whatisplateau?
Onedayofnochange,oneweek,
onemonth?)

6.3.3

RecommendationsandlinkstoDelphiconsensussurvey
Statements

24.Documentationrelatedtorehabilitationshouldbeindividualised,and
containthefollowingminimuminformation:

Basicdemographicsincludingcontactdetailsandnexttokin

Diagnosisandrelevantmedicalinformation

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

Listofcurrentmedicationsincludingallergies

Standardisedscreeningassessmentstoincludethoseidentifiedin
earlierquestions

Personfocusedrehabilitationgoals

Multidisciplinaryprogressnotes

Keycontactfromthestrokerehabilitationteamtocoordinate
healthandsocialcareneeds

Dischargeplanninginformation

Jointhealth/socialcareplansifdeveloped

Followupappointments
25.Inthedevelopmentofrehabilitationplans,effortsshouldbemadeto
encouragethepersonwhohashadastrokeandcarerstobeinvolved
andactivelyparticipate.
26.Rehabilitationplansshouldbereviewedbythemultidisciplinaryteam
atleastonceperweek.
Recommendations

30.Provideinformationandsupporttoenablethepersonwithstroke
andtheirfamilyorcarer(asappropriate)toactivelyparticipatein
thedevelopmentoftheirstrokerehabilitationplan.
31.Strokerehabilitationplansshouldbereviewedregularlybythe
multidisciplinaryteam.Timethesereviewsaccordingtothestageof
rehabilitationandthepersonsneeds.
32.Documentationaboutthepersonsstrokerehabilitationshouldbe
individualised,andshouldincludethefollowinginformationasa
minimum:
basicdemographics,includingcontactdetailsandnextofkin
diagnosisandrelevantmedicalinformation
listofcurrentmedications,includingallergies
standardisedscreeningassessments(seerecommendation18)
thepersonsrehabilitationgoals
multidisciplinaryprogressnotes
akeycontactfromthestrokerehabilitationteam(includingtheir
contactdetails)tocoordinatethepersonshealthandsocialcare
needs
dischargeplanninginformation(includingaccommodationneeds,
aidsandadaptations)
jointhealthandsocialcareplans,ifdeveloped
followupappointments.

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

Economicconsiderations Therearesomecostsassociatedwiththereviewingoftherehabilitation
planbythemultidisciplinaryteam.TheGDGhasconsideredthe
economicimplicationsandconcludedthatthebenefitsofthe
interventionintermsofimprovementinqualityoflifewereconsidered
likelytooutweighthecosts.
Otherconsiderations

TheGDGoverallagreedwiththestatementonwhatinformationshould
beincludedinplanningrehabilitation,whilstacknowledgingthiswasnot
exhaustiveandshouldbethoughtofasacorelist.Itwasfeltthatthere
wouldbeavarietyofopinionsonadditionalinformationthatshouldbe
included,butwereinagreementwiththeconsensusview.
Itwasthoughtthatcareplanningisanelementofgoalsetting.Although
somecommentshadbeenmadethatthestatementswererather
obvious,theGDGthoughtthatprovidingsupporttoenabletheperson
andcarerstobeinvolvedinthedevelopmentoftheirrehabilitationplans
throughhavingknowledgeandfeelingempoweredtoparticipatewasa
keyrecommendationtomake.
TheGDGthoughtthatspecifyingwhenrehabilitationplansshouldbe
reviewedwasnothelpful,andagreedwiththecommentsfromthe
Delphisurvey,thatthiswouldbevariable,withreviewsbeingcarried
outveryfrequentlyintheearlystagesandlesssolateron.Thegroup
agreedthatitshouldbebasedontheneedsofthepatientatdifferent
stagesoftherehabilitationpathway.

6.4 Intensityofstrokerehabilitation
Thedoseofrehabilitationthatindividualsreceivevariesfromcountrytocountryandserviceto
service.Inspecialistneurorehabilitationservicespatientsmayreceive5hoursoftherapyeachday,
inothers1or2hourseachday.Durationoftherapymayvaryfrom2weeksto3or6monthswith
somepatientsaccessingorreaccessinginputsomeyearsaftertheonsetofstroke.
TheNationalStrokeStrategy61statesPeoplewhohavehadstrokesaccesshighqualityrehabilitation
and,withtheircarer,receivesupportfromstrokeskilledservicesassoonaspossibleaftertheyhave
astroke,availableinhospital,immediatelyaftertransferfromhospitalandforaslongastheyneed
it.TheNICEstrokequalitystandard189specifiesthatPatientswithstrokeareofferedaminimumof
45minutesofeachactivetherapythatisrequired,foraminimumof5daysaweek,atalevelthat
enablesthepatienttomeettheirrehabilitationgoalsforaslongastheyarecontinuingtobenefit
fromthetherapyandareabletotolerateit.Manyfrailolderpatientswithcomorbiditiescannot
toleratesuchintensityintheearlystagesafterstroke,otherpatientscantoleratefarmore.Inother
sphereswheremotorlearningisimportantitisacceptedthatthedegreeofperformance
improvementisdependentontheamountofpractice.Instrokewherethereisarangeof
impairmentsandaspatientsmovearoundinchangingenvironmentsthereisuncertaintyaboutthe
benefitsofincreasingthetotaldoseoftherapywhetherintermsofintensity(hoursperday)or
durationoftherapy(weeks).

6.4.1

Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessof
intensiverehabilitationversusstandardrehabilitation?
ClinicalMethodologicalIntroduction

Population:

Adultsandyoungpeople16orolderwhohavehadastroke

Intervention:

Intensiverehabilitation(inpatientandoutpatient)mixedpackage
oftherapydeliveredbyaMDT.

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

6.4.1.1

ClinicalMethodologicalIntroduction

(hoursperday,numberofdaysoftreatment,weeksversus
months,largeversussmalldose)

Comparison:

Standardrehabilitationornone

Outcomes:

Lengthofstay
FunctionalIndependenceMeasure(FIM)
BarthelIndex
QualityofLife(anymeasure)
NottinghamActivitiesofDailyLiving
Rankin
RivermeadMobilityIndex
FrenchayActivitiesIndex

Clinicalevidence
SearcheswereconductedforsystematicreviewsandRCTscomparingtheeffectivenessofintense
rehabilitationwithusualcareforrehabilitationafterstrokeforadultsandyoungpeople16orolder
thathavehadastroke.Onlystudieswithaminimumsamplesizeof20participants(10ineacharm)
andincludingatleast50%ofparticipantswithstrokewereselected.Four(4)RCTswereidentified.
Table33summarisesthepopulation,intervention,comparisonandoutcomesforeachofthestudies.
Table33:Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
STUDY

POPULATION

INTERVENTION

COMPARISON

zdemir,
2001196

Patientsaged>80
yearswhohad
strokeorrecurrent
strokeandhadbeen
referredafter
medical
stabilisation.
Followup:60days

Therapeuticand
neuromuscular
exerciseswith
occupational
therapywith
professional
supervisionfor2
hoursaday,5days
aweek(intense
multidisciplinary
inpatient
rehabilitation
service).(N=30)

Conventional
Functional
exerciseswith
Independence
familycaregiverand
Measure(FIM)
limitedprofessional
supervisiongivenat
homefor2hours
onceaweek.(N=30)

Ryan,
2006225

Patientsaged>=65
yearsrecently
dischargedfrom
hospitalafter
sufferingastrokeor
hipfracture(only
thesubgroupresults
ofpeoplewith
strokewereused
includedinthe
reviewhere)
Followup:3months

Domiciliary
intensive
rehabilitation:sixor
morefacetoface
contactsperweek
frommembersofa
multidisciplinary
rehabilitationteam.
Maximumlengthof
treatmentlastedfor
12weeks.(N=45)

Standard
rehabilitation:three
orlessfacetoface
contactsperweek
frommembersofa
multidisciplinary
rehabilitationteam.
(N=44)

Smith,1981241

Patientsadmittedto Intensive
hospital,witha
rehabilitation:
recentconfirmed
physiotherapyand

NationalClinicalGuidelineCentre,2013.
154

Standard
rehabilitation:
physiotherapyand

OUTCOMES

Barthel
Index
Frenchay
Activities
Index(FAI)
EuroQol5D
(EQ5D)

Euroqol
Visual
Analogue
Scale(EQ
VAS)

Activitiesof
DailyLiving
(ADL)

StrokeRehabilitation
Planninganddeliveringstrokerehabilitation
STUDY

POPULATION
stroke,whowere
abletomanagethe
mostintensiveof
the3regimens.
Followup:12
months

INTERVENTION
occupational
therapyingroups
andindividuallyfor
fourfulldaysa
weekuptosix
months(exceptfor
fourpatientswho
madeafullrecovery
earlier)(timespent
intherapywas
recorded).(N=46)

COMPARISON
OUTCOMES
occupational
therapyingroups
andindividuallyfor
threehalfdaysa
weekuptosix
months(exceptfor
fivepatientswho
madeafullrecovery
earlier)(timespent
intherapywas
recorded).(N=43)
'Noroutine'
rehabilitation:
regularhomevisits
byahealthvisitor,
(onaverageof
sevenvisits(range
313)toeach
patient).Thesevisits
usuallylastedoneto
twohoursduring
thesixmonthsafter
dischargefrom
hospital.(N=44)

Werner,
1996282

Patientswhowere
atleast1yearpost
stroke,with
evidenceof
functional
limitationsinthe
areaofdressing,
walking,eating,or
bathing.
Followup:9months

Intensive12week
outpatient
rehabilitation
programconsisting
ofanhoureachof
physicaland
occupational
therapy,fourtimes
perweek,for12
weeks;therapy
focusedon
neuromuscular
facilitationand
functionaltasks.
(N=33)

Norehabilitation.
(N=16)

NationalClinicalGuidelineCentre,2013.
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Functional
Independence
Measure;
motormeasure
(FIMMM)

StrokeRehabilitation
Planninganddeliveringstrokerehabilitation

Comparison:Intensiverehabilitationversusstandardrehabilitationornone
Table34:IntensiverehabilitationversusstandardrehabilitationClinicalstudycharacteristicsandclinicalsummaryoffindings

Summaryoffindings
Qualityassessment

No.of
studies

Design

Effect

Limitations

Inconsistency

Indirectness

Mean
Differenc
e(MD)
(95%CI)

Intensive
rehabilitation
Mean(SD)

Standard
rehabilitation
Mean(SD)

Mean
difference
(95%CI)

Noserious
imprecision

2.75(2.1)

2.65(2.1)

0.10
(0.77,
0.97)

MD0.1
higher
(0.77
lowerto
0.97
higher)

Moderate

Noserious
imprecision

0.09(0.2)

0.01(0.1)

0.08
(0.01,
0.15)

MD0.08
higher
(0.01to
0.15
higher)

Moderate

Noserious
imprecision

0.14(0.25)

0.0(0.25)

0.14
(0.04,
0.24)

MD0.14
higher
(0.04to
0.24
higher)

Moderate

8.87(7)

8.08(7.7)

0.79(

MD0.79

Low

Imprecision

Confidence
(ineffect)

Barthelindex(3monthsfollowup)(Betterindicatedbyhighervalues)
1
Ryanet
al225

RCT
single
blinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

EuroqolVAS(3monthsfollowup)(Betterindicatedbyhighervalues)
1
Ryanet
al225

RCT
single
blinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Euroqol5D(3monthsfollowup)(Betterindicatedbyhighervalues)
1
Ryanet
al225

RCT
single
blinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Frenchayactivitiesindex(3monthsfollowup)(Betterindicatedbyhighervalues)
1

RCT

Serious

Noserious

Noserious

Serious

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Summaryoffindings
Qualityassessment

No.of
studies
Ryanet
al225

Design
single
blinded

Effect

Limitations
limitations
(a)

Inconsistency
inconsistency

Indirectness
indirectness

Imprecision
imprecision
(c)

Intensive
rehabilitation
Mean(SD)

Standard
rehabilitation
Mean(SD)

Mean
Mean
Differenc
difference e(MD)
(95%CI)
(95%CI)
2.27,
higher
3.85)
(2.27
lowerto
3.85
higher)

Confidence
(ineffect)

FunctionalIndependenceMeasure(totalscore)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
RCT
Ozdemiret unblinde
d
al.196

Veryserious
limitations
(d)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

59.63(14.19)

12.3(13.38)

47.33
(40.35,
54.31)

MD47.33
higher
(40.35
lowerto
54.31
higher)

Low

3.54

2.87

(h)

(h)
P<0.01(i)

Low(g)

3.50

2.89

(h)

(h)

Low(g)

ActivitiesofDailyLivingindex(3monthsfollowup)(Betterindicatedbyhighervalues)
1
Smithetal
241

RCT
unblinde
d

Veryserious
limitations
(e)

Noserious
inconsistency

Noserious
indirectness

(g)

ActivitiesofDailyLivingindex(12monthsfollowup)(Betterindicatedbyhighervalues)
1
Smithetal
241

RCT
unblinde
d

Veryserious
limitations
(e,f)

Noserious
inconsistency

Noserious
indirectness

(g)

(a)Unclearrandomization.Thestudydidnotachievetheprespecifiedratioof2:1(intensive/nonintensive)25%strokepatientlosstofollowup.
(b)MeandifferencedidnotreachtheagreedMIDof1.85points.
(c)ConfidenceintervalcrossedbothendsofdefaultMID.
(d)Unblindedwithinadequaterandomisationandunclearallocationconcealment.
(e)Unblindedwithnodetailsonrandomisationprocessandallocationconcealment.
(f)20%patientsdroppedoutat1year.
(g)Imprecisioncouldnotbeassessedbecauseonlymeansofdatawerereported.

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(h)Relative/absoluteeffectcouldnotbeestimatedasnostandarddeviationwasprovidedinthestudy.
(i)Pvalueasreportedbytheauthors.

Table35: IntensiverehabilitationversusnorehabilitationClinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings
Qualityassessment
No.of
studies

Design

Effect

Limitations

Inconsistency

No
rehabilitation
Mean(SD)

Mean
difference
(95%CI)

Indirectness

Imprecision

Intensive
rehabilitation
Mean(SD)

Noserious
indirectness

(d)

3.54

1.50

(e)

(e)
P<0.01
(f)

Low(d)

Noserious
indirectness

(d)

3.50

0.60

(e)

(e)
P<0.05
(f)

Low(d)

(d)

6.6

1.5

(e)

(e)

Low(d)

(d)

0.7

1.0

(e)

(e)
P=0.03
(f)

Low(d)

Pvalue

Confidence(in
effect)

ActivitiesofDailyLivingindex(3monthsfollowup)
1
RCT
Smithetal unblinded
241

Very
serious
limitations
(a)

Noserious
inconsistency

ActivitiesofDailyLivingindex(1yearfollowup)
1
RCT
Smithetal unblinded
241

Very
serious
limitations
(a,b)

Noserious
inconsistency

FunctionalIndependenceMeasure(Motor)(3monthsfollowup)
1
Werneret
al282

RCT
unblinded

Very
serious
limitations
(c)

Noserious
inconsistency

Noserious
indirectness

FunctionalIndependenceMeasure(Motor)(3to9monthsfollowup)
1
Werneret
al282

RCT
unblinded

Very
serious
limitations
(c)

Noserious
inconsistency

Noserious
indirectness

(a)Unblindedstudy,nodetailsonrandomisationprocessandunclearallocationconcealment.

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(b)20%patientsdroppedoutat12months
(c)Singleblindedstudywithunclearallocationconcealment,highdropoutrateinbotharms10ofthe33patientsintheinterventiongrouplosstofollowup(5droppedoutat3monthsandanother5dropped
outat9months);9ofthe16controlslosstofollowup;5additionalcontrolpatientswererecruitedafterthetreatmentended.
(d)Imprecisioncouldnotbeassessedbecauseonlymeansofdatawerereported.
(e)Relative/absoluteeffectcouldnotbeestimatedasnostandarddeviationwasprovidedinthestudy.
(f)Pvalueasreportedbytheauthors.

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6.4.1.2

Economicevidence
Literaturereview
Norelevanteconomicevaluationscomparingdifferentintensitiesofmultidisciplinaryrehabilitation
wereidentified.
Newcosteffectivenessanalysis
FullmethodsandresultsarepresentedinAppendixK;asummaryisprovidedbelow.
TheGDGidentifiedthecomparisonofmoreintensiveprogrammesofrehabilitationforpeoplewith
strokewithlessintensiveprogrammesasahighpriorityareaforeconomicanalysis.
Moreintensiverehabilitationmaybemorecostlytodeliverthanlessintensiverehabilitationbecause
itmayrequireadditionalstafftime.However,additionalcostsmaybeoffsetbyanimprovementin
outcomesforthepatient(suchasindependencyinactivitiesofdailyliving),leadingtoincreased
QALYsandpotentiallyareductioninfuturehealthcareandsocialcarecosts.
Thefollowinggeneralprincipleswereadheredtoindevelopingthecosteffectivenessanalysis:
TheGDGwasconsultedduringtheconstructionandinterpretationofthemodel.
Modelinputswerebasedonthesystematicreviewoftheclinicalliteraturesupplementedwith
otherpublisheddatasourceswherepossible.
Whenpublisheddatawasnotavailableexpertopinionwasusedtopopulatethemodel.
Modelinputsandassumptionswerereportedfullyandtransparently.
Theresultsweresubjecttosensitivityanalysisandlimitationswerediscussed.
ThemodelwaspeerreviewedbyanotherhealtheconomistattheNCGC.
Modeloverview
Acostutilityanalysiswasundertakentoevaluatethecosteffectivenessofmoreintensiveversusless
intensivestrokerehabilitation.Lifetimequalityadjustedlifeyears(QALYs)andcostswereestimated
fromacurrentUKNHSandpersonalsocialservicesperspective.Asisstandardpracticeineconomic
evaluation,bothcostsandQALYSwerediscountedtoreflecttimepreference;arateof3.5%per
annumwasusedinlinewithNICEmethodologicalguidance187.Thecosteffectivenessoutcomeofthe
modelwascostperQALYgained.
TheanalysiswasprimarilybasedondatafromtheUKclinicalstudyreportedbyRyanandcolleagues,
2006225describedintheclinicalreviewabove.
Aprobabilisticanalysiswasundertakentoevaluateuncertaintyinthemodelinputestimates.In
addition,varioussensitivityanalyseswereundertakentotesttherobustnessofmodelassumptions
anddatasources.Inthese,oneormoreinputswerechangedandtheanalysisreruntoevaluatethe
impactonresults.
TheGDGnotedthattheintensitylevelinthemoreintensiverehabilitationarminthestudyreported
byRyanandcolleagueswaslikelytobelowerthanthatnowspecifiedbythestrokequality
standard188.Wethereforeundertookexploratorythresholdanalysestoprovideinformationtohelp
informtheGDGdecisionmaking.

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation
Population
Thepopulationforthecosteffectivenessanalysiscomprisedadultsandyoungpeopleaged16or
olderwhohavehadastrokeandrequiredrehabilitation.
Comparators
Thecomparatorsinthemodelwere:
Lessintensivemultidisciplinaryrehabilitation
Moreintensivemultidisciplinaryrehabilitation
FollowingRyanetal.(2006)225,theinterventionwasassumedtobedeliveredathome.Lessintensive
rehabilitationwasthreeorlessfacetofacecontactsperweek,for12weeksmaximum.More
intensiverehabilitationinthestudywassixormorefacetofacecontactsperweek,for12weeks
maximum.
Modelstructure
Alifetableapproachwastakentotheanalysis.LifetablesforEnglandandWaleswereadjustedfor
theincreasedmortalityinpeoplewhohavehadastroke.Thisestimatedthenumberofpeoplealive
aftereach3monthperiod(eachcycle)andthiswasusedtoestimatelifeyearsforpeopleinthe
model.Itwasassumedthatmortalityisnotimpactedbythetypeofrehabilitationreceivedandso
lifeexpectancydidnotvarybycomparatorinthemodel.
Aqualityoflife(utility)valuewasattributedtopeoplewhowerealiveinthemodelthatdepended
onthetypeofrehabilitationreceived(moreintensiveorlessintensive).Thisresultedin
differencesinQALYsbetweenpatients.
Differencesintotalcostsbetweenthemoreandlessintensiverehabilitationgroupsweredueto
differencesinthecostofdeliveringrehabilitationthiscostwasincurredinthefirst3monthcycle.It
wasassumedinthebasecaseanalysisthatinthepostrehabilitationperiodcostsdidnotvary
betweenthemoreintensiveandthelessintensiverehabilitation.
Modelinputs
Modelinputswerebasedonclinicalevidenceidentifiedinthesystematicreviewundertakenforthe
guideline,supplementedbyadditionaldatasourcesasrequired.Modelinputswerevalidatedwith
clinicalmembersoftheGDG.Asummaryofthemodelinputsusedinthebasecase(primary)
analysisisprovidedinTable36below.Moredetailsaboutsources,calculationsandrationalecanbe
foundinthefulltechnicalreportinAppendixK.
Table36: Summaryofbasecasemodelinputs
Input

Data

Source

Probability
distribution

Comparators

Lessintensiverehabilitation
Moreintensiverehabilitation

Population

Peoplewhohavehadastroke
andneedrehabilitation

Perspective

UKNHS&PSS

NICEreferencecase187

Timehorizon

Lifetime

187

Discountrate

Costs:3.5%
Outcomes:3.5%

NICEreferencecase

n/a

Cohortsettings

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation
Probability
distribution

Input

Data

Source

Ageonentrytomodel

77years

Ryanetal.2006225

%female

225

61%

Ryanetal.2006

Mortality

Fixed
Fixed

Mortalityrate

Agedependent

EnglandandWales200709life
tables192

Fixed

Mortalityrate
adjustmentforstroke
(SMR)

Female:2.85(CI:2.66,3.05)
Male:2.58(CI:2.43,2.75)

BronnumHansenetal.200134

Lognormal

Qualityoflife(utility)
Beforerehabilitation

0.54

225

Fixed

225

Ryanetal.2006

Changeafterless
intensiverehabilitation

0(SE0.04)

Ryanetal.2006

Normal

Differenceinchange
withmoreversusless
intensiverehabilitation

0.14(SE0.05)

Ryanetal.2006225

Normal

Longtermutility
assumption

Scenario1:differenceis
maintainedoverlifetime
Scenario2:difference
disappearsovertime(3
months,1yearor5years)

Assumptions

n/a

Costs

Rehabilitationcosts

Lessintensive:634
Moreintensive:865

Derivedfromresourceuseand
unitcostsbelow

n/a

Totalnumberof
rehabilitationsessions

Less:17.9(SE1.19)
Difference,moreless:6.5(SE
1.76)

Ryanetal.2006225

Gamma
Normal

Lengthofrehabilitation 45minutes
session

Assumptionbasedontrial
Fixed
range(3060minutes)(Personal
communicationAWRyan,email
January2011)

Personneldelivering
rehabilitation

Professional:75%sessions
Assistant:25%sessions

Assumption

Fixed

Costperhourhome
visit:rehabilitation
professional(a)

54

PSSRU2010:Community;hour
costofhomevisiting50;band
6(b);includingqualifications

Fixed

Costperhourhome
visit:rehabilitation
assistant

27

PSSRU2010:Clinicalsupport
Fixed
workernursing(community);
perhourspentonhomevisits50;
band3(b);including
qualifications

Postrehabilitation
costs

Nodifference

Assumption

Fixed

CI=95%confidenceinterval;n/a=notapplicable;PSSRU=PersonalSocialServicesResearchUnit;SMR=standardised
mortalityratio;SE=standarderror
(a) Physiotherapist,occupationaltherapistandspeechandlanguagetherapist
(b) CostswerecalculatedusingPSSRUdataandapproachbutwiththesalarybandstated

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Planninganddeliveringstrokerehabilitation
Results
Theanalysisfoundthatmoreintensiverehabilitationwascosteffectivecomparedtolessintensive
rehabilitation,basedonlevelsofinterventionandoutcomesfromtheRyanetal.2006study225.
Therewasanadditionalcostassociatedwithmoreintensiverehabilitationasmorerehabilitation
sessionswereprovided;howeverthiswasoffsetbytheadditionalimprovementinqualityoflifethat
resultsinhigherQALYs.Thisconclusionwasseenwithalllongtermutilityscenarios.Therewaslow
withinanalysisuncertaintyaboutthisconclusion.Itwasalsorobusttoarangeofsensitivityanalyses
aroundinputparameters
Table37: Basecaseresultsmoreintensiveversuslessintensiverehabilitation(probabilistic
analysis)
Analysis

Meancost
difference
(moreless)(a)

MeanQALY
difference
(moreless

Incremental
cost
effectiveness
ratio(ICER)

%simulations
more
intensivecost
effective
(20K/QALY)

Scenario1differenceinutilitymaintainedovertime
Maintainedoverlifetime
226

0.70

324

99%

Scenario2utilitydifferencedisappearsovertime
Disappearsover3months
228

0.03

6,722

95%

Disappearsover1year

228

0.08

2,751

99%

Disappearsover5years

226

0.29

776

100%

(a) Minordifferenceareduetoresultsbeingfromdifferentrunsoftheprobabilisticanalysis

Thresholdanalyses
FullresultstablesareshowninthefulltechnicalreportinAppendixK.
Costs:
Ananalysiswasundertakentodeterminethecostdifferencethresholdwhereintensive
rehabilitationwasnolongercosteffective(usinga20,000perQALYgainedcosteffectiveness
threshold).Underthemostconservativelongtermutilityassumption(wheretheutilitydifference
observedattheendofrehabilitationhaddisappearedover3months),moreintensiverehabilitation
wouldnolongerbecosteffectiveifthedifferenceinrehabilitationcostwasmorethan685
(equivalenttoadifferenceofabout17sessions,of45minutes,witharehabilitationprofessional).
Underthemostfavourableutilityassumption(wherethedifferenceobservedattheendof
rehabilitationwasmaintainedindefinitely),moreintensiverehabilitationremainedcosteffective
untilthedifferenceinrehabilitationcostsexceeded13,433(equivalenttoadifferenceofover300
sessionswitharehabilitationprofessional).
QALYs:
Wealsoundertookathresholdanalysiswherewevariedthedifferenceinthenumberof
rehabilitationsessionsbetweenthegroupsandthencalculatedwhatQALYdifferencewouldbe
requiredforittobeconsideredcosteffective.TheGDGestimatedthatincurrentUKpracticealevel
ofinputinlinewiththecurrentNICEqualitystandardwouldbe45minutesofeachrelevanttherapy
atleast5daysaweekaslongastheyarecontinuingtobenefitfromit.Thusover6weeksan
individualmightreceive6090sessionsofinput.TheGDGrecognisedthattherecentStrokeSentinel
audithighlightedthataboutathirdofpatientsreceivedlessthanthiswhileinhospital123.Nodatais
availableforcommunitybasedrehabilitationservices.TheGDGestimatedthatatypicallevelofinput
wouldbethreephysiotherapysessionsperweek,oneoccupationaltherapysessionperweek,and
onespeechandlanguagetherapysessionperweek(thatis30sessions).Thiswouldbeadifference

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation
of60sessionstotalbetweenidealandtypicalinput.Thedifferenceinnumberofsessionswas
thereforevariedbetween6.5(fromtheRyanetal.2006study)and60(basedontheGDGestimate).
ThelifetimeQALYgainrequiredformoreintensiverehabilitationtobecosteffectiverangedfrom
0.010.11whenthedifferenceinnumberofrehabilitationsessionswasvariedbetween6.5and60.
Wethenalsocalculatedthenumberofmonthsforwhich,differentqualityoflife(utility)gainswould
needtobemaintained,inordertoachievetheseQALYgains.Withadifferenceof60rehabilitation
sessionswithmoreintensivecomparedtolessintensiverehabilitation,itwasfoundthatautilitygain
of0.14(asobservedintheRyanetal.2006study)wouldneedtobemaintainedfor9monthsin
orderformoreintensiverehabilitationtobecosteffective.Whenutilitygainwasvariedbetween
0.02and0.24,thisvariedfrom5monthsto64months.
Discussion
Ryanetal.(2006)studygeneralisability
Thekeylimitationsofthisanalysisarethelimitationsoftheclinicaleffectivenessdataforthe
comparisonofmoreandlessintensiverehabilitation.Onlyonestudyreportedutilitydatathatcould
beusedtocalculateQALYsandtheamountofrehabilitationreceivedinthisstudycomparedwith
thecurrentqualitystandard,andevencurrentUKpracticeisverydifferent.Instudyreportedby
Ryanandcolleaguesmoreintensiverehabilitationwasatotalof17sessionsonaverageperperson
andlessintensivewas11.TheGDGestimatedthatalevelofinterventionsimilartothat
recommendedbythecurrentNICEqualitystandardwouldbemorelike90rehabilitationsessionsper
patient(spreadacrossspecialities),andthattypicallevelsofinputintheUKwouldbearound30
sessions.
Itwasnotedthatrehabilitationisacomplexintervention,thatis,theoutcomedoesnotvarylinearly
withinputs.Onepossibilityisthatthereisacriticalthresholdforimprovement.Forexample,ifone
legisweakthepatientwillbeunabletowalk.Thestrengthmayincreaselinearlyfor6weeks,but
onlyinweek7willthepatientwalk.Ifafunctionaloutcomeisused,thepatientwillappearto
plateaufor6weeksandthenmayshowasignificantchangeinfunctionalstatus.Thisagainmakesit
difficulttoextrapolatefromthestudyreportedbyRyanandcolleagues.
Stratification
Itwasnotedthatyoungerpatientsalsooftenhavethecapacitytoparticipateinmoresessionsof
rehabilitationasthisislinkedtocardiovascularfitness,frailtyandcomorbidity,allofwhichtendto
beworseinolderpatients.Theyalsooftenhaveagreaterrangeofneeds(education,work,and
parenting).Yetoftenyoungerpatientsdonotgetmorerehabilitation.Itwasnotpossibleto
undertakesubgroupanalysisonthisbasisinthemodelasnotclinicalstudieshadexaminedthis.
Qualityoflifeassumptions
ThestudyreportedbyRyanandcolleaguesreportedEQ5Dqualityoflifedataat3monthsbutdid
nothaveanylongertermfollowupandsoassumptionsweremaderegardingwhathappenstothe
differenceinqualityoflifeovertimebetweenthegroups.Howeverbothconservativeandmore
favourableassumptionswereexploredinthemodeltotesttheimpactonresults.
Theanalysisdoesnotincludeanyimpactoncarerqualityoflifeastherewasnoevidenceavailable.It
isplausiblethatgreaterfunctionalabilityforthepersonwhohashadastrokemayalsomeanless
burdenontheircarerandthismayleadtoanimprovementinthecarersqualityoflifeaswell.Ifthis
werethecase,thiswouldincreasetheQALYgainwithmoreintensiverehabilitation,makingitmore
costeffective.

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Planninganddeliveringstrokerehabilitation
Postrehabilitationcosts
Inthebasecaseanalysisweassumednodifferenceinpostrehabilitationcosts;howevergreater
functionalabilitycouldplausiblyresultinlowerdependencyandpotentiallylowersocialcarecosts.
Thiswouldfurtherfavourmoreintensiverehabilitation.
Rehabilitationsetting
ThestudyreportedbyRyanandcolleagueswasbasedoncommunityrehabilitationandsocostsin
themodelarealsobasedoncommunityrehabilitation.TheGDGconsideredthattheamountof
rehabilitationshouldbethesamewhetherdeliveredinthecommunityorinhospital.Inadditionif
rehabilitationwastakingplaceinhospitaltheintensityofrehabilitationwouldmostlikelynotchange
thelengthofstaybutwouldjustimpacttheamountofinputfromdifferentprofessionalswhilstin
hospital.Thereforeineithersettingthecostimpactwouldlargelybeaboutpeoplestimeratherthan
changesinhospitalcapacity,overheadsorhotelcostsandsothiswasnotconsideredlikelytogreatly
impacttheresults.Itwasnotedthatpotentiallymoreintensiverehabilitationduringtheinitial
hospitalisationmayevenreducehospitalstayaspatientsbecomemorefunctionallyablemore
quickly.
6.4.1.3

Evidencestatements
Clinicalevidencestatements
Onestudy225with89participantsfoundnosignificantdifferencebetweentheintensive
rehabilitationgroupandthestandardrehabilitationgroupat3monthsontheBarthelIndex
(MODERATECONFIDENCEINEFFECT).
Onestudy225with89participantsfoundastatisticallysignificantimprovementintheintensive
rehabilitationgroupcomparedwiththestandardrehabilitationgroupat3months,ontheEuroqol
VisualAnalogueScale(MODERATECONFIDENCEINEFFECT)
Onestudy225with89participantsfoundastatisticallysignificantimprovementintheintensive
rehabilitationgroupcomparedwiththestandardrehabilitationgroupat3months,ontheEuroqol
5D(MODERATECONFIDENCEINEFFECT)

Onestudy225with89participantsfoundnosignificantdifferenceontheFrenchayActivitiesIndex
betweentheintensiverehabilitationgroupandthestandardrehabilitationgroupat3monthsfollow
up(LOWCONFIDENCEINEFFECT)
Onestudy196with60participantsfoundthattherewasastatisticallysignificantimprovementinthe
FunctionalIndependenceMeasureintheintensiverehabilitationgroupovera60dayfollowup,
comparedwiththelessintensivehomebasedgroup(LOWCONFIDENCEINEFFECT).
Evidencestatementscouldnotbeproducedforthefollowingoutcome(s)asresultswerenot
presentedinawaythatenabledthesizeoftheinterventionseffecttobeestimated:
ActivitiesofDailyLivingIndex241
FunctionalIndependenceMeasure(Motor)282
Economicevidencestatements
Moreintensiverehabilitationwasfoundtobecosteffectivecomparedtolessintensive
rehabilitation,basedonamodelledanalysisusinglevelsofinterventionandoutcomesfromtheRyan
etal.2006study(24versus18rehabilitationsessions;EQ5Ddifference0.14at3months)andarange
oflongtermutilityassumptions.However,theseconclusionsarelimitedbyconcernsregarding

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Planninganddeliveringstrokerehabilitation
applicabilityofthestudyreportedbyRyanandcolleaguestocurrentUKpractice.Exploratory
thresholdanalysesfound:
Underthemostconservativelongtermutilityassumption(wheretheutilitydifferenceobserved
attheendofrehabilitationhaddisappearedover3months),moreintensiverehabilitationwould
nolongerbecosteffectiveifthedifferenceinrehabilitationcostwasmorethan685(equivalent
toadifferenceofabout17sessions,of45minutes,witharehabilitationprofessional).
Underthemostfavourablelongtermutilityassumption(wherethedifferenceobservedatthe
endofrehabilitationwasmaintainedindefinitely),moreintensiverehabilitationremainedcost
effectiveuntilthedifferenceinrehabilitationcostsexceeded13,433(equivalenttoadifference
ofover300sessionswitharehabilitationprofessional).
Assumingadifferenceof60sessionsbetweenmoreandlessintensiverehabilitation:autility
differenceof0.14wouldneedtobemaintainedfor9monthsformoreintensivetobecost
effective;adifferenceof0.24for5months;andadifferenceof0.02for64months(about4
years).

6.4.2

Recommendationsandlinktoevidence
33.Offerinitiallyatleast45minutesofeachrelevantstroke
rehabilitationtherapyforaminimumof5daysperweekto
peoplewhohavetheabilitytoparticipate,andwhere
functionalgoalscanbeachieved.Ifmorerehabilitationis
neededatalaterstage,tailortheintensitytothepersons
needsatthattimeg.
34.Considermorethan45minutesofeachrelevantstroke
rehabilitationtherapy5daysperweekforpeoplewhohave
theabilitytoparticipateandcontinuetomakefunctional
gains,andwherefunctionalgoalscanbeachieved.
35.Ifpeoplewithstrokeareunabletoparticipatein45minutes
ofeachrehabilitationtherapy,ensurethattherapyisstill
offered5daysperweekforashortertimeatanintensitythat
allowsthemtoactivelyparticipate.
Recommendations
Relativevaluesofdifferent
outcomes

Theoutcomesofinterestincludedinthereviewwere:
lengthofstay,FunctionalIndependenceMeasure(FIM),BarthelIndex,
QualityofLife(anymeasure),NottinghamActivitiesofDailyLiving,
Rankin,Rivermeadscore,FrenchayActivitiesIndex
Thelimitednumberofstudiesavailableshowedanimprovementin
everymodelofrehabilitation.Twostudies(Smith1981,Werner
1996241,282)whichwerebothpostacutesuggestedanimprovementwith
outpatientintensiverehabilitation.
Onestudy(Ryan2006225)showedabenefitonEQ5Dsocialparticipation
healthrelatedqualityoflifemeasurebutnotonBarthel.Itwasnoted
thattheBarthelbaselinewas16andthemeanBarthelgainwas2.7.The
GDGconsideredthereasonadifferencewasnotseenbetweenthetwo
groupsmayhavebeenduetoceilingeffectsastheBarthelscaleonly
goesto20.Anaveragescoreof18.7wouldindicatethatthepatientsin

Intensity

of therapy for dysphagia, provided as part of speech and language therapy,

is addressed in recommendation 1.7.2

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Planninganddeliveringstrokerehabilitation
thestudywerelessseverelydisabled.Thegroupacknowledgedthismay
alsoaccountforthegainsfoundintheEQ5D.
ThepatientsinthestudybyOzdemir196weremoreacuteanditwas
recognisedbytheGDGthattheFIMoutcomegainswereclinicallyhighly
significantreinforcingthevalueofrehabilitationbutthattherewere
limitationsinthestudydesign.
TheGDGnotedthatpatienttolerancetothetherapiesshouldbetaken
intoconsiderationaspatientstolerancewouldvary.TheGDGagreed
thatthereisnolinearrelationshipbetweenoutcomeandintervention.
Tradeoffbetweenclinical
benefitsandharms

ThestudyreportedbyRyanandcolleagues,whichprovidesinformation
ontheEQ5Doutcomeat12weeks,showsthereissignificantdifference
inEQ5Dandthisisclinicallysignificant.TheEQ5Disastandardized
measureofhealthoutcome,domainscovermobility,selfcare,pain,
anxietyanddepressionandusualactivity.Theinterventionwouldaimto
restoreusualactivityandtheGDGagreedthattheywouldexpectthisto
bemaintainedafterthe12weekperiod.
Thegroupinthepaper(Ryan2006)wasarelativelyablegroupsoitis
reasonabletoassumethesegainswouldbemaintained.TheWerner
study282showedthatovera3monthperiod3yearspoststrokethe
intensivegroupimprovedontheFIMoutcomescaleandthiswas
maintainedoverthefollowing9months.ItwasnotedthatFIMcovers
twooftheitemswithintheEQ5D.TheGDGagreedthatacohortthat
wasmoredisabledwouldbeexpectedtomakegreatergainsfromhaving
hadmoreintenserehabilitation.
TheGDGagreedthattherewerenoparticularharmsassociatedwithany
oftheinterventionsdeliveredwithinthestudiesandtheyconsideredthe
benefitsofprovidingrehabilitationattheappropriateindividuallevel
wereclearandthosereceivingmoreintensivetherapywouldbe
expectedtoachievethegreatergains.

Economicconsiderations

Nopublishedeconomicevaluationscomparingmoreandlessintensive
rehabilitationwereundertaken.TheGDGidentifiedthisareaasahigh
priorityforanalysisandacosteffectivenessmodelwasdevelopedbased
onthestudyreportedbyRyanandcolleagues(thiswastheonlystudy
thatreportedqualityoflifedata[EQ5D]suitableforcalculatingQALYs).
Thisanalysisfoundmoreintensiverehabilitationtobecosteffective
comparedtolessintensiverehabilitation.TheGDGnotedthatthese
conclusionswerelimitedbyconcernsregardingapplicabilityofthestudy
reportedbyRyanandcolleaguestocurrentUKpractice,inparticularthe
fairlylowlevelsofrehabilitationinbothgroupscomparedtocurrent
standards;otherlimitationstothisstudyarenotedelsewhereinthis
table.Itwasalsonotedthattheanalysisincorporatedtheadditionalcost
ofmoreintensiverehabilitationbutdidnotincorporateanydownstream
costdifferencesduetoalackofevidenceonwhichtobasethese.
Potentiallytheremaybecostsavingsdownstreamofmoreintensive
rehabilitation;forexample,ifpatientsaremorefunctionallyable,social
carecostsmaybereduced.Ifthisweretobethecasethiswouldfurther
favourmoreintensiverehabilitation.
Duetotheconcernsdescribedaboveaboutapplicability,exploratory
thresholdanalyseswereundertakentohelpinformGDGdecision
making.Thecostdifferencethresholdrangedbetween685(equivalent
toadifferenceofabout17sessionsof45minuteswitharehabilitation
professional)and13,433(equivalenttoadifferenceofover300
sessionswitharehabilitationprofessional),dependingonthe
assumptionmadeabouthowshorttermqualityoflifedifferencesare
maintainedinthelongerterm.Themostconservativeutilityassumption
wasthatthequalityoflifedifferenceobservedat3monthsdisappeared

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation
by6months.Themostfavourableutilityassumptionwasthatthe
differencewasmaintainedindefinitely.Itwasagreedthatwhilethere
maybesomeconvergencebetweengroups,itwaslikelythatoverall
somedifferencewouldbemaintained.
TheGDGestimatedthattherewouldbedifferenceofaround60sessions
betweencurrentpracticeandrehabilitationprovisionatthelevelofthe
NICEqualitystandard.Withthisdifferenceinnumberofrehabilitation
sessionswithmoreintensivecomparedtolessintensiverehabilitation,it
wasfoundthatautilitygainof0.14(asobservedinthestudyreported
byRyanandcolleagues)wouldneedtobemaintainedfor9monthsin
orderformoreintensiverehabilitationtobecosteffective.Whenutility
gainwasvariedbetween0.02and0.24,thisvariedfrom5monthsto64
monthsrespectively.
TheGDGnotedthatthisanalysiswaslargelyexploratorygiventhe
limitationsofthedata.Itwasalsonotedthat,astherelationship
betweenintensitylevelandoutcomeswerenotlinear,extrapolationwas
difficult.However,theyconcludedthatbasedonthethresholdanalyses
itseemedlikelythatifmoreintensiverehabilitationprovidedqualityof
lifebenefitsitwaslikelyitwouldbecosteffective.Thereforeitwas
agreedthatincreasingintensitytothelevelinthecurrentquality
standardwaslikelytobecosteffective.Inaddition,theGDGconsidered
thatabovethiswherepeoplecontinuetomakefunctionalgainsitis
likelythatqualityoflifegainswouldmeanthatprovisionwouldbecost
effective.
Qualityofevidence

WhilstallthestudieshadsomelimitationsmethodologicallytheGDG
consideredthattherewasmodestevidencethatshowedmoreintensive
rehabilitationatthelaterstagespoststrokewasbeneficialas
demonstratedinthestudiesbyRyanandWerner225,282.Moderate
confidenceineffect(Ryan2006)wasfoundforthequalityoflife
outcomeEuroqol5Dwhichdemonstratedasignificantimprovement.
ConfidenceintheresultsshownfortheBarthelandFrenchayoutcomes
wasmoderateandlowanddemonstratednosignificantdifference.A
significantimprovementwasshownfortheFunctionalIndependence
measureovera60dayfollowup.(Ozdemir2001).
TheGDGwereconcernedthatthepatientsinbothgroupsintheRyan
study225werehigherfunctioninginbothgroupsandthereforemaynot
demonstratealotofdifference.ThepatientsintheOzdemirpaper196
wasconsideredtobemorerepresentativeoffunctioninglevelsofstroke
patientsseeninclinicalpractice.

Otherconsiderations

Onlyonestudy(Ozdemir196)waswithinthehospitalsetting,otherswere
outpatient/communitysettings.Noneofthestudieswerestartedwithin
2weeksofonsetofstrokebutsomeaddressedrehabilitationneedsin
thesubacuteandchronicphases.
TheGDGagreeditwasdifficulttostatewhatcouldbeconsidered
intensivefromthestudiesreviewed.Twoofthestudieshad2hours45
daysperweek(Werner1996,Ozdemir2001),whilethestudybyRyan
(2006)describedthenumberofcontactsmade.
TheGDGnotedthattheamountoftherapyhighlightedinthestudies
wouldnotreflecthighlyintensivepracticeversuswhatwouldnowbe
acceptedasconventional.TheGDGnotedthatintensityofrehabilitation
couldbeconsideredintermsoffrequency,time,andduration,andthat
studiesofintensitymaybeconfoundedbyothervariablessuchas
expertise,modeofdelivery,andanyspecificdeficitbeingtargeted.The
GDGagreedthattheevidencedemonstratedthatmorerehabilitation
wasbetter,butwhatremainsuncleariswhatmorerehabilitation
constitutes.TheGDGagreedthelevelofintensitydeliveredwithinthe

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StrokeRehabilitation
Planninganddeliveringstrokerehabilitation
studiesdidnotappeartobeconsistentwithcurrentmedicalpracticeor
aspirations.Itwasnotedthatfurtherresearchisrequired.
Becausethestudiesreviewedprovidednodetailsontheinterventions
delivered(otherthanstatingamixofphysiotherapyandoccupational
therapy),itisnotpossibletomakerecommendationsonwhatshouldbe
deliveredwithinapackageofintensiverehabilitation.Thegroupagreed
thatbestpracticewouldofferinterventionsthataregoaldirectedand
taskorientatedaccordingtoindividualneed.
ThegroupacknowledgedandagreedwiththeStrokeQualityStandard189
whichdefinesrehabilitationtherapyasphysiotherapy,occupational
therapyandspeechandlanguagetherapywithothertreatmentsas
requireddeliveredineitherahospitalorcommunitysetting.Each
therapyisprovidedthroughfacetofacecontacteitherindividuallyoras
partofagrouptreatmentanddoesnotincludeadministrativetasks
relatedtopatients.Thisshouldbeofferedtoallwhohavethephysical
andmentalabilitytoparticipateandwhodemonstratethroughtheir
individualgoalsthattheycontinuetobenefitfromthetherapy.
TheGDGagreeditwasimportantthatpeopleshouldbeabletoreaccess
rehabilitationatanystageofthestrokepathwaywhenneeded.

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StrokeRehabilitation
Supportandinformation

7 Supportandinformation
7.1 Providingsupportandinformation
Provisionofappropriate,accurateandtimelyinformationisakeycomponentofpoststrokecare.It
isacorerecommendationofmanypolicydocuments,suchastheNationalStrokeStrategy61.Despite
this,manyresearchreportsindicatethatpatientsandtheirfamiliesfeeltheirinformationneedshave
beenpoorlymet.Howeverinformationprovisionisanebulousconceptanditisdifficulttodetermine
anappropriateobjectiveoutcome.Itisacknowledgedthatinformationiscommonlypassively
availablethroughleaflets.TheGDGsoughttoidentifyeffectiveactivemethodsofinformation
provisionwhichwouldprovidepositivebenefitsintermsofmoodandactivitiesofdailyliving.

7.1.1

7.1.1.1

Evidencereview:Whatistheclinicalandcosteffectivenessofsupportedinformation
provisionversusunsupportedinformationprovisiononmoodanddepressioninpeople
withstroke?
ClinicalMethodologicalIntroduction

Population:

Adultsandyoungpeople16orolderwhohavehada
stroke

Intervention:

Supportedinformationgiving(activeinformation
provision,encouragefeedback,peersupport,
interactivecomputerprogramme)

Comparison:

UnsupportedInformation(suchas,leafletsand
noticeboardinformation)

Outcomes:

Impactonmood/depression:
HospitalAnxietyandDepressionScale
GeneralHealthQuestionnaire
VisualAnalogueMoodScale
StrokeAphasicDepressionQuestionnaire(SADQ)
GeriatricDepressionScale
BeckDepressionInventory
Selfefficacy
GeneralSelfefficacyScale
StrokeSelfefficacyQuestionnaire
LocusofControlScale
Extendedactivitiesofdailyliving
Nottinghamextendedactivitiesofdailyliving
FrenchayActivitiesIndex
Yalemoodscale

Clinicalevidence
SearcheswereconductedforsystematicreviewsandRCTscomparinginterventionsofsupported
informationwithunsupportedinformationforadultsoryoungpeopleof16yearsoldafterstroke.
Onlystudieswithaminimumsamplesizeof20participants(10ineacharm)wereselected.Five(5)
RCTswereidentified.
Table38summarisesthepopulation,intervention,comparisonandoutcomesforeachofthestudies.

NationalClinicalGuidelineCentre,2013.
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StrokeRehabilitation
Supportandinformation
Table38: Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
STUDY

POPULATION

INTERVENTION

COMPARISON

Ellis,2005

Patientswith
strokeinthe
previous3
monthswithno
severecognitive
impairments.

Additionalinputfrom
theStrokeNurse
Specialist(SNS),who
reviewedpatientsat
monthlyintervalsfor
approximately3
months.Individual
adviceonlifestyle
changes,the
importanceof
medication
complianceandits
relevanceto
secondaryprevention
wasgiven.(N=94)

Usualcare,which
GeriatricDepression
includedgenericrisk
Scale
factoradvicefrom
medicalstaffaswell
astheSNS,given
withintheoutpatient
context.Following
enrolmentthe
controlgrouphadno
furtherinputfrom
theSNS.(N=98)

Hoffmann,
2007112

Patientswith
stroke(mean8.4
dayspost
onset)whohada
reportedEnglish
proficiencylevel;
corrected
hearingand
vision;no
reportedor
observable
dementiaand
weremedically
stable.

Computergenerated
tailoredwritten
informationdesigned
sothatthehealth
professionalproviding
theintervention(in
thistrial,theresearch
nurse)communicates
andcollaborateswith
thepatientto
establishhisorher
informationneeds.
(N=69)

Genericwritten
Selfefficacy
information;aseries HospitalAnxietyand
ofthreestrokefact
DepressionScale
sheetsproducedby
theStroke
Associationof
Queenslandwhich
coveredtopicssuch
ashowstrokeoccurs,
riskfactors,and
physical,cognitive
andemotional
changesfollowinga
stroke.(N=69)

Lowe,
2007159

Patientswitha
primary
diagnosisof
acutestroke,
withoutsevere
cognitiveor
communication
problems

CareFileproject(an
individualised
informationbooklet)
inadditiontousual
care.(N=50)

Usualcare,including
StrokeAssociation
informationleaflets
andfollowupin
StrokeReviewClinic.
(N=50)

Rodgers,
1999218

Medicallystable
patients(5and9
dayspostonset).
Nofurther
detailsprovided.

Multidisciplinary
StrokeEducation
Program(SEP)
consistingofarolling
programofone1hour
smallgroup
educationalsessions
forinpatientsandtheir
informalcarer
followedbysix1hour
educationalsessions
afterdischargefrom
hospital.(N=121)

Informationleaflet
HospitalAnxietyand
(onanumberof
DepressionScale
topics)androutine
Nottingham
communicationwith
ExtendedActivities
nurses,doctorsand
ofDailyLiving
therapystaff

membersthroughout
inpatientstay.
(N=83)

Smith,
2004243

Patientswitha
diagnosisof

Specificallydesigned
strokeinformation

Usualpractice:
membersofthe

75

NationalClinicalGuidelineCentre,2013.
171

OUTCOMES

Mood(Yalesingle
question)

FrenchayActivities
Index.

StrokeRehabilitation
Supportandinformation
STUDY

POPULATION
acutestroke;no
receptive
aphasia;no
cognitive
impairmentand
proficientin
English.

INTERVENTION
(StrokeRecovery
Programme)manual
andpatientswere
invitedtoattend
educationmeetings
everytwoweekswith
membersoftheir
multidisciplinaryteam.
(N=84)

NationalClinicalGuidelineCentre,2013.
172

COMPARISON
strokeunit
multidisciplinary
teamwerefreeto
discussaspectsof
treatmentand
respondtoany
specificqueries.
(N=86)

OUTCOMES
HospitalAnxietyand
DepressionScale

StrokeRehabilitation
Supportandinformation

Comparison:Supportedinformationversusunsupportedinformation
Table39:Supportedinformationversusunsupportedinformationclinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings
Qualityassessment

Noof
studies

Design

Effect

Limitations

Inconsistency

Indirectness

Supported
information
Mean(SD)
Median
(IQR)/
Frequency
Imprecision (%)/

Unsupported
information
Mean(SD)
Median(IQR)/
Frequency
(%)/

Mean
Difference
/Risk
Ratio
(95%CI)

Absolute
effect/
Mean
Difference
(MD)(95%
CI)orP
value

Confidence
(ineffect)

GeriatricDepressionScore(5monthsfollowup)(Betterindicatedbylowervalues)
Ellis,200575

RCTSingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(a)

4.3(3.17)

5.1(3.24)

0.80(1.71,
0.11)

MD0.8
lower(1.71
lowerto
0.11higher)

Moderate

0.7

0.50(1.39,
0.39)

MD0.5
lower(1.39
lowerto
0.39higher)

Moderate

0.2

0.20(0.59,
0.19)

MD0.2
lower(0.59
lowerto
0.19higher)

Moderate

0.1

0.40(0.21,
1.01)

MD0.4
Moderate
higher(0.21
lowerto

Selfefficacy(togetinformationaboutthedisease)(3monthsfollowup)(Betterindicatedbyhighervalues)
Hoffmann,
2007112

RCTSingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(a)

0.2

Selfefficacy(toobtainhelpfromfamily,community,andfriends)(3monthsfollowup)(Betterindicatedbyhighervalues)
Hoffmann,
2007112

RCTSingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(a)

0.0

Selfefficacy(tocommunicatewiththedoctor)(3monthsfollowup)(Betterindicatedbyhighervalues)
Hoffmann,
2007112

RCTSingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(a)

0.3

NationalClinicalGuidelineCentre,2013.

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StrokeRehabilitation
Supportandinformation

Summaryoffindings
Qualityassessment

Noof
studies

Design

Effect

Limitations

Inconsistency

Indirectness

Supported
information
Mean(SD)
Median
(IQR)/
Frequency
Imprecision (%)/

Unsupported
information
Mean(SD)
Median(IQR)/
Frequency
(%)/

Mean
Difference
/Risk
Ratio
(95%CI)

Absolute
effect/
Mean
Difference
(MD)(95%
CI)orP
value
1.01higher)

Confidence
(ineffect)

Selfefficacy(tocontrol/managedepression)(3monthsfollowup)(Betterindicatedbyhighervalues)
Hoffmann,
2007112

RCTSingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(a)

0.0

0.3

0.30(0.83,
0.23)

MD0.3
lower(0.83
lowerto
0.23higher)

Moderate

0.4

0.3

0.10(0.18,
0.38)

MD0.1
High
higher(0.18
lowerto
0.38higher)

0.0

0.2

0.2(0.64to
1.04)

MD0.2
Low
higher(0.64
lowerto
1.04higher)

1.5

1.40(0.14,
2.66)

MD1.40
Moderate
higher(0.14
to2.66
higher)

Selfefficacy(tomanagethediseaseingeneral)(3monthsfollowup)(Betterindicatedbyhighervalues)
Hoffmann,
2007112

RCTSingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

Selfefficacy(tomanagesymptoms)(3monthsfollowup)(Betterindicatedbyhighervalues)
Hoffmann,
2007112

RCTSingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision
(b)

Anxiety(HospitalAnxietyandDepressionScale)(3monthsfollowup)(Betterindicatedbylowervalues)
Hoffmann,
2007112

RCTSingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(a)

0.1

Anxiety(scoreinHospitalandAnxietyDepressionScale>=11)(3monthsfollowup)(Betterindicatedbylowervalues)

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StrokeRehabilitation
Supportandinformation

Summaryoffindings
Qualityassessment

Effect

Noof
studies

Design

Limitations

Inconsistency

Indirectness

Smith,
2004243

RCTSingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Supported
information
Mean(SD)
Median
(IQR)/
Frequency
Imprecision (%)/
Serious
imprecision
(c)

5/49(10.2%)

Unsupported
information
Mean(SD)
Median(IQR)/
Frequency
(%)/
11/45
(24.4%)

Mean
Difference
/Risk
Ratio
(95%CI)

Absolute
effect/
Mean
Difference
(MD)(95%
CI)orP
value

Confidence
(ineffect)

RR0.42
(0.16to
1.11)

142fewer
per1000
(from205
fewerto27
more)

Moderate

RR0.76
(0.55to
1.06)

96fewerper Moderate
1000(from

181fewerto
24more)

Anxiety(scoreinHospitalAnxietyandDepressionScale>=11)(6monthsfollowup)(Betterindicatedbylowervalues)
Rodgers,
1999218,
Smith,
2004243

RCTSingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
Serious
inconsistency imprecision
(c)

44/140
(31.4%)

43/107
(40.2%)

Depression(HospitalAnxietyDepressionScale)(3monthsfollowup)(Betterindicatedbyhighervalues)
Hoffmann,
2007112

RCTSingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Very
serious
imprecision
(b)

0.4

0.3

0.1(1.46
to1.66)

MD0.1
Low
higher(1.46
lowerto
1.66higher)

31/44
(70.5%)

26/40(65%)

RR1.08
(0.81to
1.46)

52moreper Moderate
1000(from
123fewerto
299more)

Mood(YaleScale)(6monthsfollowup)(Betterindicatedbyhighervalues)
Lowe,
2007159

RCTSingle Noserious
blinded
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecisio
n(c)

Depression(scoreinHospitalAnxietyDepressionScale>=11)(3monthsfollowup)(Betterindicatedbylowervalues)

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StrokeRehabilitation
Supportandinformation

Summaryoffindings
Qualityassessment

Noof
studies
Smith,
2004243

Design

Effect

Limitations

Inconsistency

Indirectness

RCTSingle Noserious
blinded
limitations

Noserious
inconsistency

Noserious
indirectness

Supported
information
Mean(SD)
Median
(IQR)/
Frequency
Imprecision (%)/
Very
serious
imprecisio
n(d)

Unsupported
information
Mean(SD)
Median(IQR)/
Frequency
(%)/

5/49(10.2%) 9/45(20%)

Mean
Difference
/Risk
Ratio
(95%CI)

Absolute
effect/
Mean
Difference
(MD)(95%
CI)orP
value

Confidence
(ineffect)

RR0.51
(0.18to
1.41)

98fewerper Low
1000(from
164fewerto
82more)

RR0.76
(0.51to
1.14)

76fewerper Moderate
1000(from
156fewerto
44more)

Depression(scoreinHospitalAnxietyDepressionScale>=11)(6monthsfollowup)(Betterindicatedbylowervalues)
Rodgers,
1999218,
Smith,
2004243

RCTSingle Noserious
blinded
limitations

Noserious
inconsistency

Noserious
inconsistency

Serious
imprecisio
n(c)

35/140
(25%)

34/107
(31.8%)

NottinghamExtendedActivitiesofDailyLiving(6monthsfollowup)(Betterindicatedbyhighervalues)
Rodgers,
1999218

RCTSingle Noserious
blinded
limitations

Noserious
inconsistency

Noserious
indirectness

(e)

7(022)

8(021)

(f)

0.69(h)

Moderate
(e)

0(023)

(f)

(f)

High(e)

(f)

High(e)

FrenchayActivitiesIndex(3monthsfollowup)(Betterindicatedbyhighervalues)
Smith,
2004243

RCTSingle Noserious
blinded
limitations

Noserious
inconsistency

Noserious
indirectness

(e)

1(030)

FrenchayActivitiesIndex(6monthsfollowup)(Betterindicatedbyhighervalues)
Smith,
2004243

RCTSingle Noserious
blinded
limitations

Noserious
inconsistency

Noserious
indirectness

(e)

5(032)

3(033)

(a)

ConfidenceintervalcrossesoneendofdefaultMID.
ConfidenceintervalcrossesbothendsofdefaultMID.
(c)
ConfidenceintervalcrossesoneendofdefaultMID.
(d)
ConfidenceintervalcrossesbothendsofdefaultMID.
(e)
Imprecisioncouldnotbeassessedbecauseonlymedianandinterquartilerangesofdatareported.
(f)

Relativeandabsoluteeffectcouldnotbeassessedbecausemedianandinterquartilerangesofdatareported.
(b)

NationalClinicalGuidelineCentre,2013.

176

(f)

StrokeRehabilitation
Supportandinformation

7.1.1.2

Economicevidence
Literaturereview
Norelevanteconomicevaluationscomparingsupportedinformationprovisionwithusualcarewere
identified.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
Thestudiesincludedintheclinicalreviewuseddifferentinterventions.Typicalunitcostsrelevantto
theinterventionsinthestudiesincludedintheclinicalreviewwerereviewedbytheGDGin
conjunctionwiththestudyinterventiondescriptionstoaidconsiderationofcosteffectiveness.The
studyinterventionsaredescribedinfullinTable38.Estimatedunitcostshforrelevantpersonnelare
listedbelow.
AmultidisciplinarystrokeeducationprogramwasdescribedbyRodgers,1999218consistingofone
1hourgroupsessionandsix1hoursessionspostdischarge.Eachsessionwasledbyamemberof
theteam.Theusualcarecomparatorincludedroutinecommunicationwithhealthcare
professionalsandatelephonehotlinenumber.
o Districtnurse(band6)51perhourspentwithapatient
o Clinicalpsychologist(band8a)136perhourofclientcontact
o Speechandlanguagetherapist(band6)47perhourofclientcontact
o Occupationaltherapist(band6)45perhourofclientcontact
o Physiotherapist(band6)48(community)and45(hospital)perhourofclientcontact
o Socialworker54perhourofclientrelatedwork
Ellis,200575lookedataninterventionprovidedbyaStrokeNurseSpecialist.Thepatientswere
reviewedmonthlyfor3months.Thisinterventionwasadditionaltousualcare.
o Nursespecialist(band7nurseadvanced)81perhourofclientcontact.
Lowe,2007159assessedtheprovisionofinformationbookletstopatients.Thebookletincluded
generalinformationaboutstrokeaswellassectionswerepatientspecificinformationcouldbe
entered.Adiscussion(1520minutes)aboutthecontentofthebookletwasheldwithpatientsby
amemberofthemultidisciplinaryteampriortodischargeseerelevantunitcostsabove.This
interventionwasadditionaltousualcare.
ComputergeneratedtailoredinformationwasprovidedtopatientsinthestudybyHoffman,
2007.Patientswereabletoselectthetypeandamountofinformationfromarangeoftopics112.
Aresearchnursealsoelaboratedonthetopicsandplacedthebooklet(generatedfromMicrosoft
Word)inpersonalisedfolders.Thisinterventionwasadditionaltousualcare.
o Nurse(band6nursespecialist)43perhourofpatientcontact.
o Alicenceforthe'Whatyouneedtoknowaboutstrokeeducationpackagecomputer
program40developedbytheUniversityofQueensland,Australiacosts86(excludingVAT)i

h EstimatedbasedondataandmethodsfromPersonalSocialServicesResearchUnitUnitcostsofhealthandsocialcare
reportandrelevantAgendaforChangesalarybands50(typicalsalarybandidentifiedbyclinicalGDGmembers).
i AU$199(2011)convertedtoUKpounds(2010)usingpurchasingpowerparities194.

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StrokeRehabilitation
Supportandinformation
Patientsweregivenastrokerecoverymanualandinvitedtoattendeducationmeetingseverytwo

weeksinthestudybySmith,2004243.Themanualcontainedinformationaboutstroke,agreed
goalsasdiscussedatthemeetingsaswellasasectionforcarers.Themeetings(approximately20
minutes)werewithamultidisciplinaryteam(doctor,nurse,physiotherapistandoccupational
therapist).Inusualcarecomparatorarminformationleafletswerefreelyavailableandstaff
respondedtospecificquestions.
o Medicalconsultant132percontracthour
o Unitcostsforotherteammembersareaslistedabove.
Evidencestatements
Clinicalevidencestatements
Onestudy75comprising192participantsfoundnosignificantdifferenceindepressionat5months
afterstrokebetweenthegroupthatreceivedsupportedinformationandthegroupthatreceived
unsupportedinformation(MODERATECONFIDENCEINEFFECT).
Onestudy112comprising138participantsfoundnosignificantdifferencebetweenthegroupthat
receivedsupportedinformationandthegroupthatreceivedunsupportedinformationat3months
afterstrokeinselfefficacywiththefollowingsections:
Gettinginformationaboutthedisease(MODERATECONFIDENCEINEFFECT)
Obtaininghelpfromfamily,community,andfriends(LOWCONFIDENCEINEFFECT)
Communicatingwiththedoctor(MODERATECONFIDENCEINEFFECT)
Controlling/managingdepression(MODERATECONFIDENCEINEFFECT)
Managingthediseaseingeneral(HIGHCONFIDENCEINEFFECT)
Managingsymptoms(LOWCONFIDENCEINEFFECT)
Onestudy112comprising138participantsshowedsignificantimprovementinanxietyat3months
afterstrokewiththegroupthatreceivedunsupportedinformationcomparedtothegroupthat
receivedsupportedinformation(MODERATECONFIDENCEINEFFECT)
Onestudy243comprising170participantsfoundnosignificantdifferenceintheproportionof
participantsexperiencedanxietyat3monthsafterstrokebetweenthegroupthatreceived
supportedinformationandtheunsupportedinformationgroup(MODERATECONFIDENCEIN
EFFECT).
Twostudies218,243comprising374participantsfoundnosignificantdifferenceinanxietyat6months
afterstrokebetweenthegroupthatreceivedsupportedinformationandtheunsupported
informationgroup(MODERATECONFIDENCEINEFFECT).
Onestudy112comprising138participantsfoundnosignificantdifferenceindepressionat3months
afterstrokewiththegroupthatreceivedsupportedinformationandthegroupthatreceived
unsupportedinformation(LOWCONFIDENCEINEFFECT)
Onestudy243comprising170participantsfoundnosignificantdifferenceinintheproportionof
participantsexperienceddepressionat3monthsafterstrokebetweenthegroupthatreceived
supportedinformationandtheunsupportedinformationgroup(VERYLOWCONFIDENCEINEFFECT).
Onestudy159comprising100participantsfoundnosignificantdifferenceinmoodat6monthsafter
strokebetweenthegroupthatreceivedsupportedinformationandtheunsupportedinformation
group(MODERATECONFIDENCEINEFFECT).

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StrokeRehabilitation
Supportandinformation
Twostudies218,243comprising374participantsfoundnosignificantdifferenceindepressionat6
monthsafterstrokebetweenthegroupthatreceivedsupportedinformationandtheunsupported
informationgroup(MODERATECONFIDENCEINEFFECT).
Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

7.1.2

Recommendationsandlinktoevidence
36.Workingwiththepersonwithstrokeandtheirfamilyorcarer,
identifytheirinformationneedsandhowtodeliverthem,taking
intoaccountspecificimpairmentssuchasaphasiaandcognitive
impairments.Pacetheinformationtothepersonsemotional
adjustment.
37.Provideinformationaboutlocalresources(forexample,leisure,
housing,socialservicesandthevoluntarysector)thatcanhelpto
supporttheneedsandprioritiesofthepersonwithstrokeand
theirfamilyorcarer.
38.Reviewinformationneedsatthepersons6monthandannual
strokereviewsandatthestartandcompletionofanyintervention
period.
39.NICEhasproducedguidanceonthecomponentsofgoodpatient
experienceinadultNHSservices.Followtherecommendationsin
PatientexperienceinadultNHSservices(NICEclinicalguideline
138)j.
Recommendations

Relativevaluesofdifferent Itisdifficulttoidentifyandcapturethedifferentoutputsofinformation
outcomes
provision.Arangeofpotentialoutputsinclude:abetterunderstandingof
stroke,changesinbehaviour(forexamplecompliancewithmedication,
increasedsatisfactionwithservices,decreasedanxietyanddepression,
increasedactivityandparticipationinsocialrolesafterstroke).
TheGDGconsideredthattherelationshipbetweeninformationprovisionand
theoutputsareunlikelytobelinearandwillbemoderatedbyalargerangeof
factorsincluding:personalfactors(patientseducationallevels,premorbid
mentalhealthstatus),diseasefactors(suchascognitivefactorsandaphasia),
andsocialfactors(suchasfamilybeliefs).Thetimingandpacingofinformation
topatientsneedsisalsocritical.Patientgroupsrepeatedlyaskformore
informationandthereforefactorstobeconsideredarewhatinformationis
required,theappropriatemethodofdeliveryforthepatientandthe
timelinessofprovision.
Tradeoffbetweenclinical
benefitsandharms

Onthebasisofthesestudiesitappearsthatadditionalsupportedinformation
provisiondoesnotaffectimprovementinmood.
Thebaselinescoresweresuchthatthemajorityofthepatientswerenot
depressedandthechangescoreswerenotclinicallysignificant.

For recommendations on continuity of care and relationships see section 1.4 and for recommendations on
enabling patients to actively participate in their care see section 1.5.

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StrokeRehabilitation
Supportandinformation
TheGDGnotedthatstandardinformationbriefingmaynotberelevant;and
thatperhapsguidingpatientstowardarticulatingwhatinformationtheyneed
wouldbeofmorebenefittopatients.
Economicconsiderations

Supportedinformationprovisionmayhavearesourceimpactoverusualcare
butthiswouldvarydependingonthespecificintervention,andonthe
patientsneeds.Theclinicalstudiesrevieweddidnotprovideevidencethat
patienthealthoutcomeswereimproved;however,asnotedabove,theGDG
consideredthatthebenefitsofinformationprovisionwerehardtomeasure
andtheremaybeadditionalaimsandbenefitsofinformationgivingvaluedby
patientsbutnotcapturedbytheseoutcomes.

Qualityofevidence

TheGDGthoughtthatthepatientsperceptionsandattributionsareinformed
byawiderangeofsources,muchofwhichisavailableinsideandoutsideofthe
healthcareenvironment.Theincludedstudiesexaminedtheaddedvalueofa
morestructuredapproachtoinformationprovisionprovidedbyhealthcare
professionals.Thestudiesarenecessarilyreductionistinacomplex
environment.
Thecomponentsoftheinterventionswereinadequatelydescribedandthe
evidencewasgenerallyofhightolowqualityfortheoutcomesassesseddueto
imprecisionoftheeffectestimate.
Therewasconsensusthatprovisionofinformationwasuseful.Therewasvery
littleconsensusonhowandwhenthisshouldbedone,somethingthatis
reflectedinthestudydesigns.TheGDGnotedthatthestudybyEllis75was
focusedonassessingtheroleofthenursespecialistratherthanthe
intervention.TheHoffmanstudy112includedonlyEnglishspeakersand
thereforeitdidnotreflectclinicalpractice.

Otherconsiderations

TheGDGagreedthatinformationprovidedislikelytovaryfrompatientto
patientandneedstoreflectpatientsneedsandpriorities,familyexpectations,
andthelocalresourcesprovidedbyleisure,housing,socialservicesandthe
voluntarysectortosupportthese.Informationneedsarelikelytovaryat
differentstagesafterstroke.
TheGDGnotedthatspecificgroupssuchasthosewithdysphasiaorcognitive
impairmentsmayhaveparticularinformationneeds.

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StrokeRehabilitation
Cognitivefunctioning

8 Cognitivefunctioning
Followingstroke,manypeopleexperiencedifficultiesinarousal,attention,concentration,memory,
perception,problemsolving,decisionmaking,insightandotherareasofcognitionthatimpedetheir
abilitytofunctionineverydayactivities.Cognitiveabilitiesanddisabilitiesmustbeconsideredin
addressingallareasoffunctioningincludingcommunication,mobility,selfcare,socialinteraction,
recreationalpursuits,andotherproductiveactivitiessuchasschoolorwork.
Cognitiverehabilitationcanbeconceptualisedintwoways.Itcanbedesignedtofacilitate
restorationoforcompensationforunderlyingimpairment(s)withtheaimofimprovingfunctional
performance.Oftenbothrestorativeandcompensatoryapproachesareintegratedinorderto
maximisefunction.Theseinterventionsshouldbebasedonthenatureandscopeof
neuropsychologicalimpairmentsidentifiedonneuropsychologicalassessmentsusingvalidated
standardisedtests,andanassessmentoftheimpactoftheseimpairmentsonfunction.
Inpracticalterms,attention,memory,spatialawareness,apraxiaandperceptionarecriticalto
successfulrehabilitationinmanyotherdomains.However,thischapteroftheguidelinefocuseson
visualneglect,memoryandattention.
Forthereviewofpsychologicaltherapiesinrelationtoemotionalfunctioningforpeopleafterstroke
pleaseseechapter9

8.1 Visualneglect
Themoststrikingfeatureofneglectisaninabilityofthepatienttoorienttowardsandattendto
stimulieventheirownbodypartsinthecontralesionalspace(theleftsideforpatientswithright
hemispherelesions)12,despiteanabilitytomakesuchexploratorymovementswhenprompted.The
severityoftheinattentionmayvaryaccordingtocontext.Incircumstanceswherepatientsarealso
unawareoftheirdeficit(anosognosia),thedisorderbecomesaparticularlydifficultsyndrometo
rehabilitate3.Persistentneglectisoftenassociatedwithpoorfunctionaloutcome4,impactingon
everydaytaskssuchasdressing,feedingandreading.
Neglectisdifficulttotreatinclinicalpractice.Thisdifficultycanbeattributedtothefactthatitisa
syndromeanddoesnotseemtobeduetoadisruptionofjustonecognitiveprocessbutratherdue
todifferentcombinationsofneuropsychologicaldeficits4.Itis,therefore,unlikelythatasingle
therapeuticinterventionwillsuitallindividuals.
Neglectcanpresentindifferentmodalitiesforexample,sensory,motororvisual.Unilateralvisual
neglectisarelativelycommonproblemparticularlyfollowinghemisphericstroke.Approachesto
treatmentincludebothrestorativeandcompensatoryapproaches,includingtheuseofgoggleswith
prismsthatinducearightwardopticalshiftof~515hasbeentried.Theinducedopticalshift
initiallyleadstoerrorsofpointingtotherightofthevisualtarget,leadinginturntocompensatory
leftwardmanualcorrections.Inpatients,thiscompensatorybehaviouristypicallyfollowedbyan
aftereffectwhentheprismsareremovedwithmanualerrorsnowbeingbiasedtowardstheleft
instead.

8.1.1

Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessof
cognitiverehabilitationversususualcaretoimprovespatialawarenessand/orvisual
neglect?
ClinicalMethodologicalIntroduction

Population:

Adultsandyoungpeople16orolderwhohavehadastroke.

Intervention:

Prisms,eyepatchesandgoggles,

NationalClinicalGuidelineCentre,2013.
181

StrokeRehabilitation
Cognitivefunctioning
ClinicalMethodologicalIntroduction

Tracktoleft,
Approachessuchascubecopying.

8.1.1.1

Comparison:

UsualCare

Outcomes:

BehaviouralInattentionTest(BIT),
Drawingtests(clockdrawingetc.),
LineBisectiontests,
Allcancellationtests(linecancellation,bellcancellationetc.),
Sentencereading,
Targetscreenexaminations(lumptogetherallcancellationtests
anddrawingtests),
RivermeadPerceptualAssessmentBattery(RPAB)

Clinicalevidence
SearcheswereconductedforsystematicreviewsandRCTscomparingtheclinicaleffectivenessof
cognitiverehabilitationtherapieswithusualcaretoimprovespatialawarenessand/orvisualneglect
foradultsandyoungpeople16orolderwhohavehadastroke.Onlystudieswithaminimumsample
sizeof10participants(5ineacharm)wereselected.Nine(9)RCTswereidentifiedwhichaddressed
visualneglect.Table40summarisesthepopulation,interventionandoutcomesforeachofthe
studies.
Table40: Summaryofstudiesofincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixF.
STUDY

POPULATION

INTERVENTION

COMPARISON

OUTCOMES

Fanthome,
199580

Patientswithaprevious
strokeaffectingthe
rightsideofthebody;
under80yearsofage
withnohistoryof
dementiaorpsychiatric
problems.Allpatients
wereinhospitaland
receivingphysiotherapy
andoccupational
therapybutnoprevious
treatmentfortheir
visualneglect.

Wearingtheeye
movementdetection
glasseswhich
providedareminder
bleepifpatients
failedtomovetheir
eyestotheleftfor
15secondsfor2
hoursand40
minutes/weekfor4
weeks.(N=9)

Notreatment
wasprovidedfor
theirvisual
inattentionor
otherperceptual
deficitsfor4
weeks.(N=9)

BIT
conventional
subset
BIT
behavioural
subset.

Kalra,1997130

Acutestrokepatients
(themedianduration
betweentheacute
episodeand
randomizationwas6
days(range214days).
Patientswithvisual
neglectwereidentified
bycomprehensive
multidisciplinary
assessments(including
linebisectiontest).

Modifiedapproach
toconventional
therapyinvolving
spatiomotorcueing
basedonthe
attentionalmotor
integrationmodel
andearlyemphasis
onrestorationof
function.(N=25)

Conventional
therapyinput
concentratingon
restorationof
normaltone,
movement
patternsand
motoractivity
before
addressing
skilledfunctional
activity.
(N=25)

Rivermead
Perceptual
Assessment
Battery(RPAB)
RPAB
cancellation
subtest
RPABbody
imagesubtest.

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StrokeRehabilitation
Cognitivefunctioning
STUDY

POPULATION

INTERVENTION

COMPARISON

OUTCOMES

Nys,2008

Patientswithstrokeand
visualneglectas
assessedbytheBIT.
Patientswhoperformed
belowthecutoffonat
leasttwoofthefour
subtasksoftheBITwere
includedinthestudy.

Fourdayinarow
experimental
treatmentwith10
degreerightward
deviatingprisms.
(N=10)

Fourdayina
row
experimental
treatment
withoutprism.
(N=6)

Linebisection
test
Star
cancellation
test
Representatio
naldrawing
test,
BIT(total
score).

Robertson,
1990215

Patientswithsignificant
unilateralleftfield
visualneglectaccording
toBITanddefinedas
failurein3outof9
tests.

Computerised
scanningand
attentiontraining,14
sessionsof75
minuteseachusually
2times/week.
(N=20)

Exposureto
plausible
computer
activitiesthat
wereconsidered
nottoimprove
cognitive
function
wogames,
quizzesand
simplelogical
gamessuchas
redsandgreens
foranaverageof
11.4hours(SD
5.2)
(N=16)

BIT(total
score)
Letter
cancellation
test.

Robertson,
2002216

Patientswithdiagnosis
ofrighthemispheric
strokeandunilateral
visualneglect(as
definedbyascoreof51
orlessonthestar
cancellationtestofthe
BITorascoreof7or
lessonthelinebisection
test).Participantshad
nootherexisting
comorbiditiesthat
preventorinfluencethe
assessment.

Perceptualtraining
pluslimbactivating
deviceprovided
in12sessionsof45
minutesduration
overa12week
period.(N=19)

Perceptual
BIT
trainingplus
Behavioural
dummy
subset
(inactive)limb
Letter
activatingdevice
cancellation
providedin12
test.
sessionsof45
minutesduration
overa12week
period.(N=21)

Rossi,1990222

Patientswithstrokeand
homonymous
hemianopiaor
unilateralvisualneglect.

15diopterplastic
pressonfresnel
prismsplusreceiving
routine
rehabilitation
programme
(physical,
occupationalspeech
therapy).(N=18)

Noprismbut
receivingroutine
rehabilitation
programme
(physical,
occupational
speechtherapy)
(N=21)

191

NationalClinicalGuidelineCentre,2013.
183

Linebisection
test
Line
cancellation
testtask
Tangent
Screen
Examination.

StrokeRehabilitation
Cognitivefunctioning
STUDY

POPULATION

INTERVENTION

COMPARISON

Tsang,2009

Participantswere
inpatientswithsub
acutestroke(meantime
sincestroke3wks.)with
leftvisualneglectbased
onthetotalscoreon
theBIT.

4weeksof
conventional
occupationaltherapy
withrighthalffield
eyepatchingglasses,
whichwereworn
throughoutthe
occupationaltherapy
treatmentsessions.
Fiveoccupational
therapysessionsof
60minuteseach
session/
week.(N=17)

4weeksof
BIT
conventional
Conventional
occupational
subset.
therapywithout
eyepatching.
Fiveoccupational
therapysessions
of60minutes
each
session/week.
(N=17)

Turton2010264

Righthemisphericfirst
timestrokepatients(at
least20dayspost
stroke)withunilateral
spatialneglect

Participantswere
instructedto
performrepeated
pointingmovements
totargets,usingthe
rightunaffected
handwhilewearing
theprismglasses
(using10dioptre,6
degreeprisms)each
weekdayfor2
weeks.Before
wearingtheglasses,
participantswere
givensomepointing
practice,withvision
oftheterminalpoint
ofmovement,to
ensurethey
understoodthetask
(N=17)

Shamtreatment BIT
usingplain
Conventional
glasseseveryday
subset
duringtheweek
for2weeks.
Participantswere
giventhesame
pointingpractice,
withvisionofthe
terminalpointof
movementasthe
intervention
group.(N=19)

Mancuso2012166

Outpatientswithleft
visualneglectresulting
fromrighthemisphere
vascularlesion.All
patientswereselected
inaccordancewithtests
forneglectwhohad
verylowscoresonat
leasttwo(outofhow
manyisabitunclear)
visualneglecttests.

Participantscarried
outapointing
exercisewhilst
wearingprismatic
lensesproducing
opticalshiftof5
degreestotheright.
Therewereoverall
fiverehabilitation
sessionslasting
about30minutes
eachforoneweek.

Participants
receivedthe
samepointing
exercisewhilst
wearingneutral
lenses.

263

NationalClinicalGuidelineCentre,2013.
184

OUTCOMES

Line
cancellation
tests
Bells
cancellation
tests
Lines
orientation
test
Fourssubtests
ofBIT(line
bisection,
copying
drawings,
findingobjects
anddealing
playingcards
tests)

StrokeRehabilitation
Cognitivefunctioning

Comparison:Cognitiverehabilitationforspatialawarenessand/orvisualneglectversususualcare
Table41:Cognitiverehabilitationforspatialawarenessand/orvisualneglectversususualcareClinicalstudycharacteristicsandclinicalsummaryof
findings
Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectness

Cognitive
rehabilitation
Frequency
(%)/mean
(SD)/median
(range)

Usualcare
Frequency
(%)/mean
(SD)/
median
(range)

Serious
imprecision
(b)

52(24)

59.9(20.2)

7.9(
22.34,
6.54)

MD7.9
lower
(22.34
lowerto
6.54
higher)

Low

Serious
imprecision
(b)

Nys
60.2(21.9)
Robertson
60.1(18.6)

Nys
61.2(21.2)
Robertson
61.8(21.5)

1.51(
12.86,
9.85)

MD1.51
lower
(12.86
lowerto
9.85
higher)

Low

Veryserious
imprecision
(e,f)

Fanthome
93.4(41.3)
Turton14.8
(18.8)

Fanthome
90.2(48.4)
Turton9.7
(15.9)

4.97(
6.07,
16.00)

MD4.97
higher
(6.077
lowerto
16.00

Verylow

Imprecision

Mean
difference/
RiskRatio
(95%CI)

Absolute
effect/
Mean
Differen
ce(MD) Confidence
(95%CI) (ineffect)

BIT(totalscore)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
RCT
Robertson1990 single
215
blind

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

BIT(totalscore)(6monthsfollowup)(Betterindicatedbyhighervalues)
2
RCTs
single
Nys2008
191
blind

Robertson1990
215

Serious
limitations
(c)

Noserious
inconsistency

Noserious
indirectness

BITconventional(posttreatmenteffect)(Betterindicatedbyhighervalues)
2
Fanthome
199580
Turton2010264

RCTs
single
blinded

Serious
limitations
(d)

Noserious
inconsistency

Noserious
indirectness

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StrokeRehabilitation
Cognitivefunctioning

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectness

Cognitive
rehabilitation
Frequency
(%)/mean
(SD)/median
(range)

Usualcare
Frequency
(%)/mean
(SD)/
median
(range)

Absolute
effect/
Mean
Mean
difference/ Differen
RiskRatio
ce(MD) Confidence
(95%CI)
(95%CI) (ineffect)
higher)

Serious
imprecision
(b)

Fanthome
97.6(27.9)
Nys
123.2(25.1)
Turton24.5
(15.7)

Fanthome
84(50.3)
Nys
116.5(36.5)
Turton21.8
(22.2)

4.11(
7.03,
15.25)

MD4.11
higher
(7.03
lowerto
15.25
higher)

Low

Noserious
imprecision

Fanthome
37.6(21.3)
Robertson
30.2(11.9)

Fanthome
42.9(29.3)
Robertson
31.2(11.9)

1.38(
8.43,
5.67)

MD1.38
lower
(8.43
lowerto
5.67
higher)

Moderate

Noserious
imprecision

Fanthome
45.1(19)
Robertson
30.1(11.5)

Fanthome
39(26)
Robertson
32.8(11.9)

1.76(
8.62,
5.09)

MD1.76
lower
(8.62
lowerto
5.09
higher)

Moderate

Serious

30.1(13.2)

33.5(12.6)

3.40( MD3.4

Imprecision

BITconventional(12monthsfollowup)(Betterindicatedbyhighervalues)
3
Fanthome
199580
Nys2008191
Turton2010264

RCTs
single
blinded

Serious
limitations
(d)

Noserious
inconsistency

Noserious
indirectness

BITbehavioural(posttreatmenteffect)(Betterindicatedbyhighervalues)
2
Fanthome
199580
Robertson
2002216

RCTs
single
blinded

Serious
limitations
(d)

Noserious
inconsistency

Noserious
indirectness

BITbehavioural(23monthsfollowup)(Betterindicatedbyhighervalues)
2
Fanthome
199580
Robertson
2002216

RCTs
single
blinded

Serious
limitations
(d)

Noserious
inconsistency

Noserious
indirectness

BITbehavioural(6monthsfollowup)(Betterindicatedbyhighervalues)
1

RCT

Veryserious

Noserious

Noserious

NationalClinicalGuidelineCentre,2013.

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Verylow

StrokeRehabilitation
Cognitivefunctioning

Summaryoffindings
Qualityassessment

Noofstudies
Robertson
2002216

Design
single
blinded

Effect

Limitations
limitations
(g,h)

Inconsistency
inconsistency

Indirectness
indirectness

Cognitive
rehabilitation
Frequency
(%)/mean
(SD)/median
(range)

Usualcare
Frequency
(%)/mean
(SD)/
median
(range)

Absolute
effect/
Mean
Mean
difference/ Differen
RiskRatio
ce(MD) Confidence
(95%CI)
(95%CI) (ineffect)
11.42,
lower

4.62)
(11.42
lowerto
4.62
higher)

Serious
imprecision
(b)

Nys
2.6(2.8)
Tsang
0.76(1.6)

Nys
2.5(2.5)
Tsang
0.02(2.46)

0.56(
1.79,
0.68)

MD0.56
lower
(1.79
lowerto
0.68
higher)

Low

Noserious
imprecision

Nys
6.1(3.4)
Rossi
0.68(0.85)

Nys
5.2(3.1)
Rossi
2.2(2.29)

1.29(
2.29,
0.29)

MD1.29
(2.29to
0.29
lower)

Low

Nys
21.5(13.1)
Tsang
8.65(13.15)

Nys
20.7(19)
Tsang
1.88(5.02)

5.99(
0.25,
12.23)

MD5.99
higher
(0.25
lowerto
12.23
higher)

Low

Imprecision
imprecision
(b)

Linebisection(posttreatmenteffect)(Betterindicatedbyhighervalues)
2
Nys2008191
Tsang2009
263

RCT
single
blinded

Serious
limitations
(i)

Noserious
inconsistency

Noserious
indirectness

Linebisectiontest(1monthfollowup)(Betterindicatedbyhighervalues)
2
Nys2008191
Rossi1990

RCTs
single
blinded/
unblinded

Veryserious
limitations
(j)

Noserious
inconsistency

Noserious
indirectness

StarCancellationtest(posttreatmenteffect)(Betterindicatedbyhighervalues)
2
Nys2008191
Tsang2009263

RCTs
single
blinded

Serious
limitations
(i)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b)

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StrokeRehabilitation
Cognitivefunctioning

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectness

Cognitive
rehabilitation
Frequency
(%)/mean
(SD)/median
(range)

Usualcare
Frequency
(%)/mean
(SD)/
median
(range)

Veryserious
imprecision
(e,f)

43.1(13.7)

42.3(16.4)

0.80(
14.83,
16.43)

MD0.8
higher
(14.83
lowerto
16.43
higher)

Verylow

Serious
imprecision
(b)

224.32
(55.38)

199.44
(64.87)

24.88(
8.55,
58.31)

MD24.88
higher
(8.55
lowerto
58.31
higher)

Low

Kalra
37.19(13.1)

Kalra
30.12
(18.45)

7.07(
1.80
15.94)

MD7.07
higher
(1.80
lowerto
15.94
higher)

Low

13.19(1.47)

9.72(1.33)

3.47
(2.69,
4.25)

MD3.47
higher
(2.69to

Moderate

Imprecision

Mean
difference/
RiskRatio
(95%CI)

Absolute
effect/
Mean
Differen
ce(MD) Confidence
(95%CI) (ineffect)

StarCancellationtest(1monthfollowup)(Betterindicatedbyhighervalues)
1
Nys2008191

RCT
single
blinded

Serious
limitations
(k)

Noserious
inconsistency

Noserious
indirectness

RPAB(totalscore)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Kalra1997130

RCT
single
blinded

Serious
limitations
(k)

Noserious
inconsistency

Noserious
indirectness

RPAB(cancellationsubtest)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Kalra1997130

RCTs
single
blinded

Serious
limitations
(k)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b)

RPAB(bodyimagesubtest)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Kalra1997130

RCTs
single
blinded

Serious
limitations
(k)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

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StrokeRehabilitation
Cognitivefunctioning

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectness

Imprecision

Cognitive
rehabilitation
Frequency
(%)/mean
(SD)/median
(range)

Usualcare
Frequency
(%)/mean
(SD)/
median
(range)

Absolute
effect/
Mean
Mean
difference/ Differen
RiskRatio
ce(MD) Confidence
(95%CI)
(95%CI) (ineffect)
4.25
higher)

Robertson
43.4(30.4)
Tsang
10(12.12)

Robertson
43.2(28.3)
Tsang
2.65(6.52)

6.61
(0.41,
12.80)

MD6.61
higher
(0.41to
12.80
higher

Moderate

20(16.4)

23.1(14.5)

3.10(
13.21,
7.01)

MD3.10
lower
(13.21
lowerto
7.01
higher)

Low

15/18(83.3%) 7/21
(33.3%)

RR2.50
(1.32to
4.74)

500more
per1000
(from185
moreto
625more)

Low

2.4(4.24)

7.40(
11.78,
3.02)

MD7.4
lower
(11.78to

Low

Lettercancellationtest(posttreatmenteffect)(Betterindicatedbyhighervalues)
2
Robertson
1990215
Tsang2009263

RCTs
single
blinded

Serious
limitations
(c)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

LetterCancellationtest(6monthsfollowup)(Betterindicatedbyhighervalues)
1
Robertson
1990215

RCT
single
blinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b)

Tangentscreenexamination(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Rossi1990222

RCT
unblinded

Veryserious
limitations
(o)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

LineCancellationtest(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Rossi1990222

RCT
unblinded

Veryserious
limitations
(o)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

9.8(9.17)

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StrokeRehabilitation
Cognitivefunctioning

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectness

Imprecision

Cognitive
rehabilitation
Frequency
(%)/mean
(SD)/median
(range)

Usualcare
Frequency
(%)/mean
(SD)/
median
(range)

Absolute
effect/
Mean
Mean
difference/ Differen
RiskRatio
ce(MD) Confidence
(95%CI)
(95%CI) (ineffect)
3.02
lower)

Nys
0.8(0.8)
Tsang
0.18(1.19)

Nys
1(0.9)
Tsang
0.18(0.88)

0.08(
0.63,
0.47)

MD0.08
lower
(0.63
lowerto
0.47
higher)

Verylow

1.6(1)

2.3(0.5)

0.70(
1.44,
0.04)

MD0.7
lower
(1.44
lowerto
0.04
higher)

Low

Representationaldrawingtest(posttreatmenteffect)(Betterindicatedbyhighervalues)
2
Nys2008191
Tsang2009263

RCTs
single
blinded

Serious
limitations
(i)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision
(p)

Representationaldrawingtest(1monthfollowup)(Betterindicatedbyhighervalues)
1
Nys2008191

RCT
single
blinded

Serious
limitations
(k)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b,e)

(a)

Partialrandomizationandunclearallocationconcealment
ConfidenceintervalcrossedoneendofdefaultMID.
(c)
Onehadpartialrandomization(Robertson,1990),onestudyhadunclearrandomization(Nys,2008)andbothstudieshadunclearallocationconcealment.
(d)
Unclearrandomizationprocessandallocationconcealment.
(e)
Smallsamplesize,eitherarm<10participants(Nys2008;Fanthome1995).
(f)
ConfidenceintervalcrossedbothendsofdefaultMID.
(g)
Unclearrandomizationandallocationconcealment.
(h)

Dropoutrate20%ineacharm(Robertson2002).

(i)
Unclearrandomizationandallocationconcealment(Nys,2008)
(j)
Unblinded(Rossi1990)withunclearrandomizationandallocationconcealment.
(k)
Unclearrandomizationandallocationconcealment.
(l)
Inadequaterandomizationandunclearallocationconcealment.
(b)

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StrokeRehabilitation
Cognitivefunctioning

(m)

Imprecisioncouldnotbeassessedasresultswerepresentedonlyinmedians(range).
Nomeanorstandarddeviationwasreportedinthestudy,socouldnotbemetaanalysedandunabletocalculaterelativeandabsoluteeffect.
(o)
Unblindedstudywithunclearrandomizationandallocationconcealment(Rossi1990).
(p)
ConfidenceintervalcrossedbothendsofdefaultMID.
(n)

Narrativesummary
ThefollowingstudiesaresummarisedasanarrativebecausetheresultswerenotpresentedinnumericaldatathatcouldbeincludedintheGRADEtable:
Onerandomisedcontrolstudy166comprising29participants,whohadtestedpositiveforvisualneglect,reportedimprovementsforboththeexperimental
(prismaticlensesof5degreespluspointingtask)andcontrolgroup(shamlensespluspointingtask).However,participantswearingprismaticlensesdid
notimprovesignificantlymorethanthecontrolparticipants(VERYLOWCONFIDENCEINEFFECT).

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StrokeRehabilitation
Cognitivefunctioning

8.1.1.2

Economicevidence
Literaturereview
Norelevanteconomicevaluationscomparingcognitiverehabilitationinterventionswithusualcareto
improvespatialawarenessand/orvisualneglectwereidentified.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
Thestudiesidentifiedintheclinicalreviewusedavarietyofdifferentinterventions.TheGDG
consideredthatatypicalcostcouldbeestimatedbasedontheresourcesreportedintheRCTby
Turtonetal(2010)264thatlookedatusingprismglassesintensessionswithanoccupational
therapist.Theauthorwascontactedforinformationonresourcesusedinthetrial.Inthetrial,prism
glasseswerecomparedwithplainglassesandtherewasnodifferenceinpersonneluse.However,for
purposesofcosting,theresourceuseintheinterventionarmwasusedandassumedtobeontopof
usualcare.TheresourceuseandcostsaresummarisedinTable42below.
Table42: Interventioncostsprisminterventionforspatialawarenessand/orvisualneglect
Resources

Frequency

Unitcosts

Costperpatient
(c)

10sessionswithan
occupationaltherapist(a)

30minutespersession

45perhour

225

Prismsglasses(b)

n/a

44.95excludingVAT

44.95

Total

270

(a) Assessmentresourcescouldalsoberequired,suchasneuropsychologicalandfunctionaltests.
234
(b) Prismglassescost:Manufacturerwebsite .Assumedthateachpatientwoulduseonepairofglasses.Ifglassesarereused,costs
wouldbelower.
(c) EstimatedbasedondataandmethodsfromPersonalSocialServicesResearchUnitUnitscostsofhealthandsocialcarereportand
51
Agendaforchangehospitalsalaryband6 (typicalsalarybandidentifiedbyclinicalGDGmembers).

8.1.1.3

Evidencestatements
Clinicalevidencestatements
Onestudy215of36participantsfoundthattherewasnosignificantdifferenceintotalBITscore
betweenthosewhoreceivedcomputerisedscanningandattentiontrainingandthosewhoreceived
usualcareattheendofinterventionperiod(posttreatment)(LOWCONFIDENCEINEFFECT).
Twostudies191,215of52participantsfoundthattherewasnosignificantdifferenceintotalBITscore
betweenthosewhoreceivedcomputerisedscanningandattentiontrainingorrepetitiveprismand
thosewhoreceivedusualcareat6monthsfollowup(LOWCONFIDENCEINEFFECT).
Twostudies80,264of54participantsfoundthattherewasnosignificantdifferenceinBITconventional
scorebetweenthosewhoreceivedfeedbackglassesandthosewhoreceivedusualcareattheendof
interventionperiod(posttreatment)(VERYLOWCONFIDENCEINEFFECT).
Threestudies80,191,264of70participantsfoundthattherewasnosignificantdifferenceinBIT
conventionalscorebetweenthosewhoreceivedfeedbackglassesorrepetitiveprismsandthosewho
receivedusualcareatupto1monthfollowup(LOWCONFIDENCEINEFFECT).

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Twostudies80,216of58participantsfoundthattherewasnosignificantdifferenceinBITbehavioural
scorebetweenthosewhoreceivedfeedbackglassesorlimbactivationtreatmentwithperceptual
trainingandthosewhoreceivedusualcare,eitherattheendofinterventionperiod(posttreatment
)(MODERATECONFIDENCEINEFFECT)orat23monthsfollowup(MODERATECONFIDENCEIN
EFFECT).
Onestudy216of40participantsfoundthattherewasnosignificantdifferenceinBITbehavioural
scorebetweenthosewhoreceivedlimbactivationtreatmentwithperceptualtrainingandthosewho
receivedusualcareattheendof6monthsfollowup(VERYLOWCONFIDENCEINEFFECT).
Twostudies191,263of50participantsfoundthattherewasnosignificantdifferenceinlinebisection
scoreandstarcancellationbetweenthosewhoreceivedrepetitiveprismsorrighthalffieldeye
patchingandthosewhoreceivedusualcareattheendofinterventionperiod(posttreatment)(LOW
CONFIDENCEINEFFECT).
Twostudies191,222of55participantsfoundthatwearingrepetitiveprismwasassociatedwitha
statisticallysignificantgreaterimprovementinlinebisection,comparedtothosereceivingusualcare
attheendoffollowup(LOWCONFIDENCEINEFFECT).
Onestudy191of16participantsfoundnosignificantdifferenceinstarcancellationbetweenthose
whowerewearingrepetitiveprismsandthosereceivingusualcareattheendof1monthfollowup
(VERYLOWCONFIDENCEINEFFECT).
Onestudy130of50participantsfoundnosignificantdifferenceinoverallRivermeadPerceptual
AssessmentBattery(RPAB)scorebetweenspatiomotorcueingandusualcareattheendofthetrial
(LOWCONFIDENCEINEFFECT).
Onestudy130of50participantsfoundnosignificantdifferenceinspatiomotorcueingandperceptual
trainingthecancellationsubtestfromRivermeadPerceptualassessmentBattery(RPAB),compared
tousualcareattheendofinterventionperiod(posttreatment)(LOWCONFIDENCEINEFFECT).
Onestudy130of50participantsfoundthatspatiomotorcueingandperceptualtrainingwas
associatedwithastatisticallysignificantgreaterimprovementinthebodyimagesubtestfrom
RivermeadPerceptualAssessmentBattery(RPAB),comparedtousualcareattheendofthe
interventionperiod(posttreatment)(MODERATECONFIDENCEINEFFECT).
Twostudies215,263of70participantsfoundthatcomputerbasedattentiontrainingorrighthalffield
eyepatchingwasassociatedwithastatisticallysignificantgreaterimprovementinlettercancellation,
comparedtousualcareattheendofinterventionperiod(posttreatment)(LOWCONFIDENCEIN
EFFECT).
Onestudy215of36participantsfoundthattherewasnosignificantdifferenceinlettercancellation
betweenparticipantsreceivingcomputerbasedattentiontrainingandthosereceivingusualcareat
theendof6monthsfollowup(LOWCONFIDENCEINEFFECT).
Onestudy222of39participantsfoundthatprismtrainingwasassociatedwithastatistically
significantgreaterimprovementcomparedtousualcareattheendofinterventionperiod(post
treatment)onthefollowingoutcomes:
Tangentscreenexamination(LOWCONFIDENCEINEFFECT)
Linecancellation(LOWCONFIDENCEINEFFECT).
Twostudies191,263of50participantsfoundthattherewasnosignificantdifferencein
representationaldrawingtestbetweenparticipantswhoreceivedrepetitiveprismstrainingorright
halffieldeyepatchingandthosewhoreceivedusualcareattheendofinterventionperiod(post
treatment)(VERYLOWCONFIDENCEINEFFECT).

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Onestudy191of16participantsfoundthattherewasnosignificantdifferenceinrepresentational
drawingtestbetweenthosewhoreceivedrepetitiveprismandusualcareattheendof1month
followup(VERYLOWCONFIDENCEINEFFECT).
Onerandomisedcontrolstudy166comprising29participants,whohadtestedpositiveforvisual
neglect,reportedimprovementsforboththeexperimental(prismaticlensesof5degreesplus
pointingtask)andcontrolgroup(shamlensespluspointingtask).However,participantswearing
prismaticlensesdidnotimprovesignificantlymorethanthecontrolparticipants(VERYLOW
CONFIDENCEINEFFECT).
Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

8.1.2

Recommendationsandlinktoevidence
40.Screenpeopleafterstrokeforcognitivedeficits.Whereacognitive
deficitisidentified,carryoutadetailedassessmentusingvalid,reliable
andresponsivetoolsbeforedesigningatreatmentprogramme.
41.Provideeducationandsupportforpeoplewithstrokeandtheir
familiesandcarerstohelpthemunderstandtheextentandimpactof
cognitivedeficitsafterstroke,recognisingthatthesemayvaryover
timeandindifferentsettings.
42.Assesstheeffectofvisualneglectafterstrokeonfunctionaltaskssuch
asmobility,dressing,eatingandusingawheelchair,usingstandardised
assessmentsandbehaviouralobservation.
43.Useinterventionsforvisualneglectafterstrokethatfocusonthe
relevantfunctionaltasks,takingintoaccounttheunderlying
impairment.Forexample:
interventionstohelppeoplescantotheneglectedside,suchas
brightlycolouredlinesorhighlighterontheedgeofthepage
alertingtechniquessuchasauditorycues
repetitivetaskperformancesuchasdressing
alteringtheperceptualinputusingprismglasses.
Recommendations

Relativevalueplaced
ontheoutcomes
considered

TheGDGconsideredthatinterventionswhichweredesignedtoaddressthe
underlyingimpairmentmightbeevaluatedusingmeasuresoftheextentofthe
impairmentsuchaslinebisectionorcancellationtests.However,theGDGalsofelt
thatitwasimportanttoassesstheimpactofinterventionsonfunctionalactivity,
andthatstudiesshouldreportonfunctionalperformanceaswellasimpairment
levelmeasures.

Qualityofevidence

Alltheincludedstudiesforthisquestionlookedatimprovingvisualneglect.
TheGDGnotedthatallthestudiesweresmallandhadlimitationsintermsofstudy
design.Confidenceintheeffectsshownrangedfrommoderatetoverylowforall
outcomes.Theincludedstudiesuseddifferentinterventionsincludingfeedback
/prismaticglasses,computerisedscanningandattentiontraining,orperceptual
trainingpluslimbactivatingdeviceperceptiontraining,attentionalmotor
integrationandprisms.

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Somebenefitwasfoundforprismsandcomputerisedscanning191,215,222,263as
measuredbyletterorlinecancellationandlinebisectiontestoutcomes.TheGDG
notedthatuniqueinterventiondeliveredinthestudybyFanthome80andthatthis
hasnotbeenreproducedbyanyotherresearchstudy.
Tradeoffbetween
clinicalbenefitsand
harms

TheGDGagreedthatprismsofferedsmallbenefitsattheimpairmentlevelwithno
evidenceoffunctionalbenefit.Althoughlittleevidenceofclinicallyimportant
benefitwasfound,therewasnoevidenceofharmsassociatedwiththe
interventionseither.TheGDGagreedthatgiventhelimitedevidenceavailableand
thelimitationsofthestudiesarecommendationforassessmentwouldbemore
appropriate.AlthoughnoparticularinterventioncouldberecommendedtheGDG
wereofaviewthatitwasimportanttooffertherapiesthataddressedthe
individualscognitiveimpairmentinordertomaximiseanindividualsabilityto
engageineverydayactivities,andthatthiswasbestdonebyaddressingboth
impairmentsandactivitylimitations,forexamplebyencouragingscanningduring
theperformanceofadressingtask.

Economic
considerations

Nocosteffectivenessstudieswerefoundforthisquestion.Thetypicalcostper
patientfordeliveringaninterventionthataddressesneglectwasestimatedbased
onthestudybyTurtonandcolleagues264at270.TheGDGconsideredthatthe
costofprovidingthisorotherinterventionswaslikelytobeoffsetbythepotential
benefitstopatientsintermsoftheirabilitytoengageineverydayactivities,and
thusimprovedqualityoflife.

Otherconsiderations

TheGDGacknowledgedthatpeopleoftenhavemultipleinteractingcognitive
difficulties.Theresearchtendstofocusonthesedifficultiesinisolationbutinreal
lifetreatmentmodalitiesshouldrecognisethecomplexityoftheindividuals
difficulties.TheGDGconsideredtheresearchpresentedontheindividualcognitive
deficitsbuthavealsomaderecommendationsbasedonthereallifeproblems
patientsexperience.
Identificationofcognitivedeficitsisoftendonebyformalneuropsychometric
screeninginthesestudies.TheGDGagreedtheassessmentofoutcomeis
extremelycomplex,andtheuseofindividualpsychometrictestsasanoutcome
shouldbeusedandinterpretedwithcaution,becausetheyareassessments,while
theoutcomesusedtomeasurecognitiveperformancearealsotypically
multifacetedaddressingattention,memoryandperceptualissues.Analternative
wayofconsideringoutcomeistoconsidergoalachievement,buttheGDGagreed
therearedifferingviewsonwhetherthisisanappropriateoutcometouse.Itwas
acknowledgedthatstandardassessmentsareusedalongwithbehavioural
observationtoassesstheeffectofvisualneglectonusualfunctionalactivities.

TheGDGacknowledgedthestokequalitystandardtoscreenforcognitive
impairment189andagreedthatitwasimportanttomakeageneral
recommendationaboutit.TheGDGalsohighlightedtheneedforhealth
professionalstoprovideinformationandsupporttopatientsandtheircarerson
theimpactthatcognitiveimpairmentmayhave.

TheGDGagreedthatthiswasapotentialtopicforfurtherresearch.

8.2 Memoryfunction
Memoryistheabilitytoencode,storeandretrieveinformation.Memoryproblemsareacommon
cognitivecomplaintfollowingstroke.Memoryrehabilitationprogrammeseitherattempttoretrain
impairedmemoryfunctions,orteachpatientsstrategiestocopewiththem.Factorsthatcan
contributetomemorydifficultiesincludeattentionandexecutivefunction.Inaddition,thepresence
oflowmoodand/orapathyalsoneedstobeassessedasbothoftheseareassociatedwithstrokeand
canpresentwithmemoryproblems.

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Acomprehensiveassessmentofmemorywillexaminerecognitionandrecallmemoryinverbaland
nonverbaldomainsaswellasnewlearningofinformation.Rememberingtodosomethinginthe
future(prospectivememory)needstobedistinguishedfromrememberinginformationfromthepast
(retrospectivememory).
Differenttypesofmemoryimpairmentimpactonfunctioninvariousways.Forexample,theimpact
ofmemoryimpairmentsmaybeseenasdifficultiesinrememberingrecentinformationsuchasa
therapistsname,thecauseofstroke,orwhenarelativelastvisited.
Difficultywithprospectivememorymayresultinforgettingtoperformtaskssuchastakingtablets,
orpracticinganexerciseprogramme.Bothofthesememorydeficitsimpactonrehabilitation.Other
formsofdeficitsmayimpactmoresignificantlyonfamiliesandcarers.Autobiographicaland
semanticknowledgeaccumulatedduringlifethroughreadingorverbalcommunicationand
experiencesisusuallyrelativelywellpreservedalthoughdetailedexaminationmayrevealpatchy
loss.Impairednonverbalmemorymayresultinpeoplewithstrokebecominglostinparticular
situationssuchaswhentheyareoutinthecommunity.

8.2.1

Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessof
memorystrategiesversususualcaretoimprovememory
ClinicalMethodologicalIntroduction
Population:

Adultsandyoungpeople16orolderwhohavehadastroke.

Intervention:

Comparison:

Usualcare

Outcomes:

Mnemonicstrategiesassociationandorganisation,
drillandpractice,
memoryaidsinternal,
externalorboth,
errorlesslearning.
Interventionshavebeenseparatedintothreegroups:
Compensatorystrategies,RestorativestrategiesandRehearsal
drillandpracticestrategies.

WechslerMemoryScale
Rivermeadbehaviouralmemoryassessment,
CognitiveFailuresQuestionnaire
DysexecutiveQuestionnaire
EverydayMemoryQuestionnaire

8.2.1.1

Clinicalevidence
SearcheswereconductedforsystematicandRCTscomparingtheeffectivenessofmemorystrategies
withusualcareforadultsandyoungpeople16orolderwhohavehadastroke.Onlystudieswitha
minimumsamplesizeof10participants(5ineacharm)andincludingatleast50%ofparticipants
withstrokewereselected.Tworandomisedcontrolledtrials(RCTs)wereidentified.Table43below
summarisesthepopulation,interventionandoutcomesforeachofthestudies.
Table43: Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixF.
STUDY

POPULATION

INTERVENTION

Doornhein

Firsttimestroke

Memorytraining:Twicea Pseudotraining:

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COMPARISON

OUTCOMES
Fortarget

StrokeRehabilitation
Cognitivefunctioning
STUDY
199870

POPULATION
patientsadmitted
toarehabilitation
centrewith
cognitive/memory
andsensorymotor
deficits

INTERVENTION
weekfor4weeks.
Mnemonicstrategies
includingassociation
andorganisation.
Homeworkbookswere
alsoused.(N=6)

COMPARISON
Drillandpractice
exercisesincluding
spendingmore
timerepeating
material
(N=6)

OUTCOMES
memorytasks:
NameFace
PairedAssociated
MemoryTest,
StylusMazetest.
ForControl
memorytask:15
WordsTest,
OxfordRecurring
facesTest,
Subjective
Memory
Questionnaire.

Aben2,119

Patientswhohave
hadastrokeif18
monthsormore
hadelapsedsince
theirfirstandonly
stroke.Subjective
memorycomplaints
wereassessed
usingasemi
structured
telephone
interview.Patients
whoreported
memoryproblems
butnevertheless
wereableto
adequatelydeal
withthesedeficits
byusingmemory
aidswereexcluded.

Memoryselfefficacy
trainingtrainingin
memorystrategiesin9
twiceweeklysessions.
Therewere4parts:(1)
informationonmemory
andstroke(2)trainingin
internalandexternal
memorystrategies
(visualisation,diaryuse
andtakingnotes)(3)
psychoeducation(4)
realisticgoalsetting
regardingmemory
demandingtasks.

Peersupport
groupsin9twice
weeklysessionsin
whichgeneral
educationon
causesand
consequencesof
strokewas
provided.

MemorySelf
efficacy(MSE)
Delayedrecall
fromtheauditory
verballearning
task(AVLT)
Delayedrecall
fromthe
Rivermead
Behavioural
MemoryTest
(RBMT)
Qualityoflife
score(EQ5D)

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Comparison:Cognitiverehabilitation(memorystrategies)forimprovingmemoryversususualcare
SummaryofFindings
Qualityassessment

Noof
studies

Design

Riskof
bias

Inconsistency

Indirectness

Imprecisio
n

Memoryself
efficacy
training
mean
unadjusted
changescore
(SE)

Memoryselfefficacyscore(followup10days;Betterindicatedbyhighervalues)

1
Aben
20122

0.48(0.14)

randomised serious(
trials
a)

noserious
inconsistency

noserious
indirectness

serious(b)

DelayedrecallAVLT(followup10days;Betterindicatedbyhighervalues)
1
Aben
20122

randomised serious(
trials
a)

noserious
inconsistency

noserious
indirectness

Control
(peer
support)
mean
unadjusted
change
score(SE)

Effect

0.12(0.12)

0.40
(0.07
to
0.73)

beta0.40higher
(0.07higherto0.73
higher)

Low

1.22(0.29)

0.11
(0.93
to
0.71)

beta0.11lower
(0.93lowerto0.71
higher)

Low

Mean
Differ
ence
(95%
CI)

Baselineadjusted
betavalue*

Confid
ence
(in
effect)

serious(b)

1.01(0.26)

DelayedrecallRBMT(followup10days;Betterindicatedbyhighervalues)

1
Aben
20122

serious(b)

0.01(0.49)

0.97(0.46)

0.63
(2.02
to
0.76)

beta0.63lower
(2.02lowerto0.76
higher)

Low

noserious
imprecisio
n

0.02(0.02)

0.00(0.02)

0.02
(0.04
to
0.08)

beta0.02lower
(0.04lowerto0.08
higher)

Moder
ate

randomised serious(
trials
a)

noserious
inconsistency

noserious
indirectness

QualityofLifeEQ5D(followup10days;Betterindicatedbyhighervalues)
1
Aben
20122

randomised serious(
trials
a)

noserious
inconsistency

noserious
indirectness

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*Note.Apositive(ornegative)numbermeansthattheinterventiongroupscored(higher(orlower)thanthecontrolgroupatfollowupadjustedforbaseline.Thebetavalueisan
indicatoroftheinfluencethatgroupinghasonthechangefrombaselinethehigherthisvaluethelargerthebetweengroupdifference.
(a)
Thestudywasdowngradedforunclearrandomisationsequencegeneration.
(b)
TheconfidenceintervalcrossesonedefaultMID(0.5ofStandardmeandifference)

Narrativesummary
ThefollowingstudyissummarisedasanarrativebecausetheresultswerenotpresentedinnumericaldatathatcouldbeincludedintheGRADEtable:
Oneunblindedstudy70of12patientsreportedthatmnemonicstrategytreatmentshowedasignificantimprovementinthetrainedmemoryskills,but
therewasnoimprovementoncontrolmemorytasks.Subjectiveratingsofeverydaymemoryfunctioningdidnotdifferbetweenthetwogroups.

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8.2.1.2

Economicevidence
Literaturereview
Norelevanteconomicevaluationscomparingcognitiverehabilitationmemorystrategieswithusual
caretoimprovememorywereidentified.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
Inpracticemostcognitiverehabilitationwouldbebasedoncompensatorystrategiesor
environmentalmanipulation,andnottheinterventionswithinthetrialsconsidered.Typicalcostsof
deliveringaninterventionaimedatimprovingmemoryinpatientswhohavehadastrokewas
thereforeestimatedbasedonresourceuseestimatesprovidedbyclinicalmembersoftheGDG.
ThesecostsaresummarisedinTable28. Inaddition,ifcomputerprogramsareused,additionalcosts
wouldbeincurred.
Table44: Interventioncostscognitiverehabilitationformemory
Resources

Frequency

Unitcosts(a)

Costperpatient

Initialassessmentbya
psychologist

2hours

136perhour

272

Goalsettingwithmulti
disciplinaryteam

1hour,with15
minutesallocatedto
memorygoals

136perhourpsychologist
35perhournurse
45perhourphysiotherapist
45perhouroccupational
therapist
132perhourmedical
consultant

98

Interventionifinpatient:
45minutesper
136perhourpsychologist
occupationaltherapistand session,twiceaweek 45perhouroccupational
psychologistsessions
for6weeks
therapist

1629

Interventionifinthe
community:occupational
therapistandpsychologist
sessions

45minutesper
session,onceaweek
for6weeks

136perhourpsychologist
45perhouroccupational
therapist

815

Totalpersonnelcost
(incrementaloverusual
care)

Inpatient:1999
Community:1184

a)EstimatedbasedondataandmethodsfromPersonalSocialServicesResearchUnitUnitcostsofhealthandsocialcarereportandthe
51
followingAgendaforChangesalarybandspsychologist(band8),physiotherapistandoccupationaltherapist(band6),nurse(band5)
(typicalsalarybandsidentifiedbyclinicalGDGmembers).

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8.2.1.3

Evidencestatements
Clinicalevidencestatements
Onestudy2of153participantsfoundthattherewasnosignificantdifferenceindelayedrecallAVLT
betweentheparticipantswhoreceivedmemoryselfefficiencytrainingandthosewhoreceivedusual
care(peersupport)(LOWCONFIDENCEINEFFECT).
Onestudy2of153participantsfoundthattherewasnosignificantdifferenceindelayedrecallRBMT
betweentheparticipantswhoreceivedmemoryselfefficiencytrainingandthosewhoreceivedusual
care(peersupport)(LOWCONFIDENCEINEFFECT).
Onestudy2of153participantsfoundthattherewasnosignificantdifferenceinQualityofLife
(EQ5D)betweentheparticipantswhoreceivedmemoryselfefficiencytrainingandthosewho
receivedusualcare(peersupport)(MODERATECONFIDENCEINEFFECT).
Onestudy2of153participantsfoundthatasignificantimprovementininmemoryselfefficacy
scoresbetweentheparticipantswhoreceivedmemoryselfefficacytrainingandthosewhoreceived
usualcare(peersupport)(LOWCONFIDENCEINEFFECT).
Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

8.2.2

Recommendationsandlinktoevidence
44.Assessmemoryandotherrelevantdomainsofcognitivefunctioning
(suchasexecutivefunctions)inpeopleafterstroke,particularlywhere
impairmentsinmemoryaffecteverydayactivity.
45.Useinterventionsformemoryandcognitivefunctionsafterstrokethat
focusontherelevantfunctionaltasks,takingintoaccountthe
underlyingimpairment.Interventionscouldinclude:
increasingawarenessofthememorydeficit
enhancinglearningusingerrorlesslearningandelaborative
techniques(makingassociations,useofmnemonics,internal
strategiesrelatedtoencodinginformationsuchaspreview,
question,read,state,test)
externalaids(forexample,diaries,lists,calendarsandalarms)
environmentalstrategies(routinesandenvironmentalprompts).
Recommendations:

Relativevalue
placedonthe
outcomes
considered

TheGDGconsideredthatrecallinginformationinthememoryofstrokepatients
afteradelaywasthemostimportantoutcomeforthisrecommendation.Theyalso
thoughtthatbeingabletoreflectbackonthingsthathappenedpreviouslywould
benefitgeneralwellbeingandthereforepositivelyaffectqualityoflifewhichwas
anotherreportedoutcome.

Tradeoffbetween
clinicalbenefitsand
harms

TheGDGagreedthatrehabilitationisaboutacquiringskillsregardlessofthetime
periodbetweentheonsetofstrokeandintroductionofanintervention.Memory
problemsmayhavelongtermimpactonavarietyoftasks,soassessmentsshould
reflectthisandinterventionsneedtobetailoredanddeliveredaccordingly.

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TheGDGnotedthatmemoryselfefficiencytraining(includingtrainingonstrategies
toaidretentionofinformation)didnotprovideconclusiveevidenceforageneral
memoryimprovement,whichconflictedwithexperiencefromclinicalpractice,
Economic
considerations

Nocosteffectivenessstudieswerefound.Personnelcostfordeliveringamemory
interventionprogrammewasestimatedat1999(inpatient)/1184(community)
basedonGDGestimatesoftheresourceuseinvolved.TheGDGconsideredthatvery
fewrehabilitationunitswouldhavecomputersoftwareavailablecurrently;therefore
thesewouldincuradditionalcosts.TheGDGconsideredthattheadditionalcosts
wouldpotentiallybeoffsetbythelongtermbenefittopatientsintermsofimproved
qualityoflife.

Qualityofevidence

TheGDGnotedthatoneofthetwostudies70consideredwasverysmallandhad
limitationsintermsofstudydesignandimprecisionaroundtheestimateofeffect.
Theotherstudy2wasmethodologicallybetterconductedandincludedovera
hundredparticipantswhohavehadastroke.However,itusedaparticular
frameworkwiththeaimtoincreasememoryefficiencyratherthanmemorycapacity
orabilitytousememoryineverydaysituations.
TheDoornhein70studyfoundthatteachingmnemonicstrategiesofassociationand
organisationwaslinkedtoimprovedperformanceinspecifictrainedmemorytasks,
butdidnottransfertoothertasks.TheAbenstudy(2012)2didfindanimprovement
inmemoryefficiency,butnogeneralimprovementindelayedrecall.Sincethe
interventionwasmemoryselfefficiencytrainingtheGDGfeltthatanimprovement
inthisabilityonitsownwasnotaveryconvincingresult.TheGDGconsideredthat
thetypeofmemorydomainsaddressedinthestudiesdidnotaddresstherangeof
memorydifficultiesthatmaybefacedbypatients.Rotelearninganddelayedrecallis
notnecessarilydirectlytranslatableintoimprovementsindailyfunctionalabilities.

Otherconsiderations TheGDGconsideredwellestablishedresearchonsimilarmemoryproblemsinother
neurologicalconditions,andinthesestudiesitwasfoundthatpatientsdobenefit
fromtheuseofsomecompensatorystrategies,suchastheuseofmnemonics,
diaries,lists,alarmsandemployingenvironmentalpromptsorfollowingacertain
routinetohelpwithmemorydeficit.Similarstrategiesshouldbetaughttopeople
whohavehadastrokewhereappropriate.Itisimportantinthisrespectthatthe
strategiesareadaptedtotheindividualslearningstyleandparticularimpairment
ratherthanhavingonegeneraltrainingscheduletofitall.
TheGDGagreedthatfurtherresearchisrequired.Thegroupagreedthatmemory
needstobeassessedandwherememoryimpactsoneverydayactivityinterventions
shouldbetargetedatthatactivity,takingintoaccounttheunderlyingmemory
problems.TheGDGnotedthatthesuccessofotherrehabilitativeinterventionsmay
becontingentonmemoryandthereforetheimpactofmemoryonfunctionis
importantandshouldnotbeunderestimated.

8.3 Attentionfunction
Attentionproblemscanoccurfollowingstrokeandarecommoninpeoplewithdamagetotheright
sideoftheirbrain.Itisbestdescribedasthesustainedfocusonsalientinformationwhilefilteringor
ignoringextraneousinformation.Attentionisaverybasicfunctionthatoftenisaprecursortoall
otherneurological/cognitivefunctions.Fivedifferenttypesofattentionhavebeendescribed
Focusedattention:Theabilitytoresponddiscretelytospecificvisual,auditoryortactile
stimuli.
Sustainedattention:Theabilitytomaintainaconsistentbehaviouralresponseduring
continuousandrepetitiveactivity.
Selectiveattention:Theabilitytomaintainabehaviouralorcognitivesetinthefaceof
distractingorcompetingstimuli.

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Alternatingattention:Theabilityofmentalflexibilitythatallowsindividualstoshifttheir
focusofattentionandmovebetweentaskshavingdifferentcognitiverequirements.
Dividedattention:Thisisthehighestlevelofattentionanditreferstotheabilitytorespond
simultaneouslytomultipletasksormultipletaskdemands.

Althoughthereissomespontaneousrecoveryofattentioninsomepatients,somesymptomsmay
persistforyears.Cognitiverehabilitationtrainingaimsatmanagingdifferentaspectsofattentionand
canimprovepeople'sabilitytoparticipateindailyactivity.
Workingmemoryandattentionarecloselyrelated.Workingmemoryisessentialindetermining
whereattentionshouldbedirected,filteringinformationandtheabilitytoinhibitcompetingstimuli;
thiscanbedescribedascontrolofattention.
peopleafterstrokewhatistheclinicalandcosteffectivenessofsustainedattentiontrainingversus
usualcaretoimproveattention?
ClinicalMethodologicalIntroduction

Population

Adultsandyoungpeople16orolderwhohavehadastroke.

Intervention

Computerisedtrainingprogrammeusingreactiontimesand
patternrecognition.

Comparison

Usualcare

Outcomes

Testofeverydayattention,

CognitivefailuresQuestionnaire
DisexecutiveQuestionnaire
EverydayMemoryQuestionnaire

8.3.1.1

Clinicalevidence
SearcheswereconductedforsystematicreviewsorRCTsthatcomparedsustainedattentiontraining
versususualcaretoimproveattentioninadultsoryoungpeople16orolderwhohavehadastroke.
Onlystudieswithaminimumsamplesizeof10participants(5ineacharm)andincludingatleast
50%ofparticipantswithstrokewereselected.TwoRCTswereidentified.Table45belowsummarises
thepopulation,interventionandoutcomesfortheincludedstudies.
Table45: Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixF.
STUDY

POPULATION

INTERVENTION

COMPARISON

OUTCOMES

Barker
Collo
200916

Acutestroke
survivorsadmitted
toNewZealand
hospitalswho
experiencedan
attentiondeficit
within2weekspost
stroke

Attentionprocesstraining
(APT):sustained,selective,
alternating,anddivided
attentiontraining(forexample
numbercancellationwith
visualdistractor,sustained
attentioninnoiseusingaudio
CDs,flexibleshape
cancellation,setdependent
alternatingattentiontasks)
administeredbyaregistered
clinicalneuropsychologist.

Standardcare
(notspecifiedin
thepaper).
(N=40)

IntegratedVisual
Auditory
Continuous
Performancetest
(IVACPT)
Fullattention,
Auditory
attention,
Visual
attention.

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StrokeRehabilitation
Cognitivefunctioning
STUDY

POPULATION

INTERVENTION
Participantsreceivedupto30
hoursofindividualAPTfor1
houronweekdaysfor4weeks
(mean13.5hours).(N=38)

COMPARISON

OUTCOMES

Westerber
g2007284

Participantsaged
3465ofvocational
activitywhohad
experiencedstroke
1236monthsago
andhadself
reporteddeficitsin
attention.

Computerisedworking
memorytraining:was
implementedwithacomputer
softwareproductusedat
homeforabout40minutes
/day,5days/weekfor5
weeks.Tasksinvolved
reproducingalightsequence
inavisuospatialgrid,
indicatingnumbersinreverse
order,identifyingletter
positionsinasequence,
identifyingalettersequencein
pseudowords,finding
mismatchedletters,etc.
Participantsreportedtheir
dailyresultsviainternettoa
serveratthehospital.
Feedbackfromapsychologist
providedviatelephoneoncea
week.
(N=9)

Usualcare:no
memorytraining
andnocontact
witha
psychologist.
(N=9)

WechslerAdult
Intelligence
Scale:
Spanboard
(measures
visuospatial
WM),
Digitspan
(measures
auditoryWM)
Strooptime
(sec)

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Stroopraw
score
Cognitive
failure
questionnaire
scores

StrokeRehabilitation
Cognitivefunctioning

Comparison:Cognitiverehabilitation(Sustainedattentiontraining)versususualcare
Table46: SustainedattentiontrainingversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings
Qualityassessment

No.of
studies

Design

Effect

Limitations

Inconsistency

Indirectness

Sustained
attention
training
Imprecision Mean(SD)

Usual
care
Mean
(SD)

Mean
differenc
e(95%
CI)

Mean
Differen
ce(MD)
(95%CI)

(a)

(a)

2.76
(1.31,
4.21)

MD2.76
higher
(1.31to
4.21
higher)

High

(a)

(a)

2.49
(1.24,
3.74)

MD2.49
higher
(1.24to
3.74
higher)

High

(a)

(a)

1.96
(0.49,
3.43)

MD1.96
higher
(0.49to
3.43
higher)

High

(a)

(a)

0.83(
0.46,
2.12)

MD0.83
higher
(0.46
lowerto

Moderate

Confidence
(ineffect)

IVACPT(fullattention)changes(5weeksfollowup)(Betterindicatedbyhighervalues)
1
RCTsingle
16
Barker2009 blinded

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

IVACPT(fullattention)changes(6monthsfollowup)(Betterindicatedbyhighervalues)
1
RCTsingle
Barker200916 blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

IVACPT(auditoryattention)changes(5weeksfollowup)(Betterindicatedbyhighervalues)
1
RCTsingle
Barker200916 blinded

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

IVACPT(auditoryattention)changes(6monthsfollowup)(Betterindicatedbyhighervalues)
1
RCTsingle
16
Barker2009 blinded

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b)

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StrokeRehabilitation
Cognitivefunctioning

Summaryoffindings
Qualityassessment

No.of
studies

Design

Effect

Limitations

Inconsistency

Indirectness

Sustained
attention
training
Imprecision Mean(SD)

Usual
care
Mean
(SD)

Mean
differenc
e(95%
CI)

Mean
Differen
ce(MD)
(95%CI)
2.12
higher)

(a)

(a)

1.56
(0.03,
3.09)

MD1.56
higher
(0.03to
3.09
higher)

High

(a)

(a)

1.41
(0.04,
2.78)

MD1.41
higher
(0.04to
2.78
higher)

High

Confidence
(ineffect)

IVACPT(visualattention)changes(5weeksfollowup)(Betterindicatedbyhighervalues)
1
RCTsingle
16
Barker2009 blinded

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

IVACPT(visualattention)changes(6monthsfollowup)(Betterindicatedbyhighervalues)
1
RCTsingle
16
Barker2009 blinded

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

(a)

Mean(SD)changesarenotgiveninthestudybygrouponlymeandifferenceswerereported.
ConfidenceintervalcrossedoneendofdefaultMID.

(b)

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Table47:ComputerizedworkingmemorytrainingversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings
Qualityassessment

Noofstudies

Design

Limitations

Inconsistency

Indirectness

Imprecision

Computerise
dworking
memory
training
Mean(SD)

Effect
Usual
care
Mean
(SD)

Mean
difference
(95%CI)

Mean
differenc
e(MD)
(95%CI)

Confidence(
ineffect)

WechslerAdultintelligenceScaleRevisedSpanboard(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Westerberg
2007284

RCT
unclear
blinding

Veryserious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b)

6.2(1.0)

5.7
(1.8)

0.50(0.85
to1.85)

MD0.50
higher
(0.85low
erto
1.85
higher)

Verylow

WechslerAdultIntelligenceScaleRevisedDigitSpan(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Westerberg
2007284

RCT
unclear
blinding

Veryserious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

7.3(1.0)

5.7
(1.3)

1.60(0.53
to2.67)

MD1.60
higher
(0.53to
2.67
higher)

Low

Strooptime(sec)(posttreatmenteffect)(Betterindicatedbylowervalues)
1
Westerberg
2007284

RCT
unclear
blinding

Veryserious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b)

93(19)

124
(48)

31(64.73
to2.73)

MD31
lower
(64.73
lowerto
2.73
higher)

Verylow

Serious

91.1(1.27)

97.8

1.30(0.47

MD1.30 Verylow

Strooprawscore(posttreatmenteffect)(Betterindicatedbyhighervalues)
1

RCT

Veryserious

Noserious

Noserious

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StrokeRehabilitation
Cognitivefunctioning

Summaryoffindings
Qualityassessment

Noofstudies

Design

Limitations

Inconsistency

Indirectness

Imprecision

Computerise
dworking
memory
training
Mean(SD)

Effect
Usual
care
Mean
(SD)

WechslerAdultintelligenceScaleRevisedSpanboard(posttreatmenteffect)(Betterindicatedbyhighervalues)
unclear limitations
inconsistency
indirectness
imprecision
(2.4)
Westerberg
blinding (a)
(b)
2007284

Mean
difference
(95%CI)

Mean
differenc
e(MD)
(95%CI)

Confidence(
ineffect)

to3.07)

lower
(0.47
lowerto
3.07
higher)

13.8(
25.79to
1.81)

MD13.8 Verylow
lower
(25.79
lowerto
1.81
lower)

CognitiveFailureQuestionnaire(CFQscalerangingfrom0100,posttreatmenteffect)(betterindicatedbylowervalues)
1
Westerberg
2007284

RCT
unclear
blinding

Veryserious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b)

29.2(12.1)

43
(13.8)

(a)

Nodetailsonrandomisation.Unclearallocationconcealmentandblinding.
ConfidenceintervalcrossedoneendofdefaultMID(0.5ofthestandardmeandifference).

(b)

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8.3.1.2

Economicevidence
Literaturereview
Norelevanteconomicevaluationscomparingcognitiverehabilitationsustainedattentiontraining
withusualcaretoimproveattentionwereidentified.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
TheGDGadvisedtoestimateinterventioncostsbasedontheresourcesdescribedinBarker,200916
TheestimatedcostofthesoftwaretoperformanunlimitednumberofIntegratedVisualAuditory
ContinuousPerformanceTests(IVACPT)was1244kexcludingVAT(obtainedfromwww.bio
medical.com26).Personnelcosts,incrementaloverusualcare,areoutlinedinTable48.
Table48: InterventioncostspersonnelcostsassociatedwithIVACPT
Resources

Frequency

Unitcosts

Costperpatient
(b)

Baseline
neuropsychological
assessment(a)

2.5hours
repeatedat5
weeksand6
months

136perhour

1,020

IndividualAttention
ProcessTraining
(APT)sessions(a)

30hours

136perhour(b)

4,080

Totalpersonnelcost
(incrementalover
usualcare)

5,100

(a) Deliveredbyaneuropsychologist
(b) Clinicalpsychologistcostsusedascostsforaneuropsychologistcouldnotbeobtained.Estimatedbasedondataandmethodsfrom
51
PersonalSocialServicesResearchUnitUnitcostsofhealthandsocialcarereportandAgendaforChangesalaryband8 (typical
salarybandidentifiedbyclinicalGDGmembers).

8.3.1.3

Evidencestatements
Clinicalevidencestatements
Onestudy16of78participantsfoundthosewhoreceivedthesustainedattentiontraining
experiencedastatisticallysignificantimprovementinfullattentionmeasuredbytheIntegrated
VisualAuditoryContinuousPerformancetest(IVACPT)at5weeksand6monthsfollowup
comparedtothosewhoreceivedusualcare(HIGHCONFIDENCEINEFFECT).
Onestudy16of78participantsfoundthosewhoreceivedthesustainedattentiontraining
experiencedastatisticallysignificantimprovementinauditoryattentionmeasuredbytheIntegrated
VisualAuditoryContinuousPerformancetest(IVACPT)at5weeksfollowupcomparedtothosewho
receivedusualcare(HIGHCONFIDENCEINEFFECT).

k US$1895(2011)convertedtoUKpounds(2010)usingpurchasingpowerparities194

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StrokeRehabilitation
Cognitivefunctioning
Onestudy16of78participantsfoundtherewasnosignificantdifferenceontheauditoryattention
measuredbytheIntegratedVisualAuditoryContinuousPerformancetest(IVACPT)at6months
betweenparticipantswhoreceivedthesustainedattentiontrainingandthosewhoreceivedusual
care(MODERATECONFIDENCEINEFFECT).
Onestudy16of78participantsfoundthosewhoreceivedthesustainedattentiontraining
experiencedastatisticallysignificantimprovementinvisualattentionmeasuredbytheIntegrated
VisualAuditoryContinuousPerformancetest(IVACPT)at5weeksand6monthsfollowup
comparedtothosewhoreceivedusualcare(HIGHCONFIDENCEINEFFECT).
Onestudy284of18participantsfoundthattherewasnosignificantdifferenceinWechslerAdult
intelligenceScaleRevisedWAISRSpanBoardtestbetweentheparticipantswhoreceived
computerisedmemorytrainingandthosewhoreceivedusualcare(VERYLOWCONFIDENCEIN
EFFECT).
Onestudy284of18participantsfoundthatthosewhoreceivedcomputerisedmemorytraininghada
statisticallysignificantimprovementinWechslerAdultintelligenceScaleRevisedWAISRdigitspan
test,comparedwiththeparticipantswhoreceivedusualcare.(LOWCONFIDENCEINEFFECT)
Onestudy284of18participantsfoundthattherewasnosignificantdifferencethetimetakento
completetheSTROOPtask(sec)betweentheparticipantswhoreceivedcomputerisedmemory
trainingandthosewhoreceivedusualcare(VERYLOWCONFIDENCEINEFFECT).
Onestudy284of18participantsfoundthattherewasnosignificantdifferencenumberofSTROOP
itemscorrectlynamedbetweentheparticipantswhoreceivedcomputerisedmemorytrainingand
thosewhoreceivedusualcare(VERYLOWCONFIDENCEINEFFECT).
Onestudy284of18participantsfoundthatthosewhoreceivedcomputerisedmemorytraininghada
statisticallysignificantimprovementinthescoreofaCognitiveFailureQuestionnaire(CFQ),
comparedwiththeparticipantswhoreceivedusualcare.(VERYLOWCONFIDENCEINEFFECT)
Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

8.3.2

Recommendationsandlinktoevidence
46.Assessattentionandcognitivefunctionsinpeopleafterstrokeusing
standardisedassessments.Usebehaviouralobservationtoevaluate
theimpactoftheimpairmentonfunctionaltasks.
47.Considerattentiontrainingforpeoplewithattentiondeficitsafter
stroke.
48.Useinterventionsforattentionandcognitivefunctionsafterstroke
thatfocusontherelevantfunctionaltasks.Forexample,usegeneric
techniquessuchasmanagingtheenvironmentandprovidingprompts
relevanttothefunctionaltask.
Recommendations
Relativevalueplaced
ontheoutcomes
considered

TheoutcomesincludedinthereviewweretheIntegratedVisualAuditory
ContinuousPerformancetest(IVACPT):fullattention,auditoryattention,visual
attentionandWechslerAdultIntelligenceScaleofdigitspanaswellas
performanceontheSTROOPtaskandscoresonthecognitivefailurequestionnaire.

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StrokeRehabilitation
Cognitivefunctioning

Thetestsusedwereneuropsychologicalmeasuresofattentionandeventhough
thecognitivefailuresquestionnaireisaimedattestingmorefunctionalabilities
(suchaseverydaysituationsattendingtonames,andfocusingontasks)thevalidity
ofthismeasurewasquestioned.TheSTROOPtaskwasseenasagoodmeasureof
attentionalcapabilitiessinceitrequiresparticipantstofocusonparticularfeatures
whilstdisregardingotheraspects.Thisisanabilitythatcanbedirectlytranslatedto
morefunctionalperformancesuchasfocusingonataskinlightofother
distractions
Tradeoffbetween
clinicalbenefitsand
harms

AttentionimpairmentwasdefinedinthestudybyBarker16asperformanceless
than1standarddeviationbelowthenormativemeanonanytest.Inthesecond
includedstudy284attention/memoryproblemswerebasedonselfreportonlyand
thestudymethodologywaspoorlydescribed.ItwasagreedbytheGDGthat
assessmentsofcognitiveimpairmentsmaynotbeclinicallyrelevant,andattention
basedinterventionsshouldbeprovidedwhenthepersonwithstrokeortheir
carersidentifydifficultiesattributabletoattentiondifficulties.Thegroupagreed
thatarecommendationforspecificinterventionscouldnotbemadebasedon
thesetwostudies,butrecognisedthatinclinicalpracticetimewouldbespentwith
patientstoimproveattentiondeficits.Furtherresearchisrequired.

Economic
considerations

Nocosteffectivenessstudieswerefound.ThecostoftheIVACPTsoftwareto
delivertheinterventionusedinthestudyidentifiedfortheclinicalreviewwas
estimatedat1244.Inaddition,personnelcostswereestimatedat5,100per
personbasedonresourcesusedintheBarker,200916study.Giventhehighcostof
thisspecificinterventionandthelimitedevidenceofitsclinicaleffectiveness,the
evidencewasconsideredinsufficienttoconcludethatitwouldbecosteffective.

Qualityofevidence

Onewellconductedrandomisedcontrolledtrial16foundthatattentionprocess
trainingwasassociatedwithgreaterimprovementinattentionasmeasuredonthe
IVACPTvisualscaleandFullScaleAttentionQuotientat5weeksand6months
followup.
TheWesterberg284studyfoundthatacomputerisedworkingmemorytraining
programmeimprovedworkingmemorywhenmeasuredwiththeWechslerAdult
IntelligenceScaleRevisedDigitSpan(anauditorytestofworkingmemory),but
hadnoeffectwhenmeasuredbytheWechslerAdultIntelligenceScaleRevised
Spanboard(avisuospatialtestofworkingmemory).Bothofthesetestsrequire
attentionalcognitiveresources.Itwasnotedthatthetimescaleaddressedinthe
Westerbergstudyis20monthsaftertheonsetofstrokeandtheimpactofthe
interventionmaydifferifundertakeninthesubacutestage.Noimprovementwas
seenonSTROOPperformance.However,theinterventionresultedinfewer
cognitivefailuresasmeasuredbyselfreport.Thequalityoftheevidenceforthese
outcomeswaslowtoverylowandthereforewedonothaveconfidenceinthe
effectsreportedbythisstudy.

TheGDGagreedthatusualcarewouldnormallyconsistofabaselineassessment
(similartotheonereportedbyBarker,2009)butofshorterweekday
neuropsychologicalsessionsthanthosereportedinthestudywhichwere
describedasonehourperweekdayforfourweeks.TheGDGnotedthatall
interventionshaveabaselineassessmentbutthecontentoftheassessmentvaries.
TheGDGfeltthatcurrentlycomputerbasedrehabilitationmaynotbeavailable
everywhere,howeverwithincreasingfamiliarityandaccessofthepopulationto
personalcomputersthiswouldchange.Thelimitedevidencefoundindicatesthe
needforfurtherresearchtobeundertaken.

Otherconsiderations

Eventhoughevidencefromonestudycanberatedashigh,theGDGconsidered
thatthiswouldneedtobereplicatedtodemonstratearobusteffect.However,
problemswithattentionhaveseriouseffectsonselfesteemandqualityoflifein
generalandarequiteupsettingforpersonswhohavehadastrokeandtheircarers
/family.Inparticularitaffectsfunctionalperformanceineverydaysituations,such

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StrokeRehabilitation
Cognitivefunctioning
asthefocusontasksthatareimportantwhilstignoringdistractionfromother
environmentalfactors.Itwasthereforeseenasimportanttoassesspossible
impairmentsandadoptanindividualisedapproachtohelpthepersonto
participatemoreconfidentlyinactivitiesofdailyliving.

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StrokeRehabilitation
Emotionalfunctioning

9 Emotionalfunctioning
9.1 Psychologicaltherapies
Psychologicaltherapiesmaybecharacterisedasanapproachwhichinvolvesaconfidingrelationship,
thattakesplacewithinatherapeuticsetting,withatheoreticalbasis(anunderstandingofmodelsof
normalandabnormalbehaviour)involvingatherapeuticprocesswhichagainhasanunderpinning
theoreticalmodel.Therapycanbedeliveredtoanindividual,acouple,afamilyoragroup.
Manypeoplewhohavehadastrokeexperiencedistresswhichcanimpactnegativelyonfunctional
outcome.Inaddition,notonlyarethephysicalconsequencesofstrokeassociatedwithemotional
disorders,thecognitiveaspectsofstrokemayalsoimpactontheirabilitytodealwiththeemotional
consequencesofthestroke.
Psychologicaltherapiesmaybeusefulforindividualswithstroke.Theseinterventionsemphasisethe
individual'sownresidualstrengths,clarifythepatient'sconcernsandteachnewstrategiesforcoping
effectivelyandmanagingdistress.Itisoftenusefultodrawuponavarietyofpsychologicalmodels
(forexampleBehaviourtherapy,cognitivebehaviourtherapyandalsotheoriesofchange)depending
ontheindividual'spresentation.
Psychologicaltherapiesmayhelptheindividualandtheircarerswithpoststrokeemotionaldisorders
andrelationshipissues.Psychologicalinterventionsofthistypemayalsobeneededtofacilitatean
individualandcarersunderstandingandadjustmenttocognitiveimpairments,communication
impairmentsortophysicaldisabilities.Itiscriticaltonotethattheimpactofphysical,cognitiveand
emotionaldifficultiesarelikelytooverlap;thereforethedeliveryofanystandardintervention(for
example,cognitivebehaviourtherapy)islikelytoneedadaptationtosuitanindividualscognitive
and/orphysicalpresentation.WithintheNHS,psychologicaltherapiesareprovidedbymembersof
differentprofessionaldisciplines,includingclinicalneuropsychologists,clinicalpsychologists,
speciallytrainedmentalhealthnurses,occupationaltherapistsandcounsellors.Inthecontextof
stroke,wherepatientshaveimpairmentswhichimpactontheirabilitytoparticipateinpsychological
treatments,itisimportantthatthetherapistunderstandsthenatureandimpactoftheimpairments
andhowtheyinteract.

9.1.1

Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessof
psychologicaltherapiesprovidedtothefamily(includingthepatient)?
ClinicalMethodologicalIntroduction

Population:

Familycarers(familymemberorrelative,orotherunpaidcarer
support)ofpeoplewithstroketoincludeadultsandyoung
peopleover16withstroke

Intervention

FamilyTherapy
CognitiveBehaviourTherapy
Relationshipcounselling(toincludeCouplestherapy)
(allinterventionsmayincludesomeformofinformation)

Comparison:

Usualcare(usuallynothing)

Outcomes:

QualityofLife(forbothcarerandpatient)
AnyQOLanddepressionoutcomesincludingthefollowing:
strokeimpactscale,EuroQoL,caregiverburdenscale,caregiver
strainindex,carerstrainindex,burdenofstrokescale,Stroke
andaphasiaqualityoflifescale,ASCOTscale.

Occurrenceofdepression/anxiety/moodincarers

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StrokeRehabilitation
Emotionalfunctioning
ClinicalMethodologicalIntroduction

9.1.1.1

BeckDepressionInventory,BeckDepressionInventory2,
GeriatricDepressionScale,neuropsychiatryinventory,Hospital
AnxietyandDepressionScale(HADS),Generalhealth
questionnaire,VisualAnalogueMoodScale,SADQ.

Clinicalevidence
SearcheswereconductedforsystematicreviewsandRCTsorsystematicreviewsofobservational
studiescomparingpsychologicaltherapieswithusualcaretoimprovequalityoflifeforbothcarer
andstrokepatientsolderthan16yearsold.OneRCTwasidentifiedthatmettheprespecified
protocol.Table40summarisesthestudycharacteristicsoftheincludedstudy.
Table49: Summaryofthestudyincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
STUDY
242

Smith2012

POPULATION

INTERVENTION

COMPARISON

Participantswere
marriedcouples:female
caregiver(CGs)andher
husbandwhohashada
stroke(PWS).Eitherthe
caregiverorher
husbandhadtoscore
fiveormoreonthe
PersonalHealth
Questionnaire(PHQ9:
atleastmild
depression).
Participantswere
excludediftheywere
medicallyunstableor
terminallyillandifthey
werecognitivelyunable
toparticipate.

Theinterventionwas
basedontheStress
ProcessModel.It
consistedofan
onlinesupport
programoffive
components
designedtoprovide
thecaregiverswith
knowledgeresources
andskillstohelp
boththemselvesand
theirpartnerto
reducetheir
personaldistressand
toprovideoptimal
emotionalcareto
thePWS.Attempts
wererepeatedly
madeto
acknowledgethe
positiveandnegative
feelingsofboth
membersoftheCG
PWSdyad,aswellas
toillustratehow
theywere
intertwined.CGs
wereencouragedto
interactwithPWSin
waystoenhance
theirmutualwell
being.

CGPWSdyads Centrefor
hadaccesstothe
Epidemiologic
onlineresource
alStudies
centre,buthad
Depression
noexposureto
scale(CESD)
thekey
MasteryScale
intervention
(ameasureto
components.
assesscoping
ability)
SelfEsteem
scale,
Medical
Outcomes
Study(MOS)
SocialSupport
survey
(measuring
amountof
emotional,
informational
and
affectionate
support).

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OUTCOMES

StrokeRehabilitation
Emotionalfunctioning

Comparisonpsychologicaltherapiesvs.controltoimprovemoodincaregiversandpersonswithstroke
Table50: Webbasedpsychologicaltherapyvs.controloutcomesforCAREGIVERS(WIVES)only(baselineadjustedmeans(sd))
SummaryofFindings
Qualityassessment

Effect

Noof
studies

Relati
ve
Risk/
Mean
differe
nce/
(95%
CI)

Design

Riskof
bias

Inconsistency

Indirectness

Imprecisio
n

Webbased
psychological
intervention
Frequency(%)/mean
(SD)/median(range)

Control
Frequency(%)/
mean(SD)/
median(range)

Absoluteeffector
meandifference
(MD)
(95%CI)

Confid
ence
(in
effect)

CentreforEpidemiologicalStudiesDepressionscale(CESD)Posttest(followup11weeks;rangeofscores:060;Betterindicatedbylowervalues)
1
Smith
2012242

randomise
dtrials

serious
(a)

noserious
inconsistency

noserious
indirectness

serious(b)

13.9(7.7)

19.7(7.4)

5.8(
11.07
to
0.53)

MD5.8lower
(11.07to0.53
lower)

LOW

CentreforEpidemiologicalStudiesDepressionscale(CESD)1monthfollowup(rangeofscores:060;Betterindicatedbylowervalues)
1
Smith
2012242

randomise
dtrials

serious
(a)

noserious
inconsistency

noserious
indirectness

serious(b)

13.4(6.2)

16.6(6.2)

3.2(
7.5to
1.1)

MD3.2lower(7.5
lowerto1.1
higher)

LOW

23.6(2.5)

0.6(
1.21
to
2.41)

MD0.6higher
(1.21lowerto
2.41higher)

LOW

24.4(2.1)

0.3(
1.69
to

MD0.3lower
(1.69lowerto
1.09higher)

VERY
LOW

MasteryScalePosttest(followup11weeks;rangeofscores:936;Betterindicatedbyhighervalues)
1
Smith
2012242

randomise
dtrials

serious
(a)

noserious
inconsistency

noserious
indirectness

serious(b)

24.2(2.7)

MasteryScale1monthfollowup(rangeofscores:936;Betterindicatedbyhighervalues)
1
Smith
2012242

randomise
dtrials

serious
(a)

noserious
inconsistency

noserious
indirectness

very
serious(b)

24.1(1.9)

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StrokeRehabilitation
Emotionalfunctioning

SummaryofFindings
Qualityassessment

Noof
studies

Design

Effect

Riskof
bias

Inconsistency

Indirectness

Imprecisio
n

Webbased
psychological
intervention
Frequency(%)/mean
(SD)/median(range)

Control
Frequency(%)/
mean(SD)/
median(range)

Relati
ve
Risk/
Mean
differe
nce/
(95%
CI)
1.09)

Absoluteeffector
meandifference
(MD)
(95%CI)

Confid
ence
(in
effect)

SelfesteemscalePosttest(followup11weeks;rangeofscores:1040;Betterindicatedbyhighervalues)
1
Smith
2012242

randomise
dtrials

serious
(a)

noserious
inconsistency

noserious
indirectness

very
serious(c)

31.6(2.3)

31.9(2.5)

0.3(
1.96
to
1.36)

MD0.3lower
(1.96lowerto
1.36higher)

VERY
LOW

32.6(2.9)

1.5(
3.44
to
0.44)

MD1.5lower
(3.44lowerto
0.44higher)

LOW

Selfesteemscale1monthfollowup(rangeofscores:1040;Betterindicatedbyhighervalues)
1
Smith
2012242

randomise
dtrials

serious
(a)

noserious
inconsistency

noserious
indirectness

serious(b)

31.1(2.7)

MedicalOutcomesStudy(MOS)SocialSupportsurveyPosttest(followup11weeks;rangeofscores:1155;Betterindicatedbyhighervalues)
1
Smith
2012242

randomise
dtrials

serious
(a)

noserious
inconsistency

noserious
indirectness

very
serious(c)

37(6.6)

37(6.6)

0(
4.58
to
4.58)

MD0higher(4.58
lowerto4.58
higher)

VERY
LOW

MD2.5lower(6.8
lowerto1.8
higher)

VERY
LOW

MedicalOutcomesStudy(MOS)SocialSupportsurvey1monthfollowup(rangeofscores:1155;Betterindicatedbyhighervalues)
1
Smith
2012242

randomise
dtrials

serious
(a)

noserious
inconsistency

noserious
indirectness

very
serious(c)

33.8(6.2)

36.3(6.2)

2.5(
6.8to
1.8)

(a)

Allocationconcealmentisunclearandtherearebaselinedifferences(whichwouldunderestimateeffectsofintervention)andnoparticipantblinding.

(b)

TheconfidenceintervalcrossesonedefaultMID

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StrokeRehabilitation
Emotionalfunctioning

(c)

TheconfidenceintervaloftheoveralleffectcrossesthedefaultMIDfavouringtheinterventionandthedefaultMIDfavouringthecontrolgroup

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StrokeRehabilitation
Emotionalfunctioning

Table51: Webbasedpsychologicaltherapyvs.controloutcomesforPERSONSWITHSTROKE(HUSBANDS)only(baselineadjustedmeans(sd))
SummaryofFindings
Qualityassessment

Noof
studie
s

Design

Effect

Riskof
bias

Inconsistency

Indirectness

Imprecisio
n

Webbasedpsychological
interventionFrequency(%)/
mean(SD)/median(range)

control
Frequency
(%)/mean
(SD)/
median
(range)

Absolute
effector
RelativeRisk mean
/Mean
difference
difference/
(MD)(95%
(95%CI)
CI)

Confid
ence
in
effect

CentreforEpidemiologicalStudiesDepressionscale(CESD)Posttest(followup11weeks;rangeofscores:060;Betterindicatedbylowervalues)
1
Smith
201224
2

randomise
dtrials

serious
(a)

noserious
inconsistency

noserious
indirectness

very
serious(b)

19.5(8.5)

20.4(8.7)

0.9(6.86to MD0.9lower
5.06)
(6.86lower
VERY
to5.06
LOW
higher)

CentreforEpidemiologicalStudiesDepressionscale(CESD)1monthfollowup(rangeofscores:060;Betterindicatedbylowervalues)
1
Smith
201224
2

randomise
dtrials

serious
(a)

noserious
inconsistency

noserious
indirectness

serious(c)

14(8.1)

17.9(7.8)

3.9(9.45to MD3.9lower
1.65)
(9.45lower
LOW
to1.65
higher)

22.8(4.9)

1.2(4.53to MD1.2lower
2.13)
(4.53lower
LOW
to2.13
higher)

24.4(4.5)

0.2(2.85to MD0.2
3.25)
higher(2.85
lowerto3.25
higher)

VERY
LOW

27.7(3.7)

1(3.64to

MasteryScalePosttest(followup11weeks;rangeofscores:936;Betterindicatedbyhighervalues)
1
Smith
201224
2

randomise
dtrials

serious
(a)

noserious
inconsistency

noserious
indirectness

serious(c)

21.6(4.6)

MasteryScale1monthfollowup(rangeofscores:936;Betterindicatedbyhighervalues)
1
Smith
201224
2

randomise
dtrials

serious
(a)

noserious
inconsistency

noserious
indirectness

very
serious(b)

24.6(4.3)

SelfesteemscalePosttest(followup11weeks;rangeofscores:1040;Betterindicatedbyhighervalues)
1

randomise

serious

noserious

noserious

serious(c)

26.7(3.9)

NationalClinicalGuidelineCentre,2013.

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MD1lower

StrokeRehabilitation
Emotionalfunctioning

SummaryofFindings
Qualityassessment

Noof
studie
s
Smith
201224
2

Design
dtrials

Effect

Riskof
bias
(a)

Inconsistency
inconsistency

Indirectness
indirectness

Imprecisio
n

Webbasedpsychological
interventionFrequency(%)/
mean(SD)/median(range)

control
Frequency
(%)/mean
(SD)/
median
(range)

Absolute
effector
RelativeRisk mean
/Mean
difference
difference/
(MD)(95%
(95%CI)
CI)
1.64)
(3.64lower
to1.64
higher)

Confid
ence
in
effect
LOW

27.2(4.9)

1.3(2.03to
4.63)

MD1.3
higher(2.03
lowerto4.63
higher)

LOW

MD0.5
higher(4.08
lowerto5.08
higher)

VERY
LOW

Selfesteemscale1monthfollowup(rangeofscores:1040;Betterindicatedbyhighervalues)
1
Smith
201224
2

randomise
dtrials

serious
(a)

noserious
inconsistency

noserious
indirectness

serious(c)

28.5(4.6)

MedicalOutcomesStudy(MOS)SocialSupportsurveyPosttest(followup11weeks;rangeofscores:1155;Betterindicatedbyhighervalues)
1
Smith
201224
2

randomise
dtrials

serious
(a)

noserious
inconsistency

noserious
indirectness

very
serious(b)

41.5(6.6)

41(6.6)

0.5(4.08to
5.08)

MedicalOutcomesStudy(MOS)SocialSupportsurvey1monthfollowup(rangeofscores:1155;Betterindicatedbyhighervalues)
1
Smith
201224
2

(a)

randomise
dtrials

serious
(a)

noserious
inconsistency

noserious
indirectness

very
serious(b)

43.2(4.6)

44(4.9)

0.8(4.13to MD0.8lower
2.53)
(4.13lower
VERY
to2.53
LOW
higher)

Allocationconcealmentisunclearandtherearebaselinedifferences(whichwouldunderestimateeffectsofintervention)andnoparticipantblinding.

(b)

TheconfidenceintervaloftheoveralleffectcrossesthedefaultMIDfavouringtheinterventionandthedefaultMIDfavouringthecontrolgroup

(c)

TheconfidenceintervalcrossesonedefaultMID

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9.1.1.2

Economicevidence
Literaturereview
Norelevanteconomicevaluationscomparingpsychologicaltherapiesforthefamilywithusualcare
wereidentified.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
Beforedeliveringthepsychologicaltherapyformoodtothepatient,somescreeningswouldbe
requirestoassessthepatientsneuropsychologicalprofile.Abriefscreeningofcognitionand
communicationcoulddetermineifthereareanygrossissueswhichmightformbarrierstoeffective
participationintherapy.Iftherearenone,psychologicaltherapiescouldbestartedrightaway.
Whereissuesareindicatedwithcognition,communicationorbehaviour,atalevelthatmayaffect
deliveryofandengagementtotherapy,additionalneuropsychologicalassessmentwouldberequired
toassessthepatientscapabilitiesandcapacityforparticipatinginpsychologicaltherapyandto
provideabasisforanypossibleadaptationstotherapy.
Theinitialneuropsychologicalassessmenttestkitvariesandwouldcomeinatapproximatelyoneoff
costof2000to3000dependingonwhichtestsarepurchasedasthisisusuallydowntothe
cliniciansdiscretionandthisisusuallyupdatedannuallyforaoneoffcostof500.Assessmentsare
carriedoutbyaBand8clinicianandcouldtakebetween24hours.Theestimatedcostperhourof
clientcontactforacommunitybasedclinicalpsychologist(Band8a)is136l;thereforethe
assessmentcostwouldbebetween272and544perpatient.
Thepsychologicaltherapyformoodforthepatientusuallyinvolvesanindirectconsultationwiththe
multidisciplinaryteamandfamilyanddirectclinicalconsultationwiththepersonwhohashada
stroke.(Ifaclinicalconsultationisneeded,thepackageoftherapywouldbenegotiatedwiththe
patient)
Bothassessmentandtherapyinputvaryaccordingtothepatientsneed.Asaballparkfigureupto12
sessionsofpsychologicaltherapymaybeofferedtostrokepatientsfordepression;usuallyone
sessioniscarriedoutperweekandeachsessionwouldtakebetween45minutesandonehour.The
estimatedcostperhourofclientcontactforclinicalpsychologist(band8a)is136m.Thetotal
averagecostoftherapywouldbe1,224perpatient.
Intheeventthatthepsychologistidentifiesmoresignificantmooddisorderforwhichpsychological
therapyisnotappropriate,pharmacologicaltreatmentandtheneuropsychiatricinputwouldbe
requiredforbothassessmentandprescriptionofpharmacologicaltherapy.

9.1.1.3

Evidencestatements
Researchintopsychologicaltherapyforthisgroupofpatientsiswellknowntobeverydifficultandin
itsrelativeinfancyandthereforetheevidencepoolisverylimited.

l EstimatedbasedondataandmethodsfromPersonalSocialServicesResearchUnitUnitcostsofhealthandsocialcare
reportandAgendaforChangesalaryband8a51(typicalsalarybandidentifiedbyclinicalGDGmembers).
m EstimatedbasedondataandmethodsfromPersonalSocialServicesResearchUnitUnitcostsofhealthandsocialcare
reportandAgendaforChangesalaryband8a51(typicalsalarybandidentifiedbyclinicalGDGmembers).

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StrokeRehabilitation
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Clinicalevidencestatements
Forcaregivers:
Onestudy242comprising32pairsoffemalecaregiversandtheirhusbandsfoundthatcaregivers
depression,asmeasuredbytheCentreforEpidemiologicalStudiesDepressionscale(CESD),
statisticallyimprovedwhentheyreceivedanonlinepsychologicalinterventioncomparedtothosein
thecontrolconditionattheendofthe11weekinterventionperiod(LOWCONFIDENCEINEFFECT)
Onestudy242comprising32pairsoffemalecaregiversandtheirhusbandsfoundthattherewasno
significantimprovementincaregiversdepression,asmeasuredbytheCentreforEpidemiological
StudiesDepressionscale(CESD),whentheyreceivedanonlinepsychologicalinterventioncompared
tothoseinthecontrolconditionat1monthfollowupaftertheendofintervention(LOW
CONFIDENCEINEFFECT)
Onestudy242comprising32pairsoffemalecaregiversandtheirhusbandsfoundthattherewasno
significantimprovementincaregiverslevelofcoping,asmeasuredbytheMasteryScale,whenthey
receivedanonlinepsychologicalinterventioncomparedtothoseinthecontrolconditionattheend
ofthe11weekinterventionperiod(LOWCONFIDENCEINEFFECT)
Onestudy242comprising32pairsoffemalecaregiversandtheirhusbandsfoundthattherewasno
significantimprovementincaregiverslevelofcoping,asmeasuredbytheMasteryScale,whenthey
receivedanonlinepsychologicalinterventioncomparedtothoseinthecontrolconditionat1month
followupaftertheendofintervention(VERYLOWCONFIDENCEINEFFECT)
Onestudy242comprising32pairsoffemalecaregiversandtheirhusbandsfoundthattherewasno
significantimprovementincaregiverslevelofselfesteem,whentheyreceivedanonline
psychologicalintervention,comparedtothoseinthecontrolconditionattheendofthe11week
interventionperiod(VERYLOWCONFIDENCEINEFFECT)
Onestudy242comprising32pairsoffemalecaregiversandtheirhusbandsfoundthattherewasno
significantimprovementincaregiverslevelofselfesteem,whentheyreceivedanonline
psychologicalinterventioncomparedtothoseinthecontrolconditionat1monthfollowupafterthe
endofintervention(LOWCONFIDENCEINEFFECT)
Onestudy242comprising32pairsoffemalecaregiversandtheirhusbandsfoundthattherewasno
significantimprovementincaregiverslevelofsocialsupportskills,whentheyreceivedanonline
psychologicalintervention,comparedtothoseinthecontrolconditionattheendofthe11week
interventionperiod(VERYLOWCONFIDENCEINEFFECT)
Onestudy242comprising32pairsoffemalecaregiversandtheirhusbandsfoundthattherewasno
significantimprovementincaregiverslevelofsocialsupportskills,whentheyreceivedanonline
psychologicalinterventioncomparedtothoseinthecontrolconditionat1monthfollowupafter
theendofintervention(LOWCONFIDENCEINEFFECT)
Forthepersonwhohashadastroke:
Onestudy242comprising32pairsoffemalecaregiversandtheirhusbandsfoundthattherewasno
significantimprovementinthelevelofdepressionofthepersonwhohashadastroke,asmeasured
bytheCentreforEpidemiologicalStudiesDepressionscale(CESD)whentheyreceivedanonline
psychologicalinterventioncomparedtothoseinthecontrolconditionattheendofthe11week
interventionperiod(VERYLOWCONFIDENCEINEFFECT)
Onestudy242comprising32pairsoffemalecaregiversandtheirhusbandsfoundthattherewasno
significantimprovementinthelevelofdepressionofthepersonwhohashadastroke,asmeasured
bytheCentreforEpidemiologicalStudiesDepressionscale(CESD),whentheyreceivedanonline

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StrokeRehabilitation
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psychologicalinterventioncomparedtothoseinthecontrolconditionat1monthfollowupafterthe
endofintervention(LOWCONFIDENCEINEFFECT)
Onestudy242comprising32pairsoffemalecaregiversandtheirhusbandsfoundthattherewasno
significantimprovementinthelevelofcopingofthepersonwhohashadastroke,asmeasuredby
theMasteryScale,whentheyreceivedanonlinepsychologicalinterventioncomparedtothoseinthe
controlconditionattheendofthe11weekinterventionperiod(LOWCONFIDENCEINEFFECT)
Onestudy242comprising32pairsoffemalecaregiversandtheirhusbandsfoundthattherewasno
significantimprovementinthelevelofcopingofthepersonwhohashadastroke,asmeasuredby
theMasteryScale,whentheyreceivedanonlinepsychologicalinterventioncomparedtothoseinthe
controlconditionat1monthfollowupaftertheendofintervention(VERYLOWCONFIDENCEIN
EFFECT)
Onestudy242comprising32pairsoffemalecaregiversandtheirhusbandsfoundthattherewasno
significantimprovementinthelevelofselfesteemofthepersonwhohashadastroke,whenthey
receivedanonlinepsychologicalintervention,comparedtothoseinthecontrolconditionattheend
ofthe11weekinterventionperiod(LOWCONFIDENCEINEFFECT)
Onestudy242comprising32pairsoffemalecaregiversandtheirhusbandsfoundthattherewasno
significantimprovementinthelevelofselfesteemofthepersonwhohashadastroke,whenthey
receivedanonlinepsychologicalinterventioncomparedtothoseinthecontrolconditionat1month
followupaftertheendofintervention(LOWCONFIDENCEINEFFECT)
Onestudy242comprising32pairsoffemalecaregiversandtheirhusbandsfoundthattherewasno
significantimprovementinthelevelofsocialsupportskillsofthepersonwhohashadastroke,when
theyreceivedanonlinepsychologicalintervention,comparedtothoseinthecontrolconditionatthe
endofthe11weekinterventionperiod(VERYLOWCONFIDENCEINEFFECT)
Onestudy242comprising32pairsoffemalecaregiversandtheirhusbandsfoundthattherewasno
significantimprovementinthelevelofsocialsupportskillsofthepersonwhohashadastroke,when
theyreceivedanonlinepsychologicalinterventioncomparedtothoseinthecontrolconditionat1
monthfollowupaftertheendofintervention(VERYLOWCONFIDENCEINEFFECT)
Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

9.1.2

Recommendationsandlinktoevidence
49.Assessemotionalfunctioninginthecontextofcognitivedifficulties
inpeopleafterstroke.Anyinterventionchosenshouldtakeinto
considerationthetypeorcomplexityofthepersons
neuropsychologicalpresentationandrelevantpersonalhistory.
50.Supportandeducatepeopleafterstrokeandtheirfamiliesand
carers,inrelationtoemotionaladjustmenttostroke,recognising
thatpsychologicalneedsmaychangeovertimeandindifferent
settings.
51.Whenneworpersistingemotionaldifficultiesareidentifiedatthe
persons6monthorannualstrokereviews,referthemto
appropriateservicesfordetailedassessmentandtreatment.
Recommendations

52.Managedepressionoranxietyinpeopleafterstrokewhohaveno

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StrokeRehabilitation
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cognitiveimpairmentinlinewithrecommendationsinDepression
inadultswithachronicphysicalhealthproblem(NICEclinical
guideline91)andGeneralisedanxietydisorder(NICEclinical
guideline113).

Relativevaluesofdifferent Anyqualityoflifeordepressionoutcomewasincludedintheclinicalreview.
outcomes
Thestudyreporteddepression,abilitytocope,selfesteemandemotional
support.
Tradeoffbetweenclinical
benefitsandharms

Havingastrokecanaffectrelationshipsbetweentheindividualwithstroke
andaspouseorpartner.Transitiontonewrolesandadaptationtodisability
arechallenging,andhavebeenlikenedtonavigatingunchartedterritory.The
NationalServiceFrameworkforPeoplewithLongTerm(Neurological)
Conditionshighlightedtheneedforlifelongcareandsupportforpeoplewith
longtermneurologicalconditions,theirfamiliesandcarers.Inviewofthisthe
GDGwishedtospecificallyexaminetheevidencearoundsupportingfamilies
andcouples.Onlyonestudywasfoundinthisarea.Thisparticular
interventionusedanonlinesupportprogrammetoprovidecaregiverswith
knowledgeandskillstoreducetheirownpersonalstressandprovide
emotionalsupporttothepersontheywerecaringfor.WhiletheGDGagreedit
wasimportanttoprovidestrategiestohelppeoplecopeeffectivelyand
managedistressandanumberofdifferentpsychologicalapproachescouldbe
drawnupon,ofwhichonecouldbetheuseofcomputerbasedtherapies,it
wasquestionedwhetherthiswouldbethemostsuitableformatforsome
people,inparticularanoldergeneration.
TheGDGnotedthatprevalenceofdepressioninstrokesurvivorshasbeen
estimatedat1520%.Theynotedthatdepressioninstrokesurvivorsimpacts
onfamilymembers.TheGDGagreedthatanassessmentofemotional
functioningshouldbeconductedinallpatientswithstroke.TheGDG
consideredthatwhilstitwasnotpossibletoprovidedetailonwhatthe
assessmentshouldcomprise,ageneralrecommendationshouldbemadeas
thepersonsmoodwouldhaveamajorimpactonthequalityoflifeofboththe
patientandtheircarers.TheGDGbasedtheirrecommendationonconsensus
opinion.

Economicconsiderations

Nocosteffectivenessstudieswereidentifiedforthisquestion.
Bothassessmentandtherapyvaryaccordingtothepatientsneed.
AssessmentsarecarriedoutbyaBand8Aclinicianandcouldtakebetween2
4hours.Theestimatedcostperhourofclientcontactforacommunitybased
clinicalpsychologist(band8a)is136nthereforetheassessmentcostwouldbe
between272and544perpatient.
Upto12sessionsofpsychologicaltherapymaybeofferedtostrokepatients
fordepression;usuallyonesessioniscarriedoutperweekandeachsession
wouldtakearoundonehour.Thetotalaveragecostoftherapywouldbe
1,224perpatient.
Intheeventthatthepsychologistidentifiesmoresignificantemotional
difficultiesforwhichpsychologicaltherapyisnotappropriate,pharmacological
treatmentandtheneuropsychiatricinputwouldberequiredatthisstagefor
bothassessmentandprescriptionofpharmacologicaltherapy.
TheGDGconsideredthesecoststobelikelyoffsetbythebenefitsandthe
improvementsinthepatientsqualityoflifegeneratedbythepsychological
therapy.

Qualityofevidence

Thestudydemonstratedthatcaregiversdepressionstatisticallyimproved

n EstimatedbasedondataandmethodsfromPersonalSocialServicesResearchUnitUnitcostsofhealthandsocialcare
reportandAgendaforChangesalaryband8a51(typicalsalarybandidentifiedbyclinicalGDGmembers).

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StrokeRehabilitation
Emotionalfunctioning
whentheyreceivedanonlinepsychologicalinterventioncomparedtothe
depressionscoresofthoseinthecontrolcondition.Thiswastheonlyoutcome
thatdemonstratedasignificantresult.Howeverconfidenceintheresultsfor
thisoutcomewaslowduetothestudybeingdowngradedforseriousriskof
biasandimprecision.Itwasnotclearatwhattimepointafterstrokethestudy
wasconducted.Theinterventionwasdeliveredtopeopleathome,andresults
werereportedattheendofintervention(11weeks)andatonemonthfollow
up.TheGDGagreedthatittakestimeforthepersonafterstroketobeready
forrehabilitationduetothepsychologicaladjustmentrequired,andthiswould
includecarerstoo.Thereforehavingonlyonemonthfollowupmaybea
limitingfactorofthisstudy.
Thegroupagreedthatprovisionofpsychologicalinterventionswasimportant
forfamiliesandcarersofpeopleafterstrokeandfurtherresearchneedstobe
conductedinthisarea.
Otherconsiderations

TheGDGagreedwiththerecommendationsmadeintheNICEguidanceonthe
managementofdepressioninadultswithachronichealthproblem(CG91),
Depression:thetreatmentandmanagementofdepressioninadults(CG90),
andGeneralisedanxietydisorderandpanicdisorder(withorwithout
agoraphobia)inadults(CG113).Theybelievedthesetobeapplicabletopeople
afterstrokewiththeaddedobservationthatduetocognitiveandlanguage
difficultiespsychologicaltherapiesneedtobedeliveredbyanappropriately
trainedandsupervisedprofessionalwhohasanunderstandingofthenatureof
thecognitiveandphysicaldifficultiesandtheirimpact.TheGDGagreedthat
peoplepresentingwithemotionaldifficultiesattheir6monthorannual
reviewsshouldbereferredfordetailedassessment.

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StrokeRehabilitation
Vision

10 Vision
Visionmaybeaffectedafterstrokeinanumberofways.Peoplewithstrokemaybeawareof
difficultieswithperipheralvisionasaresultofavisualfielddefect,doublevisionasaresultof
impairedeyedmovementsorpoorcoordinationofeyemovements,andproblemsarisingasaresult
ofdifficultieswithvisualprocessing.Thischapterfocusesonthetreatmentofhemianopiaand
doublevision.

10.1 Eyemovementtherapy
Hemianopiasareestimatedtoaffectbetween8and25%ofpeoplewithstroke17,92.Thisvision
defectischaracterisedbylowvisionorblindnessincorrespondinghalvesofthefieldofvision.
Peoplesufferingfromhemianopiaorquadrantanopiamayrunintoobjects,triporfall,knockthings
over,andlosetheirplacewhenreading,orbesurprisedbypeopleorobjectsthatseemtoappear
suddenlyoutofnowhere.Somepeoplemaynotbeawareofthedeficit,especiallythosewith
associatedneglect.Eyemovementtherapyencouragesscanningintotheaffectedvisualfieldandis
atechniqueusedwithpatientswithahemianopiapoststroke.

10.1.1

Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofeye
movementtherapyforvisualfieldlossversususualcare?
ClinicalMethodologicalIntroduction
Population:

Adultsandyoungpeople16orolderwhohavehadastroke

Intervention:

Eyemovementtherapyincluding:
Visualsearchtherapy
Visualscanning
Scanningcompensatorytraining

Comparison:

Usualcare(usuallynothing)
Shamvisualrehabilitation

Outcomes:

Reading(speedandaccuracy)
Eyemovementtasks
Scanning
LetterCancellationTest

10.1.1.1

Clinicalevidence
SearcheswereconductedforsystematicreviewsandRCTscomparingeyemovementtherapyasan
interventionforvisualfieldlossinpeopleafterstroke.Onlystudieswithaminimumsamplesizeof
10participants(5ineacharm)andincludingatleast50%ofparticipantswithstrokewereselected.
ThreeRCTswereidentified.Table52summarisesthepopulation,intervention,comparisonand
outcomesforeachofthestudies.
Table52: Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
STUDY
37

Carter,1983

POPULATION

INTERVENTION

COMPARISON

OUTCOMES

Acutestroke
patientsina
hospitalsetting
withouttumours

Cognitiveskill
retraininginvolving
visualscanningand

Routinestroke
program.(N=17)

Lettercancellation
test
Visualspatialtasks

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StrokeRehabilitation
Vision
STUDY

POPULATION
INTERVENTION
orextensive
visualspatialtasks.
bilateraldamage. (N=16)

COMPARISON

OUTCOMES
matchingtosample
(Identifyingobjects)

Spitzyna,2007 Patientswitha
246
rightsided

homonymous

hemianopiathat
interferedwith
reading(69%of
themhad
experienced
stroke).

Readingmovingtext
Shamvisual
(MovingText)that
rehabilitation
scrolledfromrightto therapy.(N=8)
left,dailyfortwofour
weekblocks.(N=11)

Readingspeed
Textreadingspeed
Singlewordreading
speed
Eyemovementtask
Visualfieldperimetry

Modden
2012174

Thereweretwo
different
interventions:(1)
Restitutiontraining:A
computerbased
therapyintegrated
perimeterprogram
whichcreatedthe
exactmeasurement
oftheindividual
visualfieldborder.
Targetstimuli
appearedinthe
hemianopicborder
zonetowhichthe
participanthadto
respond(intervention
basedontheprincipal
ofcovertattention
shift.(N=15)
(2)Compensatory
therapy:Acomputer
basedtherapywhich
wasadapted
individuallyaccording
tothesideofthe
hemianopia.The
therapywasusing
visualscanningand
theparticipanthadto
respondtoatarget
icon.(N=15)

Visualfield
expansion(TAP*
visualfield
omissions)
Visualsearch
(cancellationtaskof
theBIT)
Readingperformance
(standardisedtexts
oftheWechsler
MemoryTest)
Attention(alertness
test(TAPPhasic
Alertness)
Visualconjunction
search(TAP,visual
scanning)
BarthelIndex

Patientswith
homonymous
hemianopiawitha
posteriorcerebral
arterystroke.
Patientswere
excludedifthey
hadvisualneglect
eyemovement
disorders,
neuropsychological
disorderslike
aphasia,
dysexecutive
syndromes,
memorydeficits,
orhigherorder
motor
impairmentslike
apraxia.

Occupational
therapy
consistingof
individually
adapted
stimulationof
dailyactivity
tasksto
compensatevia
eye,head,and
body
movements.
(N=15)

*Note.TAP=TestbatteriezurAufmerksamkeitsprfung(Attentiontestbattery)Zimmermann&Fimm(2002)

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Comparison:EyeMovementTherapy(EMT)forvisualfieldlossversususualcare/shamvisualrehabilitation
Table53:EyeMovementTherapyversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings
Qualityassessment

Author

Design

Effect

Limitations

Inconsistency

Indirectness

Eye
Movement
Therapy
Mean(SD)

Mean
Usualcare difference
Mean(SD) (95%ci)

Noserious
imprecision

35.9(21.3)

3.8(13.2)

32.10
(15.96,
48.24)

MD32.1
higher
(15.96to
48.24
higher)

Moderate

Noserious
imprecision

31(22.8)

3.3(18)

34.30
(19.28,
49.32)

MD34.3
higher
(19.28to
49.32
higher)

Moderate

Imprecision

Mean
Difference
(MD)(95%
CI)

Confidence
(ineffect)

Visualscanninglettercancellationtest(Betterindicatedbyhighervalues)
Carter,
198337

RCT

Serious
Noserious
limitations(a) inconsistency

Noserious
indirectness

Visualspatialtasksmatchingtosample(Betterindicatedbyhighervalues)
Carter,
198337

(a)

RCT

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Randomization,blindingandallocationconcealmentnotclear.

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StrokeRehabilitation
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Table54: Restitutionaltraining/compensatorytreatmentvs.usualcare(occupationaltherapy)
Qualityassessment
Noof
studies

Design

SummaryofFindings
Riskof
bias

Inconsistency

Indirectness

Imprecision Restitutionaltraining
/compensatory
therapy
Mean(SD)

Usual
care
(OT)
Mean
(SD)

Effect
Mean
difference
(95%CI)

Meandifference
(MD)(95%CI)

Confidence
ineffect

Visualfieldenlargement(TAP,VisualFieldAssessment)RestitutionalTraining(followup15days;measuredwith:meanchangescores;Betterindicatedbyhigher
values)
Modde
n
2012174

randomised Serious
trials
(a)

noserious
inconsistency

noserious
indirectness

serious(b)

3.9(4.9)

1.3
(4.7)

2.60(
0.84,6.04)

MD2.6higher
(0.84lowerto
6.04higher)

LOW

Visualfieldenlargement(TAP,VisualFieldAssessment)CompensatoryTreatment(followup15days;measuredwith:meanchangescores;Betterindicatedbyhigher
values)
Modde
n
2012174

randomised Serious
trials
(a)

noserious
inconsistency

noserious
indirectness

serious(b)

2.9(4.0)

1.3
(4.7)

1.60(
1.52,4.72)

MD1.6higher
(1.52lowerto
4.72higher)

LOW

BITcancellationtaskRestitutionalTraining(followup15days;measuredwith:meanchangescores;Betterindicatedbyhighervalues)
Modde
n
2012174

randomised Serious
trials
(a)

noserious
inconsistency

noserious
indirectness

serious(b)

5.3(10.5)

2.3
(5.0)

3(2.89,
8.89)

MD3higher
(2.89lowerto
8.89higher)

LOW

BITcancellationtaskCompensatoryTreatment(followup15days;measuredwith:meanchangescores;Betterindicatedbyhighervalues)
Modde
n
2012174

randomised Serious
trials
(a)

noserious
inconsistency

noserious
indirectness

serious(b)

5.4(5.2)

2.3
(5.0)

3.1(0.55,
6.75)

MD3.1higher
(0.55lowerto
6.75higher)

LOW

Readingperformance(WechslerMemoryTest)RestitutionalTraining(followup15days;measuredwith:meanchangescores;Betterindicatedbyhighervalues)
Modde
n
2012174

randomised Serious
trials
(a)

noserious
inconsistency

noserious
indirectness

very
serious(c)

0.9(2.4)

0.7
(1.0)

0.2(1.12,
1.52)

MD0.2higher
(1.12lowerto
1.52higher)

VERYLOW

Readingperformance(WechslerMemoryTest)CompensatoryTreatment(followup15days;measuredwith:meanchangescores;Betterindicatedbyhighervalues)
Modde
n

randomised Serious
trials
(a)

noserious
inconsistency

noserious
indirectness

very
serious(c)

0.9(1.1)

0.7
(1.0)

0.2(0.55,
0.95)

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MD0.2higher
(0.55lowerto

VERYLOW

StrokeRehabilitation
Vision

Qualityassessment
Noof
studies

Design

SummaryofFindings
Riskof
bias

Inconsistency

Indirectness

Imprecision Restitutionaltraining
/compensatory
therapy
Mean(SD)

Usual
care
(OT)
Mean
(SD)

Effect
Mean
difference
(95%CI)

2012174

Meandifference
(MD)(95%CI)

Confidence
ineffect

0.95higher)

Attention(TAP,PhasicAlertness)RestitutionalTraining(followup15days;measuredwith:meanchangescores;Betterindicatedbyhighervalues)
Modde
n
2012174

randomised Serious
trials
(a)

noserious
inconsistency

noserious
indirectness

serious(b)

28.5(56.9)

13.3
(112.7)

41.8
(22.09,
105.69)

MD41.8higher
(22.09lowerto
105.69higher)

LOW

Attention(TAP,PhasicAlertness)CompensatoryTreatment(followup15days;measuredwith:meanchangescores;Betterindicatedbyhighervalues)
Modde
n
2012174

randomised Serious
trials
(a)

noserious
inconsistency

noserious
indirectness

serious(b)

77.8(112.9)

13.3
(112.7)

91.1
(10.37,
171.83)

MD91.1higher
(10.37to171.83
higher)

LOW

Visualconjunctionsearch(TAPvisualscanning)RestitutionalTraining(followup15days;measuredwith:meanchangescores;Betterindicatedbyhighervalues)
Modde
n
2012174

randomised Serious
trials
(a)

noserious
inconsistency

noserious
indirectness

very
serious(c)

2.7(5.1)

3.5
(6.8)

0.8(5.10, MD0.8lower
3.50)
(5.1lowerto3.5
higher)

VERYLOW

Visualconjunctionsearch(TAPvisualscanning)CompensatoryTreatment(followup15days;measuredwith:meanchangescores;Betterindicatedbyhighervalues)
Modde
n
2012174

randomised Serious
trials
(a)

noserious
inconsistency

noserious
indirectness

serious(b)

7.0(5.0)

3.5
(6.8)

3.5(77,
7.77)

MD3.5higher
(0.77lowerto
7.77higher)

LOW

ExtendedBarthelIndexRestitutionalTraining(followup15days;measuredwith:meanchangescores;Betterindicatedbyhighervalues)
Modde
n
2012174

randomised Serious
trials
(a)

noserious
inconsistency

noserious
indirectness

serious(d)

1.5(2.8)

1.8
(2.0)

0.3(2.04, MD0.3lower
3.50)
(2.04lowerto
1.44higher)

LOW

ExtendedBarthelIndexCompensatoryTreatment(followup15days;measuredwith:meanchangescores;Betterindicatedbyhighervalues)
Modde
n
2012174

randomised Serious
trials
(a)

noserious
inconsistency

noserious
indirectness

serious(d)

3.3(3.6)

1.8
(2.0)

1.5(0.58,
3.58)

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MD1.5higher
(0.58lowerto
3.58higher)

LOW

StrokeRehabilitation
Vision

(a)

Therewasnoallocationconcealmentandonlyparticipantswereblinded.

(b)

Theconfidenceintervalofthetotaleffectrangesfromimprovementassociatedwiththeinterventiontonoeffect(crossingonedefaultMID)

(c)

Theconfidenceintervalofthetotaleffectrangesfromappreciablebenefittoappreciableharm(crossedtwodefaultMIDs)

(d)

Theconfidenceintervalofthetotaleffectrangesfromappreciableimprovementassociatedwithusualcaretonoeffect(crossingagreedMID1.85)

(e)

Theconfidenceintervalofthetotaleffectrangesfromappreciableimprovementassociatedwiththeinterventiontonoeffect(crossingagreedMID1.85)

NarrativeSummary
ThefollowingstudyissummarisedasanarrativebecausetheresultswerenotpresentedinnumericaldatathatcouldbeincludedintheGRADEtable:
Spitzynaetal,2007246comparedreadingmovingtexttoashamvisualrehabilitationinhemianopicpatients(mainlystrokepatients).Readingmovingtext
inducedsmallfieldoptokineticnystagmus(OKN)andpreferentiallyaffectedreadingsaccadesintotheblindfield.Theoutcomesreportedwere:reading
speeds,eyemovementsandvisualfieldperimetry.Authors246reportedasignificantimprovementinthereadingspeedsandassociatedeyemovements
withparticipantsinthereadingmovingtextgroupcomparedwiththeshamvisualrehabilitationgroupbuttherewasnochangewiththevisualfield
perimetryacrossthegroups.

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10.1.1.2

Economicevidence
Literaturereview
Norelevanteconomicevaluationscomparingeyemovementtherapyforvisualfieldlosswithusual
carewereidentified.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
TheGDGconsideredthateyemovementtherapyforvisualfieldlosswouldmostlikelybedelivered
byanorthoptistoranoccupationaltherapistintheNHSandwouldtypicallyconsistofaninitial60
minuteassessmentwitha30minutefollowupappointmenteverythreeweeksandfollowupwould
berequiredonaveragefor6months.Theestimatedcostperhourofclientcontactforaband7
orthoptistis59o51(typicalsalarybandidentifiedbyclinicalGDGmembers).Thisequatestoan
estimatedtotalcostperpatientof285.

10.1.1.3

Evidencestatements
Clinicalevidencestatement(s)
Onestudy37comprisingof33participantsshowedastatisticallysignificantimprovementinthevisual
scanning(lettercancellation)testintheeyemovementtherapygroupcomparedtotheusualcare
group(MODERATECONFIDENCEINEFFECT).
Onestudy37comprisingof33participantsshowedastatisticallysignificantimprovementinvisual
spatialtasksforparticipantswhoreceivedeyemovementtherapycomparedtotheusualcare
group(MODERATECONFIDENCEINEFFECT).
Visualfieldenlargement
Restitutionaltraining
Onestudy174comprisingof15participantsintherestitutionaltraininggroupand15control
participantsshowednosignificantimprovementinvisualfieldenlargement(asassessedby
anattentionvisualfieldassessment)betweenrestitutionaltrainingandcontrolgroups(LOW
CONFIDENCEINEFFECT).
Compensatorytherapy
Onestudy174comprisingof15participantsinthecompensatorytreatmentgroupand15
controlparticipantsshowednosignificantimprovementinvisualfieldenlargement(as
assessedbyanattentionvisualfieldassessment)betweencompensatorytreatmentand
controlgroups(LOWCONFIDENCEINEFFECT).
Visualsearch(BITcancellationtest)
Restitutionaltraining

o EstimatedbasedondataandmethodsfromthePersonalSocialServicesResearchUnitUnitcostsofhealthandsocial
carereportandAgendaforChangesalaryband7.Assumedthatanorthoptistiscostedsimilartootheralliedhealth
professionals.

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StrokeRehabilitation
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Onestudy174comprisingof15participantsintherestitutionaltraininggroupand15control
participantsshowednosignificantimprovementinvisualsearchability(asassessedbythe
BITcancellationtask)betweenrestitutionaltrainingandcontrolgroups(LOWCONFIDENCE
INEFFECT).
Compensatorytherapy
Onestudy174comprisingof15participantsinthecompensatorytreatmentgroupand15
controlparticipantsshowednoimprovementinvisualsearchability(asassessedbytheBIT
cancellationtask)betweencompensatorytreatmentandcontrolgroups(LOWCONFIDENCE
INEFFECT).
Readingperformance(readingtextfromWechslerMemoryTest)
Restitutionaltraining
Onestudy174comprisingof15participantsintherestitutionaltraininggroupand15control
participantsshowednosignificantimprovementinreadingperformance(readingtextfrom
theWechslerMemoryTest)betweenrestitutionaltrainingandcontrolgroups(VERYLOW
CONFIDENCEINEFFECT).
Compensatorytherapy
Onestudy174comprisingof15participantsinthecompensatorytreatmentgroupand15
controlparticipantsshowednoimprovementinreadingperformance(readingtextfromthe
WechslerMemoryTest)betweencompensatorytreatmentandcontrolgroups(VERYLOW
CONFIDENCEINEFFECT).
Attention(PhasicAlertness)
Restitutionaltraining
Onestudy174comprisingof15participantsintherestitutionaltraininggroupand15control
participantsshowednosignificantimprovementinattentioncontrolbetweenrestitutional
trainingandcontrolgroups(LOWCONFIDENCEINEFFECT).
Compensatorytherapy
Onestudy174comprisingof15participantsinthecompensatorytreatmentgroupand15
controlparticipantsshowedastatisticallysignificantimprovementinattentioncontrol
associatedwithcompensatorytreatmentcomparedtousualcare(LOWCONFIDENCEIN
EFFECT).
Visualconjunctionsearch(visualscanningtest)
Restitutionaltraining
Onestudy174comprisingof15participantsintherestitutionaltraininggroupand15control
participantsshowednosignificantimprovementinvisualconjunctionsearchskills(assessed
byavisualscanningtest)betweenrestitutionaltrainingandcontrolgroups(VERYLOW
CONFIDENCEINEFFECT).
Compensatorytherapy
Onestudy174comprisingof15participantsinthecompensatorytreatmentgroupand15
controlparticipantsshowednoimprovementinvisualconjunctionsearchskills(assessedby
avisualscanningtest)betweencompensatorytreatmentandcontrolgroups(LOW
CONFIDENCEINEFFECT).

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StrokeRehabilitation
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Activitiesofdailyliving(BarthelIndex)
Restitutionaltraining
Onestudy174comprisingof15participantsintherestitutionaltraininggroupand15control
participantsshowednosignificantimprovementinperformanceofactivitiesofdailyliving
(assessedbytheBarthelIndex)betweenrestitutionaltrainingandcontrolgroups(VERYLOW
CONFIDENCEINEFFECT).
Compensatorytherapy
Onestudy174comprisingof15participantsinthecompensatorytreatmentgroupand15
controlparticipantsshowednoimprovementinperformanceofactivitiesofdailyliving
(assessedbytheBarthelIndex)betweencompensatorytreatmentandcontrolgroups(LOW
CONFIDENCEINEFFECT).
Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

10.1.2

Recommendationsandlinktoevidence
53.Screenpeopleafterstrokeforvisualdifficulties.
54.Offereyemovementtherapytopeoplewhohavepersisting
hemianopiaafterstrokeandwhoareawareofthecondition.
55.Whenadvisingpeoplewithvisualproblemsafterstrokeaboutdriving,
consulttheDriverandVehicleLicensingAgency(DVLA)regulations.
Recommendation

Relativevaluesof
differentoutcomes

Theoutcomesofinterestincludedinthereviewwere:readingspeedand
accuracy,eyemovementscanningandlettercancellation.TheGDGconsidered
thattheoutcomesmeasuresincludedinthereviewwereofequalvalue,although
readingspeedandaccuracyrepresentsareallifetaskwhereasscanningandletter
cancellationareimpairmentlevelmeasures.

Tradeoffbetween
clinicalbenefitsand
harms

Homonymoushemianopiacanimpactonarangeofactivitiesofdailyliving
including,reading,driving,navigation,eating,hygienerelatedactivities,andsocial
interaction.Therearesignificantsafetyissuesassociatedwithmisseddiagnosis
includingfalls,injuriesandmotorvehicleaccidents.
Thereisabenefittoadiagnosisofpersistenthomonymoushemianopiainterms
ofaccesstoregistrationofvisualimpairmentandsubsequentaccesstosensory
rehabilitationteams.
Aproportionofpatientsdospontaneouslyadapttotheimpairment,butthe
numbersarepresentlyunknown.Persistent(nonrecovered)homonymous
hemianopiacanhaveasignificantimpactonqualityoflife.Thegroupconsidered
thattreatingthisconditionwouldprovidemajorbenefitsintermsofimproving
qualityoflifefortheindividualpatient.TheGDGalsobelievedthebenefitsofthe
interventionaresignificantgiventherisksofleavingtheconditionuntreated.
Patientswithhomonymoushemianopiamustnotdrivewithinoneyearoftheir
strokeonset.TheymaybeabletoreapplytotheDVLAafteroneyeariftheycan
provethattheyhavelearnedtocompensateforthedefect.(Medicalpractitioners
AtaGlanceGuidetotheCurrentMedicalStandardsofFitnesstoDrive,DVLA,
201171).

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StrokeRehabilitation
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Economic
considerations

Nocosteffectivenessstudieswereidentified.Deliveringeyemovementtherapy
forvisualfieldlosswouldinvolvesomeadditionalcostsintermsofanorthoptist
oroccupationaltherapistassessmentandfollowuptime.TheGDGconsidered
thattheadditionalcostswouldpotentiallybeoffsetbythelongtermbenefitto
patientsintermsofimprovedqualityoflife.

Qualityofevidence

OnesmallstudybyCarter,198337examiningamixedpopulationofpatientswith
neglectandhomonymoushemianopia,demonstratedanimprovementinvisual
scanningstrategiesafterinterventionasmeasuredbylettercancellationand
visualspatialtestandtheconfidenceintheseeffectswasgradedasmoderate.
Asecondsmallstudy(Spitzyna,2007)examinedpatients(75%ofwhomhada
stroke)withpersistenthomonymoushemianopia,usinganovelinterventionof
movingtext.Theauthorsreportedasignificantimprovementinreadingspeed
andeyemovementsbutresultswerenotpresentedinnumericaldatathatcould
beincludedwithintheGRADEanalysis.
TheGDGnotedthattheCarterStudywaspoorlydefinedintermsofpatient
recruitmentandthatitwasunclearifthepatientshadhemianopaorvisual
neglect,orboth,butthesameinterventionwasusedforbotheffectively.
TheGDGconsideredthattherewasinsufficientevidencetoreachgeneralised
conclusionsregardingefficacyrelatedtoactivitiesofdailyliving,althoughthereis
someevidenceregardingeffectivenessforreading.TheGDGconsideredthatit
wasimportantforpeoplewhohavehadastroketobeassessedforvisualfield
defectsandbecauseoftheimpactthisimpairmenthasonthequalityofthe
personslifeandtheserioussafetyissuesinleavingthisuntreated,TheGDG
agreedthatastronglywordedrecommendationneededtobemadetoreflect
theseconcernseventhoughtheevidencewaslimitedtoonesmallstudy.
Itwasnotedthatfurtherresearchinthisareaisrequired.

Otherconsiderations

TheGDGwereuncertainabouttheprevalenceofhomonymoushemianopiawithin
astrokepopulationandrequestedthatanadditionalliteraturesearchbe
conducted.Sixstudies17;45;79;99;92;261wereidentifiedwhichaddressedprevalence,
thesewereofvaryingquality,oftenexaminingaselectedpopulationwithina
hospitalsetting.Onthebasisofthesestudies,theGDGfeltaprevalenceof
persistenthomonymoushemianopiainthecommunitywaslikelytobebetween8
and25%.
Halfofthepatientswithinthepapersreviewedwerenotawarethattheywere
sufferingfromhomonymoushemianopia.Itwasnotedthatroutinescreeningfor
visualfielddefectswasnotcurrentlyuniversalandthereforepotentialpatients
werenotidentifiedorreferredfortherapy.Attentionshouldbepaidatstroke
onsettoelicitingvisualfielddefects.Thegroupconsideredthatperforming
screeningassessmentisgoodpracticeandshouldbeundertaken.

10.2 Diplopiaorotherongoingvisualsymptomsafterstroke
Astrokemayleadtoproblemswitheyemovementswhichresultinbotheyesnotworkingtogether
asapair.Thiscanmakeitdifficulttofocusonspecificthingsbecauseofblurredvisionaswellas
diplopia(ordoublevision)whichimpactsonreading,walkingandperformingeverydayactivities.
Treatmentcaninvolveprisms,exercisesandocclusion.
Asearchforsystematicreviewswascarriedoutforevidenceonthemanagementofdiplopiaand
ongoingvisualsymptomsinpeopleafterstroke.Noreviewswereidentifiedandtherefore
recommendationsinthissectionwerebasedonmodifiedDelphiconsensusstatementswhichwere
basedonrecommendationsfrompublishednationalandinternationalguidelines.Belowweprovide
tablesofstatementsthatreachedconsensusandstatementsthatdidnotreachconsensusandgivea
summaryofhowtheywereusedtodrawuptherecommendations.Fordetailsontheprocessand
methodologyusedforthemodifiedDelphisurveyseeAppendixF.ThissectionoftheDelphisurvey

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StrokeRehabilitation
Vision
wasaimedatDelphipanelmemberswiththerelevantexperiencetocommentonvisualimpairments
instroke.Othermemberscouldoptoutofthissection.Thereforetheresponseratewaslower.

10.2.1

10.2.2

Evidencereview:Howshouldpeoplewithvisualimpairmentsincludingdiplopiabebest
managedafterastroke?
Population

Adultsandyoungpeople16orolderwhohavehadastroke

Components

Continuedmonitoringandreaccessintorehab
Longtermsupport/careathome
Socialparticipationactivities
Carer/familysupport&education

Outcomes

Patientandcarersatisfaction
Qualityoflife
optimisedstrategiestominimiseimpairmentandmaximiseactivity/participation

Delphistatementswhereconsensuswasachieved
Table55: Tableofconsensusstatements,resultsandcomments(percentageintheresultscolumn
indicatestheoverallrateofresponderswhostronglyagreedwithastatementand
amountofcommentsinthefinalcolumnreferstorateofresponderswhousedthe
openendedcommentsboxes,i.e.No.peoplecommented/No.peoplewhoresponded
tothestatement)

Number

Statement

10.2.3

Peoplewhohavepersistingdouble
visionafterstrokerequireaformal
orthopticassessment.

Results
%
70.8

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes
1/24(4%)panelmember
commented

Thepersonwhocommentedthought
thatallotherformsofvisual
impairmentwouldalsorequire
orthopticassessment.

Delphistatementwhereconsensuswasnotreached
Table56: Tableofnonconsensusstatementswithqualitativethemesofpanelcomments
Number
1.

Statement
Allpeoplewhohaveimpairedacuity,
doublevisionoravisualfielddefect
followingastrokerequireaformal
ophthalmologyassessment.

Results
%

Amountandcontentofpanel
commentsorthemes

23.8

Inround27/24(29%)panel
memberscommented;7/21(33%)in
round3

Itwaspointedoutthatdifferent
aspectsinthestatementrequire
differentactions(Impairedacuity
anddoublevisionbothrequirean
ophthalmologicaldiagnosis.Visual
fielddefectafterstrokeisless
problematic,andthediagnosisis
usuallyknowninsuchcases
adaptivetreatmentsandeducation

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StrokeRehabilitation
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Number

Statement

Results
%

Amountandcontentofpanel
commentsorthemes
arethepriority.).

Othercommentsalsohighlighted
thatthisisnotalwaysneeded.

2.

Peoplewhohaveongoingvisual
symptomsafterastroke,shouldbe
providedwithinformationon
compensatorystrategiesfrom:
Ophthalmologyservices
Orthopticservices
Occupationaltherapyservices

15.7
50.0
31.5

Inround26/23(26%)panel
memberscommented;9/20(45%)in
round3

Itwashighlightedthatitdependson
availabilityandontheneed
(OccupationalTherapistsaremost
likelytoadvisererehabilitationand
applicationtodailylifewhereas
orthoptistscanadviseonvision
strategies.OphthalmologywillAx
andRxeyeproblemsbutperhapsnot
somuchadviseonstrategies.).

Onepanelmemberwasinvolvedin
thedevelopmentofwebbased
therapiesthatworkbyinducing
compensatoryeyemovements

3.

Peoplewhohavehadastrokeand
havevisualimpairmentsshouldbe
providedwithcontactdetailsforthe
RNIBorStrokeAssociationforfurther
informationonvisualimpairments
afterstroke.

38.1

Inround24/23(17%)panel
memberscommented;1/21(5%)in
round3

Peoplewhohavepersistingdouble
visionafterstrokerequireaformal
orthopticassessment.

Itwaspointedoutthatthisshouldbe
doneifsymptomspersistandnot
givenroutinelytoeverybody.
4.

Assessmentandinformationfor
registeringassightimpairedor
severelysightimpairedshouldbe
providedbyreferraltoan
ophthalmologist.

47.6

NationalClinicalGuidelineCentre,2013.
236

Inround22/24(8%)panel
memberscommented;5/21(24%)in
round3
Itwascommentedthat:
Allinvolvedinstrokecareshould
realisethatonlyophthalmologists
cansignthecertificationofvisual
impairmentform.

Othersqueriedwhetheran
orthoptistcouldalsodothis.

StrokeRehabilitation
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10.2.4

RecommendationsandlinkstoDelphiconsensussurvey
Statements

27.Peoplewhohavepersistingdoublevisionafterstrokerequireaformal
orthopticassessment.
56.Referpeoplewithpersistingdoublevisionafterstrokeforformal
orthopticassessment.

Economicconsiderations Therearecostsassociatedwithaformalorthopticassessment.The
estimatedcostperhourofclientcontactforaband7orthoptistis59p51
(typicalsalarybandidentifiedbyclinicalGDGmembers).Thereis
currentlyalackofconvincingevidenceinfavourofanyinterventionfor
thetreatmentofdiplopiaafterstroke.However,theGDGthoughtthata
formalorthopticassessmentmightindicateunderlyingindividualcauses
thatmayleadtopossibletreatmentactivities.Forthisreason,theGDG
consideredthecostsassociatedwithorthopticassessmentlikelytobe
offsetbyitsbenefits.
Otherconsiderations

TheGDGinterpretedthelackofconsensusasindicatingnoconclusive
agreementcouldbedrawnfromtheDelphipanelonwhatisbeneficial
fordiplopia.TheGDGtookintoaccountthatthisisaconditionthat
wouldseriouslyaffectanindividualsqualityoflifeandthatitistherefore
importantthatthisisformallyassessed.
Eventhoughthereisnotenoughrobustevidencetosupportone
treatmentoveranotherfordiplopiaatpresent,theGDGthoughtthatthe
resultsmayindicateapathoftreatmentoptionsbasedonindividual
need.Itisalsopossiblethataformalorthopticassessmentmightindicate
underlyingindividualcausesthatmayleadtopossibletreatment
activities,suchasprismsorpatching.
TheGDGalsoconsideredthatthattheprovisionofinformationtothe
personwhoexperiencesdiplopiapoststrokeandtheircarer/familyis
centralinthisprocess(includingavailabletreatmentoptions).However,
theGDGstressedthatitisimportantforclinicianstokeepinmindthat
thereiscurrentlyalackofconvincingevidenceinfavourofany
intervention.Itisthereforenecessaryindiscussionswiththepatientand
theircarers/familytobesensitiveandsetrealisticgoals.

p EstimatedbasedondataandmethodsfromthePersonalSocialServicesResearchUnitUnitcostsofhealthandsocial
carereportandAgendaforChangesalaryband7.Assumedthatanorthoptistiscostedsimilartootheralliedhealth
professionals.

NationalClinicalGuidelineCentre,2013.
237

StrokeRehabilitation
Swallowing

11 Swallowing
Dysphagia(difficultyswallowing)iscommonfollowingstroke,occurringinupto67%ofstroke
patients.Strokepatientswithdysphagiahavehigherratesofchestinfection,aspirationpneumonia,
dehydrationandmalnutritionthanstrokepatientswithoutdysphagia.Thepresenceofdysphagiais
alsoassociatedwithasignificantlyincreasedriskofdeath,disability,lengthofhospitalstay,and
institutionalcare.
Symptomsandsignswhichmayindicatethepresenceofdysphagiainclude:

Afeelingthatfoodorliquidisstickinginthethroat;

Asensationofaforeignbodyor"lump"inthethroat;

Aneedtomodifyorrestrictcertainfoodtypes

Drooling;

Difficultyinitiatingaswallow

Nasalregurgitationoffoodordrinkduringswallowing

Coughingorchokingduringeatinganddrinking

Gurglyorwetvoiceafterswallowing

Unexplainedweightloss

Respiratorysymptomsincludingincreasingrespiratoryrateandshortnessofbreath.

Dysphagiarehabilitationprogrammesuseacombinationofapproachesaimedateither
improvingorcompensatingfortheunderlyingdisorder.Programmesmayfocuson
strengtheningmusclesoronusingdifferentgroupsofmusclestoassumethefunctionof
thedamagedmuscles.Generaldysphagiamanagementprogrammesthatincorporate
earlyidentificationofswallowingdifficultiesthroughscreeningorassessmentand
modificationoforalintakehavebeenassociatedwithareducedriskofpneumoniainthe
acutestageofstroke.
11.1.1

Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessof
interventionsforswallowingversusalternativeinterventions/usualcaretoimprove
difficultyswallowing(dysphagia)?
ClinicalMethodologicalIntroduction

Population:

Adultsandyoungpeople16orolderwhohavehada
stroke

Intervention:

Carbonatedwater
Frazierfreewaterprotocol
Swallowingexercises:
a.effortfulswallowingtechnique
b.headpositioning
c.tongueexercises
d.thickenedfluids/texturemodification

NationalClinicalGuidelineCentre,2013.
238

StrokeRehabilitation
Swallowing

ClinicalMethodologicalIntroduction

e.Mendelssohnsmanoeuvre

11.1.1.1

Comparison:

Usualcare
Thickeningfluids
NilbymouthAlternativeinterventions
Nasogastricfeeding

Outcomes:

Occurrenceofaspirationpneumonia
Occurrenceofchestinfections
Reductioninhospitalstay
Reductioninreadmission
Returntonormaldiet

Clinicalevidence
SearcheswereconductedforsystematicreviewsandRCTscomparinginterventionstoimprove
swallowingforreducingdysphagiainpatientswithstroke.Onlystudieswithaminimumsamplesize
of20participants(10ineacharm)andincludingatleast50%ofparticipantswithstrokewere
selected.Three(3)RCTswereidentified.
Table57:Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
STUDY

POPULATION

INTERVENTION

COMPARISON

Carnaby
etal,
200636

Patientswithstroke Standardlowintensity
withintheprevious
swallowingtherapy:
7dayswitha
appropriatedietary
clinicaldiagnosisof
modificationand
swallowing
swallowingcompensation
difficultyandno
strategies,mainly
historyof
environmental
swallowing
modifications(for
treatmentor
exampleupright
surgeryofthehead
positioningforfeeding),
orneck.
safeswallowingadvice
(forexamplereducedrate
ofeating)for3timesper
weekforamonthor
duringthehospitalstay(if
lessthanamonth)
(N=102)
Standardhighintensity
swallowingtherapy:
dietarymodificationand
directswallowing
exercises(forexample,
effortfulswallowing,
supraglotticswallow
technique)everyworking
dayforamonthordaily
forthedurationof
hospitalstay(iflessthana

NationalClinicalGuidelineCentre,2013.
239

OUTCOMES

Usualcare:
Returntopre
strokedietin6
Physiciansreferred
months.
theirpatientsto
thespeechand
Occurrenceof
languagetherapists
severechest
iftheyconsideredit
infection
tobeappropriate.

Treatment,if
offered,consisted
mainlyof
supervisionfor
feedingand
precautionsforsafe
swallowing(for
example,
positioning,slowed
rateoffeeding).
(N=102)

StrokeRehabilitation
Swallowing
STUDY

POPULATION

INTERVENTION
month).(N=102)

COMPARISON

OUTCOMES

DePippo
etal,
199463

Acutestroke
patientsover20
yearsoldwith
strokeina
rehabilitationunit
withnoknown
historyof
significantoralor
pharyngeal
anomaly.

Dietcontrolanddaily
reinforcementof
compensatoryswallowing
techniquesaddedtoformal
dysphagiatreatmentsession
(dietprescription,dietand
compensatoryswallowing
technique
recommendations)bya
dysphagiatherapist.(N=39)

Formaldysphagia
treatmentsession
(dietprescription,
dietand
compensatory
swallowing
technique
recommendations)
byadysphagia
therapist(N=38).

Occurrenceof
pneumonia

Garonet Patientswithstroke Patientshadallliquids

al,199789 withinthelast3
thickenedbutwereallowed
weekswitha
freeaccesstowater
documented
(amountmeasured)butnot
aspirationofthin
withmealsorforanhour
liquidsonly.
aftermeals;no
compensatoryswallow
techniques,director
indirectswallowtherapyor
cuesgiven.(N=10)

Patientshad
thickenedfluids
only(withmealsor
asrequested);no
compensatory
swallow
techniques,direct
orindirectswallow
therapyorcues
given.(N=10)

Occurrenceof
aspiration
pneumonia

NationalClinicalGuidelineCentre,2013.
240

StrokeRehabilitation
Swallowing

Comparisonofbehaviouralinterventionsfordysphagiaversususualcare
Table58:StandardlowintensityswallowingtherapyfordysphagiaversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings
Qualityassessment

Noof
studies

Design

Limitations

Standard
low
intensity
swallowing
therapy
Frequencies
(%)

Effect

Usualcare
Frequencies
(%)

Relative
Risk
(95%CI)

Absolute
effect(95% Confidence
CI)
(ineffect)

Inconsistency

Indirectness

Imprecision

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(a)

65/102
(63.7%))

57/102
(55.9%)

1.14
(0.91to
1.43)

78more
per1000
(from50
fewerto
240more)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b)

26/102
(25.5%)

48/102
(47.1%)

0.54
(0.37to
0.8)

216fewer Moderate
per1000
(from94
fewerto
296fewer)

Returntoprestrokedietin6months
1
Carnaby
200636

RCT
Noserious
single
limitations
blinded

Moderate

Occurrenceofseverechestinfection
1
Carnaby
200636

(a)
(b)

RCT
Noserious
single
limitations
blinded

ConfidenceintervalcrossedoneendofdefaultMID(1.25).
ConfidenceintervalcrossedoneendofdefaultMID(0.75).

NationalClinicalGuidelineCentre,2013.

241

StrokeRehabilitation
Swallowing

Table59:StandardhighintensityswallowingtherapyfordysphagiaversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings
Qualityassessment

Noof
studies

Design

Limitations

Standard
high
intensity
swallowing
therapy
Frequencies
(%)

Effect
Usual
care
Frequenc
ies(%)

Relative
Risk(95%
CI)

Absolute
effect(95%
CI)

Confidence
(ineffect)

Inconsistency Indirectness

Imprecision

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(a)

71/102
(69.6%)

57/102
(55.9%)

1.25(1to
1.54)

140moreper
1000(from0
moreto302
more)

Moderate

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b)

28/102
(27.5%)

48/102
(47.1%)

0.58(0.4to
0.85)

198fewerper
1000(from71
fewerto282
fewer)

Moderate

Returntoprestrokedietin6months
1
Carnaby
200636

RCTsingle Noserious
blinded
limitations

Occurrenceofseverechestinfection
1
Carnaby
200636
(a)
(b)

RCTsingle Noserious
blinded
limitations

ConfidenceintervalcrossedoneendofMID(1.25)
ConfidenceintervalcrossedoneendofMID(0.75)

NationalClinicalGuidelineCentre,2013.

242

StrokeRehabilitation
Swallowing

Table60:ReinforcementofswallowingposturesversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings
Qualityassessment

Noof
studies

Design

Limitations

Inconsistency Indirectness

Imprecision

Reinforcement
ofswallowing
postures
(frequencies%)

Usual
care
(frequen
cies%)

Effect

Relative
Risk(95%
CI)

Absolute
effect(95%
CI)

Occurrenceofpneumonia
1
DePippo
199463

(a)
(b)

RCT

Serious
limitations
(a)

Confidence
(ineffect)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision
(b)

2/39(5.1%)

5/38
(13.2%)

Noallocationconcealment,unclearblinding
ConfidenceintervalcrossedbothendsofMID(0.75,1.25)

NationalClinicalGuidelineCentre,2013.

243

0.39(0.08
to1.89)

80fewer
per1000
(from121
fewerto
117more)

Verylow

StrokeRehabilitation
Swallowing

Comparisonofunlimitedoralintakeofwaterinadditiontothickenedliquidsversusthickenedliquidsonly
Table61:UnlimitedoralintakeofwaterinadditiontothickenedliquidsversusthickenedliquidsonlyClinicalstudycharacteristicsandclinical
summaryoffindings
Summaryoffindings
Qualityassessment

Noof
studies

Design

Limitations

Inconsistency Indirectness

Imprecision

Unlimited
oralintake
ofwater
(plus
thickened
liquids)
(frequenci
es%)

Thickened
liquids
only
(frequenci
es%)

Effect

Relative
Risk(95%
CI)

Absolute
effect(95%
CI)

Occurrenceofaspirationpneumonia
1Garon
199789

RCT
unblinded

Very
serious
limitations(
a)

Confidence
(ineffect)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

0/10

0/10

(b)

(a) Unblindedstudy;randomisationandallocationconcealmentunclear.
(b) Noeventsexperiencedinanygroup(intervention,control)sonorelativeandabsoluteeffectcouldbeestimated.

NationalClinicalGuidelineCentre,2013.

244

(b)

Low

StrokeRehabilitation
Swallowing

11.1.2

EconomicLiteraturereview
Onestudywasincludedthatincludedtherelevantcomparison.169Thisissummarisedinthe
economicevidenceprofilebelow(Table62andTable63).Seealsothefullstudyevidencetablesin
AppendixI.
Table62: StandardlowintensityswallowingtherapyversususualcareEconomicstudy
characteristics
Study
169

Marsh2010
(UK)

Limitations

Applicability

Othercomments

Minorlimitations(a)

Directlyapplicable
(b)

Theauthorslabelledthisstudyasacost
benefitanalysis;howeveritisinfacta
costanalysistakingintoaccountinitial
andfuturecosts.

(a) EffectivenessdataisbasedononeRCTsodoesnotreflectalltheevidenceinthisareaastheclinicalreviewincluded
morestudies.
(b) Theprobabilityofrequiringhospitalorcommunitycareforchestinfectionwasbasedondatanotspecifictopeoplewith
dysphagia.

Table63: StandardlowintensityswallowingtherapyversususualcareEconomicsummaryof
findings
Study
169

Marsh2010
(UK)

Incremental
cost

Incremental
effects

NetBenefit

Uncertainty

saves213
(a)

NR

NR

Thresholdanalysis:standardlow
intensityswallowingtherapyiscost
savingaslongasprobabilityof
developingachestinfectionwith
standardtherapyisbelow38%.

Thecostofchestinfectionrequiring
hospitaladmissionwasvariedbetween
1,800and5,100.Standardlow
intensityswallowingtherapyiscost
savingaslongasthecostofchest
infectionrequiringhospitaladmissionis
above2,000.

(a) Costsofstafftimefortheinitialstrategy,futurecostsoftreatingchestinfectionsinhospitalandcommunity.Standard
lowintensityswallowingtherapyismorecostlyinitiallywhencomparedtousualcare(219versus59)butitis
associatedwithlowerratesofchestinfectionsandlowercostoftreatingchestinfections(659versus872).

11.1.3

Evidencestatements
Clinicalevidencestatement(s)
Standardlowintensityswallowingtherapyfordysphagiaversususualcare
Onestudy(Carnaby200636)comprising204peoplewhohavehadastrokeshowedthatpeoplewho
receivedastandardlowintensityswallowingtherapywerenomorelikelytoreturntotheirpre
strokedietafter6monthsthanthosewhoreceivedusualcare(moderateconfidenceintheeffect).
Onestudy(Carnaby200636)comprising204peoplewhohavehadastrokeshowedthattherewere
significantlyfewerpeopleofthosewhoreceivedastandardlowintensityswallowingtherapy

NationalClinicalGuidelineCentre,2013.
245

StrokeRehabilitation
Swallowing
experiencingchestinfectionscomparedtothosewhoreceivedusualcare(moderateconfidencein
theeffect).
Standardhighintensityswallowingtherapyfordysphagiaversususualcare
Onestudy(Carnaby200636)comprising204peoplewhohavehadastrokeshowedthatpeoplewho
receivedastandardhighintensityswallowingtherapyweresignificantlymorelikelytoreturntotheir
prestrokedietafter6monthsthanthosewhoreceivedusualcare(moderateconfidenceinthe
effect).
Onestudy(Carnaby200636)comprising204peoplewhohavehadastrokeshowedthattherewere
significantlyfewerpeopleofthosewhoreceivedastandardhighintensityswallowingtherapy
experiencingchestinfectionscomparedtothosewhoreceivedusualcare(moderateconfidencein
theeffect).
Reinforcementofswallowingposturesversususualcare
Onestudy(DePippo199463)comprising77peoplewhohavehadastrokeshowedthatpeoplewho
receivedreinforcementofswallowingposturesdidnothavehigherratesofpneumoniacomparedto
thosewhoreceivedusualcare(verylowconfidenceintheeffect).
Unlimitedoralintakeofwaterinadditiontothickenedliquidsversusthickenedliquidsonly
Onestudy(Garon199789)comprising20peoplewhohavehadastrokeshowednocaseofaspiration
pneumoniaineitherthegroupwhoreceivedunlimitedoralintakeofwaterinadditiontothickened
liquidsorthethickenedliquidsonlygroup(verylowconfidenceintheeffect)
Healtheconomicevidencestatement(s)

OnedirectlyapplicablestudywithminorlimitationsshowedthatlowintensitySLTsavesaround

213perpatientcomparedtousualcarewheninitialcostsandcostoftreatingchestinfections
areincluded.

NationalClinicalGuidelineCentre,2013.
246

11.1.4

Recommendationsandlinktoevidence
57.Assessswallowinginpeopleafterstrokeinlinewith
recommendationsinStroke(NICEclinicalguideline68).
58.Offerswallowingtherapyatleast3timesaweektopeople
withdysphagiaafterstrokewhoareabletoparticipate,foras
longastheycontinuetomakefunctionalgains.Swallowing
therapycouldincludecompensatorystrategies,exercisesand
posturaladvice.
59.Ensurethateffectivemouthcareisgiventopeoplewith
difficultyswallowingafterstroke,inordertodecreasethe
riskofaspirationpneumonia.
60.Healthcareprofessionalswithrelevantskillsandtrainingin
thediagnosis,assessmentandmanagementofswallowing
disordersshouldregularlymonitorandreassesspeoplewith
dysphagiaafterstrokewhoarehavingmodifiedfoodand
liquiduntiltheyarestable(thisrecommendationisfrom
Nutritionsupportinadults[NICEclinicalguideline32]).
61.Providenutritionsupporttopeoplewithdysphagiainline
withrecommendationsinNutritionsupportinadults(NICE
clinicalguideline32)andStroke(NICEclinicalguideline68).

Relativevaluesofdifferent
outcomes

Theoutcomesreportedinthestudiesincluded:returntonormaldiet,
occurrenceofchestinfectionandaspirationpneumonia.
Intheshorttermthepreventionofaspirationpneumoniaisacritical
outcome,butinthelongtermareturntoanormaldiethasasignificant
impactonqualityoflifeforbothpatientsandcarers.Dysphagiamay
resultinpercutaneousendoscopicgastrostomy(PEG)feeding,which
mayhaveasignificantnegativeimpactonqualityoflifeaswellas
significantlyincreasedcosts.

Tradeoffbetweenclinical
benefitsandharms

Untreateddysphagiacouldleadtoseriouscomplicationsincluding:
aspirationpneumonia,dehydrationanddeath.Normalswallowing
allowspeopletoenjoymealtimesandrelatedsocialinteractions,andis
thereforeconsideredtobelinkedtoanimprovementinqualityoflife.
Peoplewhoarehavingthickenedfoodmayneedassistancewithoral
hygieneandthisshouldbemonitored.TheGDGagreedthatgoodoral
hygienehasbeenlinkedwithareductioninaspirationpneumoniaand
shouldbeincorporatedintoanydysphagiamanagementplan.Thegroup
notedthatpeoplewithdysphagiahaveahigherriskofaspiration
pneumonia.

Economicconsiderations

Onedirectlyapplicablestudywithminorlimitationsshowedthatlow
intensityswallowingtherapysavesaround213perpatientcomparedto
usualcarewheninitialcostsandcostoftreatingchestinfectionsare
included.
TheGDGagreedthatthecostofprovidingswallowingtherapyfor

NationalClinicalGuidelineCentre,2013.
247


dysphagiacomparedtousualcarecouldpotentiallybeoffsetbycost
savingsduetoreductionsinchestinfectionsandimprovedoutcomesfor
patientsincludingreducedmortalityandimprovementinqualityoflife.
Qualityofevidence

TheGDGconsideredtheCarnabystudy36tobeawellconductedsingle
centredstudy,whichexaminedtheeffectsofhighandlowintensity
swallowingonreturntoprestrokedietat6monthsandaspiration
pneumoniacomparedtoacontrolgroup.Thecontrolgroupwasnot
typicalofcurrentUKpractice,wherephysiciansonlyreferredtheir
patientstothespeechandlanguagetherapistsiftheyconsideredittobe
appropriatewasnottypicalofcurrentUKpractice.Treatment,ifoffered,
consistedmainlyofsupervisionforfeedingandprecautionsforsafe
swallowing(forexample,positioning,slowedrateoffeeding).
Appraisalofthisstudygradedtheresultsfortheoutcomesreportedas
moderate.Theevidenceshowedthatasignificantlylowerproportionof
participantswhoreceivedtheswallowingtherapyexperiencedchest
infectionscomparedtousualcaregroup.Inadditionasignificantly
higherproportionofparticipantsreceivingthehighintensityswallowing
therapyreturnedtoprestrokedietat6monthscomparedtousualcare.
Thestudywasnotpoweredtocomparelowagainsthighintensity
therapy,buttherewasconsensusamongstthegroupthatthebenefitof
swallowingtherapyemployingafullrangeoftechniquesclearly
outweighedtheharmsandshouldbeofferedatleastthreetimesaweek
topatientswithdysphagia.
Itisnotpossibletorecommendthehighintensityinterventionfromthe
evidencereviewed,buttheGDGagreedthattherangeofswallowing
therapiesshouldbespecifiedandthattheminimumshouldbethelow
intensitytherapyofatleast3timesperweek,butinsomecircumstances
thehighintensitymaybemoreappropriateforthosepatientswhoare
medicallystable,abletotolerateanhouroftherapyeachdayandfollow
instructions/informationprovided.

OnesmallstudybyGaron89examinedtheeffectsofthickenedfluidsand
freeaccesstowaterontheoccurrenceofpneumoniabuttherewereno
episodesofpneumoniaineithergroup.Onthebasisofthisstudy,the
authorsreportedthattheyallowfreeaccesstowater.However,
membersoftheGDGwereawareofotherstudiesinvestigatingfree
accesstowaterbutnootherRCTdatawasavailableatpresent.The
GDGdidnotconsidertheresultsfromthisstudyweresufficientto
recommendfreeaccesstowater.Therewasuncertaintyamongstthe
GDGaboutwhethertheremaybepotentialharmsbutitwasagreedthis
wasanimportantareawhichrequiresfurtherresearch.

Otherconsiderations

Thegroupwereawareofagrowingevidencebaseofthebenefitsof
postoperativepatientsarefullyhydratedinreducinglengthofstayin
hospital.
TheGDGnotedthatpatientsshouldbeweighedregularlyandany
weightlossneedstobeexplainedandagreedthattheproblemofweight
lossmaybeduetodysphagia,butcouldalsobeattributedtoother
causessuchasdifficultiesfeedingduetoneglect,orupperlimb
weaknessordepression.

NationalClinicalGuidelineCentre,2013.
Draftforconsultation:22112012
248

12 Communication
12.1 Aphasia
Aphasiadescribesalanguagedisorderthatresultsfromdamagetoareasofthebrainresponsiblefor
differentaspectsoflanguage.Oneorseveralmodesofcommunicationincludingcomprehensionand
expressionwhichinvolvespeech,writingandgesture,maybeaffected.Beyondthedirect
impairment,aphasiaimpactsonmanyaspectsoftheindividualslifesuchasrelationships,social
engagementandindependence.Ithasbeenestimatedthatapproximatelyonethirdofstroke
survivorsareaffectedbyaphasia(DepartmentofHealth2007).
TheSpeechandLanguageTherapistsassessmentresultsinformtheaimsandobjectivesoftargeted
intervention.Thiswillhavebeennegotiatedwiththeindividualandasappropriatewiththeirfamily
orcarers.SpeechandLanguageTherapyisfocusedonimprovinganindividual'sabilityto
communicatethroughmultiplestrategiesbyaimingto:
helpthepersontouseandenhanceremainingabilities.
restorelanguageabilitiesasmuchaspossible.
compensateforlanguageproblemsbydevelopingstrategies.
learnothermethodsofcommunicating.
Coachothers(family,healthandsocialcarestaff)tolearneffectivecommunicationskillsto
maximisetheaphasicpatientscompetence.
AsearchforevidencefromsystematicreviewswascarriedoutandaCochranesystematicreview
(Bradyetal,201230)wasidentifiedforthemanagementofaphasiaanddysarthria.Thissystematic
reviewwasupdatedandrecommendationsweredrawnonthisevidence.Therewasalackofdirect
evidenceforinterventionsfordysphasia,dysarthriaandapraxiaofspeechandthereforemodified
Delphistatementsweredevelopedforthistopicareabasedonrecommendationsinpublished
nationalandinternationalguidelines(section12.3).

12.1.1

EvidenceReview:Inpeoplewhohaveaphasiaafterstrokeisspeechandlanguagetherapy
comparedtonospeechandlanguagetherapyorplacebo(socialsupportandstimulation)
effectiveinimprovinglanguage/communicationabilitiesand/orpsychologicalwellbeing?
ClinicalMethodologicalIntroduction
Population

Adultsandyoungpeople16orolderwhohaveaphasiaafterstroke
andwhohavebeenassessedashavingaphasia.

Intervention

Speechandlanguagetherapy:

Comparison

Anyformoftargetedpracticetasksormethodologieswiththe
aimofimprovinglanguageorcommunicationabilitiesnot
necessarilyprovidedbyaprofessionalspeechandlanguage
therapist
Nospeechandlanguagetherapy
Placebo(socialsupportandcommunicativestimulation):
Emotional,psychologicalorcreativeinterventions(suchasart,
danceormusic),conversationorotherinformal,unstructured
communicativeinteractions.Thiscomparisondoesnotinclude
targetedtherapeuticinterventionsthataimtoresolve
participantsexpressiveorreceptivespeechandlanguage
impairments

NationalClinicalGuidelineCentre,2013.
249


ClinicalMethodologicalIntroduction
Outcomes

12.1.1.1

Functionalcommunication(languageorcommunicationskills
sufficienttopermitthetransmissionofmessageviaspoken,
writtenornonverbalmodalities,oracombinationofthese
channels)
Formalmeasuresofreceptivelanguageskills(language
understanding)
Formalmeasuresofexpressivelanguageskills(language
production)
Overalllevelofseverityofaphasiaasmeasuredbyspecialisttest
batteries(mayincludeWesternAphasiaBatteryorPorchIndexof
CommunicativeAbilities)
Psychologicalorsocialwellbeingincludingdepression,anxietyand
distress
Patientsatisfaction/carerandfamilyviews
Compliance/dropout

ClinicalEvidenceReview
AsearchwasconductedforsystematicreviewscomparingtheclinicaleffectivenessofSpeechand
LanguageTherapy(SLT)withnoSLTorplacebo(socialsupportandstimulation)toimprovelanguage,
communicationabilitiesand/orpsychologicalwellbeinginadultsandyoungpeople16orolderwho
havehadastroke.
OneCochranesystematicreview(Brady201230)thatassessedtheeffectivenessofSLTforaphasia
afterstrokewasidentified.TheCochranereviewincludedatotalof39trials(RCTs).Fromthesetrials,
weincluded12trialsmatchingourprotocol(Table64)andweinspectedanadditionaltrial107from
theCochranelistofexcludedtrials.Wedeemedthistrialsuitableforreinclusion.Weexcluded
studieswithChineselanguageoutcomemeasures(duetomajorlinguisticdifferences)andthose
withanacutestrokepopulation.
AfurtherupdatesearchwasconductedforanytrialpublishedsinceJuly2011whichwasthesearch
cutoffdateoftheincludedCochranereviewandonestudy(Palmer2012198)(Table66)was
identified.
IntheCochranesystematicreviewthefollowingstrategyofanalysiswasadopted:
TrialswereincludediftheyreportedacomparisonbetweenagroupthatreceivedSLT
intervention(providedeitherbyaspeechandlanguagetherapist,atrainedvolunteeror
computer)andagroupthatreceived:
o NoSLTintervention(Table64);or
o Socialsupportorstimulation(Table9)
SixFivetrials133241283157236randomisedparticipantsacrossthreeormoregroups(trialarms).For
thepurposeofmetaanalysis,datafromthesetrialswerepresentedandpooledwithinpaired
comparisons(seeGRADEtablesandforestplots)
Thereviewpresenteddatafromthesefivetrials133241283157236inpairedsubcomparisons.For
exampledatafromWertz1986weredividedintotwosubcomparisonsof(1)conventionalSLT
versusnoSLT(Wertz1986i283),(2)volunteeredfacilitatedSLTversusnoSLT(Wertz1986ii283)
(Table64).Otherexampleswere;Katz1997i133;Katz1997ii133;Smith1981i241;Smith1981ii241;
Wertz1986i283;Wertz1986ii283
Differentmeasurementtools(forexample,WesternAphasiaBattery(WAB),Amsterdam
NijmeganEverydayLanguageTest(ANELTA),PorchIndexofCommunicativeAbilities(PICA)
amongstothers)assessingasingleoutcomewerecombinedanddatapresentedinameta

NationalClinicalGuidelineCentre,2013.
250

analysisusingstandardisedmeandifferencesummarystatistic(seeGRADETablesandforest
plots)
ForSLTversusnoSLT,reportedfollowupassessmentsrangedfromtwomonths(Smania2006240)
to12months(MacKay1988)(seeGRADEtableandforestplots)
ForSLTversussocialsupportandstimulation,reportedfollowupassessmentsrangedfromfour
weeks(Rochon2005217)totenmonths(Hartman1987107)
Nonlanguageoutcomeswerealsoreported.Thesewereselfreportedanxiety,depressionand
hostility.
Inadditionnumberofdropoutsandnoncompliancewithtreatmentwerealsoanalysed

Forthisreview,wehaveincluded9trials(Table64)comparingSLTtonoSLTand5trials(Table9)
comparingSLTtoplacebo(socialsupportandstimulation).
Wehavealsoincludedanadditionaltrial(Hartman1987107)comparingconventionalSLTwith
emotionallysupportivecounsellingtherapy(placebo)(Table9).Itwasclassifiedasaquasi
randomisedstudybytheCochrane.Thisstudyhadseriousstudylimitationsduetopoorallocation
concealment,butweconcludedthatitwasarandomisedstudyandreincludeditintheanalysis.The
studylimitationswerethenconsideredintheGRADErating(seeGRADETable68).

Overallfunctionalcommunication,receptivelanguage,expressivelanguageandseverityof
impairmentacrossincludedtrialsaswellasthedifferentassessmenttoolsusedtomeasurethese
outcomeswereanalysed.Forthisreason,wehaveonerowrepresentingthetotaleffectand23
followingrowsforthedifferentassessmenttoolsused.
Theevidencestatementsalsoreflectthetotaleffectsaswellastheeffectsoftheassessmenttools
used.
PleaseseeAppendixMforexcludedtrials.
Table64: SpeechandLanguageTherapy(SLT)versusnoSLT
OverviewofincludedstudiesfromtheCochranesystematicreview
NUMBEROF
PARTICIPANTS

STUDIES
66

INTERVENTION

OUTCOMES

Doesborgh2004 ;
Katz1997i133;Katz1997ii
133

103participants

ComputermediatedSLT:
Improvenamingusing
computercueing
programme;computerised
languagetasksusingvisual
matchingandreading
comprehension.

Functional
communication
Receptivelanguage
skills
Expressivelanguage
skills
Severityofaphasia
Psychologicalor
socialwellbeing
includingdepression,
anxietyanddistress
Compliance/drop
out

Jufeng2005iiLincoln
1984156;Smania2006240;
Smith1981ii241;Wertz
1986i283

548participants

AllusedconventionalSLT:
Aschosenbyeachspeech
andlanguagetherapist.

NationalClinicalGuidelineCentre,2013.
251


NUMBEROF
PARTICIPANTS

STUDIES
163

INTERVENTION

MacKay1988 ;Wertz
1986ii283

179participants

VolunteerfacilitatedSLT:
SLTadministeredbytrained
volunteer(family
member/friend)withno
previoushealthcare
experience.

Smith1981i241

33participants

IntensiveSLT:
TypeofintensiveSLTnot
described,butintensivedue
tonumberandlengthof
sessionsperweek

OUTCOMES

Table65: SpeechandLanguageTherapy(SLT)versusplacebo(socialsupportandstimulation)
OverviewofincludedstudiesfromtheCochranesystematicreviewandoneadditionalstudy
(Hartman1987107)thatwasexcludedintheCochranereviewbutaddedtothisreview
NUMBEROF
PARTICIPANTS

STUDIES
56

INTERVENTION

David1982 ;Elman
199976;Hartman
1987107;Lincoln
1982iii157;Shewan
1984iii236

284participants

ConventionalSLT:
Aschosenbyeach
speechandlanguage
therapist

Rochon2005217

5participants

Sentencemapping
SLT:

Shewan1984ii236

53participants

Languageoriented
SLT:

SOCIALSUPPORT
AND
STIMULATION*
Untrained
volunteers
receiveddetails
aboutparticipants
aphasia,andwere
instructedto
stimulate
communicationto
thebestoftheir
ability.Theywere
notgiven
instructioninSLT
techniques;
participantsalso
attendedsocial
groupactivitiesof
theirchoice.

Unstructured
conversation
4levelsoftreatment: aboutcurrent
events;
active,subjectcleft,
participantswere
passive,objectcleft
givenanarrative
sentences
retellingtaskon
alternatesessions

Basedon
psycholinguistic
(psychologyof
language)principles
providedbyspeech
andlanguage

NationalClinicalGuidelineCentre,2013.
252

Basedon
stimulation
orientation,
providing
psychological
support,
communicationin
unstructured
settingscarried

OUTCOMES
Functional
communication
Receptive
languageskills
Expressive
languageskills
Severityof
aphasia
Psychologicalor
socialwellbeing
including
depression,
anxietyand
distress
Carers
perspectiveof
theparticipants
communication
Compliance/
dropout

NUMBEROF
PARTICIPANTS

STUDIES
Bowen201229
ACTNoW(Assessing
theeffectivenessof
Communication
TherapyintheNorth
West)

170participants
and135carers

INTERVENTION
therapists
Therapystarted2
weeksafterstoke
andinvolved22
contacts,for18
hours(mean),
deliveredover13
weeksinboth
hospitaland
communitysettings
byqualifiedNHSSL
therapists.

(N=85)

SOCIALSUPPORT
AND
STIMULATION*
outbynurses

OUTCOMES

19contacts,for15
hours(mean),
deliveredover13
weeksby
employedvisitors
withno
professional
experienceof
strokeorSL
therapy.Visitors
weretrainedto
deliversocial
attentionabsent
ofanyintuitive
formof
communication
therapyor
strategy.
(N=85)

*supportandcommunicativestimulation:Providedbyvolunteers.TheyweregivennoguidanceorinstructioninSLT
techniquesbutwereprovidedwithdetailedinformationontheirpatientscommunicationproblemsandwereinstructed
tostimulatecommunicationtothebestoftheirability.

Table66: OverviewofadditionalRCT(Palmer2012198)sincethesearchcutoffdateofthe
Cochranesystematicreview
STUDY

POPULATION

INTERVENTION

COMPARISON

OUTCOMES

Palmer
2012198

Participantswith
strokeandaphasia
withwordfinding
difficultiesasoneof
thepredominant
features;abilityto
repeatspoken
words;nolonger
receivingspeech
andlanguage
therapy.

Usuallanguage
activitiesasforcontrol
groupplusspeechand
languagetherapy
deliveredthrough
independentuseof
computerprogram
(StepbyStep;libraryof
over13000language
exercises)supported
byavolunteer;work
throughexercisesfor
atleast20minutes3
daysaweekfor5
months

Participationin
activitiesthat
providegeneral
language
stimulation:
attendanceat
communication
supportgroupsand
conversation,
readingandwriting
activitiesthatare
partofdailylife

Percentage
improvementin
wordretrieval
ability(from
Objectand
ActionNaming
Battery)

NationalClinicalGuidelineCentre,2013.
253

Comparison:SpeechandLanguageTherapy(SLT)versusnoSLT
Table67: SpeechandLanguageTherapy(SLT)versusnoSLTStudyreferencesandsummaryoffindings
Qualityassessment

Summaryoffindings
Effect

Noof
studies

Design

Limitations

Inconsistency

Indirectness

Imprecision

Standard
Mean
Difference
SLT
NoSLT
(SMD)/
Mean(SD)/ Mean(SD)/ Mean
Frequency Frequency difference
(%)
(%)
(95%CI)

Absolute
effect/
Standard
Mean
Difference
(SMD)(95% Confidence
CI)
(ineffect)

Noserious
indirectness

Serious
imprecision(
b)

Seesub
groupfor
means

Seesub
groupfor
means

0.28(0.03,
0.59)

SMD0.28
Low
higher(0.03
lowerto
0.59higher)

Serious
imprecision(
b)

Katz(i):
13.8(5.3)
Katz(ii):
13.8(5.3)

Katz(i):
13.7(5)
Katz(ii):
12.2(6.7)

0.14(0.40,
0.69)

SMD0.14
Low
higher(0.4
lowerto
0.69higher)

Serious
imprecision(
b)

34.3(8.4)

25.5(10.3)

0.88(0.10,
1.87)

SMD0.88
Low
higher(0.1
lowerto
1.87higher)

Wertz(i):
55.60

0.25(0.16;
0.66)

SMD0.25
Low
higher(0.16

Functionalcommunication(Betterindicatedbyhighervalues)
3
RCTsingle
blind
Seesub
groups
below(next
6rows)

Serious
limitations(a
)

Noserious
inconsistency

FunctionalcommunicationWAB(Betterindicatedbyhighervalues)
1
Katz1997i
133
;Katz
1997ii133

RCTsingle
blind

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

FunctionalcommunicationANELTA(Betterindicatedbyhighervalues)
1
Doesborgh
200466

RCTsingle
blind

Serious
limitations(d
)

Noserious
inconsistency

Noserious
indirectness

FunctionalcommunicationFunctionalCommunicationProfile(Betterindicatedbyhighervalues)
1
Wertz

RCTsingle
blind

Serious
limitations(a

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(

Wertz(i):
59.35

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254

Qualityassessment

Summaryoffindings
Effect

Noof
studies
1986i283;
Wertz
1986ii283

Design

Limitations
)

Inconsistency

Indirectness

Imprecision
b)

Standard
Mean
Difference
SLT
NoSLT
(SMD)/
Mean(SD)/ Mean(SD)/ Mean
Frequency Frequency difference
(%)
(%)
(95%CI)
(19.62)
(19.56)
Wertz(ii):
Wertz(ii):
62.05
55.60
(21.83)
(19.56)

Absolute
effect/
Standard
Mean
Difference
(SMD)(95% Confidence
CI)
(ineffect)
lowerto
0.66higher)

Seesub
groupfor
means

Seesub
groupfor
means

0.10(0.20,
0.39)

SMD0.1
Moderate
higher(0.2
lowerto
0.39higher)

Katz(i):
61.7(19.8)
Katz(ii):
61.7(19.8)

Katz(i):
58.7(25.3)
Katz(ii):
57.9(23.9)

0.15(0.40,
0.69)

SMD0.15
Low
higher(0.4
lowerto
0.69higher)

Smania:
18.2(7.65)
Wertz(i):
118.39
(41.95)
Wertz(ii):
119.89

Smania:
14.94
(10.23)
Wertz(i):
119.91
(38.48)
Wertz(ii):

0.08(0.27,
0.43)

SMD0.08
Moderate
higher(0.27
lowerto
0.43higher)

Receptivelanguage:auditorycomprehension(Betterindicatedbyhighervalues)
3
RCTsingle
blind
Seesub
groups
below(next
4rows)

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

Receptivelanguage:auditorycomprehensionPICAsubtest(Betterindicatedbyhighervalues)
1
Katz1997i
133
;Katz
1997ii133

RCTsingle
blind

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
b)

Receptivelanguage:auditorycomprehensionTokenTest(Betterindicatedbyhighervalues)
2
Smania
2006240;
Wertz
1986i283;
Wertz
1986ii283

RCTsingle
blind

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

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255

Qualityassessment

Summaryoffindings
Effect

Noof
studies

Design

Limitations

Inconsistency

Indirectness

Imprecision

Standard
Mean
Difference
SLT
NoSLT
(SMD)/
Mean(SD)/ Mean(SD)/ Mean
Frequency Frequency difference
(%)
(%)
(95%CI)
(45.06)
119.91
(38.48)

Absolute
effect/
Standard
Mean
Difference
(SMD)(95% Confidence
CI)
(ineffect)

Seesub
groupfor
means

0.11(0.21,
0.44)

SMD0.11
Moderate
higher(0.21
lowerto
0.44higher)

Wertz(i):
75.03
(18.06)
Wertz(ii):
75.03
(18.06)

0.11(0.3,
0.52)

SMD0.11
Low
higher(0.3
lowerto
0.52higher)

Katz(i):
69.8(22.6)
Katz(ii):
69.8(22.6)

Katz(i):
69.3(20.2)
Katz(ii):
65.1(22.2)

0.12(0.42,
0.67)

SMD0.12
Low
higher(0.42
lowerto
0.67higher)

Katz(i):
79.8(14.1)

Katz(i):
66.3(21.9)

8.04(1.55,
14.52)

MD8.04
Low
higher(1.55

Receptivelanguage:readingcomprehension(Betterindicatedbyhighervalues)
2
RCTsingle
blind
Seesub
groups
below(next
4rows)

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

Seesub
groupfor
means

Receptivelanguage:readingcomprehensionReadingComprehensionBatteryforAphasia(Betterindicatedbyhighervalues)
1
Wertz
1986i283;
Wertz
1986ii283

RCTsingle
blind

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
b)

Wertz(i):
76.90
(16.97)
Wertz(ii):
77.24
(20.79)

Receptivelanguage:readingcomprehensionPICAreadingsubtest(Betterindicatedbyhighervalues)
1
Katz1997i
133
;Katz
1997ii133

RCTsingle
blind

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
b)

Receptivelanguage:gestureusePICAGesturalsubtest(Betterindicatedbyhighervalues)
2
Katz1997i

RCTsingle
blind

Serious
limitations(a

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(

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256

Qualityassessment

Summaryoffindings
Effect

Noof
studies
133
;Katz
1997ii133;
Wertz
1986i283;
Wertz
1986ii283

Design

Limitations
)

Inconsistency

Indirectness

Imprecision
e)

Standard
Mean
Difference
SLT
NoSLT
(SMD)/
Mean(SD)/ Mean(SD)/ Mean
Frequency Frequency difference
(%)
(%)
(95%CI)
Katz(ii):
Katz(ii):
79.8(14.1) 68.30(23)
Wertz(i):
Wertz(i):
65.32
59.68
(19.03)
(20.98)
Wertz(ii):
Wertz(ii):
62.78
59.68
(25.67)
(20.98)

Absolute
effect/
Standard
Mean
Difference
(SMD)(95% Confidence
CI)
(ineffect)
to14.52
higher)

Receptivelanguage:gesturecomprehension(postintervention)Unnamedgesturecomprehensionassessmenttool(Betterindicatedbyhighervalues)
1
Smania
2006240

RCTsingle
blind

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
b)

7.36(2.17)

8.28(1.36)

0.92(
2.19,0.35)

MD0.92
Low
lower(2.19
lowerto
0.35higher)

Receptivelanguage:gesturecomprehension(2monthsfollowup)Unnamedgesturecomprehensionassessmenttool(Betterindicatedbyhighervalues)
1
Smania
2006240

RCTsingle
blind

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
b)

6.75(2.81)

7.89(1.17)

1.14(
3.23,0.95)

MD1.14
Low
lower(3.23
lowerto
0.95higher)

Noserious
indirectness

Serious
imprecision(
b)

Seesub
groupfor
means

Seesub
groupfor
means

0.2(0.27,
0.68)

SMD0.2
Low
higher(0.27
lowerto
0.68higher)

Expressivelanguage:naming(Betterindicatedbyhighervalues)
2
RCTsingle
blind
Seesub
groups
below(next
4rows)

Serious
limitations(a
)

Noserious
inconsistency

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257

Qualityassessment

Summaryoffindings
Effect

Noof
studies

Design

Limitations

Inconsistency

Indirectness

Imprecision

Standard
Mean
Difference
SLT
NoSLT
(SMD)/
Mean(SD)/ Mean(SD)/ Mean
Frequency Frequency difference
(%)
(%)
(95%CI)

Absolute
effect/
Standard
Mean
Difference
(SMD)(95% Confidence
CI)
(ineffect)

75.6(38.7)

75.7(36.7)

SMD0
Verylow
higher(0.93
lowerto
0.93higher)

Katz(i):7
(2.4)
Katz(ii):7
(2.4)

Katz(i):6.9 0.27(0.27,
(2.8)
0.82)
Katz(ii):5.5
(3.3)

Expressivelanguage:namingBostonNamingTest(Betterindicatedbyhighervalues)
1
Doesborgh
2004b66

RCTsingle
blind

Serious
limitations(d
)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision(f
)

0.00(0.93,
0.93)

Expressivelanguage:namingWABNamingsubtest(Betterindicatedbyhighervalues)
1
Katz1997i
133
;Katz
1997ii133;

RCTsingle
blind

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
b)

SMD0.27
Low
higher(0.27
lowerto
0.82higher)

Expressivelanguage:namingObjectandActionNamingBattery5monthsfollowup(Meandifferenceinchangefrombaselinebetterindicatedbyhighervalues)
1
Palmer
202198

RCTsingle
blind

Noserious
inconsistenc
y

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
b)

N=15

N=13

N/A

Mean
difference
from
baseline
19.8(4.4
35.2)

Moderate

Expressivelanguage:namingObjectandActionNamingBattery8monthsfollowup(Meandifferenceinchangefrombaselinebetterindicatedbyhighervalues)
1
Palmer
202198

RCTsingle
blind

Noserious
inconsistenc
y

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
b)

N=12

N=11

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258

N/A

Mean
difference
from
baseline

Moderate

Qualityassessment

Summaryoffindings
Effect

Noof
studies

Design

Limitations

Inconsistency

Indirectness

Standard
Mean
Difference
SLT
NoSLT
(SMD)/
Mean(SD)/ Mean(SD)/ Mean
Frequency Frequency difference
(%)
(%)
(95%CI)

Absolute
effect/
Standard
Mean
Difference
(SMD)(95% Confidence
CI)
(ineffect)
11.3(7.4
29.9)

Katz(i):
62.3(22.3)
Katz(ii):
62.3(22.3)
Wertz(i):
56.48
(18.29)
Wertz(ii):
57.41
(20.1)

Katz(i):
58.1(19.1)
Katz(ii):
50.6(24.5)
Wertz(i):
52.8
(19.48)
Wertz(ii):
52.8
(19.48)

5.28(1.33,
11.89)

MD5.28
Low
higher(1.33
lowerto
11.89
higher)

Serious
imprecision(
b)

Katz(i):
61.9(14.8)
Katz(ii):
61.9(14.8)

Katz(i):
60.4(19)
Katz(ii):
55.4(24.2)

3.88(5.75,
13.5)

MD3.88
Low
higher(5.75
lowerto
13.5higher)

Serious
imprecision(
b)

Seesub
groupfor
means

Seesub
groupfor
means

0.28(0.05,
0.61)

SMD0.28
Low
higher(0.05
lowerto
0.61higher)

Imprecision

Expressivelanguage:generalPICAVerbalsubtest(Betterindicatedbyhighervalues)
2
Katz1997i
133
;Katz
1997ii133;
Wertz
1986i283;
Wertz
1986ii283

RCTsingle
blind

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
g)

Expressivelanguage:writtencopyingPICACopyingsubtest(Betterindicatedbyhighervalues)
1
Katz1997i
133
;Katz
1997ii133

RCTsingle
blind

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

Expressivelanguage:written(Betterindicatedbyhighervalues)
2
RCTsingle
blind
Seesub
groups
below(next

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

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259

Qualityassessment

Summaryoffindings
Effect

Noof
studies
4rows)

Design

Limitations

Inconsistency

Indirectness

Standard
Mean
Difference
SLT
NoSLT
(SMD)/
Mean(SD)/ Mean(SD)/ Mean
Frequency Frequency difference
(%)
(%)
(95%CI)

Absolute
effect/
Standard
Mean
Difference
(SMD)(95% Confidence
CI)
(ineffect)

Serious
imprecision(
b)

Katz(i):
66.9(23.2)
Katz(ii):
66.9(23.2)

Katz(i):
59.2(23.1)
Katz(ii):
57.9(25.3)

0.34(0.21,
0.89)

SMD0.34
Low
higher(0.21
lowerto
0.89higher)

Serious
imprecision(
b)

Wertz(i):
72.64
(16.6)
Wertz(ii):
74.86
(21.74)

Wertz(i):
68.57
(22.69)
Wertz(ii):
68.57
(22.69)

0.25(0.16,
0.66)

SMD0.16
Low
higher(0.16
lowerto
0.66higher)

Katz(i):7.3
(2.9)
Katz(ii):7.3
(2.9)

Katz(i):6.7 0.92(0.76,
(3.4)
2.61)
Katz(ii):6.1
(3.4)

MD0.92
Low
higher(0.76
lowerto
2.61higher)

Katz(i):
66.4(19.4)
Katz(ii):

Katz(i):
61.3(17.4)
Katz(ii):

SMD0.26
Low
higher(0.07
lowerto

Imprecision

Expressivelanguage:writtenPICAWritingsubtest(Betterindicatedbyhighervalues)
1
Katz1997i
133
;Katz
1997ii133

RCTsingle
blind

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

Expressivelanguage:writtenPICAGraphic(Betterindicatedbyhighervalues)
1
Wertz
1986i283;
Wertz
1986ii283

RCTsingle
blind

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Expressivelanguage:repetitionWABRepetitionsubtest(Betterindicatedbyhighervalues)
1
Katz1997i
133
;Katz
1997ii133

RCTsingle
blind

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
b)

Severityofimpairment:PorchIndexofCommunicativeAbility(Betterindicatedbylowervalues)
2
Katz1997i
133
;Katz

RCTsingle
blind

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
b)

NationalClinicalGuidelineCentre,2013.

260

0.26(0.07,
0.58)

Qualityassessment

Summaryoffindings
Effect

Noof
studies
1997ii133;
Wertz
1986i283;
Wertz
1986ii283

Design

Limitations

Inconsistency

Indirectness

Standard
Mean
Difference
SLT
NoSLT
(SMD)/
Mean(SD)/ Mean(SD)/ Mean
Frequency Frequency difference
(%)
(%)
(95%CI)
66.4(19.4)
56.3(20.9)
Wertz(i):
Wertz(i):
65.65
61.66
(24.64)
(21.21)
Wertz(ii):
Wertz(ii):
67.19
61.66
(24.64)
(21.21)

Absolute
effect/
Standard
Mean
Difference
(SMD)(95% Confidence
CI)
(ineffect)
0.58higher)

3(3.2)

2.6(2.6)

0.4(0.57,
1.37)

MD0.4
High
higher(0.57
lowerto
1.37higher)

Noserious
imprecision

6.9(6.6)

6.2(5.8)

0.7(1.38,
2.78)

MD0.7
High
higher(1.38
lowerto
2.78higher)

Noserious
imprecision

2.7(2.7)

2.8(2.1)

0.1(0.9,
0.7)

MD0.1
High
lower(0.9
lowerto0.7
higher)

Imprecision

Psychosocial:MAACLAnxietyScale(MAACL)(Betterindicatedbylowervalues)
1
Lincoln
1984156

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

Psychosocial:MAACLDepressionScale(MAACL)(Betterindicatedbylowervalues)
1
Lincoln
1984156

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Psychosocial:MAACLHostilityScale(MAACL)(Betterindicatedbylowervalues)
1
Lincoln
1984156

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Numberofdropouts(anyreason)

NationalClinicalGuidelineCentre,2013.

261

Qualityassessment

Summaryoffindings
Effect

Noof
studies
7
Doesborgh
200466;
Katz1997i
133
;Katz
1997ii133;
Lincoln
1984156;
Mackay
1988163;
Smania
2006240;
Smith
1981i241;
Smith
1981ii241;
Wertz
1986i283;
Wertz
1986ii283

Standard
Mean
Difference
SLT
NoSLT
(SMD)/
Mean(SD)/ Mean(SD)/ Mean
Frequency Frequency difference
(%)
(%)
(95%CI)

Absolute
effect/
Standard
Mean
Difference
(SMD)(95% Confidence
CI)
(ineffect)

Design

Limitations

Inconsistency

Indirectness

Imprecision

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

121/372
(32.50%)

122/342
(35.70%)

RR0.92
(0.76,1.11)

29fewer
per1000
(from86
fewerto39
more)

High

Noserious
indirectness

Veryserious
imprecision(
b)

7/20
(35%)

5/21
(23.8%)

RR1.47
(0.56to
3.88)

112more
per1000
(from105
fewerto

Verylow

Noncompliancewithallocatedintervention(anyreason)
1
Smania
2006240

RCTsingle
blind

Serious
limitations(c
)

Noserious
inconsistency

NationalClinicalGuidelineCentre,2013.

262

Qualityassessment

Summaryoffindings
Effect

Noof
studies
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)

Design

Limitations

Inconsistency

Indirectness

Imprecision

Standard
Mean
Difference
SLT
NoSLT
(SMD)/
Mean(SD)/ Mean(SD)/ Mean
Frequency Frequency difference
(%)
(%)
(95%CI)

Unclearrandomisation;unclearallocationconcealment.Limitationswereconsideredbystudyweightsinthemetaanalysis
ConfidenceIntervalcrossesoneendofdefaultMID(0.5)
Unclearallocationconcealment
Outcomeassessorsnotblinded
ConfidenceIntervalcrossesMID(10.72)
ConfidenceIntervalcrossesbothendsofdefaultMID(0.5)
ConfidenceIntervalcrossesMID(9.74)
Heterogeneity=82%

NationalClinicalGuidelineCentre,2013.

263

Absolute
effect/
Standard
Mean
Difference
(SMD)(95% Confidence
CI)
(ineffect)
686more)

Comparison:SpeechandLanguageTherapy(SLT)versusplacebo(socialsupportandstimulation)
Table68: SpeechandLanguageTherapy(SLT)versusplacebo(socialsupportandstimulation)Studyreferencesandsummaryoffindings
Qualityassessment

Summaryoffindings
Effect

Noof
studies

Design

Limitations

Inconsistency

Indirectness

Imprecision

SLT
Mean
(SD)/
Frequency
(%)

Placebo
(social
supportand
stimulation)
Mean(SD)/
Frequency
(%)

Seesub
groupfor
means

Seesub
groupfor
means

Standard
Mean
Difference
/Mean
difference
(95%CI)

Absolute
effect/
Standard
Mean
Difference
(SMD)or
Mean
Difference
(MD)(95%
CI)

Confidence
(ineffect)

FunctionalcommunicationFunctionalCommunication(Betterindicatedbyhighervalues)
2
4
rows)Davi
d1982

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

0.04(0.22, SMD0.04
0.29)
higher
(0.22lower
to0.29
higher)

High

0.10(
0.50,0.30)

SMD0.10
lower(0.50
lowerto
0.30
higher)

High

0.13(
0.20,0.47)

SMD0.13
lower(0.20
lowerto

High

FunctionalcommunicationFunctionalCommunicationProfile(postintervention)(Betterindicatedbyhighervalues)
1
David
198256

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

67(20.3)

69.2(22.4)

FunctionalcommunicationTherapyoutcomemeasuresTOMs(postintervention)(Betterindicatedbyhighervalues)
1
Bowen

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

67(20.3)

69.2(22.4)

NationalClinicalGuidelineCentre,2013.

264

Qualityassessment

Summaryoffindings
Effect

Noof
studies
201229
ACTNoW

Design

Limitations

Inconsistency

Indirectness

Imprecision

SLT
Mean
(SD)/
Frequency
(%)

Placebo
(social
supportand
stimulation)
Mean(SD)/
Frequency
(%)

Standard
Mean
Difference
/Mean
difference
(95%CI)

Absolute
effect/
Standard
Mean
Difference
(SMD)or
Mean
Difference
(MD)(95%
CI)
0.47
higher)

Confidence
(ineffect)

FunctionalcommunicationFCP(3monthfollowup)(Betterindicatedbyhighervalues)
1
David
198256

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
a)

70.4(19.1) 69(21.8)

1.4(8.01,
10.81)

MD1.4
higher
(8.01lower
to10.81
higher)

Moderate

69.3(19.6) 68(21.2)

1.3(8.07,
10.67)

MD1.3
higher
(8.07lower
to10.67
higher)

Moderate

6(12.94,
24.94)

MD6
higher
(12.94
lowerto
24.94
higher)

Verylow

FunctionalcommunicationFCP(6monthfollowup)(Betterindicatedbyhighervalues)
1
David
198256

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
a)

Receptivelanguage:auditorycomprehensionSentenceComprehensionTest(PCB)(Betterindicatedbyhighervalues)
1
Rochon
2005217

RCTsingle
blind

Veryserious Noserious
limitation(b) inconsistency

Noserious
indirectness

Veryserious
imprecision(
c)

72(16)

66(4)

NationalClinicalGuidelineCentre,2013.

265

Qualityassessment

Summaryoffindings
Effect

Noof
studies

Design

Limitations

Inconsistency

Indirectness

Imprecision

SLT
Mean
(SD)/
Frequency
(%)

Placebo
(social
supportand
stimulation)
Mean(SD)/
Frequency
(%)

Standard
Mean
Difference
/Mean
difference
(95%CI)

Absolute
effect/
Standard
Mean
Difference
(SMD)or
Mean
Difference
(MD)(95%
CI)

Confidence
(ineffect)

Receptivelanguage:auditorycomprehensionPictureComprehensionTest(PCB)(Betterindicatedbyhighervalues)
1
Rochon
2005217

RCTsingle
blind

Veryserious Noserious
limitation(b) inconsistency

Noserious
indirectness

Veryserious
imprecision(
c)

78(16)

70(4)

MD8(
10.94,
26.94)

MD8
higher
(10.94
lowerto
26.94
higher)

Verylow

59(13.93)

62.83(16.13) 3.83(
18.95,
11.29)

MD3.83
lower
(18.95
lowerto
11.29
higher)

Verylow

0.87(1.7,
0.04)

MD0.87
lower(1.7
to0.04
lower)

Low

7(11.67,

MD7lower Low

Receptivelanguage:auditorycomprehensionTokenTest(Betterindicatedbyhighervalues)
1
157

Rochon
2005

RCTsingle
blind

Veryserious Noserious
limitation(b) inconsistency

Noserious
indirectness

Veryserious
imprecision(
c)

Receptivelanguage:auditoryandwrittencomprehensionPICAGesturalsubtest(Betterindicatedbyhighervalues)
1
Lincoln
1982iii157

RCTsingle
blind

Serious
Noserious
limitation(d) inconsistency

Noserious
indirectness

Serious
imprecision(
a)

12.14(0.8) 13.01(0.87)

Expressivelanguage:singlewordsObjectNamingTest(ONT)(Betterindicatedbyhighervalues)
1

RCTsingle

Serious

Noserious

Noserious

Serious

9.83(6.32) 16.83(3.76)

NationalClinicalGuidelineCentre,2013.

266

Qualityassessment

Summaryoffindings
Effect

Noof
studies
Lincoln
1982iii157

Design
blind

Limitations
limitation(d)

Inconsistency
inconsistency

Indirectness
indirectness

Imprecision
imprecision(
a)

Absolute
effect/
Standard
Mean
Difference
(SMD)or
Mean
Difference
(MD)(95%
CI)
(11.67to
2.33lower)

SLT
Mean
(SD)/
Frequency
(%)

Placebo
(social
supportand
stimulation)
Mean(SD)/
Frequency
(%)

10(5.98)

24(6.72)

14(
20.35,
7.65)

MD14
lower
(20.35to
7.65lower)

Moderate

7(2)

5(3)

2(2.73,
6.73)

MD2
higher
(2.73lower
to6.73
higher)

Verylow

3(0.5)

3(0.63,
5.37)

MD3
higher
(0.63to
5.37
higher)

Verylow

Standard
Mean
Difference
/Mean
difference
(95%CI)
2.33)

Confidence
(ineffect)

Expressivelanguage:singlewordsWordfluency(Betterindicatedbyhighervalues)
1
Lincoln
1982iii157

RCTsingle
blind

Serious
Noserious
limitation(d) inconsistency

Noserious
indirectness

Noserious
imprecision

Expressivelanguage:sentencesCaplan&HannaTest:total(Betterindicatedbyhighervalues)
1
Rochon
2005217

RCTsingle
blind

Veryserious Noserious
limitation(b) inconsistency

Noserious
indirectness

Veryserious
imprecision(
c)

Expressivelanguage:sentencesCaplan&HannaTest:treated(Betterindicatedbyhighervalues)
1
Rochon
2005217

RCTsingle
blind

Veryserious Noserious
limitation(b) inconsistency

Noserious
indirectness

Veryserious
imprecision(
c)

6(2)

Expressivelanguage:sentencesCaplan&HannaTest:untreated(Betterindicatedbyhighervalues)

NationalClinicalGuidelineCentre,2013.

267

Qualityassessment

Summaryoffindings
Effect

Noof
studies
1
Rochon
2005217

Design

Limitations

Inconsistency

Indirectness

Imprecision

RCTsingle
blind

Veryserious Noserious
limitation(b) inconsistency

Noserious
indirectness

Veryserious
imprecision(
c)

Absolute
effect/
Standard
Mean
Difference
(SMD)or
Mean
Difference
(MD)(95%
CI)

SLT
Mean
(SD)/
Frequency
(%)

Placebo
(social
supportand
stimulation)
Mean(SD)/
Frequency
(%)

1(1)

2(3)

1(5.31,
3.31)

Lincoln
(iii):33.67
(22)
Rochon:
34.67
(4.04)

Lincoln(iii):
30.67(7.87)
Rochon:27
(11.31)

0.26(0.62, SMD0.26
1.15)
higher
(0.62lower
to1.15
higher)

Standard
Mean
Difference
/Mean
difference
(95%CI)

Confidence
(ineffect)

MD1lower Verylow
(5.31lower
to3.31
higher)

Expressivelanguage:picturedescriptionPicturedescription(Betterindicatedbyhighervalues)
2
Lincoln
1982iii157;
Rochon
2005217

RCTsingle
blind

Serious
limitation(e)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision(
c)

Verylow

Expressivelanguage:picturedescriptionPicturedescriptionwithstructuremodelling:treateditems(Betterindicatedbyhighervalues)
1
Rochon
2005217

RCTsingle
blind

Veryserious Noserious
limitation(b) inconsistency

Noserious
indirectness

Veryserious
imprecision(
c)

16(2.65)

14(4.24)

0.45(1.44, SMD0.45
2.33)
higher
(1.44lower
to2.33
higher)

Verylow

Expressivelanguage:picturedescriptionPicturedescriptionwithstructuremodelling:untreateditems(Betterindicatedbyhighervalues)
1
Rochon
2005217

RCTsingle
blind

Veryserious Noserious
limitation(b) inconsistency

Noserious
indirectness

Veryserious
imprecision(
c)

18.67
(3.06)

16(7.07)

NationalClinicalGuidelineCentre,2013.

268

0.41(1.46, SMD0.41
2.28)
higher
(1.46lower

Verylow

Qualityassessment

Summaryoffindings
Effect

Noof
studies

Design

Limitations

Inconsistency

Indirectness

Imprecision

SLT
Mean
(SD)/
Frequency
(%)

Placebo
(social
supportand
stimulation)
Mean(SD)/
Frequency
(%)

Standard
Mean
Difference
/Mean
difference
(95%CI)

Absolute
effect/
Standard
Mean
Difference
(SMD)or
Mean
Difference
(MD)(95%
CI)
to2.28
higher)

Confidence
(ineffect)

Expressivelanguage:overallspokenPICAverbalsubtest(Betterindicatedbyhighervalues)
1
Lincoln
1982iii157

RCTsingle
blind

Serious
Noserious
limitation(d) inconsistency

Noserious
indirectness

Noserious
imprecision

10.52(1.2) 12.08(0.74)

1.56(
MD1.56
2.46,0.66) lower(2.46
to0.66
lower)

Moderate

7.52(1.34) 8.91(1)

1.39(
MD1.39
2.49,0.29) lower(2.49
to0.29
lower)

Low

0.07(
0.74,0.60)

Verylow

Expressivelanguage:writtenPICAgraphicsubtests(Betterindicatedbyhighervalues)
1
Lincoln
1982iii157

RCTsingle
blind

Serious
Noserious
limitation(d) inconsistency

Noserious
indirectness

Serious
imprecision(
a)

Expressivelanguage:singlewordsPICA7monthfollowupchangefrombaseline(Betterindicatedbyhighervalues)
1
Hartman
1987

RCTsingle
blind

Veryserious
limitations(b
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
a)

9.341.73
(1.28)

9.111.8
(1.37)

MD0.07
lower(0.74
lowerto
0.60
higher)

Expressivelanguage:singlewordsPICA10monthsfollowupchangefrombaseline(Betterindicatedbyhighervalues)
1

RCTsingle
blind

Veryserious
limitations(b

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(

11.221.88
(1.1)

10.861.75
(1.47)

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269

0.13(0.59, MD0.13
0.85)
higher

Verylow

Qualityassessment

Summaryoffindings
Effect

Noof
studies
Hartman
1987

Design

Limitations
)

Inconsistency

Indirectness

Imprecision
a)

Noserious
indirectness

Serious
imprecision(
a)

SLT
Mean
(SD)/
Frequency
(%)

Placebo
(social
supportand
stimulation)
Mean(SD)/
Frequency
(%)

Standard
Mean
Difference
/Mean
difference
(95%CI)

Absolute
effect/
Standard
Mean
Difference
(SMD)or
Mean
Difference
(MD)(95%
CI)
(0.59lower
to0.85
higher)

Confidence
(ineffect)

Severityofimpairment:PICA(Betterindicatedbylowervalues)
1
Lincoln
1982iii157

RCTsingle
blind

Serious
Noserious
limitation(d) inconsistency

10.3(1.01) 11.43(0.67)

1.13(
MD1.13
1.91,0.35) lower(1.91
to0.35
lower)

Low

Psychosocial:CommunicationOutcomesAfterStrokescale(COAST)(6monthfollowup)(Betterindicatedbyhighervalues)
1
Bowen
201229
Bowen
2012

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

71(18)

73(18)

2.00(
8.59,4.59)

MD2.00
lower(8.59
lowerto
4.59
higher)

High

62(21)

62(18)

0.00(6.73, MD0.00
6.73)
(6.73lower
to6.73
higher)

High

Psychosocial:CarerCOAST(6monthfollowup)(Betterindicatedbyhighervalues)
1
Bowen
201229
Bowen
2012

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

NationalClinicalGuidelineCentre,2013.

270

Qualityassessment

Summaryoffindings
Effect

Noof
studies

Design

Limitations

Placebo
(social
supportand
stimulation)
Mean(SD)/
Frequency
(%)

Standard
Mean
Difference
/Mean
difference
(95%CI)

Absolute
effect/
Standard
Mean
Difference
(SMD)or
Mean
Difference
(MD)(95%
CI)

Inconsistency

Indirectness

Imprecision

SLT
Mean
(SD)/
Frequency
(%)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(f
)

47/221
(21.3%)

5870/206
(34%)

RR0.69
(0.52to
0.92)

105fewer
per1000
(from27
fewerto
163fewer)

Moderate

Noserious
indirectness

Noserious
imprecision

8/216
(3.7%)

33/193
(17.1%)

RR0.21
(0.10to
0.45)

135fewer
per1000
(from94
fewerto
154fewer)

High

Confidence
(ineffect)

Numberofdropoutsforanyreason
34
Bowen
201229
ACTNoW
David
198256;
Elman
199976;
Shewan
1984ii236;
Shewan
1984iii236

RCTsingle
blind

Noserious
limitation

Noncompliancewithallocatedintervention(anyreason)
4
Bowen
201229
ACTNoW
David
198256;
Elman

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

NationalClinicalGuidelineCentre,2013.

271

Qualityassessment

Summaryoffindings
Effect

Noof
studies
199976;
Shewan
1984ii236;
Shewan
1984iii236
(a)
(b)
(c)
(d)
(e)
(f)

Design

Limitations

Inconsistency

Indirectness

Imprecision

SLT
Mean
(SD)/
Frequency
(%)

Placebo
(social
supportand
stimulation)
Mean(SD)/
Frequency
(%)

ConfidenceIntervalcrossesoneendofdefaultMID(0.5)
Unclearrandomisation,allocationconcealmentandblinding
ConfidenceIntervalcrossesbothendsofdefaultMID(0.5)
Unclearallocationconcealment
Unclearallocationconcealment.Limitationswereconsideredbystudyweightsinthemetaanalysis
ConfidenceintervalcrossesoneendofdefaultMID(0.75)

NationalClinicalGuidelineCentre,2013.

272

Standard
Mean
Difference
/Mean
difference
(95%CI)

Absolute
effect/
Standard
Mean
Difference
(SMD)or
Mean
Difference
(MD)(95%
CI)

Confidence
(ineffect)

StrokeRehabilitation
Communication

12.1.1.2

Economicevidence
Onestudythatincludedtherelevantcomparisonwasfound.29Thisissummarisedintheeconomic
evidenceprofilebelow(Table69andTable70).Seealsothefullstudyevidencetablein
AppendixI.Table69:
Earlyspeechtherapy(speechtherapydeliveredinthe
hospitalandcontinuedafterdischargeinthecommunity)versusnospeechtherapy
(attentioncontrol)Economicstudycharacteristics
Study
29

Bowen

Limitations

Applicability

Othercomments

Potentiallyserious
limitations(a)

Directlyapplicable

Costeffectivenessanalysisbased
onastudyincludedinour
clinicalreview.
Followup:6months.

(a) Utilityscoreswereobtainedatfollowupbutnotatbaselineastheauthorsfeltitwasnotfeasibletodoso.Therewasa
differenceinstrokeseverityatbaselinebetweenthetwogroupsmeaningthatitcannotbeassumedthatthetwogroups
wouldhavesimilarutilityscores.QALYscouldnotbecalculatedandthehealthoutcomeisjustthedifferenceinutilityat
theendoffollowup.Thescoresdontshowhowhealthstatushaschangedovertimeasthevalueisfromonetimepoint
(attheendoffollowup).Therewasalotofmissingobservationsfortheresourceuseandhealthoutcomesinboth
groups.Thismeantthatusingavailablecasedatacouldbiastheresults.Theauthorsusedmultipleimputationsto
imputemissingvaluesforparticipantswhocompletedscheduledfollowupforatleastoneoftheoutcomemeasures.
Thiswasdonetoreducetheimpactofmissingobservations.

Table70: Earlyspeechtherapy(speechtherapydeliveredinthehospitalandcontinuedafter
dischargeinthecommunity)versusnospeechtherapy(attentioncontrol)Economic
summaryoffindings

Study
29

Bowen2012
UKNHS

Increment
alcostper
patient()

Incremental
effects
(QALY)

Incremental
cost
effectiveness
(/QALY)

110(a,b)

0.005(a,b,c)

22,000(d)

NationalClinicalGuidelineCentre,2013.
273

Uncertainty
Inthedeterministicanalysis,speechand
languagetherapyisdominatedby
attentioncontrolwhentheincremental
costsandutilitiesareadjustedfor
baselinecovariates.

TheprobabilitythatSLtherapyiscost
effectiveis48%atawillingnesstopay
thresholdof20,000.
Attentioncontrolwasmorecost
effectivewhenthefollowingvariables
wereanalysed:usingtrialspecificcosts
ratherthannationalcosts,usingonly
availablecasedata,usingalternative
outcomemeasuresratherthantheEQ
5Dscores.
SLtherapywasmorecosteffectivewhen
thefollowingvariableswereanalysed:
usinganalternativeregressionmodelto
estimateincrementalcostsand
outcomes;usingtheTOMmeasureof
communicationoutcomesmeasure;
usingtheCommunicationOutcomes
AfterStrokescale(COAST)in
combinationwiththeDiscreteChoice
ExperimentweightsratherthanEQ5D

StrokeRehabilitation
Communication

Study

Increment
alcostper
patient()

Incremental
effects
(QALY)

Incremental
cost
effectiveness
(/QALY)

Uncertainty
scores.

(a) Incrementalvaluesoversixmonthsasreportedinthestudybasedontheprobabilisticresultscalculatedbyconducting
10,000simulationsontheestimatesofincrementalcostsandoutcomes.
(b) Includesmultipleimputationvaluesandareadjustedforbaselinecovariates.
(c) BasedonEQ5Ddatawascollectedfromstudyparticipantsattheendoffollowup.
(d) CalculatedbyNCGCbasedonthecostsandutilitydata.

12.1.1.3

Evidencestatements
Clinicalevidencestatements
SpeechandLanguageTherapy(SLT)versusNoSLT
Functionalcommunication
Threestudiescomprising176participantsfoundnosignificantdifferenceinfunctional
communicationbetweentheparticipantsthatreceivedspeechandlanguagetherapy(SLT)andthose
thatdidnotreceivespeechandlanguagetherapy(NoSLT)(LOWCONFIDENCEINEFFECT).
Onestudy133i133iicomprising55participantsfoundnosignificantdifferenceinfunctional
communication(usingtheWesternAphasiaBattery(WAB)assessmenttool)betweenthe
participantsthatreceivedspeechandlanguagetherapy(SLT)andthosethatdidnotreceive
speechandlanguagetherapy(NoSLT)(LOWCONFIDENCEINEFFECT).
Onestudy66comprising18participantsfoundnosignificantdifferenceinfunctional
communication(usingtheAmsterdamNijmegenEverydayLanguageTest(ANELTA))
betweentheparticipantsthatreceivedspeechandlanguagetherapy(SLT)andthosethatdid
notreceivespeechandlanguagetherapy(NoSLT)(LOWCONFIDENCEINEFFECT).
Onestudy283i283iicomprising103participantsfoundnosignificantdifferenceinfunctional
communication(usingthefunctionalcommunicationprofileassessmenttool)betweenthe
participantsthatreceivedspeechandlanguagetherapy(SLT)andthosethatdidnotreceive
speechandlanguagetherapy(NoSLT)(LOWCONFIDENCEINEFFECT).
Receptivelanguage:auditorycomprehension
Threestudiescomprising191participantsfoundnosignificantdifferenceinauditorycomprehension
skillsbetweentheparticipantsthatreceivedspeechandlanguagetherapy(SLT)andthosethatdid
notreceivespeechandlanguagetherapy(NoSLT)(MODERATECONFIDENCEINEFFECT).
Onestudy133i133iicomprising55participantsfoundnosignificantdifferenceinauditory
comprehensionskills(usingthePorchIndexofCommunicativeAbilities(PICA))betweenthe
participantsthatreceivedspeechandlanguagetherapy(SLT)andthosethatdidnotreceive
speechandlanguagetherapy(NoSLT)(LOWCONFIDENCEINEFFECT).
Twostudies283i283ii240comprising136participantsfoundnosignificantdifferenceinauditory
comprehensionskills(usingthetokentestassessmenttool)betweentheparticipantsthat
receivedspeechandlanguagetherapy(SLT)andthosethatdidnotreceivespeechand
languagetherapy(NoSLT)(MODERATECONFIDENCEINEFFECT).

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Receptivelanguage:readingcomprehension
Twostudiescomprising158participantsfoundnosignificantdifferenceinreadingcomprehension
skillsbetweentheparticipantsthatreceivedspeechandlanguagetherapy(SLT)andthosethatdid
notreceivespeechandlanguagetherapy(NoSLT)(MODERATECONFIDENCEINEFFECT).
Onestudy283i283iicomprising103participantsfoundnosignificantdifferenceinreading
comprehensionskills(usingthereadingcomprehensionbatteryforaphasia)betweenthe
participantsthatreceivedspeechandlanguagetherapy(SLT)andthosethatdidnotreceive
speechandlanguagetherapy(NoSLT)(LOWCONFIDENCEINEFFECT).
Onestudy133i133iicomprising55participantsfoundnosignificantdifferenceinreading
comprehensionskills(usingthePorchIndexofCommunicativeAbilities(PICA)reading
subset)betweentheparticipantsthatreceivedspeechandlanguagetherapy(SLT)andthose
thatdidnotreceivespeechandlanguagetherapy(NoSLT)(LOWCONFIDENCEINEFFECT).
Receptivelanguage:gestureuse
Twostudies133i133ii283i283iicomprising158participantsshowedasignificantdifferenceingestureuse
(usingthePICAgesturalsubtest)infavourofthegroupthatreceivedspeechandlanguagetherapy
comparedtothosethatdidnotreceivespeechandlanguagetherapy(NoSLT)(LOWCONFIDENCEIN
EFFECT)
Receptivelanguage:gesturecomprehension
Onestudy240comprising33participantsfoundnosignificantdifferenceingesturecomprehension
skillsbetweentheparticipantsthatreceivedspeechandlanguagetherapy(SLT)andthosethatdid
notreceivespeechandlanguagetherapy(NoSLT)postintervention(LOWCONFIDENCEINEFFECT).
Receptivelanguage:gesturecomprehension2monthfollowup
Onestudy240comprising17participantsfoundnosignificantdifferenceingesturecomprehension
skillsbetweentheparticipantsthatreceivedspeechandlanguagetherapy(SLT)andthosethatdid
notreceivespeechandlanguagetherapy(NoSLT)at2monthfollowup(LOWCONFIDENCEIN
EFFECT).
Expressivelanguage:naming
Twostudiescomprising73participantsfoundnosignificantdifferenceinnamingskillsbetweenthe
participantsthatreceivedspeechandlanguagetherapy(SLT)andthosethatdidnotreceivespeech
andlanguagetherapy(NoSLT)(LOWCONFIDENCEINEFFECT).
Onestudy66comprising18participantsfoundnosignificantdifferenceinnamingskills(using
theBostonnamingtest)betweentheparticipantsthatreceivedspeechandlanguage
therapy(SLT)andthosethatdidnotreceivespeechandlanguagetherapy(NoSLT)(VERY
LOWCONFIDENCEINEFFECT).
Onestudy133i133iicomprising55participantsfoundnosignificantdifferenceinnamingskills
(usingtheWesternAphasiaBattery(WAB)namingtest)betweentheparticipantsthat
receivedspeechandlanguagetherapy(SLT)andthosethatdidnotreceivespeechand
languagetherapy(NoSLT)(LOWCONFIDENCEINEFFECT).
Expressivelanguage:namingat5and8monthsfollowup(ObjectandActionNamingBattery)
Onestudy198comprising28participantsfoundasignificantimprovementinnamingability(usingthe
ObjectandActionNamingBattery)favouringcomputerbasedlanguagetherapyoverusualcare
(MODERATECONFIDENCEINEFFECT)at5monthsbutthisimprovementwasnolongerobservedat
the8monthfollowup(MODERATECONFIDENCEINEFFECT).

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Expressivelanguage:general
Twostudies133i133ii283i283iicomprising158participantsfoundnosignificantdifferenceinexpressive
languageskills(usingthePICAverbalsubtest)betweentheparticipantsthatreceivedspeechand
languagetherapy(SLT)andthosethatdidnotreceivespeechandlanguagetherapy(NoSLT)(LOW
CONFIDENCEINEFFECT).
Expressivelanguage:written
Twostudiescomprising158participantsfoundnosignificantdifferenceinwrittenexpressive
languageskillsbetweentheparticipantsthatreceivedspeechandlanguagetherapy(SLT)
andthosethatdidnotreceivespeechandlanguagetherapy(NoSLT)(MODERATE
CONFIDENCEINEFFECT).Onestudy133i133iicomprising55participantsfoundnosignificant
differenceinwrittenskills(usingthePICAcopyingandwritingsubtest)betweenthe
participantsthatreceivedspeechandlanguagetherapy(SLT)andthosethatdidnotreceive
speechandlanguagetherapy(NoSLT)(LOWCONFIDENCEINEFFECT).Onestudy283i283ii
comprising103participantsfoundnosignificantdifferenceinwrittenskills(usingthePICA
graphicsubtest)betweentheparticipantsthatreceivedspeechandlanguagetherapy(SLT)
andthosethatdidnotreceivespeechandlanguagetherapy(NoSLT)(LOWCONFIDENCEIN
EFFECT).
Expressivelanguage:repetition
Onestudy133i133iicomprising55participantsfoundnosignificantdifferenceinrepetitionskills(using
theWABrepetitionsubtest)betweentheparticipantsthatreceivedspeechandlanguagetherapy
(SLT)andthosethatdidnotreceivespeechandlanguagetherapy(NoSLT)(LOWCONFIDENCEIN
EFFECT).
Severityofimpairment
Twostudies133i133ii283i283iicomprising165participantsfoundnosignificantdifferenceintheseverity
ofaphasiaimpairment(usingthePorchIndexofCommunicativeAbility)betweentheparticipants
thatreceivedspeechandlanguagetherapy(SLT)andthosethatdidnotreceivespeechandlanguage
therapy(NoSLT)(LOWCONFIDENCEINEFFECT).
Psychosocial
Onestudy156comprising137participantsfoundnosignificantdifferenceinanxiety,depressionand
hostilityscalesbetweentheparticipantsthatreceivedspeechandlanguagetherapy(SLT)andthose
thatdidnotreceivespeechandlanguagetherapy(NoSLT)(HIGHCONFIDENCEINEFFECT).
Numberofdropouts(anyreason)
Sevenstudies66133i133ii156163240241i241ii283i283iicomprising714participantsfoundnosignificant
differenceinthenumberofdropoutsbetweentheparticipantsthatreceivedspeechandlanguage
therapy(SLT)andthosethatdidnotreceivedspeechandlanguagetherapy(NoSLT)(HIGH
CONFIDENCEINEFFECT).
Noncompliancewithallocatedintervention(anyreason)
Onestudy240comprising41participantsfoundnosignificantdifferenceinthenumberofparticipants
complyingwiththeallocatedinterventionbetweentheparticipantsthatreceivedspeechand
languagetherapy(SLT)andthosethatdidnotreceivedspeechandlanguagetherapy(NoSLT)(VERY
LOWCONFIDENCEINEFFECT).

SpeechandLanguageTherapy(SLT)versusPlacebo(socialsupportandstimulation)

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Functionalcommunication
Twostudies2956comprising249participantsfoundnosignificantdifferenceinfunctional
communication(usingthefunctionalcommunicationprofileassessmenttool)betweenthe
participantsthatreceivedspeechandlanguagetherapy(SLT)andthosethatreceivedsocialsupport
andstimulation(HIGHCONFIDENCEINEFFECT)postintervention.
Onestudy56comprising96participantsfoundnosignificantdifferenceinfunctional
communication(usingthefunctionalcommunicationprofileassessmenttool)betweenthe
participantsthatreceivedspeechandlanguagetherapy(SLT)andthosethatreceivedsocial
supportandstimulation(HIGHCONFIDENCEINEFFECT)postintervention.
Onestudy29comprising153participantsfoundnosignificantdifferenceinfunctional
communication(usingtheTherapyOutcomeMeasureSubscale(TOM))betweenthe
participantsthatreceivedspeechandlanguagetherapy(SLT)andthosethatreceivedsocial
supportandstimulation(MODERATECONFIDENCEINEFFECT)postintervention.
Onestudy56comprising73participantsfoundnosignificantdifferenceinfunctionalcommunication
(usingthefunctionalcommunicationprofileassessmenttool)betweentheparticipantsthatreceived
speechandlanguagetherapy(SLT)andthosethatreceivedsocialsupportandstimulation
(MODERATECONFIDENCEINEFFECT)at3and6monthfollowup.
Receptivelanguage:auditorycomprehension
Onestudy217comprising5participantsfoundnosignificantdifferenceinauditorycomprehension
skills(usingthePhiladelphiacomprehensionbatterysentenceandpicturesubtests)betweenthe
participantsthatreceivedspeechandlanguagetherapy(SLT)andthosethatreceivedsocialsupport
andstimulation(VERYLOWCONFIDENCEINEFFECT).
Onestudy157iiicomprising18participantsfoundnosignificantdifferenceinauditorycomprehension
skills(usingthetokentest)betweentheparticipantsthatreceivedspeechandlanguagetherapy(SLT)
andthosethatreceivedsocialsupportandstimulation(VERYLOWCONFIDENCEINEFFECT).
Receptivelanguage:other
Onestudy157iiicomprising18participantsshowedasignificantdifferenceinauditoryandwritten
comprehensionskills(usingthePICAgesturalsubtest)infavouroftheparticipantsthatreceived
socialsupportandstimulationcomparedtothosethatreceivedSLT(LOWCONFIDENCEINEFFECT).
Expressivelanguage:singlewords
Onestudy157iiicomprising18participantsshowedasignificantdifferenceinnamingskills(usingthe
ObjectNamingTest(ONT))infavouroftheparticipantsthatreceivedsocialsupportandstimulation
comparedtothosethatreceivedSLT(LOWCONFIDENCEINEFFECT).
Onestudy157iiicomprising18participantsshowedasignificantdifferenceinnamingskills(usingthe
wordfluencytest)infavouroftheparticipantsthatreceivedsocialsupportandstimulation
comparedtothosethatreceivedSLT(MODERATECONFIDENCEINEFFECT).
Expressivelanguage:singlewords(followupmeasuresat7and10months)
Onestudy107comprising60participantsfoundnosignificantdifferenceinexpressivelanguageskills
betweentheparticipantsthatreceivedspeechandlanguagetherapy(SLT)andthosethatreceived
socialsupportandstimulationat7and10monthsfollowup(VERYLOWCONFIDENCEINEFFECT).
Expressivelanguage:sentenceproduction

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Onestudy217comprising5participantsfoundnosignificantdifferenceinoverallsentenceproduction
(usingtheCaplan&Hannatest)betweentheparticipantsthatreceivedspeechandlanguagetherapy
(SLT)andthosethatreceivedsocialsupportandstimulation(VERYLOWCONFIDENCEINEFFECT).
Onestudy217comprising5participantsshowedasignificantdifferenceinsentenceproduction(using
treateditemsfromtheCaplan&Hannatest)infavouroftheparticipantsthatreceivedspeechand
languagetherapy(SLT)comparedtothosethatreceivedsocialsupportandstimulation(VERYLOW
CONFIDENCEINEFFECT).
Onestudy217comprising5participantsfoundnosignificantdifferenceinsentenceproduction(using
untreateditemsfromtheCaplan&Hannatest)betweentheparticipantsthatreceivedspeechand
languagetherapy(SLT)andthosethatreceivedsocialsupportandstimulation(VERYLOW
CONFIDENCEINEFFECT).
Expressivelanguage:picturedescription
Twostudies157iii217comprising23participantsfoundnosignificantdifferenceinpicturedescription
tasksbetweentheparticipantsthatreceivedspeechandlanguagetherapy(SLT)andthosethat
receivedsocialsupportandstimulation(VERYLOWCONFIDENCEINEFFECT).
Onestudy217comprising5participantsfoundnosignificantdifferenceinpicturedescriptiontasks
withstructuremodelling(treatedanduntreateditems)betweentheparticipantsthatreceived
speechandlanguagetherapy(SLT)andthosethatreceivedsocialsupportandstimulation(VERY
LOWCONFIDENCEINEFFECT).
Expressivelanguage:overallspoken
Onestudy157iiicomprising18participantsshowedasignificantdifferenceinoverallspokentest(using
thePICAverbalsubtest)infavouroftheparticipantsthatreceivedsocialsupportandstimulation
comparedtothosethatreceivedSLT(MODERATECONFIDENCEINEFFECT).
Expressivelanguage:written
Onestudy157iiicomprising18participantsshowedasignificantdifferenceinwrittenskills(usingthe
PICAgraphicsubtest)infavouroftheparticipantsthatreceivedsocialsupportandstimulation
comparedtothosethatreceivedSLT(LOWCONFIDENCEINEFFECT).
Severityofimpairment
Onestudy157iiicomprising18participantsshowedthatparticipantsthatreceivedsocialsupportand
stimulationweresignificantlylessimpairedasaresultofaphasia(usingtheshortenedPICA)
comparedtothosethatreceivedSLT(LOWCONFIDENCEINEFFECT).
Psychosocial:CommunicationOutcomesafterStrokescale(COAST)
Onestudy29comprising117participantsfoundnosignificantdifferenceintheCommunication
OutcomesAfterStrokescale(COAST))betweentheparticipantsthatreceivedspeechandlanguage
therapy(SLT)andthosethatreceivedsocialsupportandstimulation(HIGHCONFIDENCEINEFFECT)
at6monthfollowup.
Psychosocial:CarerCommunicationOutcomesafterStrokescale(COAST)
Onestudy29comprising129participantsfoundnosignificantdifferenceintheCarerCommunication
OutcomesAfterStrokescale(COAST)betweentheparticipantsthatreceivedspeechandlanguage
therapy(SLT)andthosethatreceivedsocialsupportandstimulation(HIGHCONFIDENCEINEFFECT)
at6monthfollowup.
Numberofdropouts(anyreason)

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Fourstudies29,5676236ii236iiicomprising427participantsshowedthatparticipantswhoreceivedSLT
weresignificantlylesslikelytodropoutcomparedtothosewhoreceivedsocialsupportand
stimulation(MODERATECONFIDENCEINEFFECT).
Noncompliancewithallocatedintervention(anyreason)
Fourstudies29,5676236ii236iiicomprising409participantsshowedthatparticipantswhoreceivedSLT
weresignificantlymorecompliantwiththeallocatedinterventioncomparedtothosewhoreceived
socialsupportandstimulation(MODERATECONFIDENCEINEFFECT).Economicevidencestatements
Acosteffectivenessstudydirectlyapplicableandwithpotentiallyseriouslimitationsshowsthatthe
incrementalcosteffectivenessratioofspeechandlanguagetherapycomparedtoother
interventions(attentioncontrol)isaround22,000perQALYgained.Howeverthereisahigh
uncertaintyaroundthisestimate.

12.2 Dysarthria
Dysarthriaismotorspeechdisorder,characterisedbyslowslurred,imprecisespeechandquietvocal
volume.Thecommoneffectofthesesymptomsisanimpactonintelligibility,makingcommunication
difficult.Thisinturncanaffectsocialinteraction,employmentandfeelingsofsocialstigmatisation65.

12.2.1

EvidenceReview:Inpeopleafterstrokeisspeechandlanguagetherapycomparedto
socialsupportandstimulationeffectiveinimprovingdysarthria?
ClinicalMethodologicalIntroduction
Population

Adultsandyoungpeople16orolderwhohavehadastroke.

Intervention

Speechandlanguagetherapy:

Anyformoftargetedpracticetasksormethodologieswiththe
aimofimprovinglanguageorcommunicationabilities

Comparison

Socialsupportandcommunicativestimulation:Emotional,
psychologicalorcreativeinterventions(suchasart,danceor
music),conversationorotherinformal,unstructured
communicativeinteractions.Thiscomparisondoesnotinclude
targetedtherapeuticinterventionsthataimtoresolve
participantsexpressiveorreceptivespeechandlanguage
impairments

Outcomes

Measuresoffunctionalcommunication
Formalmeasuresofreceptivelanguageskills(language
understanding)
Formalmeasuresofexpressivelanguageskills(language
production)
Psychologicalorsocialwellbeingincludingdepression,anxietyand
distress
FrenchayDysarthriaAssessment.
Measuresofarticulation(range,speed,strength,andco
ordination)
Perceptualmeasuresofvoiceandprosody(forexample,Vocal
ProfileAnalysis)
Acousticmeasures(forexample,fundamentalfrequency,pitch
perturbation(jitter),amplitudeperturbation(shimmer),etc.as
measuredby,forexample,computerisedsoundspectrography)

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12.2.1.1

ClinicalEvidenceReview
AsearchwasconductedforsystematicreviewscomparingtheclinicaleffectivenessofSpeechand
LanguageTherapy(SLT)withsocialsupportandstimulationtoimprovedysarthriainadultsand
youngpeople16orolderwhohavehadastroke.
OneCochranesystematicreview(Sellars2005235)thatassessedtheeffectivenessofspeechand
languagetherapyfordysarthriawasidentified(Table71).Trialswereconsiderediftheyreporteda
comparisonbetweenagroupthatreceivedSLTinterventionandagroupthatreceived(1)noSLT
interventionand(2)aninterventionundertakenbynonSLTpersonnel,forexample,deliveredby
volunteers(i.e.,SLTversusnonSLT).Sixteentrialswereconsideredforinclusionbutrejectedfrom
thereview.
AfurthersystematicupdatesearchwasconductedforanytrialpublishedsinceSeptember2004
whichwasthesearchcutoffdateoftheincludedCochranereviewandonestudy(Bowen201229
ACTNoWstudy)wasidentified.

Table71: OverviewofadditionalRCT(Bowen201229)sincethesearchcutoffdateofthe
Cochranesystematicreview
STUDY

POPULATION

INTERVENTION

COMPARISON

Bowen
201229
ACTNoW
(Assessing
the
effectiveness
of
Communicat
ionTherapy
intheNorth
West)

Onehundredand
seventyadultswith
aphasia,dysarthria
orbothadmittedto
hospitalwithstroke.
Sixtysixparticipants
haddysarthria.
Participantsranged
inagefrom32to97
years(mean70
years)

Therapystarted2
weeksafterstokeand
involved22contacts,
for18hours(on
average),delivered
over13weeksinboth
hospitaland
communitysettingsby
qualifiedNHSSL
therapists.
Interventionwas
tailoredtoindividual
needsandabilities
(Outcomeinformation
availableonN=33
participantswith
dysarthria)

19contacts,for15
Functional
hours(onaverage),
communicative
deliveredover13
abilityonthe
weeksbyemployed
Therapy
visitorswithno
Outcome
professional
Measure
experienceofstroke
activitysubscale
orSLtherapy.
(TOM)
Visitorsweretrained
todeliversocial
attentionwhich
involvedgeneral
conversation,
involvingthepatient
invariousactivities
(reading,watching
televisionorvideos,
playingaselectionof
games)
(Outcome
information
availableonN=27
participantswith
dysarthria)

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OUTCOMES

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Comparison:SpeechandLanguageTherapy(SLT)versussocialsupportandstimulation
Table72: SpeechandLanguageTherapy(SLT)versussocialsupportandstimulationStudyreferencesandsummaryoffindings
Qualityassessment

Summaryoffindings

Noof
studies

Social
supportand
SLT
stimulation
Mean(SD) Mean(SD)

Effect

Design

Limitations

Inconsistency

Indirectness

Imprecision

Mean
difference
(95%CI)

Mean
Difference
(MD)(95%
CI)

Confidence
(ineffect)

FunctionalcommunicationTherapyOutcomeMeasureactivitysubscale(TOM)(6monthfollowup)(Betterindicatedbyhighervalues)
1
Bowen
201229

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Serious
indirectness(
a)

Veryserious
imprecision(
b)

3.1(1.4)

3.1(1.7)

0.00(0.80, MD0.00
0.80)
(0.80lower
to0.80
higher)

(a) Amixedpopulationofconsistingofpeoplewithdysarthriaaloneandalsopeoplewithdysarthriaaswellasaphasia
(b) ConfidenceIntervalcrossesbothendsofdefaultMID(0.5)

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Verylow

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12.2.1.2

Economicevidence
Literaturereview
Norelevanteconomicevaluationswereincludedinthereview.TheeconomicanalysisintheACT
NoWstudy29wassetuptocoverbothpeoplewithaphasiaanddysarthria;however,sincethe
majorityofthepatientsintheeconomicanalysishadaphasia(90%),thisstudywasincludedinthe
reviewforaphasia(see12.1.1)butconsiderednotapplicabletopeoplewithdysarthria(39%ofthe
populationinthepaperhadeitherbothdysarthriaandaphasiaordysarthriaalone)asthetreatment
wouldbedifferentfromtheoneusedinthestudy.
Economicconsiderations
Theestimatedcostofaband6speechandlanguagetherapistis47perhourofclientcontactq.

12.2.1.3

Evidencestatements
Clinicalevidencestatements
SpeechandLanguageTherapy(SLT)versussocialsupportandstimulation
Functionalcommunication:TherapyOutcomeMeasureactivitysubscale(TOM)
Onestudy29comprising66participantswithdysarthriafoundnosignificantdifferenceinfunctional
communication(usingtheTherapyOutcomeMeasureactivitysubscale(TOM))betweenthe
participantsthatreceivedspeechandlanguagetherapy(SLT)andthosethatreceivedsocialsupport
andstimulationat6monthfollowup(VERYLOWCONFIDENCEINEFFECT).
Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

12.2.2

Recommendationsandinktoevidence
AphasiaandDysarthria
62.Screenpeopleafterstrokeforcommunicationdifficultieswithin
72hoursofonsetofstrokesymptoms.
63.Eachstrokerehabilitationserviceshoulddeviseastandardisedprotocol
forscreeningforcommunicationdifficultiesinpeopleafterstroke.
64.Provideappropriateinformation,educationandtrainingtothe
multidisciplinarystroketeamtoenablethemtosupportand
communicateeffectivelywiththepersonwithcommunication
difficultiesandtheirfamilyorcarer.

65.Speechandlanguagetherapyforpeoplewithstrokeshouldbeledand
supervisedbyaspecialistspeechandlanguagetherapistworking
collaborativelywithotherappropriatelytrainedpeopleforexample,

q EstimatedbasedondataandmethodsfromPersonalSocialServicesResearchUnitUnitcostsofhealthandsocialcare
50
reportandAgendaforChangesalaryband6 (typicalsalarybandidentifiedbyclinicalGDGmembers).

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speechandlanguagetherapyassistants,carersandfriends,and
membersofthevoluntarysector.
66.Provideopportunitiesforpeoplewithcommunicationdifficultiesafter
stroketohaveconversationandsocialenrichmentwithpeoplewho
havethetraining,knowledge,skillsandbehaviourstosupport
communication.Thisshouldbeinadditiontotheopportunitiesprovided
byfamilies,carersandfriends.
67.Speechandlanguagetherapistsshouldassesspeoplewithlimited
functionalcommunicationafterstrokefortheirpotentialtobenefitfrom
usingacommunicationaidorothertechnologies(forexample,home
basedcomputertherapiesorsmartphoneapplications).
68.Providecommunicationaidsforthosepeopleafterstrokewhohavethe
potentialtobenefit,andoffertraininginhowtousethem.
69.Tellthepersonwithcommunicationdifficultiesafterstrokeabout
communitybasedcommunicationandsupportgroups(suchasthose
providedbythevoluntarysector)andencouragethemtoparticipate.
70.Whenpersistingcommunicationdifficultiesareidentifiedatthepersons
6monthorannualstrokereviews,referthembacktoaspeechand
languagetherapistfordetailedassessment,andoffertreatmentifthere
ispotentialforfunctionalimprovement.
71.Makesurethatallwritteninformation(includingthatrelatingto
medicalconditionsandtreatment)isadaptedforpeoplewithaphasia
afterstroke.Thisshouldinclude,forexample,appointmentletters,
rehabilitationtimetablesandmenus.

Relativevaluesof
differentoutcomes

TheGDGrecognisedthatoutcomesinspeechandlanguagetherapycouldlookat
bothimpairmentandfunction.Whileimprovementinfunctionistheultimateaim,
smalltargetedstudiesmaydetectimpairmentchangesmoreeasily.
SomemembersoftheGDGquestionedtheresponsivenessoftheFunctional
communicativeabilityontheTherapyOutcomeMeasureactivitysubscaleTOM.(ACT
NOW)toreflectclinicallymeaningfulchange,butwerenotawareofanypublications
reportingresponsivenesswiththisinstrument.Itwasqueriedwhetherstepscouldbe
consideredequal(i.e.achangefrom0to1isfunctionallythesamechangeasone
from3to4).Itwasfeltthatitwasnotclearhowyoumovedfromonepointto
anotherwithinthescaleanditmaybeopentointerpretation.
TheCommunicationOutcomesAfterStrokescale(COAST)whichwasdevelopedfor
useintheACTNoWstudyhasreportedvalidityandreliabilitydataforuseinthe
study.TheGDGagreedthewaythishadbeendevelopedwasreasonable.

Tradeoffbetween
clinicalbenefitsand
harms

TheGDGwerenotawareofanypotentialharmsfromlanguagebasedtherapies.
Howevertheimportanceofregularreviewtoreassesspeoplewithcommunication
difficultieswasnoted,andtheGDGagreedtheguidanceof6monthandthenannual
reviewasgivenintheNationalStrokeStrategyshouldberecommended.61

Economic
considerations

TheGDGnotedthatSLTiscurrentlyroutinelyprovidedintheNHStopeoplewith
aphasia.Thecostofaband6or7speechandlanguagetherapistis47or57per

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hourofclientcontact. TheACTNoWstudyshowedthatthereisahighuncertainty
overthecosteffectivenessofspeechandlanguagetherapycomparedtoattention
control.
Inthisstudypatientsreceivedspeechandlanguagetherapyonaveragefor18hrsand
22contactsover13weeksperpatient.Thiswasconsideredtobealowlevelof
intensitybytheGDG.Atthislevelofintensitythereisuncertaintythatitiscost
effectiveoverandabovepaidvisitorsandahigherlevelofintensitycouldmakethe
interventionmorecosteffective.
Basedontheseconsiderationsandonthelevelofimprovementofpatientswho
receivedtheintervention,theGDGfeltthatthebenefitsofSLTarelikelytooutweigh
thecosts.
Therearehighcostsassociatedwithprovidingcommunicationaidsassomesoftware
areexpensive(upto2,000)andtrainingpeopletousethemwouldrequirearound
threemonths.Howeverotherapplicationsareavailablefromsmartphonesandthey
arenotveryexpensive.TheGDGhasdecidedthatgiventhepotentialhighcosts
involved,communicationaidsshouldbeprovidedonlytothosepeoplewhoarelikely
tobenefit.
Qualityofevidence

TheCochranesystematicreviewincludedstudiesiftheyreportedacomparison
betweenagroupthatreceivedSLTinterventionandagroupthatreceivednoSLTor
socialsupportorstimulation.Eightstudiesthatmatchedtheprotocolwereincluded
forSLTversusnoSLTandfiveforSLTversussocialsupportorstimulationplusan
additionalstudynotincludedintheCochranereview.
Themajorityofstudieswerefoundtobesmall,poorlydescribed,oldandestimated
effectsformostoftheoutcomesspecifiedwerenonsignificant.Theconfidencein
theeffectofspecifiedoutcomesrangedfromverylowtohighwiththemajority
beinglow.Outcomesweredowngradedforstudylimitations,inconsistencyand
imprecision.
Nosignificantdifferencewasfoundforanyofthefunctionalcommunication
outcomesinbotharms.SpeechandLanguageTherapy(SLT)showedsignificant
improvementinreceptivelanguagecomparedtonoSLTwhilesocialsupportand
communicativestimulationshowedsignificantimprovementinreceptivelanguage,
expressivelanguageandinreducingtheseverityofimpairment.Theimprovements
seenwithsocialsupportandcommunicativestimulationwereallfromonestudy
(Lincoln1982iii157)comprisingof18participants.TheGDGnotedthattheresult
shouldbereadwithcautionasitlacksgeneralisabilityasitisnotatrue
representationoftheaphasicpopulation.
TheGDGnotedthatcurrentpracticehaschangedsincemanyofthestudieswere
published,andthatthedetailsoftheinterventionwasnotprovidedorpoorly
describedinmanyofthestudies.ThismadeitdifficultfortheGDGtodraw
meaningfulconclusions.Thegroupdidagreethattheresultshighlightthebenefitsof
supportedcommunicationanditwasagreedthatSLThasbecomebroaderthanis
reflectedinthestudiesandwouldnowincludesupportandstimulation.
AmorerecentwellconductedstudywastheACTNOWstudydeliveredonaverage
18hrsoftherapyover13weeksinbothhospitalandcommunitysettings.The
interventionswerelargelydeliveredbyband6speechandlanguagetherapists,
althoughpatientsimproved,asimilarlevelofgainwasachievedbypaidvisitors.
Therewere6elementstothespeechandlanguagetherapyinterventions:
assessment,informationprovision,provisionofcommunicationmaterials,carer
contact,indirectcontact(includingdiscwithclinicalteamsandgoalsetting),and
directcontact(includingimpairment,activityandparticipationskills).However,the
outcomemeasurefocussedonfunctionalcommunicationwhichwasonlyoneaspect
oftheSpeechandLanguageTherapistsintervention.TheGDGnotedthatthetrial
wasconductedonparticipantssoonafteronsetofstroke(2weeks),andthatthis
doesnotreflectallstagesofstrokerecovery.Peoplemaymakechangeatalater
stageofrecoveryandthisstudydoesnotreflecttheentirescopeofSLTinput.
TheACTNoWstudywasawellconductedstudyofspeechandlanguagetherapy

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comparedwithpaidvisitors,earlyafterstroke.TheGDGnotedanumberofareas
thatmightinfluenceclinicalinterpretationincludingtherelativelylowdoseof
therapyandthepowerofthestudy.

Dysarthria
IntheACTNoWstudy39%oftheparticipantshaddysarthria,and29%hadboth
aphasiaanddysarthria,andasubanalysisforthetherapyoutcomemeasureactivity
subscaleoutcome(TOM)wasconducted.Nosignificantdifferencewasfound
betweentheSLTgroupandthesocialsupportandstimulationgroup.TheGDG
discussedtheuseofafunctionalinterventioninthispopulationandagreedthatfor
thissubgrouptheinterventionwouldinitiallybeimpairmentbasedandfunctional
communicationtherapywouldbegivenlaterinthepersonsrehabilitation.Itwas
feltthatthisanalysisdidnotprovideanyusefulinformationtoprovidespecific
guidanceforthisgroup.

Other
considerations

TheGDGwasawarethatpracticehaschangedinthepast30years.Thefindings
relatingtothebenefitsofsocialsupportinterventionsshouldnotbeoverlookedin
deliveringservices.Theincreasinguseofcommunicationtoolssuchascomputerand
smartphonetechnologieswasalsonoted.
TheGDGwereawareoftheCollegeofSpeechandlanguagetherapistsaphasia
commissioningdocument,whichprovidesanoverviewofthevarioustherapies.223.
ThegroupexpressedconcernthattheACTNoWstudyshouldnotbeover
interpretedandstressedthecentralroleofSpeechandLanguagetherapyinthe
organisation,assessmentandtreatmentofcommunicationdifficultiesoverthe
wholestrokepathway,shouldberecognised.Itwasagreedthatitwasimportantto
starttherapyassoonaspossibleafterstrokeandthatanassessmentof
communicationshouldbeundertakenwithin72hoursofadmissionandthiswas
currentlyusualpractice.Itwasacknowledgedthatscreeningwouldbeundertaken
onadmissiontoanacuteunit;howevernoparticularscreeningtoolcouldbe
recommended.Thestudieshaveemphasisedtheimportanceofsocialsupportand
providinganenrichedenvironmentindeliveryofSLTandtheGDGacknowledged
trainedvolunteersplayanimportantroleinprovidingthis.TheGDGagreedthat
therapyshouldbemanagedandledbyaspecialistspeechandlanguagetherapist.
Thepatientrepresentativehighlightedthatforpeoplewithdysarthriaguidanceon
helpwithmovementofthetongueisimportantandthiscouldonlybeprovideda
SLTtherapist.TheGDGalsonotedthatthenumberofdropoutsandnon
compliancetoallocatedinterventionwaslowerintheSLTgroupcomparedtosocial
supportandintervention.
TheGDGalsoconsideredthequalitativecomponentoftheACTNoWstudy.Inthis
sectionparticipantsandcarersviewsandexperiencesofSLTorvisitorsupport
whereevaluated.TheGDGfeltthatitwasimportantthatparticipants/carersvalued
outsidecontactregardlessofwhetheraSLTorvisitor.Personalqualitiesof
SLT/visitorswerehighlightedbyparticipants(forexampleputtingpeopleatease,
abilitytomakeparticipantsfeelimportantetc.).MembersoftheGDGfeltthatitwas
alsoimportantthatpatientsexperienceddifferentaspectsoftheirmeetingswith
SLTs/visitorasmeaningful,suchasthosewhohadtheSLThighlightedexplicit
strategiesthatwerehelpfultobuildconfidence;whereasthosewhohadvisitors
valuedthesocialengagementprocessesandeverydaypracticeaspectofthis
contact.
Itwasthereforenotedthatopportunitiestoengagewithcommunicationpartners
shouldplayapartintherehabilitationofpeoplewhohavehadastrokeandhave
languageimpairmentandthatprofessionalsshouldaimtoprovidesuchcontacts.

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12.3 Speechandlanguagetherapiesfordysarthriaandapraxiaofspeech
Therewasalackofdirectevidencefordysphasia,dysarthriaandapraxiaofspeech(sections12.2and
12.3).ThereforerecommendationsinthesesectionswerebasedonmodifiedDelphiconsensus
statements(basedonrecommendationsinpublishednationalandinternationalguidelines).Below
weprovidetablesofstatementsthatreachedconsensusandstatementsthatdidnotreach
consensusandgiveasummaryofhowtheywereusedtodrawuptherecommendations.Fordetails
ontheprocessandmethodologyusedforthemodifiedDelphisurveyseeAppendixF.

12.3.1

12.3.2

Whatinterventionsimprovecommunicationinpeopledysphasia,dysarthriaandapraxia
ofspeech?
Population

Adultsandyoungpeople16orolderwhohavehadastrokeandwhohavespeechand
languageimpairments

Components

8. Assessment
9. Speechandlanguagetherapies
10. Communicationaids

Outcomes

11. Qualityoflife
12. Communicationskills
13. Socialparticipation

Delphistatementswhereconsensuswasachieved
Table73: Tableofconsensusstatements,resultsandcomments(percentageintheresultscolumn
indicatestheoverallrateofresponderswhostronglyagreedwithastatementand
amountofcommentsinthefinalcolumnreferstorateofresponderswhousedthe
openendedcommentsboxes,i.e.No.peoplecommented/No.peoplewhoresponded
tothestatement)

Number

1.

Results
%

Statement

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes

Forallpeoplewithspeechand
languageimpairmentstheSpeechand
LanguageTherapistneedstoexplain
anddiscusstheimpairmentwiththe
personwhohashada
stroke/family/carers/treatmentteam
andteachthemhowtomanagethe
condition.

78.6

3/28(11%)panelmembers
commented

Onepersoncommentedthatthis
doesnotneedtobecarriedoutbya
speechandlanguagetherapistas
longasitisundertheguidanceof
one.

Carerinvolvementwasalso
highlighted.

Onepersonexpressedsurprisethat
CommunicationSupportServices
werenotincludedinthewhole
speechandlanguagesection.

Earlyafterstrokethepersonwitha
speechandlanguageimpairment
shouldbefacilitatedtocommunicate
everydayneedsandwishes,and
supportedtounderstandand

93.1

4/29(14%)panelmembers
commented

Itwascommentedthatthereare

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Number

12.3.3

Statement
participateindecisionsaround,for
example,medicalcare,transfertothe
community,andhousing.Thismay
needalternativeandaugmentative
formsofcommunication.

Results
%

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes
interactionswithcognitionand
emotionandthereforeinputfrom
otherMDTmembersmaybe
needed.

ItwasstatedthatAACmaybelow
techandsimplepaperandpenor
highertechIpadappscouldbe
used.

Onecommentwasthatthisdepends
onthepersonsindividual
assessment,readinesstoparticipate
andhis/herstatedgoals.

Trainingforsomemembersofthe
MDTmayalsobenecessary.

2.

Peoplewhohavehadastrokeand
whohavepersistingspeechand
languagedeficitsshouldbeassessed
foralternativemeansof
communication(gesture,drawing,
writing,useofcommunicationaids).

73.1

2/26(8%)panelmembers
commented
Onepersonstatedthatmixing
peoplewithlanguageandthosewith
speechimpairmentstogetherisnot
appropriateinthisstatement.

Theotherpersonthoughtthatthis
statementwastooobvioustobe
useful.

3.

Theimpactofspeechandlanguage
impairmentsonliferolesforexample
family,leisure,work,etc.shouldbe
assessedandpossibleenvironmental
barriers(forexamplesigns,attitudes),
shouldbeaddressed,jointlywiththe
MDT.

81.5

3/27(11%)panelmembers
commented

Onepersonpointedoutthatthis
wouldnothappenintheacutestage
ofrehabilitation.

Anotherpersonthoughtthatit
shouldalsoinvolvefamilyand
friends,employersandrelevant
otheragencies

Athirdpersonindicatedthat
addressedwasnotclear.

Delphistatementwhereconsensuswasnotreached
Table74: Tableofnonconsensusstatementswithqualitativethemesofpanelcomments
Number
1.

Statement
Thekeyaimofspeechandlanguage
therapyearlyafterstrokeshouldbeto

Results
%

Amountandcontentofpanel
commentsorthemes

55.0

Inround217/27(63%)panel
memberscommented;11/20(55%)

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Number

2.

Statement
minimisethecommunication
impairment.

Thelistofapproachesthatmaybe
usedwithapatientwhoisdysphasic:
Picturecards
Drawings
SoundBoards
Writing
Phonologicalsoundcueing
Modellingwords
Sentencecompletion
Melodicintonationtherapy
Neurolinguisticapproach
Computerisedapproach

Results
%

Amountandcontentofpanel
commentsorthemes
inround3

Panelmembersthoughtthatthere
aremanyfacetstotheaimsof
speechandlanguagetherapythat
werenotcapturedbythis
statement.Suchas:
Todealwiththeimpactofthe
communicationimpairment
Toassessandeducateregardingthe
extentofthedifficulty
Toaddressthepersonsconfidence,
Toenhanceskillsofcommunication
partners
Toremovebarriersto
communication
Extract:
Thiscanbeverybroadlydefined.
Minimisingthecommunication
impairmentisnotnecessarilyjust
reducingtheactualimpairment.It
maybeprovidingadviceand
informationwhichenhances
understandingandindirectly
minimisestheproblem,itmaybe
usingstrategiestofacilitate
communication,itmaybeproviding
facilitatedemotionalsupportto
reducetraumawhichcanenhance
communication.

36.8
42.1
12.5
33.3
27.7
22.2
33.3
5.8
27.7
38.8

Inround220/27(74%)panel
memberscommented;11/19(58%)
inround3

Somefurtherapproacheswere
suggested:
Talkingmats
Semanticcueing
Gesture
Cognitiveneuropsychological
approaches
Constraintinducedtherapy(which
usespicturecards)
Augmentativeandalternative
communication

Onepersonhighlightedthatany
approachneedstobeevidence
based.

Itwasalsohighlightedthatthe
statementimpliesafocuson

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StrokeRehabilitation
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Number

3.

Statement

Thelistofapproachesthatmightbe
usedwithapatientwhoisdysarthric:
Oralmuscularexercises
Monitoringrateofspeechproduction
Pausing
Alphabetsupplementation

Results
%

Amountandcontentofpanel
commentsorthemes
languageimpairmentratherthan
focusontheskillsandcompetence
ofthepersonwhohasdysphasiaand
thoseintheircommunicative
environment.Thispanelmember
suggestedthefollowingapproaches
todothis:
Informationandsupportforthe
personandtheir
family/friends/serviceproviders
(andalsoaboutlanguage
strengths)
Trainingofconversationpartners
Accesstopeersupport

Othersspecificallyfavoured
impairmentbasedapproaches.

Itwashighlightedthatthiswould
varyfrompersontoperson(The
SpeechandLanguageTherapist
wouldmakeacommunicationbook
tailoredtotheindividualratherthan
alphabetchartand/ortalkingmats
toaiddiscussion).

21.7
34.7

26.0
27.2

Inround212/24(47%)panel
memberscommented;14
commentedinround3(freetext
prompt)

Thefollowingapproacheswere
suggested:
Initiationofvocalisation(exercises
forarticulation)
Coordinationbetweenbreathing
andspeech(breathingsupport
exercises)
Sustainingvoiceduringspeech
production
Pacing
Gesture
Adviceaboutcondition,andtraining
ofconversationpartners
Computertherapy
Writing/drawing
Augmentativeandalternative
communication
Compensatoryslowingofspeech
ratewithexaggerated
articulation

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Number

Statement

Results
%

Amountandcontentofpanel
commentsorthemes

Onepersonhighlightedthatthis
shouldbeafocusedapproachbased
onassessment(thesystemthatis
mostcompromisedwouldbe
targetedforexamplerespiration,
palatalmovement,voice,
articulation,rateofspeech,phrasing,
intonation).

4.

Listofapproachesthatmightbeused
withapatientwhohas
dysarthrophonia:
Biofeedback
Voiceamplifier
Intensetherapytoincreaseloudness

12.5
11.7
0.0

Inround29/23(39%)panel
memberscommented;7/17(41%)in
round3

Noclearapproachesweresuggested.
Itwasstatedthatthisdependson
thepatientspresentationand
severity.

Itwasalsohighlightedthatthisisa
rareproblemandthatthereisno
evidencetosupportaparticular
approach.

5.

Thelistofapproachesthatmightbe
usedwithapatientwhohas
articulatorydyspraxia:
Cognitivelinguistictherapy
Repetitivedrills
Auditoryinput/analysis
Automaticspeech
Singing
Phonemiccueing
Wordimitation
Computerprogrammes
Varleyapproach
AAC(AugmentativeandAlternative
Communication)readingaloud
Distractionpracticewithfeedback
Phonememanipulationtasks
SegmentbySegmentapproach
SWORD(computersoftware)
Prosodictherapy

20.0
41.6
33.3
38.4
8.3
16.6
8.3
38.4
27.2
18.1

11.1
9.0
18.1
27.2
25.0

Inround216panelmembers
commented(freetextprompt);
8/14(57%)inround3

Nofurtherapproacheswere
suggestedanditwashighlightedthat
anyapproachneedstobeevidence
based.

6.

Anypatientwithseverearticulation
difficulties(<50%intelligibility)
reasonablecognitionandlanguage
functionshouldbeassessedforand
providedwithalternativeor
augmentativecommunicationaids.

61.1

Inround23/25(12%)panel
memberscommented;3/18(17%)in
round3
Itwoulddependonstageofrehab,
successofrehabilitationand
prognosis.

Onepersonobjectedtoalevel(i.e.
below50%intelligibility)being

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StrokeRehabilitation
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Number

12.3.4

Results
%

Statement

Amountandcontentofpanel
commentsorthemes
stated(asitmaybedifferentfor
eachpatientandintelligibilitymay
dependonfamiliaritywiththe
patient.

RecommendationsandlinkstoDelphiconsensussurvey
Statements

28.ForallpeoplewithspeechandlanguageimpairmentstheSpeechand
LanguageTherapistneedstoexplainanddiscusstheimpairmentwith
thepersonwhohashadastroke/family/carers/treatmentteamand
teachthemhowtomanagethecondition.
29.Earlyafterstrokethepersonwithaspeechandlanguageimpairment
shouldbefacilitatedtocommunicateeverydayneedsandwishes,and
supportedtounderstandandparticipateindecisionsaround,for
example,medicalcare,transfertothecommunity,andhousing.This
mayneedalternativeandaugmentativeformsofcommunication.
30.Peoplewhohavehadastrokeandwhohavepersistingspeechand
languagedeficitsshouldbeassessedforalternativemeansof
communication(gesture,drawing,writing,useofcommunication
aids).
31.Theimpactofspeechandlanguageimpairmentsonliferolesfor
examplefamily,leisure,work,etc.shouldbeassessedandpossible
environmentalbarriers(forexamplesigns,attitudes),shouldbe
addressed,jointlywiththeMDT.
72.Helpandenablepeoplewithcommunicationdifficultiesafterstroke
tocommunicatetheireverydayneedsandwishes,andsupportthem
tounderstandandparticipateinbotheverydayandmajorlife
decisions.
73.Ensurethatenvironmentalbarrierstocommunicationareminimised
forpeopleafterstroke.Forexample,makesuresignageisclearand
backgroundnoiseisminimised.

Considerations

TheGDGagreedthatsupportandinformationforthepatientandtheir
carerwasextremelyimportant,butalsothatgoodcommunicationskills
arerequiredbyallofthemultidisciplinaryrehabilitationteam.The
speechandlanguagetherapisthasaroletoeducateandprovidetraining
toalloftheteaminordertoensurethatappropriatemethodsof
communicatingwiththepersonareused,andthatthereisgreater
awarenessofenvironmentalfactors,suchasnoise,signsandnotices
withintherehabilitationunitthatcouldimpactonthepersonsabilityto
communicate.
Noconsensuswasachievedonspecificformsoftherapytoofferto
peoplewithotherformsofspeechandlanguageimpairment,however
theGDGagreedthattherecommendationsmadefromthereviewof
peoplewithaphasiacouldapplytoallpeoplewithcommunication

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StrokeRehabilitation
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difficulties,andthepreferredapproachtoadoptwouldbedetermined
throughadetailedassessmentbythetherapistandtheneedsandwishes
ofthepatient.
Theuseofalternativemethodsofcommunicationaidssuchas
technologiesviacomputersandsmartphoneswasacknowledged,andit
wasagreedtheusageoftheseislikelytoincrease.Howeverthesewould
notbesuitableforallpeopleanduseofdrawingandwritingdown
informationsuchasappointmentletters,rehabilitationtimetablesetc.
shouldbeprovidedtothosethatneedthem.

12.4 Intensityofspeechandlanguagetherapy
12.4.1

Evidencereview:Inpeopleafterstrokewithcommunicationdifficultieswhatistheclinical
andcosteffectivenessofintensivespeechtherapyversusstandardspeechtherapy?
ClinicalMethodologicalIntroduction

12.4.1.1

Population

Adultsandyoungpeople16orolderwhohavehadastrokeand
havecommunicationdifficulties

Intervention

Intensivespeechtherapy:
aphasiatherapy,
constraintinducedaphasiatherapy
(Anystudyincludingmoreintensiveversuslessintensivespeech
therapy)

Comparison

Lessspeechtherapy
Notherapy

Outcomes

Anyoutcomereportedinthepapers.
Examplesinclude:
FunctionalAssessmentofCommunicationSkillsforAdults
(ASHAFACS)
BostonNamingTest
WesternAphasiaBattery
StrokeDyphasiaIndex
McKennaGradedNamingTest

Clinicalevidencereview
SearcheswereconductedforsystematicreviewsandRCTsthatcomparedtheeffectivenessof
intensivespeechtherapytolessspeechtherapyornotherapytoimprovespeechandlanguage
functioninadultsandyoungpeople16orolderafterstroke.Eight(8)RCTswereidentified.Table75
summarisesthepopulation,intervention,comparisonandoutcomesforeachofthestudies.
Table75: Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
AUTHOR

POPULATION

INTERVENTION

COMPARISON

OUTCOME

Bakheit,
200713

Firsttimestroke
patients(meandays

Five1hourlyspeech
therapysessionsa

Lessspeechtherapy
(i.e.thesameas

Western
AphasiaBattery

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StrokeRehabilitation
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AUTHOR

POPULATION
poststrokeonset:31)
withascoreof<93.8
onWesternAphasia
Battery.

INTERVENTION
weekfor12weeks,
targetedat
improving
understandingand
expressionofspoken
andwritten
language,including
picture/object
selection,naming
objects,describing
andrecognising
associationsbetween
items,facilitating
expressionoffeelings
andopinions,
improving
communicationskills,
usinggesturesand
nonverbal
communication,
usingcommunication
aidsandequipment
(partof
multidisciplinary
rehabilitation)(Mean
amount4.3hours(SD
1.0)perweek
achieved).(N=51)

COMPARISON
providedto
interventiongroupbut
onlyfortwo1hour
sessionsperweek;
actualmeanamount
achieved1.6hours(SD
0.5)perweek).(N=46)

Bowen
201229
ACTNoW
(Assessing
the
effectivene
ssof
Communic
ation
Therapyin
theNorth
West)

Onehundredand
seventyadultswith
aphasiaordysarthria
admittedtohospital
withstroke.
Participantsrangedin
agefrom32to97
years(mean70years)
and56%weremen.
Almostallhadaphasia
(90%).

Therapyonaverage
started2weeksafter
stokeandinvolved
22speechand
languagetherapy
contacts,for18
hours(mean),
deliveredover13
weeksinboth
hospitaland
communitysettings.
(N=85)

AttentionControl:An
Therapy
averageof19visitor
Outcome
contacts,forameanof
Measure
15hours.Visitorsdid
activity
notprovidetherapyor
subscale
anycommunication
(TOM)
strategies.Visitorshad
Communicatio
excellentsocialskills
nOutcomes
andgeneral
AfterStroke
competencyandwere
scale(COAST)
trainedtodeliversocial
attentionabsentofany Carers
Communicatio
intuitiveformof
nOutcomes
communication
AfterStroke
therapyorstrategy.
scale(COAST)
(N=85)

Denes,
199659

Patientswithstroke
(meanmonthspost
strokeonset;3)with
globalaphasiawith
lesionrestrictedtoleft
hemisphere.

Individualspeech
therapysessions
(totalmeannumber:
130(range94160))
of4560minutes
eachoverameanof
6months(range5.2
7months)including
conversational
setting,using
speaking,gesturing,
facialexpression.

Lessintensivespeech
Aachener
therapy:mean60
AphasiaTest
(range5670)
(AAT)5
individualspeech
SubtestsToken
therapysessionsof45
Test,
60minuteseachovera
Repetition,
meanof6months
Written
(range5.27months)
Language,
including
naming,
conversationalsetting,
Comprehension
usingspeaking,
andProfile
gesturing,facial
Level

NationalClinicalGuidelineCentre,2013.
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OUTCOME

StrokeRehabilitation
Communication
AUTHOR

INTERVENTION
(N=8)

COMPARISON
expression.(N=9)

OUTCOME

Doesborgh, Chronicstroke
2004
patients(atleast11
67
monthspoststroke)

aged2086yearsold,
withsemantic(as
assessedbythe
SemanticAssociation
Testandthe
Psycholinguistic
Assessmentof
LanguageProcessing
inAphasiaPALPA)
andphonological
deficits(asmeasured
bytheAachenAphasia
TestAATRepetition
subtest).However
peoplewhowere
assessedashaving
globalaphasiaor
recoveredorno
aphasiaaccordingto
theAATwere
excluded.

Individualmulticue
treatment(computer
programmeforword
finding)total
duration1011
hoursinsessionsof
3045minuteseach
withafrequencyof
twotothreetimesa
weekinaperiodof
approximately2
months.(N=9)

Notherapyfor68
weeks.(N=10)

Hartman,
1987107

Firststroke(1month
poststrokeonset)
patientswithlesion
affectedtoleft
hemisphereandwith
functionallynormal
hearingandvision.

Individual
conventionalspeech
therapyincluding
languagedrills,home
practice,auditory
stimulationatsingle
wordandphrase
level,followspoken
commands,reading,
repetition,sentence
completion,cueing
strategies,twice
weeklyfor6months.
(N=30)

Unstructured
conversationbased
counselling/support
focusedonproblems
ofeverydaylife;
encouraging
independentproblem
solvingby
patient/family,twice
weeklyfor6months.
(N=30)

Katz,
1997133

Chronicstroke
patients(atleast1
yearpoststroke)with
aphasiasubsequentto
asingle,left
hemisphere,
thromboembolic
infarctandno
languagetreatment
duringthe3months
beforeentryintothe
study.

Individualcomputer Notherapy.(N=15)
providedreading
treatmentforchronic
aphasicadults.
(N=21)

Acutestroke(1stor
latertime)patients.
Patientswithverymild
aphasiaorsevere

Individualtwo1hour
speechtherapy
sessionsperweek
(nospecifictypeof

Lincoln,
1984156

POPULATION

PorchIndexof
Communicative
Ability(PICA)

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Nospeechtherapy
(controlsoffered
treatmentatweek34).
(N=164)

Boston
NamingTest
(BNT)
Amsterdam
Nijmegan
Everyday
Language
Test,scaleA
(ANELTA).

ThePorch
Indexof
Communicati
veAbility
(PICA)
Western
aphasia
Battery
(WAB)
Aphasia
Quotient
(AQ)
PorchIndex
of
Communicati
veAbility

StrokeRehabilitation
Communication
AUTHOR

POPULATION
dysarthriawere
excluded.

INTERVENTION
therapywas
included;therapists
organisedtheirown
formoftreatment)
fromweek10post
stroketoweek34.
(N=163)

COMPARISON

OUTCOME
(PICA)
Functional
Communicati
onProfile
(FPA)

Wertz,
1986283

Acutefirsttimestroke
(224weekspost
stroke)maleveteran
patients75yearsor
underwithaleft
hemisphericlesion

Individualspeech
therapyadministered
byaspeechtherapist
for810hours/week
for12weeks,after
thennotreatment
wasgiven.(N=38)
Speechtherapy
administeredat
home:trainedfamily
memberorfriend
administered810
hours/weekfor12
weeks,afterthenno
treatmentwasgiven.
(N=43)

Notherapyfor12
weeks(afterthat
speechtherapist
administered810
hours/weekfor12
week.)(N=40)

PorchIndexof
Communicative
Ability(PICA)

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Comparison:Intensivespeechtherapyversuslessintensivespeechtherapyornothing
Table76:IntensivespeechtherapyversuslessintensivespeechtherapyClinicalstudycharacteristicsandclinicalsummaryoffindings

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectness

Imprecision

Intensive
speech
therapy
Mean(SD)

Less
intensive
therapy
Mean(SD)

Relative
Mean
difference
(95%CI)

5.2(7.8)

6.2(3.32,
15.72)

MD6.2
higher
(3.32
lowerto
15.72
higher)

Moderate

6.1(6.1)

2.8(3.86,
9.46)

MD2.8
higher
(3.86
lowerto
9.46
higher)

Verylow

11(9.8)

2.1(3.1)

8.9(1.81,
15.99)

MD8.9
higher
(1.81to
15.99
higher)

Moderate

10.2(9.9)

4.5(4.2)

5.7(1.69,

MD5.7

Low

Absolute

Confidence
(ineffect)

AachenerAphasiaTest(AAT)tokentest(6monthsfollowup)(Betterindicatedbyhighervalues)
1
Denes1996
59

RCT

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

11.4(11.6)

AachenerAphasiaTest(AAT)repetition(6monthsfollowup)(Betterindicatedbyhighervalues)
1
Denes1996
59

RCT

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision
(B)

8.9(7.7)

AachenerAphasiaTest(AAT)writtenlanguage(6monthsfollowup)(Betterindicatedbyhighervalues)
1
Denes1996
59

RCT

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

AachenerAphasiaTest(AAT)Naming(6monthsfollowup)(Betterindicatedbyhighervalues)
1

RCT

Serious

Noserious

Noserious

Serious

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Summaryoffindings
Qualityassessment

Noofstudies
Denes1996
59

Design

Effect

Limitations
limitations
(a)

Inconsistency
inconsistency

Indirectness
indirectness

Imprecision
imprecision
(c)

Intensive
speech
therapy
Mean(SD)

Less
intensive
therapy
Mean(SD)

Relative
Mean
difference
(95%CI)
13.09)

2.3(3.8)

10.3(0.52, MD10.3
21.12)
higher
(0.52
lowerto
21.12
higher)

Low

10(8.6)

4.3(3.8)

2.7(0.76,
12.16)

MD2.7
higher
(0.76
lowerto
12.16
higher)

Low

63.1(13.5)

63.2(13.5) 0.1(5.48,
5.28)

MD0.1
lower
(5.48
lowerto
5.28
higher)

High

Absolute
higher
(1.69
lowerto
13.09
higher)

Confidence
(ineffect)

AachenerAphasiaTest(AAT)Comprehension(6monthsfollowup)(Betterindicatedbyhighervalues)
1
Denes1996
59

RCT

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(c)

12.6(15.2)

AachenerAphasiaTest(AAT)Profilelevel(6monthsfollowup)(Betterindicatedbyhighervalues)
1
Denes1996
59

RCT

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(c)

WesternAphasiaBattery(2monthsfollowup)(Betterindicatedbyhighervalues)
1
Bakheit2007
13

RCTsingle
blinded

Serious
limitations(d
)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

WesternAphasiaBattery(3monthsfollowup)(Betterindicatedbyhighervalues)

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Summaryoffindings
Qualityassessment

Effect

Noofstudies

Design

Limitations

Inconsistency

Indirectness

Imprecision

1
Bakheit2007
13

RCTsingle
blinded

Serious
limitations(d
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(e)

Intensive
speech
therapy
Mean(SD)

Less
intensive
therapy
Mean(SD)

Relative
Mean
difference
(95%CI)

67.7(13.4)

69.2(13.4) 1.5(6.84,
3.84)

MD1.5
lower
(6.84
lowerto
3.84
higher)

Low

68.6(15.4)

71.4(15.4) 0.4(0.16,
0.96)

MD2.8
lower
(8.94
lowerto
3.34
higher)

Low

Absolute

Confidence
(ineffect)

WesternAphasiaBattery(6monthsfollowup)(Betterindicatedbyhighervalues)
1
Bakheit2007
13

RCTsingle
blinded

Serious
limitations(d
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(c)

(a)

Allocationconcealmentandblindingofoutcomeassessorsnotreported.
ConfidenceintervalcrossedbothendsofdefaultMID.
(c)
ConfidenceintervalcrossedoneendofdefaultMID.
(d)
Unclearrandomization.

(b)

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Table77: IntensivespeechtherapyversusnotherapyClinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings
Qualityassessment

Noofstudies

Design

Limitations

Inconsistency

Indirectness

Imprecision

Intensive
speech
therapy
Mean(SD)

Effect
No
therapy
Mean(SD)

Mean
difference
(95%CI)

Mean
Difference Confidence
(95%CI)
(ineffect)

BostonNamingTest(BNT)(2monthfollowup)(Betterindicatedbyhighervalues)
1
Doesborgh
2004
67

RCT

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision(b
)

75.6(38.7)

75.7(36.7) 0.1(
35.26,
35.06)

MD0.1
lower
(35.26
lowerto
35.06
higher)

Verylow

25.5(10.3) 8.8(0.16,
17.44)

MD8.8
higher
(0.16to
17.44
higher)

Low

MD5.1
higher(7
lowerto
17.2
higher)

Low

MD5
lower
(17.88
lowerto
7.88
higher)

Low

AmsterdamNijmegenEverydayLanguageTestANELTA(2monthfollowup)(Betterindicatedbyhighervalues)
1
Doesborgh
2004
67

RCT

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

34.3(8.4)

PorchIndexofCommunicativeability(PICA)moreintensiveversusnotreatment(26weekfollowup)(Betterindicatedbyhighervalues)
1
Katz1997
133

RCT

Serious
limitations(d
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(c)

66.4(19.4)

61.3(17.4) 5.1(7.0,
17.2)

PorchIndexofCommunicativeability(PICA):lessintensiveversusnotreatment(26weekfollowup)(Betterindicatedbyhighervalues)
1
Katz1997
133

RCT

Serious
limitations(d
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

26.3(20.9)

61.3(17.4) 5.0(
17.88,
7.88)

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Summaryoffindings
Qualityassessment

Noofstudies

Design

Limitations

Inconsistency

Indirectness

Imprecision

Intensive
speech
therapy
Mean(SD)

Effect
No
therapy
Mean(SD)

Mean
difference
(95%CI)

Mean
Difference Confidence
(95%CI)
(ineffect)

WesternAphasiaBattery:moreintensiveversusnotreatment(26weekfollowup)(Betterindicatedbyhighervalues)
1
Katz1997
133

RCT

Serious
limitations(d
)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision(b
)

73.6(22.6)

72.2(23.7) 1.40(14,
16.8)

MD1.4
higher(14
lowerto
16.8
higher)

Verylow

MD8.8
lower
(26.35
lowerto
8.75
higher)

Low

WesternAphasiaBattery:lessintensiveversusnotreatment(26weekfollowup)(Betterindicatedbyhighervalues)
1
Katz1997
133

RCT

Serious
limitations(d
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

63.4(28.5)

72.2(23.7) 8.8(
26.35,
8.75)

PorchIndexofCommunicativeAbility(PICA)(1monthfollowupafterlesiononset)(Betterindicatedbyhighervalues)
1
Hartman
1987
107

RCT

Serious
limitations(e
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

9.34(3.28)

9.11(3.82) 0.23(1.74, MD0.23

Low
2.2)
higher
(1.74
lowerto
2.2higher)

PorchIndexofCommunicativeAbility(PICA)(10monthfollowupafterlesiononset)(Betterindicatedbyhighervalues)
1
Hartman
1987
107

RCT

Serious
limitations(e
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

11.22(2.88)

10.86
(4.02)

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0.36(1.57, MD0.36
2.29)
higher
(1.57
lowerto
2.29
higher)

Low

StrokeRehabilitation
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(a)

Blindingofoutcomeassessorsnotreported.
ConfidenceintervalcrossedtwoendsofdefaultMID.
(c)
ConfidenceintervalcrossesoneendofdefaultMID.
(d)
Detailsofblinding,randomisationandallocationconcealmentnotreported.
(e)
Allocationconcealmentnotreported.
(b)

Table78: Earlyintensivespeechtherapy(speechtherapydeliveredinthehospitalandcontinuedafterdischargeinthecommunity)versusnospeech
therapy(attentioncontrol)
Qualityassessment

Summaryoffindings

Noof
studies

Early
intensive
speech
Nospeech
therapy
therapy
Mean(SD) Mean(SD)

Design

Limitations

Inconsistency

Indirectness

Imprecision

Effect
Mean
difference
(95%CI)

Mean
Difference
(MD)(95%
CI)

Confidence
(ineffect)

TherapyOutcomeMeasureactivitysubscale(6monthfollowup)(Betterindicatedbyhighervalues)
1
Bowen
201229

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
a)

3.3(1.4)

3.0(1.6)

0.30(0.18, MD0.3
0.78)
higher
(0.18lower
to0.78
higher)

Moderate

73(18)

2.00(
8.59,4.59)

MD2.00
lower(8.59
lowerto
4.59
higher)

High

0.00(6.73, MD0.00
6.73)
(6.73lower
to6.73
higher)

High

CommunicationOutcomesAfterStrokescale(COAST)(6monthfollowup)(Betterindicatedbyhighervalues)
1
Bowen
201229

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

71(18)

CarerCommunicationOutcomesAfterStrokescale(CarerCOAST)(6monthfollowup)(Betterindicatedbyhighervalues)
1
Bowen
201229

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

62(21)

62(18)

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(c) ConfidenceIntervalcrossesoneendofdefaultMID(0.5)

Narrativesummaries
ThefollowingstudiesaresummarisedasanarrativebecausetheresultswerenotpresentedinnumericaldatathatcouldbeincludedintheGRADEtable:
Onestudyofmoderateriskofbias(Lincolnetal,1984)156usingthePICAandtheFunctionalCommunicationProgramme(FCP)showedimprovementin
bothstandardspeechtherapygroupandmorespeechtherapygroupwithnosignificantdifferencesinlanguagerecoverybetweenthetwogroups
duringtreatmentandat34weekposttreatment.
Onestudyofhighriskofbias(Wertzetal,1986)283usingthePICApercentilesuggestedthatclinictreatmentforaphasiawasefficaciousand
delaying/deferringtreatmentfor12weeksdidnotcompromiseultimateimprovement.Resultsofhometreatmentdidnotdifferfromthoseofclinic
treatmentordeferredtreatment.

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12.4.1.2

Economicevidence
Onestudywasincludedthatincludedtherelevantcomparison169.Thisissummarisedintheeconomic
evidenceprofilebelow(Table79andTable80).SeealsothefullstudyevidencetablesinAppendixI.
Table79: EnhancedversusstandardspeechtherapyEconomicstudycharacteristics
Study
169

Marsh2010
(UKNHS)

Limitations

Applicability

Othercomments

Potentiallyserious
limitations(a)

Directlyapplicable

BasedontheRCTbyBakheitetal200713
includedinourclinicalreview.
UsualSLTdefinedas2hoursaweekfor
12weeks(inpracticewas0.57hoursper
week).
EnhancedSLTdefinedas2hoursaweek
for12weeks(inpracticewas1.6hours
perweek).
TheoriginalRCTcomparedenhanced
SLTalsowithintensiveSLT(definedas5
hoursaweekfor12weeks,inpractice
was3hoursperweek);however
intensiveSLThadnosignificanteffect
overandaboveenhancedSLT,therefore
intensiveSLTwasnotconsideredinthe
economicanalysis(itwouldbe
dominatedbyenhancedSLT).

(a) TheconversionofWABtestscoresintoQALYgainswasbasedonanumberofassumptions.Forexample,itassumed
thattheWABtestiscomparabletotheAphasiatestandthatbothscaleshaveasimilardistribution.TheWABtestis
scoredoutof1to100,whiletheaphasiatestisscoredbetween0and20.Issuesaroundtranslationaphasiascalestothe
Barthelindexwhichmeasuresfunction.TheeffectivenessdatausedintheanalysisisbasedononeRCT;howeverthe
NCGCclinicalreviewhasidentifiedadditionalrelevantstudies.

Table80: EnhancedversusstandardspeechtherapyEconomicsummaryoffindings

Study
169

Marsh2010
(UKNHS)

Incremental
cost()

Incremental
effects
(QALYs)

ICER
(/QALY)

844(a)

0.057(b)

14,807

Uncertainty
ThepercentageimprovementinWAB
testfollowingenhancedSLTwasvaried
between70%and80%.EnhancedSLT
remainedcosteffectiveaslongasthe
improvementwasabove72%.

ThechangeinQALYgainwasvaried
between0.040and0.058.Enhanced
SLTremainedcosteffectiveaslongas
theincrementalQALYgainwasabove
0.042.

(a) 2009UKpounds.Costsincorporated:communitySLTcosts(band7).StandardSLTcostwascalculatedas6.9hoursper
patientover12weeks.EnhancedSLTcostwascalculatedas19.3hoursperpatientover12weeks.
(b) TheimprovementinWABtestscores(frombaselineto24weeks)wascalculatedandconvertedtoaphasiatestscores.
ThesescoreswerethentranslatedtotheBarthelindex.TheQALYgainwasobtainedbymappingfromtheBarthelindex
toEQ5DusingalinearregressionanalysisreportedinapaperbyExeletal(2004).271

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12.4.1.3

Evidencestatements
Clinicalevidencestatements
Onestudy59comprisingof17participantsfoundthemoreintensivespeechinterventionwas
associatedwithastatisticallysignificantimprovementinthefollowingsubsetsofAachenerAphasie
Testcomparedwiththelessintensiveinterventionat6monthsfollowup:
o tokentest(MODERATECONFIDENCEINEFFECT)
o writtenlanguage(MODERATECONFIDENCEINEFFECT)
Onestudy59comprisingof17participantsfoundnosignificantdifferencebetweenthemoreintensive
speechgroupandthelessintensivegroupat6monthsfollowupatthefollowingsubsetsof
AachenerAphasieTest:
repetition(VERYLOWCONFIDENCEINEFFECT)
naming(LOWCONFIDENCEINEFFECT)
comprehension(LOWCONFIDENCEINEFFECT)
profilelevel(LOWCONFIDENCEINEFFECT)
Onestudy13comprisingof97participantsfoundnosignificantdifferenceinWesternAphasiaBattery
scorebetweentheintensivespeechgroupandlessintensivegroupattheendof2,3and6months
followup(MODERATE,LOWandMODERATECONFIDENCEINEFFECT,respectively).
Onestudy67comprisingof19participantsfoundnosignificantdifferenceintheBostonNamingTest
betweentheintensivespeechgroupandthenotherapygroupat2monthsfollowup(VERYLOW
CONFIDENCEINEFFECT).
Onestudy67comprisingof19participantsfoundthattheparticipantsreceivedmoreintensivespeech
therapyshowedastatisticallysignificantimprovementintheAmsterdamNijmeganEveryday
LanguageTestcomparedwiththenotherapygroupat2monthsfollowup(LOWCONFIDENCEIN
EFFECT).
Onestudy133comprisingof36participantsfoundnosignificantdifferencebetweenthemore
intensivespeechgroupandthenotherapygroupat6monthsfollowuponthefollowingoutcomes:
PorchIndexofCommunicativeAbility(PICA)(LOWCONFIDENCEINEFFECT)
WesternAphasiaBattery(LOWCONFIDENCEINEFFECT)
Onestudy133comprisingof36participantsfoundnosignificantdifferencebetweenthelessintensive
groupandthenotherapygroupat6monthsfollowuponthefollowingoutcomes:
PorchIndexofCommunicativeAbility(PICA)(VERYLOWCONFIDENCEINEFFECT)
WesternAphasiaBattery(LOWCONFIDENCEINEFFECT)
Onestudy107comprisingof60participantsfoundnosignificantdifferenceinthePorchIndexof
CommunicativeAbility(PICA)betweenthemoreintensivespeechgroupandthenotherapygroupat
1and10monthsfollowupafterlesiononset(LOWCONFIDENCEINEFFECT).
Onestudy29comprising153participantsfoundnosignificantdifferenceintheTherapyOutcome
MeasureSubscale(TOM)betweentheearlyintensivespeechtherapygroupandthenotherapy
groupat6monthfollowup(MODERATECONFIDENCEINEFFECT)
Onestudy29comprising117participantsfoundnosignificantdifferenceintheCommunication
OutcomesAfterStrokescale(COAST)betweentheearlyintensivespeechtherapygroupandtheno
therapygroupat6monthfollowup(HIGHCONFIDENCEINEFFECT)

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Onestudy29comprising129participantsfoundnosignificantdifferenceintheCarerCommunication
OutcomesAfterStrokescale(carerCOAST)betweentheearlyintensivespeechtherapygroupand
thenotherapygroupat6monthfollowup(HIGHCONFIDENCEINEFFECT)
Economicevidencestatements
Onedirectlyapplicablestudy169withpotentiallyseriouslimitationsshowedthatenhancedspeech
therapyiscosteffectivecomparedtostandardspeechtherapy.Enhancedspeechtherapyismore
costlybutalsomoreeffectivethanstandardspeechtherapyandtheICERisbelowthe20,000/QALY
threshold(14,807perQALYgained).TheseresultsweresensitivetotheimprovementinWABtest
andtotheQALYgainachievedwithenhancedtherapy.

12.4.2

Recommendationsandlinktoevidence
74.Referpeoplewithsuspectedcommunicationdifficultiesafter
stroketoaspeechandlanguagetherapistfordetailed
analysisofspeechandlanguageimpairmentsandassessment
oftheirimpact.
75.Speechandlanguagetherapistsshould:
providedirectimpairmentbasedtherapyfor
communicationimpairments(forexample,aphasiaor
dysarthria)
helpthepersonwithstroketouseandenhancetheir
remaininglanguageandcommunicationabilities
teachothermethodsofcommunicating,suchasgestures,
writingandusingcommunicationprops
coachpeoplearoundthepersonwithstroke(including
familymembers,carersandhealthandsocialcarestaff)to
developsupportivecommunicationskillstomaximisethe
personscommunicationpotential
helpthepersonwithaphasiaordysarthriaandtheirfamily
orcarertoadjusttoacommunicationimpairment
supportthepersonwithcommunicationdifficultiesto
rebuildtheiridentity
supportthepersontoaccessinformationthatenables
decisionmaking.

Tradeoffbetweenclinical
benefitsandharms

TheGDGagreedthatitwasunlikelythattherewereanysignificant
harmsassociatedwiththisformoftherapyprovidedpatient
expectationswerekeptrealistic,afocusremainedonparticipation,and
thepatient,familyandfriendsweresupportedtomanageanypersisting
disability.Itwasfeltthatanimprovementintheabilitytocommunicate
wouldhaveasignificantimpactintermsofqualityoflifeforthepatient
withstroke.

Economicconsiderations

TheGDGnotedthatspeechtherapiesarecurrentlyroutinelyofferedin
theUKNHStostrokepatientswithaphasia.Moreintensivetherapy
wouldbeassociatedwithincreasedpersonnelcosts.Oneeconomic
evaluation169basedonanRCTincludedinourreviewshowedthat
enhancedspeechtherapy(whichwas1.6hoursaweekfor12weeks)is

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morecostlybutalsomoreeffectivethanstandardspeechtherapy(which
was0.57hoursaweekfor12weeks)andtheICERisbelowthe20,000
perQALYthreshold,thereforethiswouldbeconsideredcosteffective.
However,intensivespeechtherapy(whichwas3hoursperweekfor12
weeks)wasnotincludedintheformalanalysissinceintheRCTthiswas
morecostlyandnotmoreeffectivethanenhancedspeechtherapy.
Intensivespeechtherapyisthereforenotcosteffective.
Qualityofevidence

Thestudiesshouldbeconsideredasfeasibilitystudiesduetothesmall
samplesize.Itwasnotedthattheywereunderpowered.
Onestudyshowedthatmoreintensivespeechtherapywasassociated
withanimprovementintokentestandwrittenlanguageasassessedby
AachenerAphasieTestat6monthsfollowupcomparedtolessintensive
speechtherapy(Denes59).Confidenceintheeffectshownforthese
outcomeswasgradedasmoderate.
TheGDGconsideredthatthepopulationsincludedinthetrialsdidnot
reflectthosewhowouldbeseeninclinicalpractice,manyofwhom
wouldhavehadspeechproblemsforasignificantlylongertime.

InstudiesofintensityintheACTNoWstudytheGDGagreedthe
evidencesuggeststhatgreaterintensitywhencomparedtosocial
supportwithoutdirectspeechandlanguagetherapyresultedingreater
benefit,althoughthiswasnotstatisticallysignificant.TheGDGagreed
thatthequestionstilltobeansweredwaswhethermoreintensespeech
andlanguagetherapydeliveredbymoreskilledstaffwoulddeliver
greaterbenefit.WhattheACTNoWstudyaddsisthevalueof
appropriatelytrainedpaidvisitorstoaidtherecoveryoffunctional
communicationafterstroke.

Otherconsiderations

Theincludedstudieslookedatmoreintensivespeechtherapycompared
tolessintensiveanditwastheviewoftheGDGthatnoneofthestudies
presentedwereparticularlyfocussedonintensity.Threestudies
includedinterventionarmsthatwereonlyshortsessions23timesper
week(Doesborgh2004,Hartman1987,Lincoln198467,107,156)theGDG
agreedthat18hoursand22contactsover13weeksdeliveredintheACT
NoWstudywasnotparticularlyintensive.Thegroupalsonotedthatthe
interventionwasdeliveredtwoweeksafterstroke,andthoughtthat
providingSLTthisearlyafterstrokewouldoftennotbeanappropriate
time.
TherewasadiscussionintheGDGaboutthenatureofintensityin
speechandlanguagetherapy,anditwasfeltthatoperationaldefinitions
ofintensityneedtobeagreed.TheGDGnotedthatalltherapieswere
providedinonetoonesessionsandconsideredthiswasappropriatefor
thistypeofrehabilitation.TheGDGalsorecognisedthatmanypeople
withaphasiaalsobenefitfromspeechtherapyingroupstoenhance
functionalcommunicationandconfidence.
Furtherresearchisrequiredthatconsidersover8hoursoflanguage
therapyaweekreflectingtheamountoftherapydeliveredbytheWertz
study283.
TheGDGacknowledgedthestandardspeechtherapyof5x45minsper
week.Thegroupfeltthatthistobetheminimumbutwereawarethat
thisisnotconsideredstandardcare.
Theassessmentoflanguagedeficitsandtherapytailoredtorestore
thosedeficitsshouldbeconductedbyspecialistspeechandlanguage
therapists.Theapproachtakenforeachindividualpatientwilldependon
theprofileofdeficitsandthereforeagenerictreatmentcannotbe
recommended.HoweverforpeoplewithaphasiaordysarthriatheGDG

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StrokeRehabilitation
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recognisedtheuseofimpairmentbasedtherapytohelprestorespeech
orlanguage.

12.5 Listeneradvice
Aphasiacanimpactonapersonsabilitytounderstandandtoexpresslanguagethrougha
rangeofmodalitiesincludingspeech,writing,drawingandgesturemakingcommunication
difficultfortheindividualwhohashadastrokeandthecommunicationpartner.Social
isolationisarguablythemostdevastatingconsequenceofaphasia.Itisthereforeimportant
thatfamilies/carersofthestrokepatientaskeycommunicationpartnersareactively
involvedinaphasiarehabilitationprogrammes.SpeechandLanguageTherapyaimsto
addressaphasiarehabilitationusingasupportedcommunicationapproachwhichincludes
listeneradviceandmultifunctionalskillstofacilitatecommunication.
Keycomponentsoflisteneradvicetraininginvolvesomeofthefollowing:
Useofandencouragementofmultimodalcommunicationi.e.writing,drawing,gesture,
speech,augmentativeandalternativecommunicationaids
Simplificationoflanguagebyusingshort,uncomplicatedsentences.
Facilitationofcomprehensionskillsbycheckingthatthemessageisunderstood.This
mayrequirerepetition
Writingdownkeywordstoclarifymeaningasneeded.
Minimisingdistractionswheneverpossible.
Encouragingengagementofthepersonwithaphasiainconversations.
Maintaininganaturalconversationalmannerappropriateforanadult.
Avoidingcorrectingthepersonsspeechorinterrupting
Allowingthepersonplentyoftimetotalk.
Encouragingconversationalturntaking
Askingforandvaluingtheopinionofthepersonwithaphasia,especiallyregardingfamily
matters.
12.5.1

Whatlisteneradviceskills/trainingorinformationwouldhelpfamilymembers/carers
improvecommunicationinpeoplewithaphasiaafterstroke?
ClinicalMethodologicalIntroduction

12.5.1.1

Population

Familiesandcarersofadultsandyoungpeople16orolderwith
aphasiaafterstroke

Intervention

Listeneradviceskills/trainingorinformation

Comparison

Usualcareornothing,shamoralternativeinterventions

Outcomes

Anyoutcomereportedinthepaper
Qualityoflife

Clinicalevidencereview
SearcheswereconductedforsystematicreviewsandRCTscomparingtheeffectivenessoflistener
adviceskills/trainingorinformationwithusualcare,shamoralternativeinterventionsthatwouldaid

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StrokeRehabilitation
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familymembers/carersimprovecommunicationinpeoplewithaphasiaafterstroke.TwoRCTswere
identified.
Table81summarisesthepopulation,interventionandoutcomesofeachofthestudiesincludedin
theevidencereview.
Table81:Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
STUDY

POPULATION

INTERVENTION

COMPARISON

OUTCOME

Kagan,
2001127

Atleastoneyear
poststroke
patientswith
moderateto
severeaphasia.

Conversationwith
trainedvolunteer;
Supported
Conversationfor
adultswith
Aphasia":for
examplekeeping
talkasnaturalas
possible,avoiding
beingpatronising,
ensuring
understanding,
allowingpersonto
expressknowledge,
thoughtsand
feelings,verifying,
usinggesture,
writinganddrawing.
(N=20)

Conversationwith
untrainedvolunteer
(N=20)

MeasureofSkill
inProviding
Supported
Conversation
forAdultswith
Aphasia(MSCA)

Measureof
Participationin
Conversation
forAdultswith
Aphasia(MPCA)

Worrall,
2000288

Patientswith
chronicaphasia
duetostroke(at
least12months
postonset)in
language
dominant
hemisphere.

Functional
communication
therapyprogramme
(SpeakingOut)
deliveredbytrained
volunteersin
patient'shome;
focusingon
strategiesto
improve
communication
activities(,for
examplepayingbills
directlyfrombank
account,using
multitripbus
tickets)for10
weeks.(N=6)

Nonverbalrecreational
programmefor10weeks.
(N=8)

Western
AphasiaBattery
(WAB),
American
Speech
Language
Hearing
Association
Functional
Assessmentof
Communication
Skills(ASHA
FACS)
Communication
Effectiveness
Index(CETI)
Functional
Communication
Therapy
Planner(FCTP)
ShortForm36
(SF36).

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StrokeRehabilitation
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Comparison:Listeneradviceskills/trainingorinformationversususualcare,nothing,shamoralternativeinterventionsforstrokerehabilitation
Table82:Listeneradviceskills/trainingorinformationversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectness

Imprecision

Listener
advice
Mean(SD)

Usualcare Mean

difference
Mean(SD) (95%CI)

Mean
Difference
(MD)(95% Confidence
CI)
(ineffect)

MeasureofSkill(oflistener)inprovidingSupportedConversationforAdultswithAphasia(acknowledgecompetence)(Posttest)(Betterindicatedbylowervalues)
1
Kaganetal,
2001127

RCTquasi
randomised
single
blinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

2.6(0.7)

1.5(0.8)

1.1
(0.63,1.57)

MD1.1
higher
(0.63to
1.57
higher)

Moderate

MeasureofSkill(oflistener)inprovidingSupportedConversationforAdultswithAphasia(revealcompetence)(Posttest)(Betterindicatedbylowervalues)
1
Kaganetal,
2001127

RCTquasi
randomised
single
blinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

2.7(0.6)

0.7(0.4)

2.0(1.68,
2.32)

MD2
higher
(1.68to
2.32
higher)

Moderate

MeasureofParticipation(ofpersonwithaphasia)inConversationforAdultswithAphasia(interaction:socialconnection)(Posttest)(Betterindicatedbyhighervalues)
1
Kaganetal,
2001127

RCTquasi
randomised
single
blinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b)

2.6(9)

2.2(9)

0.4(0.16,
0.96)

MD0.4
higher
(0.16
lowerto
0.96
higher)

Low

MeasureofParticipation(ofpersonwithaphasia)inConversationforAdultswithAphasia(transaction:exchangeofcontent)(Posttest)(Betterindicatedbylower
values)
1

RCTquasi

Serious

Noserious

Noserious

Noserious

2.7(8)

2.0(8)

NationalClinicalGuidelineCentre,2013.

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0.7(0.20,

MD0.7

Moderate

StrokeRehabilitation
Communication

Summaryoffindings
Qualityassessment

Noofstudies
Kaganetal,
2001127
(a)
(b)

Design
randomised
single
blinded

Effect

Limitations
limitations
(a)

Inconsistency
inconsistency

Indirectness
indirectness

Imprecision
imprecision

Listener
advice
Mean(SD)

Usualcare Mean

difference
Mean(SD) (95%CI)
1.20)

Mean
Difference
(MD)(95% Confidence
CI)
(ineffect)
higher(0.2
to1.2
higher)

Unclear randomization process.

Confidence interval crossed one default MID.

Narrativesummary
ThefollowingstudyissummarisedasanarrativebecausetheresultswerenotpresentedinnumericaldatathatcouldbeincludedintheGRADEtable:
Onematchedpairsingleblindedrandomisedstudy(Worralletal)288reportedthattherewasastatisticallysignificantimprovementontheWestern
AphasiaBatteryinthosewhoreceiveda10weekfunctionalcommunicationtherapy(SpeakingOut)programmedeliveredbytrainedvolunteers,
comparedtothosewhoreceivedusualcarewithrecreationalactivities/notreatment.Therewerenosignificantdifferencesinanyofthefunctional
communicationmeasures.Apositivemeanchangeof29.3(SD=19.3)ontheGeneralHealthscaleoftheaphasicpersonsSF36inonegroupwasobserved
andtherewasastatisticallysignificantnegativemeanchangeof18.1(SD=18.06)forthebodilypainscaleofthespousesSF36intheothergroup,
followingtheSpeakingOutprogramme.

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12.5.1.2

Economicevidence
Literaturereview
Norelevanteconomicevaluationscomparinglisteneradviceskills/informationtofamilymembers
/carerstoimprovecommunicationinpeoplewithaphasiaafterstrokewithusualcareorno
interventionwereidentified.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
CostsoftheinterventionwereestimatedbasedonastudybyVanderGaagetal,2008268.Thisstudy
wasacostanalysisofvariousspeechandlanguageprogrammes.Costswerecalculatedonthebasis
of7sessionswith17patientspersession.BasedontheresourceusebreakdownshowninTable83,
thetotalcostperpatientis517.Itisassumedthisisontopofusualcare.
Table83: Interventioncostslisteneradviceskills/informationtofamilymembers/carers
Resource

Quantity/hrs.(a)

Cost(b)

Seniorspeechandlanguagetherapist(band7)

57/hr.ofclientcontact

Speechandlanguagetherapist(band6)

47/hr.ofclientcontact

Assistant

25/hr.spentwithapatient

Transport

40/visit(a)

517

(c)

Totalcostperpatient
268

(a) Source:VanderGaagetal,2008
(b) EstimatedbasedondataandmethodsfromPersonalSocialServicesResearchUnitUnitcostsofhealthandsocialcare
reportandrelevantAgendaforChangesalarybands51(typicalsalarybandidentifiedbyclinicalGDGmembers)
(c) Assumedtobecostedsimilartoaband2clinicalsupportworkernursing(community)

12.5.1.3

Evidencestatements
Clinicalevidencestatements
Onequasirandomisedstudy127of40participantsfoundthatthetrainedvolunteersscoreda
statisticallysignificanthigherratingofskillinacknowledgingandrevealingcompetenceoftheir
partnerswithaphasiausingtheMSCA(measureofsupportedconversationforadultswithaphasia),
comparedwiththeuntrainedvolunteers(MODERATECONFIDENCEINEFFECT).
Onequasirandomisedstudy127of40participantsfoundthattherewasnosignificantdifferencein
theratingofMPCAinteraction:socialconnection(ratedbyaphasicindividuals)betweenthosewho
receivedtheSupportedConversationforAdultswithAphasia(SCA)interventionwithtrained
volunteerscomparedwithusualcareattheendoftheintervention(LOWCONFIDENCEINEFFECT).
Onequasirandomisedstudy127of40participantsfoundthatthosewhoreceivedtheSupported
ConversationwithAdultsinterventionwithtrainedvolunteersscoredastatisticallysignificanthigher
ratingofMPCAtransaction:messageexchange(ratedbyaphasicindividuals)comparedwithusual
careattheendoftheintervention(MODERATECONFIDENCEINEFFECT).

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StrokeRehabilitation
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Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

12.5.2

Recommendationsandlinktoevidence
76.Offertrainingincommunicationskills(suchasslowingdown,
notinterrupting,usingcommunicationprops,gestures,
drawing)totheconversationpartnersofpeoplewithaphasia
afterstroke.

Relativevalueplacedonthe
outcomesconsidered

Anyoutcomereportedinthestudieswasincludedinthereview.
ItwasnotedthattheKaganstudy127measuredboththeacquiredskillsof
patientsandthevolunteerlisteners.TheGDGfeltthatinthecontextof
conversationpartners,itwasimportanttoconsideroutcomesforboth
groupsofparticipants.
Noqualityoflifeoutcomeswereaddressedintheevidencepresented.The
GDGconsideredthattheseoutcomemeasureswouldconsiderthesocial
andpsychologicalchallengesassociatedwithaphasiawhichareparticularly
relevanttothisintervention.Thelackofstandardisedoutcomesinthe
studieswasnoted.

Qualityofevidence

TheGDGagreedthatevidencepresentedwaslimitedtotwo,smallstudies
whichmightberegardedasfeasibilitystudiesandthereforenotrobust.
127 288
HowevertheGDGnotedthattheKaganstudydemonstratedtraining
volunteersresultedinapositivebenefitforthemeasureofskilloutcomes
andalsodemonstratedabenefitinparticipationinconversationbythe
personwithaphasia.Confidenceintheresultsshownfortheseoutcomes
wasgradedasmoderateduetounclearrandomisation.Anothersmall
study288reportedasignificantimprovementinthosewhoreceiveda10
weekfunctionalcommunicationtherapydeliveredbytrainedvolunteers.
Howevertheseresultswerenotpresentedinnumericaldatathatcouldbe
includedintheGRADEanalysis.
Thedifficultyofrecruitingasuitablylargepatientpopulationand
volunteersforthistypeofinterventionwasrecognised.Itwasagreedthat
thefeasibilityofofferingthisinterventionanditsapplicabilitytoUK
practicewasdemonstrated.

Tradeoffbetweenclinical
benefitsandharms

TheGDGdiscussedthedefinitionoflistenersadviceandtheelementsof
supportedconversationtraining.TheGDGconsideredtherewerelikelyto
bebenefitsfromprovidingsimplecommunicationskillstrainingtofamily
members,carersandvolunteersandthetypesofskillsemployedwithinthe
studiesreviewedshouldbegivenasexamplessuchasslowingspeech
down,notinterrupting,usinggesturesandwritingordrawing.

TheGDGacknowledgedthattheKaganstudy127mayhavedifferent
applicabilitywheninterventionsaredeliveredtofamilymemberswhere
otherfactorsmayimpact.

Economicconsiderations

Nocosteffectiveevidencewasfound.Thecostofprovidingtrainingin
communicationskillstotheconversationpartnersofpeoplewithaphasia
wasestimatedataround517perpatient.TheGDGconsideredthiscost
likelytobeoffsetbythebenefitsoftrainingtheconversationpartners.

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StrokeRehabilitation
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13 Movement
Weaknessiscommonafterstroke;thismayariseduetotheuppermotorneuronlesioncompounded
byinactivityasaconsequenceoflimitedphysicalmobility.Weaknesslimitspatientsabilitytomove
thebody,includingchangingbodyposition,transferringfromoneplacetoanother,andwalkingas
wellasupperlimbfunctionssuchascarrying,movingormanipulatingobjects.Italsolimits
performanceofactivitiesofdailylivingandmayleadtoamoregeneralisedlossoffitness.
Theabilitytowalkfollowingastrokeisoftenaffectedorlostduetomultipleandcomplexdeficitsof
motorandsensorysystemsgivingrisetolossofmovement,balanceandposturalcontrol.
Rehabilitationofgaitideallyattemptstorestoreanormalwalkingpatternorifthisisnotpossibleto
developacompensatoryapproachusingvariousaidstopromoteasafeandfunctionallevelof
mobility.Theabilitytowalkfollowingastrokeisoftenseenbyboththepatientwithstrokeandtheir
teamasamajordesirableoutcomeatanystagethroughouttherehabilitationjourneyandsignificant
timeandeffortisoftenrequiredbythepatientandtheirteaminordertoreeducategaitand
promoteindependentmobility.
Maximisingupperlimbrecoveryafterstrokesimilarlyrequiressignificanttimeandeffortbythe
patientafterstrokeandtherehabilitationteam.Ithasbeenestimatedthatupperlimbparalysis
affectsonethirdofthestrokepopulation.Thesiteandsizeofthelesionisamajordeterminantof
outcome,withsomepeopleafterstrokehavingsuchseverelossthatnoamountoftherapywill
affectfunctionalrecovery.However,asignificantproportionofpeoplefollowingstrokewillregain
goodarmfunctionthroughspontaneousrecovery.Intheremainder,additionaltherapymayimprove
outcomes.
Manyofthetechniquesusedtosupportthepatientinrelearningmotorskillsdependonrepetitive
taskpractice.Repetitivetasktrainingencompassesanumberofideas;firstlythatrepetitivepractice
earlyafterstrokemayleadtobeneficialneuroplasticchangeswithinthebrain;secondlythat
repetitivepracticereducesweakness;thirdly,thatcomplexmovementscanbebrokendowninto
theircomponentsallowingpracticeofsimpleelementsbeforeincorporatingtheentiremovement;
fourthly,thatvaryingtaskcomplexityandtrainingschedules(distributedpractice,contextual
interference)promotesmotorlearningandgeneralisationtoreallifesituationsandretentionof
skills;andfifthlythatfeedbackiscriticaltolearningthemotorskills.

Inadditionstrengthtrainingcanbeusedtoaddressthesecondarymuscleweaknessthatarisesasa
resultofinactivity.Theunderlyingmechanismsofneuromuscularweaknessafterstrokepossibly
includeatrophyoftypeIIfibers,increasedproportionoftypeIfibers,lossofmotorunits,collateral
reinnervation,andalteredfiringofmotorunitgroups.Itisthoughtthatremodellingofmotorunits
occursinthemonthsafterstrokeanditmaybepossibletoenhancethisprocesswiththerapies
directedtowardincreasingmusclestrengthandthusfunctionalability.

Inpracticethedistinctionbetweenstrengthtrainingandrepetitivetaskpracticemaybelessclear,
forexample,treadmilltrainingwithbodyweightsupportmaybeusedtofacilitateabettergait
patternwhilebuildingstrengthandendurance.

13.1 Strengthtraining
Decreasedmusclepoweriscommonafterstroke;thismaybeduetocompromisedmusclefunction
poststroke,compoundedbyinactivityasaconsequenceoflimitedphysicalmobility.Decreased
musclepowerlimitspatientsabilitiesinactivitiesofdailylivingandmayleadtoamoregeneralised
lossoffitness.

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StrokeRehabilitation
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Strengthtrainingthroughrepetitivepracticemayrepresentoneapproachtoimprovingupperand
lowerfunctionafterstroke.

13.1.1

Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessof
strengthtrainingversususualcareonimprovingfunctionandreducingdisability?
ClinicalMethodologicalIntroduction
Population

Adultsandyoungpeople16orolderwhohavehadastroke

Intervention

Upperlimbstrengthtrainingand/or
Lowerlimbstrengthtraining
TrunkTypesofinterventionsinclude:weighttraining,resistance
training,IsometricandIsotonicexercises,circuittrainingfor
strength

13.1.1.1

Comparison

Usualcare

Outcomes

UpperLimb
MRCScale
NewtonMetres
FuglmeyerAssessment
ActionResearchArmTest(ARAT)
FunctionalIndependenceMeasurement(FIM)
BarthelIndex
Adverseeventspainorspasticity
LowerLimb/Trunk
TimedUpandGoTest
Anytimedwalk
Walkingdistance
FunctionalIndependenceMeasure(FIM)
BarthelIndex
Adverseeventsfalls,painorspasticity
NewtonMetres

ClinicalEvidenceReview
SearcheswereconductedforsystematicreviewsandRCTscomparingtheclinicaleffectivenessof
strengthtrainingwithusualcaretoimprovefunctionandreducedisabilityforadultsandyoung
people16orolderwhohavehadastroke.Onlystudieswithaminimumsamplesizeof20
participants(10ineacharm)wereselected.NineRCTswereidentified.
Table84summarisesthepopulation,intervention,comparisonandoutcomesforeachofthestudies.
Table84: Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
STUDY
47

Cooke,2010

POPULATION

INTERVENTION

COMPARISON

OUTCOMES

Inpatientswithstroke
(113weekspost
strokeonset)who
wereindependently
mobile(withor
withoutaids)priorto
theindexstrokeand
wereabletofollowa1
stagecommand.

Functionalstrength
trainingplus
conventional
physiotherapy;
focusedon
repetitive,
progressiveresistive
exerciseduringgoal
orientedfunctional

Routine
conventional
physiotherapy
byaclinical
physiotherapist
includedsoft
tissue
mobilisation,
facilitationof

NationalClinicalGuidelineCentre,2013.
314

Walkingspeed
(m/sec)
Kneeflexion
peaktorque
Kneeextension
peaktorque

StrokeRehabilitation
Movement
STUDY

POPULATION

Donaldson,
200968

Strokepatients(mean
timeafterstroke:20.2
days(SD=14.0)).

Flansbjer,
200884

Kim,2001136

INTERVENTION
activity.All
additionaltherapy
wasdeliveredusing
standardized
treatmentschedules
forupto1hour,4
days/weekfor6
weeks.(N=36)

COMPARISON
muscleactivity,
facilitationof
coordinated
multijoint
movement,
tactileand
proprioceptive
input,resistive
exerciseand
functional
retraining.
(N=38)

OUTCOMES

Functionalstrength
training(FST)plus
conventional
physiotherapybya
physiotherapistupto
1hour,4days/week
for6weeks(total24
hours).FSTwas
basedonthe
positioningofthe
handandthenusing
ittomanipulate
objects.Treatment
wasprogressedusing
repetition,altering
thesizeandweight
ofitems,andusing
heavierweights.
(N=10)
Strokepatients(mean Progressive
timesincestroke:18.9 resistancetraining
months(SD7.9)forthe providedfor10
traininggroupand20
weekstwiceweekly
months(SD11.6)for
usingLeg
thecontrolgroup.
Extension/Curl
Rehabilitation
exercisemachine.
Each(N=15)

Conventional

physiotherapy
instructedbya

physiotherapist.
(N=10)

Usualcare:

patientswere
encouragedto
continueusual
dailyactivities
andtrainingbut
nottoengagein
anyprogressive
resistance
training(PRT).
(N=9)

Gait
performance
TimedUp
andGotest
Fastwalking
speed
6minute
walktest
(m).

Chronicstroke
survivors,withresidual
unilateralweakness;
aged50yearsorolder;
historyofasingle
strokeatleast6
monthsbefore
participatinginthe
study.

Thesameas

intervention
exceptthe
resisted

contractions
replacedwith
passiverangeof
motion
movements.
(N=10)

Selfselectedgait
speed/Habitual
gaitspeed(m/s)
Maximalgait
speed(m/s)

Maximalisokinetic
strengtheningwith
anisokinetic
dynamometer
consistingofthree
45minutesessions
perweekfor6
consecutiveweeks
foratotalof18
sessions.
Participantswere
askedtowalkattheir
mostcomfortable
speed(i.e.,self

NationalClinicalGuidelineCentre,2013.
315

ActionResearch
ArmTest(ARAT)
HandGripforce
(N)
Pinchgrip
force(N)
Isometricelbow
flexionforce(N)
Isometricelbow
extensionforce
(N).

StrokeRehabilitation
Movement
STUDY

POPULATION

INTERVENTION
selectedspeed)for5
trialsandthen
safelyasfastas
possible(i.e.,
maximalspeed)for
another5trialsalong
an8mwalkway.
(N=10)

COMPARISON

Langhammer,
2007142

Strokepatientwith
hemispherelesion:
Right(n):19intensive
exercise;19regular
exercise
Left(n):16intensive
exercise;21regular
exercise.

Functionalexercise
programme;high
intensityof
endurance,strength,
andbalance.
Individualised
trainingprogrammes
aimedatfunctional
improvementsbut
withvariations,for
examplegettingup
fromachair,walking
indoors,Nordic
walkingoutdoors,
stationarybicycling
andstairwalking,
wherethe
physiotherapist
monitoredthelevels
ofintensity.Total
treatmentperiodat
least80hours
(minimum20hours
everythirdmonthfor
thefirstyearafter
discharge;2
3timesperweekifat
homeorattending
private
physiotherapy
practiceordailyifin
rehabilitationward)
(N=35)

Usualcare:

physical
exercisesin

accordancewith
theroutinesin
thecommunity,
andonlyif
neededthey
wouldhavea
followup
(N=40)

Moreland,
2003178

Strokepatients:
Nonlacunar36(53%)
progressiveresistance;
36(55%)control
group.

Strengthtraining:
conventional
physiotherapyplus
progressive
resistanceexercises
withweightsatwaist
oronlower
extremities.
Useofankle
exercisertowhich
variableweights
appliedfor30minute
exercisesessions(2
setsof10

Conventional
physiotherapy
butnoexternal
resistancewas
appliedwith
weights.(N=65)

NationalClinicalGuidelineCentre,2013.
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OUTCOMES

BarthelIndex
(BI)
Gripstrength
(paretic,non
paretichand)

2minutewalk
test(m)

StrokeRehabilitation
Movement
STUDY

POPULATION

INTERVENTION
repetitions)3timesa
week.(N=68)

COMPARISON

Ouellette,
2004195

Patientsaged50
years;6monthsto6
yearsfollowingasingle
unilateralmildto
moderatestrokewith
residuallower
extremityhemiparesis,
communitydwelling;
independent
ambulationwithor
withoutanassistive
device

Progressive
ResistanceTraining:
Subjectsperformed
seatedbilateralleg
press(LP);unilateral
pareticandnon
pareticlimbknee
extension(KE),
unilateralankle
dorsiflexion(DF),and
planterflexion(PF)3
timesperweekfor
12weeks.
Habitualand
maximalGait
VelocitiesSubjects
wereinstructedto
walk10metresat
theirnormaland
maximalvelocity
respectively.
(N=21)

Bilateralrange

ofmotion
(ROM)and

upperbody
flexibility
exercises
performed3

timesperweek.
(N=21)

Sixminutewalk
(min)
HabitualGait
Velocity/self
gaitspeed
(m/sec)
MaximalGait
Velocity(m/sec)

Winstein,
2004285

Strokepatients(mean
timesincestroke16
days(SD17.7).85%of
patientshadischaemic
typeofstroke.

Strengthandmotor
controltraining(ST):
resistanceto
availablearm
motion.(N=21)

Standardcare
byan
occupational
therapist:
muscle
facilitation
exercises,
neuromuscular
electric
stimulation
applied
primarilyfor
shoulder
subluxation,
stretching
exercises,
activitiesof
dailyliving(self
carewherethe
upperlimbwas
usedasan
assist)and
caregiver
training.(N=21)

FuglMeyer
assessment
(FMA):
rangeof
movement
pain
sensory
motorfunction
FIM:
mobility
selfcare

40participantswere
assessedat2weeks
afterstrokeandwere
thosewithaconfirmed
diagnosisofafirst
unilateralstroke(MRI
orCT),noimpairment

Usualcare
Usualcare
physiotherapyplus
physiotherapy
familymediated
(N=20)
exerciseintervention.
IndividualisedFAME
programswere
conductedfor35

Galvin201188

NationalClinicalGuidelineCentre,2013.
317

OUTCOMES

Lowerlimbsection
oftheFuglMeyer
Assessment(LL
FMA).
Motorassessment
Scale(MAS),
BergBalanceScale

StrokeRehabilitation
Movement
STUDY

POPULATION
ofcognition(24of30
ontheMiniMental
StateExamination),
participatingina
physiotherapyprogram
andafamilymember
willingtoparticipatein
theprogram.To
controlfor
heterogeneity
individualswhoscored
from3.2to5.2onthe
OrpingtonPrognostic
Scalewererecruited.
Thefamilymember
hadtobemedically
stableandphysically
abletoassistinthe
deliveryofexercises.

INTERVENTION
minutesdailyatthe
bedsidewiththe
assistanceoftheir
nominatedfamily
member.The
emphasisofthe
lowerlimbexercise
interventionwason
achievingstability
andimprovinggait
velocityandlower
limbstrengthbased
onpatternsand
wereprogress
accordingtothe
individualsability
(N=20)

NationalClinicalGuidelineCentre,2013.
318

COMPARISON

OUTCOMES
(BBS),
6MWT
BarthelIndex(BI)

StrokeRehabilitation
Movement

Comparison:Functionalstrengthtraining(upper,lowerlimb)versususualcare
Table85:UpperlimbfunctionalstrengthtrainingusualcareClinicalstudycharacteristicsandclinicalsummaryoffindings

Summaryoffindings
Qualityassessment

Noofstudies

Design

Limitations

Indirectnes
Inconsistency s

Imprecision

Upper
limb
Functiona
lstrength
training
Mean
(SD)

Effect
Usual
care

Mean
(SD)

84.5
(23.9)

Mean
differenc
e
(95%CI)

Mean
Differen
ce(MD)
(95%CI)

91.2
(19.9)

6.7(
17.55to
4.15)

MD6.7
lower
(17.55
lowerto
4.15
higher)

Low

0.55
(0.42)

0.55
(0.41)

0(0.2to
0.2)

MD0
higher
(0.2
lowerto
0.2
higher)

Moderate

0.77
(0.35)

0.81
(0.31)

0.04(
0.2to
0.12)

MD0.04
lower
(0.2
lowerto
0.12
higher)

Low

Confidence
(ineffect)

BarthelIndex(6monthsfollowup)(Betterindicatedbyhighervalues)
1
Langhammer
142
2007

RCTdouble
blinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious
Serious
indirectness imprecision(
b)

Gripstrengthparetichand(6monthsfollowup)(Betterindicatedbyhighervalues)
1
Langhammer
2007142

RCTdouble
blinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious
Noserious
indirectness imprecision

Gripstrengthnonparetichand(6monthsfollowup)(Betterindicatedbyhighervalues)
1
Langhammer
2007142

RCTdouble
blinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious
Serious
indirectness imprecision(
c)

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Limitations

Indirectnes
Inconsistency s

Imprecision

Upper
limb
Functiona
lstrength
training
Mean
(SD)

Effect
Usual
care

Mean
(SD)

80.8
(29.5)

Mean
differenc
e
(95%CI)

Mean
Differen
ce(MD)
(95%CI)

87.7
(27.8)

6.9(
21.05to
7.25)

MD6.9
lower
(21.05
lowerto
7.25
higher)

Verylow

0.63
(0.46)

0.67
(0.43)

0.04(
0.26to
0.18)

MD0.04
lower
(0.26
lowerto
0.18
higher)

Low

0.87
(0.4)

0.99
(0.32)

0.12(
0.3to
0.06)

MD0.12
lower
(0.3
lowerto
0.06
higher)

Low

43.6
(18.9)

45
(13.93
)

1.4(
16.58to
13.78)

MD1.4
lower
(16.58

Low

Confidence
(ineffect)

BarthelIndex(1yearfollowup)(Betterindicatedbyhighervalues)
1
Langhammer
2007142

RCTdouble
blinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious
Veryserious
indirectness imprecision(
e)

Gripstrengthparetichand(1yearfollowup)(Betterindicatedbyhighervalues)
1
Langhammer
2007142

RCTdouble
blinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious
Serious
indirectness imprecision(
c)

Gripstrengthnonparetichand(1yearfollowup)(Betterindicatedbyhighervalues)
1Langhammer
2007142

RCTdouble
blinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious
Serious
indirectness imprecision(
c)

ActionResearchArmTest(ARAT)(3monthsfollowup)(Betterindicatedbyhighervalues)
1
Donaldson200968

RCTsingle
blinded

Noserious
limitation

Noserious
inconsistency

Noserious
Veryserious
indirectness imprecision(
d)

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Limitations

Indirectnes
Inconsistency s

Imprecision

Upper
limb
Functiona
lstrength
training
Mean
(SD)

Effect
Usual
care

Mean
(SD)

Mean
differenc
e
(95%CI)

Mean
Differen
ce(MD)
(95%CI)
lowerto
13.78
higher)

58.5
(60.18)

64.75
(39.25
)

6.25(
52.41to
39.91)

MD6.25
lower
(52.41
lowerto
39.91
higher)

Low

25.8
(21.26)

24.5
(19.7)

1.3(
17.67to
20.27)

MD1.3
higher
(17.67
lowerto
20.27
higher)

Low

59.5
(44.69)

75
(38.67
)

15.5(
54.04to
23.04)

MD15.5
lower
(54.04
lowerto
23.04
higher)

Low

Confidence
(ineffect)

Gripforce(N)(3monthsfollowup)(Betterindicatedbyhighervalues)
1
Donaldson200968

RCTsingle
blinded

Noserious
limitation

Noserious
inconsistency

Noserious
Veryserious
indirectness imprecision(
c)

Pinchforce(N)(3monthsfollowup)(Betterindicatedbyhighervalues)
1
Donaldson200968

RCTsingle
blinded

Noserious
limitation

Noserious
inconsistency

Noserious
Veryserious
indirectness imprecision(
c)

Elbowflexionforce(N)(3monthsfollowup)(Betterindicatedbyhighervalues)
1
Donaldson200968

RCTsingle
blinded

Noserious
limitation

Noserious
inconsistency

Noserious
Veryserious
indirectness imprecision(
c)

Elbowextensionfore(N)(3monthsfollowup)(Betterindicatedbyhighervalues)

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Limitations

Indirectnes
Inconsistency s

1
Donaldson200968

RCTsingle
blinded

Noserious
limitation

Noserious
inconsistency

Imprecision

Noserious
Veryserious
indirectness imprecision(
c)

Upper
limb
Functiona
lstrength
training
Mean
(SD)
49.2
(34.19)

Effect
Usual
care

Mean
(SD)

Mean
differenc
e
(95%CI)

Mean
Differen
ce(MD)
(95%CI)

68.63
(39.61
)

19.43(
54.11to
15.25)

MD
19.43
lower
(54.11
lowerto
15.25
higher)

(a)

Allocationconcealmentnotreported.16%losttofollowup.
MeandifferencedidnotreachtheagreedMIDof9.25points.
(c)
ConfidenceintervalcrossedoneendofdefaultMID.
(d)
MeandifferencedidnotreachtheagreedMIDof12and17pointsfortheaffecteddominantandnondominantsidesrespectively
(e)
ConfidenceintervalcrossedbothendsofdefaultMID.
(b)

NationalClinicalGuidelineCentre,2013.

322

Confidence
(ineffect)
Low

StrokeRehabilitation
Movement

Comparison:lowerlimbfunctionalstrengthtrainingversususualcare
Table86: LowerlimbfunctionalstrengthtrainingversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings
Qualityassessment

Noofstudies

Design

Limitations

Inconsistency

Indirectness

Usual
care

Mea
n
(SD)

Effect

Imprecision

Lower
limb
Functional
strength
training
Mean(SD)

Noserious
imprecision

0.46
(0.37)

0.44
(0.39
)

0.02(
0.19to
0.23)

MD0.02
higher
(0.19
lowerto
0.23
higher)

Moderate

Serious
imprecision(b
)

29.4
(21.2)

25.2
(22.9
)

4.2(9.36
to17.76)

MD4.2
higher
(9.36
lowerto
17.76
higher)

Low

42.1
(27.5)

37.9
(27.8
)

4.2(
12.71to
21.11)

MD4.2
higher
(12.71
lowerto
21.11
higher)

Low

Relative
Mean
differenc
e(MD)
(95%CI)

Mean
Differen
ce(MD)
(95%CI)

Confidence
(ineffect)

Walkingspeed(m/sec)(3monthsfollowup)(Betterindicatedbyhighervalues)
1
Cooke201047

RCTsingle
blinded

Serious
limitations(
a)

Noserious
inconsistency

Noserious
indirectness

Kneeflexionpeaktorque(3monthsfollowup)(Betterindicatedbyhighervalues)
1
Cooke201047

RCTsingle
blinded

Serious
limitations(
a)

Noserious
inconsistency

Noserious
indirectness

Kneeextensionpeaktorque(3monthsfollowup)(Betterindicatedbyhighervalues)
1
Cooke201047

RCTsingle
blinded

Serious
limitations(
a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(b
)

(a)26%losttofollowupat12weeks.
(b)ConfidenceintervalcrossedoneendofdefaultMID

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StrokeRehabilitation
Movement

Comparison:Resistancetrainingversususualcare
Table87:ResistancetrainingversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectnes
s

Imprecision

Usual
Resistance care
training
Mean
Mean(SD) (SD)

Mean
differenc
e(MD)
(95%CI)

15(7.14)

14.1
(7.58)

0.90(
3.66,
5.46)

MD0.90
higher
(3.66
lowerto
5.46
higher)

Low

2.44
(1.82)

5.67
(5.47)

3.23(
6.14to
0.32)

MD3.23
lower
(6.14to
0.32
lower)

Low

16.15
(5.81)

17(5.17)

0.85(
4.26,
2.56)

MD0.85
lower
(4.26
lowerto
2.56
higher)

Low

Confidenc
Mean
Differenc e
e(95%CI) (ineffect)

FIMmobilitychanges(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Winstein
2004285

RCTunblinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious Serious
indirectness imprecision(b)

FIMmobilitychanges(9monthsfollowup)(Betterindicatedbyhighervalues)
1
Winstein
2004285

RCTunblinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious Serious
indirectness imprecision(b)

FIMselfcarechanges(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Winstein
2004285

RCTunblinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious Serious
indirectness imprecision(b)

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectnes
s

Imprecision

Usual
Resistance care
training
Mean
Mean(SD) (SD)

Mean
differenc
e(MD)
(95%CI)

2.75
(4.34)

3.32(
6.48to
0.16)

Confidenc
Mean
Differenc e
e(95%CI) (ineffect)

FIMselfcarechanges(9monthsfollowup)(Betterindicatedbyhighervalues)
1
Winstein
2004285

RCTunblinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious Serious
indirectness imprecision(b)

6.07
(4.62)

MD3.32
lower
(6.48to
0.16
lower)

Low

0.15(
1.37,
1.07)

MD0.15
lower
(1.37
lowerto
1.07
higher)

Low

0.33
(1.45)

1.8(
3.43to
0.17)

MD1.8
lower
(3.43to
0.17
lower)

Low

0.6
(1.79)

0.10(
1.38,
1.18)

MD0.10
lower
(1.38
lowerto
1.18
higher)

Low

UpperextremityFuglMeyerAssessmentRangeofMovementchanges(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Winstein
2004285

RCTunblinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious Serious
indirectness imprecision(c)

0.75(2)

0.6
(1.93)

UpperextremityFuglMeyerAssessmentRangeofMovementchanges(9monthsfollowup)(Betterindicatedbyhighervalues)
1
Winstein
2004285

RCTunblinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious Serious
indirectness imprecision(c)

2.13
(2.96)

UpperextremityFuglMeyerAssessmentPainchanges(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Winstein
2004285

RCTunblinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious Serious
indirectness imprecision(c)

0.7(2.3)

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectnes
s

Imprecision

Usual
Resistance care
training
Mean
Mean(SD) (SD)

Mean
differenc
e(MD)
(95%CI)

Confidenc
Mean
Differenc e
e(95%CI) (ineffect)

UpperextremityFuglMeyerAssessmentPainchanges(9monthsfollowup)(Betterindicatedbyhighervalues)
1
Winstein
2004285

RCTunblinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious Serious
indirectness imprecision(c)

1.19(4)

1
(2.88)

0.19(
2.63to
2.25)

MD0.19
lower
(2.63
lowerto
2.25
higher)

Low

0.75
(1.33)

0.55(
0.59,
1.69)

0.55
higher
(0.59
lowerto
1.69
higher)

Low

0.07
(1.03)

0.18(
0.44to
0.8)

MD0.18
higher
(0.44
lowerto
0.8
higher)

Low

9.05(7.6) 9.15
(2.35,
15.95)

MD9.15
higher
(2.35to
15.95
higher)

Low

UpperextremityFuglMeyerAssessmentsensorychanges(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Winstein
2004285

RCTunblinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious Serious
indirectness imprecision(c)

1.3(2.23)

UpperextremityFuglMeyerAssessmentsensorychanges(9monthsfollowup)(Betterindicatedbyhighervalues)
1
Winstein
2004285

RCTunblinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious Serious
indirectness imprecision(c)

0.25
(0.68)

UpperextremityFuglMeyerAssessmentmotorfunctionchanges(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Winstein
2004285

RCTunblinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious Serious
indirectness imprecision(c)

18.2
(13.54)

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectnes
s

Imprecision

Usual
Resistance care
training
Mean
Mean(SD) (SD)

Mean
differenc
e(MD)
(95%CI)

Confidenc
Mean
Differenc e
e(95%CI) (ineffect)

UpperextremityFuglMeyerAssessmentmotorfunctionchanges(9monthsfollowup)(Betterindicatedbyhighervalues)
1
Winstein
2004285

RCT
unblinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious Serious
indirectness imprecision(c)

5.38
(9.11)

8.33
(11.26)

2.95(
10.19to
4.29)

MD2.95
lower
(10.19
lowerto
4.29
higher)

Low

23.6
(11.1)

26.7
(18.9)

3.1(
16.67to
10.47)

MD3.1
lower
(16.67
lowerto
10.47
higher)

Verylow

16.1
(9.9)

19.4
(17.8)

3.3(
15.96to
9.36)

MD3.3
lower
(15.96
lowerto
9.36
higher)

Low

58.6
(52.7)

63.2
(49.1)

4.6(
23.98to
14.78)

MD4.6
lower
(23.98
lowerto
14.78

Moderate

Timedupandgotest(sec)(5monthsfollowup)(betterindicatedbylowervalues)

1Flansbjer
200884

RCTsingle
blinded

Serious
limitations
(e)

Noserious
inconsistency

Noserious Veryserious
indirectness imprecision(d)

Fastwalkingspeed(m/sec)(5monthsfollowup)(Betterindicatedbyhighervalues)
1
Flansbjer
200884

RCTsingle
blinded

Serious
limitations
(e)

Noserious
inconsistency

Noserious Serious
indirectness imprecision(h)

2minutewalktest(m)(6monthsfollowup)(Betterindicatedbyhighervalues)
1
Moreland
2003178

RCTsingle
blinded

Serious
limitations(g
)

Noserious
inconsistency

Noserious Noserious
indirectness imprecision

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Usual
Resistance care
training
Mean
Mean(SD) (SD)

Mean
differenc
e(MD)
(95%CI)

239.1
(30.3)

234.8
(36.9)

4.30(
16.12,
24.72)

Veryserious
imprecision(f)

251(144)

Noserious Serious
indirectness imprecision(j)

Kim:0.04
(0.13)
Ouellette:
0.64(0.08)

Indirectnes
s

Imprecision

Confidenc
Mean
Differenc e
e(95%CI) (ineffect)
higher)

6minutewalktest(m)(3monthsfollowup)(Betterindicatedbyhighervalues)
1
Ouellette,
2004195

RCTSingle
Serious
Noserious
blinded limitation(e) inconsistency

Noserious Noserious
indirectness imprecision

MD4.3
higher
(16.12
lowerto
24.72
higher)

Moderate

240(140) 11.00(
105.95,

127.95)

MD11
higher
(105.95
lowerto
127.95
higher)

Verylow

Kim:0.09
(0.07)
Ouellette
:0.64
(0.09)

MD0.01
lower
(0.06
lowerto
0.03
higher

Low

6minutewalktest(m)(5monthsfollowup)(Betterindicatedbyhighervalues)
1
Flansbjer
200884

RCTsingle
blinded

Serious
limitations(
e)

Noserious
inconsistency

Noserious
indirectness

Selfselected/Habitualgaitspeed(Betterindicatedbyhighervalues)
2
Kim,2001136,
Ouellette,
2004195

RCTdouble
blinded(Kim)
RCTsingle
blinded
(Ouellette)

Serious
limitations(i
)

Noserious
inconsistency

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0.01(
0.06,
0.03)

StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectnes
s

Imprecision

Usual
Resistance care
training
Mean
Mean(SD) (SD)

Mean
differenc
e(MD)
(95%CI)

Kim:0.05
(0.09)
Ouellette:
0.86(0.11)

0.01(
0.07,
0.04)

Confidenc
Mean
Differenc e
e(95%CI) (ineffect)

Maximalgaitspeed(Betterindicatedbyhighervalues)
2
Kim,2001136,
Ouellette,
2004195

RCTdouble
blinded(Kim)
RCTsingle
blinded
(Ouellette)

Serious
limitations(i
)

Noserious
inconsistency

Noserious Serious
indirectness imprecision(j)

Kim:0.07
(0.08)
Ouellette
:0.87
(0.12)

(a)

Unblindedstudy.Unclearrandomizationandinadequateallocationconcealment.27%losttofollowupat9months.
MeandifferencedidnotreachtheagreedMIDof17pointsforthemotorscaleandthe3pointsforthecognitivescale.
(c)
MeandifferencedidnotreachtheagreedMIDof10%betweentheinterventionandcontrolgroups.
(d)
MeandifferencedidnotreachtheagreedMIDof10secbetweentheinterventionandcontrolgroups.
(e)
Allocationconcealmentnotreported;Nodetailsofrandomisation
(f)
ConfidenceintervalcrossedbothendsofdefaultMID.
(g)
Unclearblinding;20%losttofollowupat6months.
(h)
ConfidenceintervalcrossedoneendofthedefaultMID.
(i)Unclearrandomisation;unclearallocationconcealment
(J)MeandifferencedidnotreachtheagreedMIDof0.2m/secbetweentheinterventionandcontrolgroups.
(b)

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329

MD0.01
lower
(0.07
lowerto
0.04
higher

Low

StrokeRehabilitation
Movement

Comparison:Familymediatedexerciseinterventionversususualcare(physiotherapy)
Table88: GRADEcharacteristicsandclinicalsummaryoffindings
Qualityassessment
Noof
studies

Design

SummaryofFindings
Riskof
bias

Inconsistency

Indirectness

Imprecision

Family
mediated
strength
trainingMean
(SD)

Usualcare
(physiotherapy)
Mean(SD)

Effect
Mean
Differenc
e
(95%CI)

Mean
Difference
(95%CI)

Confidence
(ineffect)

LowerlimbFuglMeyerAssessmentPostintervention(followup8weeks;measuredwith:Meanchangefrombaseline;rangeofscores:036;Betterindicatedby
highervalues)
1
Galvin
201188

randomise
dtrials
single
(assessor)
blinded

serious
(a)

noserious
inconsistency

noserious
indirectness

serious(b)

9.5(9.9)

1.75(6.3)

7.75
(2.61,
12.89)

MD7.75higher LOW
(2.61to12.89
higher)

LowerlimbFuglMeyerAssessmentFollowupafter3months(measuredwith:Meanchangefrompostintervention;rangeofscores:036;Betterindicatedbyhigher
values)
Galvin
201188

randomise
dtrials
single
(assessor)
blinded

serious
(a)

noserious
inconsistency

noserious
indirectness

noserious
imprecision

1.6(2.4)

1.3(5.2)

0.3(
2.21,
2.81)

MD0.3higher
(2.21lowerto
2.81higher)

MODERAT
E

MotorassessmentscalePostintervention(followup8weeks;measuredwith:Meanchangefrombaseline;rangeofscores:048;Betterindicatedbyhighervalues)
Galvin
201188

randomise
dtrials
single
(assessor)
blinded

serious
(a)

noserious
inconsistency

noserious
indirectness

serious(c)

11.9(7.8)

4.75(6.2)

7.15
(2.78,
11.52)

MD7.15higher LOW
(2.78to11.52
higher)

MotorassessmentscaleFollowupafter3months(measuredwith:Meanchangefrompostintervention;rangeofscores:048;Betterindicatedbyhighervalues)
Galvin
201188

randomise
dtrials

serious
(a)

noserious
inconsistency

noserious
indirectness

serious(c)

1.8(3.8)

0.7(2.6

1.1(
0.92,

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330

MD1.1higher
(0.92lowerto

LOW

StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

SummaryofFindings
Riskof
bias

Inconsistency

Indirectness

Imprecision

Family
mediated
strength
trainingMean
(SD)

Usualcare
(physiotherapy)
Mean(SD)

single
(assessor)
blinded

Effect
Mean
Mean
Differenc Difference
e
(95%CI)
(95%CI)
3.12)
3.12higher)

Confidence
(ineffect)

BergBalanceScalePostintervention(followup8weeks;measuredwith:Meanchangefrombaseline;rangeofscores:056;Betterindicatedbyhighervalues)
Galvin
201188

randomise
dtrials
single
(assessor)
blinded

serious
(a)

noserious
inconsistency

noserious
indirectness

serious(c)

22.8(18.1)

9(9)

13.8
(4.94,
22.66)

MD13.8higher LOW
(4.94to22.66
higher)

BergBalanceScaleFollowupafter3months(measuredwith:Meanchangefrompostintervention;rangeofscores:056;Betterindicatedbyhighervalues)
Galvin
201188

randomise
dtrials
single
(assessor)
blinded

serious
(a)

noserious
inconsistency

noserious
indirectness

serious(d)

0.9(2.5)

1.8(8.5)

0.9(
4.78,
2.99)

MD0.9lower
(4.78lowerto
2.98higher)

LOW

6MinuteWalkTestPostintervention(followup8weeks;measuredwith:Meanchangefrombaselinemetres;Betterindicatedbyhighervalues)
Galvin
201188

randomise
dtrials
single
(assessor)
blinded

serious
1

noserious
inconsistency

noserious
indirectness

noserious
imprecision

164.1(128.7)

47.2(50.6)

116.9
(56.29,
177.51
)

MD116.9
higher(56.29
to177.51
higher)

MODERAT
E

6MinuteWalkTestFollowupafter3months(measuredwith:Meanchangefrompostinterventionmetres;Betterindicatedbyhighervalues)
Galvin
201188

randomise
dtrials
single
(assessor)
blinded

serious
(a)

noserious
inconsistency

noserious
indirectness

serious(e)

39.8(55.4)

3.5(32.7)

43.3
MD43.3higher LOW
(15.11, (15.11to71.49
71.49) higher)

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

SummaryofFindings
Riskof
bias

Inconsistency

Indirectness

Imprecision

Family
mediated
strength
trainingMean
(SD)

Usualcare
(physiotherapy)
Mean(SD)

Effect
Mean
Differenc
e
(95%CI)

Mean
Difference
(95%CI)

Confidence
(ineffect)

BarthelIndexPostintervention(followup8weeks;measuredwith:Meanchangefrombaseline;rangeofscores:0100;Betterindicatedbyhighervalues)
Galvin
201188

randomise
dtrials
single
(assessor)
blinded

serious
(a)

noserious
inconsistency

noserious
indirectness

noserious
imprecision

32.3(24)

16.3(14.2)

16
(3.78,
28.22)

MD16higher
(3.78to28.22
higher)

MODERAT
E

BarthelIndexFollowupafter3months(measuredwith:Meanchangefrompostintervention;rangeofscores:0100;Betterindicatedbyhighervalues)
Galvin
201188

randomise
dtrials
single
(assessor)
blinded

serious
(a)

noserious
inconsistency

noserious
indirectness

very
serious(f)

3.8(8.3)

1.5(11.6)

2.3(
3.95,
8.55)

(a)

MD2.3higher
(3.95lowerto
8.55higher)

VERYLOW

Unclear allocation concealment.

The confidence interval crosses the agreed MID of 10% of the Fugl-Meyer scale from appreciable benefit to no effect in favour of FAME intervention
(c)
The confidence interval crosses the default MID (0.5 of standard mean difference) for individual studies, i.e. ranging from appreciable benefit of the FAME intervention to no effect.
(d)
The confidence interval crosses the default MID (0.5 of standard mean difference) for individual studies, here ranging from appreciable negative effect of the FAME study to no effect.
(e)
The confidence interval crossed the agreed MID of 28 metres, i.e. ranging from appreciable benefit of the FAME study to no effect
(f)
The confidence interval crosses both sides of the agreed MID (1.85) ranging from appreciable negative effect to appreciable positive effect associated with the FAME intervention
(b)

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13.1.1.2

Economicevidence
Literaturereview
Norelevanteconomicevaluationscomparingstrengthtrainingwithusualcarewereidentified.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
Thecostofprovidingstrengthtraining(Table89)wasestimatedbasedontheresourcesusedintwo
studies(Flansbjer,200884andCooke,201047)includedintheclinicalreview.Theremainingstudies
includedintheclinicalreview68,142,178,285werenotusedastheydidnotprovidesufficientinformation
aboutthetypeoramountofresourcesused.
Table89: Interventioncostsmusclepowertraining

Source

Unitcosts(a)

Resourceuse

Incrementalcost
(interventionoverusual
care)

Resistancetraining
Flansbjer
200884

90minutesessionsbyphysiotherapist
includingprogressiveresistance
training(b)(<6minutes)for10weeks,
twiceweekly(1.5hrsx20=30hrs)

45perhourofclient
contact(band6)

1350

45perhourofclient
contact(band6)

1080

Lowerlimbstrengthtraining
Cooke
201047

1hoursessionbyphysiotherapist,for
4daysperweekfor6weeks(1hrx24
=24hrs)

(a) EstimatedbasedondataandmethodsfromthePersonalSocialServicesResearchUnitUnitcostsofhealthandsocialcarereportand
51
AgendaforChangesalaryband6 (typicalsalarybandidentifiedbyclinicalGDGmembers).
(b) Trainingwasdoneusingalegextension/curlrehabilitationexercisemachine.

TheseestimatesrepresentthecostofmusclepowertrainingprovidedbyNHSorPSSstaffinthe
earlyphaseafterstroke.However,inlaterstages,strengthtrainingmaybehandedovertoan
appropriatelyqualifiedgyminstructorandthiswouldhavelowercosts.
13.1.1.3

Evidencestatements
Clinicalevidencestatements
Onestudy142of75participantsfoundnosignificantdifferenceinBarthelIndexbetweenthose
participantswhoreceivedupperlimbfunctionaltrainingandthosewhoreceivedusualcareata
followupof6months(LOWCONFIDENCEINEFFECT).
Onestudy142of75participantsfoundnosignificantdifferenceingripstrength(paretichand)
betweenthoseparticipantswhoreceivedupperlimbfunctionaltrainingandthosewhoreceived
usualcareatafollowupof6months(MODERATECONFIDENCEINEFFECT

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Onestudy142of75participantsfoundthattherewasnosignificantdifferenceingripstrength(non
paretichand)betweenthoseparticipantswhoreceivedupperlimbfunctionaltrainingandthosewho
receivedusualcareatafollowupof6months(LOWCONFIDENCEINEFFECT).
Onestudy142of75participantsfoundnosignificantdifferenceinBarthelIndexbetweenthose
participantswhoreceivedupperlimbfunctionaltrainingandthosewhoreceivedusualcareata
followupof1year(VERYLOWCONFIDENCEINEFFECT).
Onestudy142of75participantsfoundnosignificantdifferenceingripstrength(paretichand)
betweenthoseparticipantswhoreceivedupperlimbfunctionaltrainingandthosewhoreceived
usualcareatafollowupof1year(LOWCONFIDENCEINEFFECT).
Onestudy142of75participantsfoundnosignificantdifferenceingripstrength(nonparetichand)
betweenthoseparticipantswhoreceivedupperlimbfunctionaltrainingandthosewhoreceived
usualcareatafollowupof1year(LOWCONFIDENCEINEFFECT).
Onestudy68of20participantsfoundnosignificantdifferenceinActionResearchArmTest(ARAT)
betweenthoseparticipantswhoreceivedupperlimbfunctionaltrainingandthosewhoreceived
usualcareat3monthsfollowup(LOWCONFIDENCEINEFFECT)
Onestudy68of20participantsfoundthattherewasnosignificantdifferenceinGripforce(N)
betweenthoseparticipantswhoreceivedupperlimbfunctionaltrainingandthosewhoreceived
usualcareat3monthsfollowup(LOWCONFIDENCEINEFFECT).
Onestudy68of20participantsfoundthattherewasnosignificantdifferenceinpinchforce(N)
betweenthoseparticipantswhoreceivedupperlimbfunctionaltrainingandthosewhoreceived
usualcareat3monthsfollowup(LOWCONFIDENCEINEFFECT).
Onestudy68of20participantsfoundnosignificantdifferenceinElbowflexionforce(N)between
thoseparticipantswhoreceivedupperlimbfunctionaltrainingandthosewhoreceivedusualcareat
3monthsfollowup(LOWCONFIDENCEINEFFECT).
Onestudy68of20participantsfoundnosignificantdifferenceinElbowextensionforce(N)between
thoseparticipantswhoreceivedupperlimbfunctionaltrainingandthosewhoreceivedusualcareat
3monthsfollowup(LOWCONFIDENCEINEFFECT).
Onestudy47of74participantsfoundnosignificantdifferenceinwalkingspeed(m/sec)between
thoseparticipantswhoreceivedlowerlimbfunctionaltrainingandthosewhoreceivedusualcareat
afollowupof3months(MODERATECONFIDENCEINEFFECT).
Onestudy47of74participantsfoundnosignificantdifferenceinkneeflexionpeaktorquebetween
thoseparticipantswhoreceivedlowerlimbfunctionaltrainingandthosewhoreceivedusualcareat
afollowupof3months(LOWCONFIDENCEINEFFECT).
Onestudy47of74participantsfoundnosignificantdifferenceinkneeextensionpeaktorquebetween
thoseparticipantswhoreceivedlowerlimbfunctionaltrainingandthosewhoreceivedusualcareat
afollowupof3months(LOWCONFIDENCEINEFFECT).
Onestudy285of43participantsfoundthattherewasnosignificantdifferenceinFIMmobilityscore
betweentheparticipantswhoreceivedresistancetrainingandthosewhoreceivedusualcareafter
treatment(LOWCONFIDENCEINEFFECT).
Onestudy285of43participantsfoundthatusualcarewasassociatedwithstatisticallysignificant
improvementinFIMmobilityscorecomparedtoresistancetrainingatafollowupof9months,
althoughthisdifferencewasnotofclinicalsignificance(LOWCONFIDENCEINEFFECT).

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Onestudy285of43participantsfoundthattherewasnosignificantdifferenceinFIMselfcarescore
betweentheparticipantswhoreceivedresistancetrainingandthosewhoreceivedusualcareafter
treatment(LOWCONFIDENCEINEFFECT).
Onestudy285of43participantsfoundthatusualcarewasassociatedwithstatisticallysignificant
improvementinFIMselfcarescorecomparedtoresistancetrainingat9monthsfollowup,
althoughthisdifferencewasnotofclinicalsignificance(LOWCONFIDENCEINEFFECT).
Onestudy285of43participantsfoundthattherewasnosignificantdifferenceinFuglMeyerROM
scorebetweentheparticipantswhoreceivedresistancetrainingandthosewhoreceivedusualcare
aftertreatment(LOWCONFIDENCEINEFFECT).
Onestudy285of64participantsfoundthatusualcarewasassociatedwithstatisticallysignificant
improvementinFuglMeyerrangeofmotionscorecomparedtoresistancetrainingatafollowup
of9months(LOWCONFIDENCEINEFFECT).
Onestudy285of43participantsfoundthattherewasnosignificantdifferenceinFuglMeyerpain
scorebetweentheparticipantswhoreceivedresistancetrainingandthosewhoreceivedusualcare
aftertreatmentandatafollowupof9months(LOWCONFIDENCEINEFFECT).
Onestudy285of64participantsfoundnosignificantdifferenceinFuglMeyersensoryscore
betweenthoseparticipantswhoreceivedresistancetrainingandthosewhoreceivedusualcare
aftertreatmentandatafollowupof9months(LOWCONFIDENCEINEFFECT).
Onestudy285of43participantsfoundthatresistancetrainingwasassociatedwithstatistically
significantimprovementinFIMmotorfunctionscorecomparedtousualcareaftertreatment,
althoughthisdifferencewasnotofclinicalsignificance(LOWCONFIDENCEINEFFECT).
Onestudy285of64participantsfoundnosignificantdifferenceinFuglMeyermotorfunctionscore
betweenthoseparticipantswhoreceivedresistancetrainingandthosewhoreceivedusualcareata
followupof9months(LOWCONFIDENCEINEFFECT).
Onestudy84of24participantsfoundnosignificantdifferenceingaitperformanceassessedbytimed
upandgotest(sec)betweenthoseparticipantswhoreceivedresistancetrainingandthosewho
receivedusualcareatafollowupof5months(VERYLOWCONFIDENCEINEFFECT).
Onestudy84of24participantsfoundnosignificantdifferenceingaitperformanceassessedbyfast
gaitspeed(10m/sec)betweenthoseparticipantswhoreceivedresistancetrainingandthosewho
receivedusualcareatafollowupof5months(LOWCONFIDENCEINEFFECT)
Onestudy178of133participantsfoundnosignificantdifferencein2minutewalktestbetweenthose
participantswhoreceivedresistancetrainingandthosewhoreceivedusualcareatafollowupof6
months(MODERATECONFIDENCEINEFFECT).
Onestudy195of42participantsfoundnosignificantdifferenceingaitperformanceassessedby6
minutewalktestbetweenthoseparticipantswhoreceivedresistancetrainingandthosewho
receivedusualcareatafollowupof3months(MODERATECONFIDENCEINEFFECT).
Onestudy84,of24participantsfoundnosignificantdifferenceingaitperformanceassessedby6
minutewalktestbetweenthoseparticipantswhoreceivedresistancetrainingandthosewho
receivedusualcareatafollowupof5months(VERYLOWCONFIDENCEINEFFECT).
Twostudies136,195of62participantsfoundnosignificantdifferenceinselfselected/habitualgait
speedbetweenthoseparticipantswhoreceivedresistancetrainingandthosewhoreceivedusual
care(LOWCONFIDENCEINEFFECT)

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Twostudies136,195of62participantsfoundnosignificantdifferenceinmaximalgaitspeedbetween
thoseparticipantswhoreceivedresistancetrainingandthosewhoreceivedusualcare(LOW
CONFIDENCEINEFFECT)
Familymediatedexercise(FAME)interventioncomparedtousualcare(physiotherapy)
Onestudy88of40participantsfoundasignificantimprovementinLowerLimbFuglMeyermotor
functionassociatedwiththeFAMEinterventioncomparedtousualcareattheendofthe8week
intervention(LOWCONFIDENCEINEFFECT).Thisimprovementwasnotmaintainedattheendofthe
3monthsfollowupperiod(MODERATECONFIDENCEINEFFECT).
Onestudy88of40participantsfoundasignificantimprovementineverydaymotorfunction(as
assessedbytheMotorAssessmentScale)associatedwiththeFAMEinterventioncomparedtousual
careattheendofthe8weekintervention(LOWCONFIDENCEINEFFECT).Thisimprovementwasnot
maintainedattheendofthe3monthsfollowupperiod(LOWCONFIDENCEINEFFECT).
Onestudy88of40participantsfoundasignificantimprovementinperson'sstaticanddynamic
balanceabilities(asassessedbytheBergBalanceScale)associatedwiththeFAMEintervention
comparedtousualcareattheendofthe8weekintervention(LOWCONFIDENCEINEFFECT).This
improvementwasnotmaintainedattheendofthe3monthsfollowupperiod(LOWCONFIDENCEIN
EFFECT).
Onestudy88of40participantsfoundasignificantimprovementinfunctionalexercisecapacity(as
assessedbythe6minutewalktest)associatedwiththeFAMEinterventioncomparedtousualcareat
theendofthe8weekintervention(MODERATECONFIDENCEINEFFECT).Thisimprovementwasstill
significantattheendofthe3monthsfollowupperiodbuttheeffectwasnotaslargeaspost
intervention(LOWCONFIDENCEINEFFECT).
Onestudy88of40participantsfoundasignificantimprovementintheperformanceinactivitiesof
dailyliving(asassessedbytheBarthelIndex)associatedwiththeFAMEinterventioncomparedto
usualcareattheendofthe8weekintervention(MODERATECONFIDENCEINEFFECT).This
improvementwasstillsignificantattheendofthe3monthsfollowupperiodbuttheeffectwasnot
aslargeaspostintervention(LOWCONFIDENCEINEFFECT).
Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

13.1.2

Recommendationsandlinktoevidence
77.Providephysiotherapyforpeoplewhohaveweaknessintheir
trunkorupperorlowerlimb,sensorydisturbanceorbalance
difficultiesafterstrokethathaveaneffectonfunction.
78.Peoplewithmovementdifficultiesafterstrokeshouldbe
treatedbyphysiotherapistswhohavetherelevantskillsand
traininginthediagnosis,assessmentandmanagementof
movementinpeoplewithstroke.

79.Treatmentforpeoplewithmovementdifficultiesafterstroke
shouldcontinueuntilthepersonisabletomaintainor
progressfunctioneitherindependentlyorwithassistance
fromothers(forexample,rehabilitationassistants,family
members,carersorfitnessinstructors).

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80.Considerstrengthtrainingforpeoplewithmuscleweakness
afterstroke.Thiscouldincludeprogressivestrengthbuilding
throughincreasingrepetitionsofbodyweightactivities(for
example,sittostandrepetitions),weights(forexample,
progressiveresistanceexercise),orresistanceexerciseon
machinessuchasstationarycycles.

Relativevaluesofdifferent
outcomes

Therangeofoutcomesreflectedimpairment(force),activity(walking
speedanddistance,ActionResearchArmtest),anddependence(Barthel
IndexandFunctionalIndependenceMeasure).Improvementsin
strengthwouldbepostulatedtoleadtoimprovementsoffunctionand
thusmeasuresofmobility,activity,anddependenceareofpotentially
moreinterest.However,insmallstudiesmeasuresofimpairmentmay
beresponsivetotheintervention.
Adverseeventswerealsoregardedasanimportantoutcome,
particularlythedevelopmentofincreasedtone.TheGDGnotedthat
somehealthprofessionalshaveexpressedaconcernthatstrength
trainingmaybeassociatedwithanincreaseintonethatintime,may
leadtodeteriorationinfunction.Inthiscontext,theGDGconsideredit
importanttorecognisetheincidenceofdisablingspasticityinstroke
whichhasbeenreportedas4%byLumstrometal.161

Tradeoffbetweenclinical
benefitsandharms

Onestudy84statedtherewerenoinjuriesassociatedwiththeresistance
trainingexercisemachineused.Noneoftheotherstudiesreportedany
adverseeventsfromthestrengthtraininginterventions.TheGDG
agreedthatthattherewouldnotnormallybeanydetrimentaleffect
fromthesetypesofinterventions.
Weaknessoftheface,upperlimb,trunkandlowerlimbarecommon
deficitsafterstroke,Aswellasstrength,sensorydisturbanceand
balancedifficultiesimpactonmovement.Itwasfeltthattrained
physiotherapistswiththerelevantskillsandtraininginthediagnosis,
assessmentandmanagementofmovementinpeoplewithstrokeshould
regularlymonitorandtreatpeoplewithmovementdifficultiesuntilthey
areabletomaintainorprogressfunctioneitherindependentlyorwith
assistancefromothers(rehabilitationassistants,carers,fitness
instructorsetc.).Onestudyreportedsignificantimprovementsinmotor
andbalancefunctionassociatedwithstrengthtrainingusingfamily
membersascotrainers.Theevidenceforoutcomesfromthisstudywere
oflowtomoderatequality.However,improvementswerenot
maintainedoverathreemonthfollowupperiod.

Economicconsiderations

Nocosteffectivenessstudieswereidentifiedforthisquestion.Themain
differenceincostsbetweentheprovidingmusclepowertrainingand
usualcarewasduetotheamountofadditionalpersonneltimerequired.
Inaddition,theremayalsobesomedevicecosts,forexamplean
exercisemachinewasusedinoneofthestudiesincludedintheclinical
review.However,whenthecostofthemachineisspreadoverthe
lifetimeoftheequipmentandtheamountofusage,thecostperpatient
persessionisexpectedtobelow.BasedonresourceusefromCooke
(2010lowerlimbstrengthtrainingintervention)47theadditionalcostof
strengthtrainingoverusualcarewasestimatedtobe1080andbased
onFlansbjer(2008resistancetrainingintervention)84itwasestimated
tobe1350(personnelcostsonly).
TheGDGconsidereditlikelythatstrengthtrainingwouldbecost
effectiveasthepotentialimprovementforpatientsintermsofqualityof
lifefromimprovedfunctionwouldjustifyanyadditionalcostsofthe

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StrokeRehabilitation
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intervention.
Qualityofevidence

Manyofthestudieswerelimitedbysmallnumbers(maximumsample
size=133),somewerefeasibilitystudies,inadequatelypoweredand
durationoffollowupandtimesinceonsetofstrokevariedbetween
studies.Becauseofthewiderangeofdifferenttypesofstrengthtraining
andoutcomemeasuresincludedwithinthestudiesitwasnotpossibleto
carryoutanymetaanalysisandthereforeinterpretationoftheresults
waslimited.
Confidenceintheresultsshownforthemajorityoftheoutcomeswas
lowtoverylowbecauseofstudylimitations(unclearblinding,unclear
randomisationandlackofallocationconcealment)andimprecision
aroundtheeffectestimate.
Thegroupagreeditwasnotclearwhethertherewouldbeapersistent
differencebetweenthegroupsat6monthsor1year.TheGDGagreed
thatitwasdifficulttodeterminethetreatmenteffectfromthesmall
studysizespresented.
Thegroupagreedthattherewasnoclearevidencetoshowthatstrength
trainingisbetterthanthecontrolinterventions(usualpractice)butboth
strengthtrainingandusualpracticeledtoimprovementssothe
consensusofthegroupwasthatthisstrengthtrainingisusefulforthose
withweaknessinupperorlowerlimbs,andthereforecouldbe
consideredaspartofapersonsrehabilitation.

Otherconsiderations

Definitionsofstrengthtrainingvaryfromtraditionalresistancetraining
tofunctionalstrengthtraining.Conventionalresistancetrainingwould
includeexercisessuchasliftingweightsinagym,whereasfunctional
strengthtrainingfocusesonbuildingstaminathrougharangeoftasks
suchaswalkingandgradedactivitiesdeliveredbyarehabilitation
professional.Thenatureofstrengthtrainingvariedaccordingtowhether
itwasupperorlowerlimbandtimesinceonsetofthestroke.

Therewasnoindicationfromthestudiespresentedofwhatdoseof
strengthtrainingisappropriate.Itwasalsohighlightedthatevidencefor
strengthtrainingwhichinvolvedafamilymembershowedshortterm
improvements.Yetthesewereshortlivedandthereforeseemnotto
makeacontributiontolongtermfunctionalgains.

13.2 FitnessTraining
13.2.1

Inpeopleafterstroke,doescardiorespiratoryorresistancefitnesstrainingimprove
outcome(fitness,function,qualityoflife,mood)andreducedisability?
ClinicalMethodologicalIntroduction
Population

Adultsandyoungpeople16orolderwhohavehadastroke.

Intervention

Anycardiorespiratoryorresistancefitnesstrainingsuchas:
Aquaticphysicalexercise
Cycle,rowingortreadmillergometry
Weightbearingresistancetraining
Dynamicandisokineticmusclestrengthtraining

Comparison

Usualcare(otherphysiotherapy)

Outcomes

Mortalityrate
Dependenceorlevelofdisability
Physicalfitness

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StrokeRehabilitation
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ClinicalMethodologicalIntroduction
Mobility
Physicalfunction
Qualityoflife
Mood

Indicesandscalesmayinclude:
Bloodpressure
Bodymass
Maximaloxygenupdate(peakVO2(ml/kg/min)
Endurance
Barthel
Rivermeadmobilityindex
SF36
EuroQol
HADS
BeckDepressionIndex
Geriatricdepressionscale
Epidemiologicstudiesfordepressionscale(CESD)

13.2.1.1

ClinicalEvidenceReview
Searcheswereconductedforsystematicreviewscomparingtheclinicaleffectivenessoffitness
training(cardiorespiratoryorresistance)withusualcaretoimprovefunctionandreducedisabilityfor
adultsandyoungpeople16orolderwhohavehadastroke.
OneCochranesystematicreview(Brazzelli201131)wasidentified.ThisCochranereviewwasadapted
toaddressthecurrentprotocol(thecomparisonofmixedcardiorespiratoryvs.usualcarewas
removedandoutcomesthathadalreadybeenincludedinthereviewin12.1wereremovedfromthe
resistancevs.usualcarecomparison).TheCochranereviewincluded32trials.Fromthesetrials(32),
21trialsmatchingourprotocolwereincludedforthisreview.
AfurthersystematicsearchwasconductedforanytrialpublishedsincetheCochranesearchcutoff
(March2010)andfourtrials(Globas201294,Holmgren2010113,Jin2012125andVanDePort2012267)
wasidentified.
Inthesystematicreviewthefollowingstrategyofanalysiswasadopted:
Theeffectsoftheinterventionswereseparatelyanalysedattheendoftheinterventionandat
theendoffollowup.Endofinterventionreferstothetimepointwhenatrainingprogramme
finishes(rangedfrom214weeks)andendoffollowupreferstoanytimepointoccurringafter
theendofintervention(rangedfrom1236weeks).(SeeindividualGRADETable92/Table93
forcardiorespiratoryandTable94/Table95forresistancetraining).Retainedtrainingeffectswere
measuredattheendoffollowup.
Studieswereincludedinwhichcontrolswereexposedtoeitherphysicalactivityoccurringduring
usualcareornotrainingafterusualcare.Notrainingreferstonointerventionoranonexercise
intervention.TheseweresubgroupanalyseswithineachGRADEtable
Cardiorespiratorytrainingwasalsocomparedwithresistancetrainingusingonemobilityoutcome
(seeGRADETable96)
Whenthereisanoutcomewithsubgroup,overalleffectsaswellassubgroupanalyses(initalics)
arepresented(seeGRADEtables)
Theevidencestatementsalsoreflectthetotaleffectsaswellasthesubgroupanalysis.

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StrokeRehabilitation
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PleaseseeAppendixMforexcludedtrialsfromtheCochranereview.
Table90summarisesthepopulation,intervention,comparisonandoutcomesforeachofthestudies.
Table90: OverviewofstudiesincludedintheCochranereview
COMPARISON
Cardiorespirat
oryvs.usual
care

STUDIES
3

Aidar2007 ;Bateman
200119;Cuviello
Palmer198852;da
Cunha200252;Eich
200474;Glasser1986
93
;KatzLeurer2003
134
;Lennon2008152;
Moore2010177;
Mudge2009180;Pohl
2002208;Potempa
1995211;Salbach2004
229
;Smith2008244

TOTALNUMBEROF
PARTICIPANTS

RANGEOF
INTERVENTIONS

718participants

Twoofthese
trialsassessed
circuittraining
(Mudge2009;
Salbach2004),
onetrialassessed
aquatictraining
(Aidar2007),
whilethe
remainingtrials
employed
differentformsof
ergometry(cycle,
treadmillor
Kinetron)

NationalClinicalGuidelineCentre,2013.
340

OUTCOMES
Disability
Functional
Independence
Measure(FIM)
Rivermead
MobilityIndex
PhysicalActivity
andDisability
Scale
Nottingham
ExtendedADL
Frenchay
ActivitiesIndex

Mobility
Functional
Ambulation
Categories
Maximalgait
speed(m/min)
Preferredgait
speed(m/min)
6MinuteWalk
Test(metres)
Gaitendurance
6metrewalking
time(sec)
StrokeImpact
Scale(mobility
domain)
Peakactivity
index(steps/min)
Maximumstep
ratein1min

Riskfactors
Bloodpressure
(systolicand
Diastolic)

HealthRelatedQoL
SF36
EuroQoL

Mood

StrokeRehabilitation
Movement

COMPARISON

STUDIES

TOTALNUMBEROF
PARTICIPANTS

RANGEOF
INTERVENTIONS

OUTCOMES
BeckDepression
Index
HospitalAnxiety
andDepression
Scale
Geriatric
DepressionScale
Centrefor
Epidemiologic
Studiesfor
DepressionScale

Casefatality

Resistancevs.
usualcare

192participants
Bale200814;Cooke
47
2010* ;Flansbjer
200884;Kim2001136;
Ouellette2004195;
Sims2009238;Winstein
2004285

Allemployed
muscle
contractions
resistedby
weights,exercise
machines,or
elasticdevices.
Fivetrialslimited
thestrength
trainingtothe
lowerlimbs,one
trialtotheupper
limbs(Winstein
2004),andone
trialtrainedboth
theupperand
lowerlimbs(Sims
2009).

Physicalfitness
PeakVO2
(ml/kg/min)
Gaiteconomy,
VO2
(ml/kg/metre)
Maximumcycling
workrate(Watts)
Bodymass(Kg)
Composite
measureof
musclestrength
Knee
flexion/knee
extension(Nm)

Physicalfunction
BergBalance
Scale
TimedUpandGo
(sec)
Weightbearing
(affectedside)
Stairclimbing,
maximal
(sec/step)

Cardiorespirat
oryvs.
resistance

CuvielloPalmer1988
52
;KatzLeurer2003
134
;Moore2010177;
Salbach2004229;Bale
200814;Kim2001136;
Ouellette2004195

Walkingspeed

Preferredgait
speed(m/min)

301participants

*Cooke2010wasincludedinthemixedcardiovascularresistancegroupwhichisnotinourprotocol.However,thisstudy
includedonlyresistancetrainingasaninterventionandthereforewasmovedtothiscomparisoninoureditedversionofthe
Cochranereview.

NationalClinicalGuidelineCentre,2013.
341

StrokeRehabilitation
Movement
Table91.DetailsoffouradditionalRCTsthatwerecompletedsincetheCochranereviewandwere
addedtothecurrentreview.SeeAppendixHforextraction
STUDY

POPULATION

INTERVENTION

COMPARISON

OUTCOMES

Holmgren
2010113

34patientswith
stroke.
36monthsafter
strokeonset
15allocatedto
interventionand19
allocatedtocontrol.

Sevensessionsaweek
dividedover3days
withindividualized
grouptraining,
supervisedbya
physiotherapist(PT)
plusonesessiona
weekfor1hrwith
educationalgroup
discussionsaboutfall
riskandsecurity
aspectsledbyaPTand
anOT
(N=15)

Onesessionaweek
for1hreachduring
the5weekperiod.
Sessionwasan
educationalgroup
discussionsession
ledbyone
occupational
therapist(OT)
(N=19)

Globas
201294

38patientswith
stroke(>6months)
aged>60yearswith
residualhemiparetic
gait(atleast1
clinicalsignfor
paresis,spasticityor
circumductionof
affectedlegwhile
walking);abilityto
walkontreadmillat
0.3km/hr.for3
minuteswith
handrailsupport.

Highintensityaerobic
treadmillexercise
(TAEX)for3months
(39sessions)starting
with1020minutesat
4050%heartrate
reserve(HRR)building
upto3050minutesat
6080%HRR

ConventionalCare
Physiotherapy(13
sessionsof1hour
each/week)
includingpassive
muscletone
regulatingexercises
forupperandlower
extremity,balance
training

Bodymass
adjustedpeak
VO2;
Sustained
walkingability(6
minutewalk).
2ry:
10mtimedwalk
atcomfortable
andmaximal
speeds;
5chairrisetest;
Bergbalance
scale;
Rivermead
Index;
SF12

Jin2012125

133participantsage
50orolder;single
stroke>6months
ago;independentin
ambulationwithor
withoutwalkingaid

Cyclingexercisegroup:
8weekaerobiccycling
training+paretic
lowerlimbweights40
mins./day5timesa
week,targetaerobic
intensity5070%heart
ratereserve

Lowintensityover
groundwalking
training2030%
heartratereserve.
Bothgroupshad
balanceexercise30
minutesand
supervised
stretching20
minutes

6minutewalking
distance,
Rivermead
MobilityIndex.
Kneemuscle
strength
(dynamometer);
balance(Berg
scale);
Spasticity
(Modified
AshworthScale)

VanDePort
2012267

250participants
withverifiedstroke
whohadcompleted
inpatient
rehabilitation
(dischargedhome)
assoonasthey
wereabletostart

Taskorientedcircuit
training:90minute
gradedtaskoriented
circuittrainingtwicea
weekfor12weeks
aimedatimproving
walkingcompetency
(warmup5minutes;

Usualphysiotherapy
carefor12weeks
accordingto
guidelines;no
restrictionson
content,timeor
duration

StrokeImpact
ScaleMobility
domainsSIS;
RMI,
NEADL,
HADS,
fatigueseverity,

NationalClinicalGuidelineCentre,2013.
342

SF36
Geriatric
Depression
Scale15

StrokeRehabilitation
Movement
STUDY

POPULATION
outpatient
rehabilitation;able
towalkaminimum
of10mwithout
physicalassistance;
needtocontinue
physiotherapyto
improvewalking
competencyor
physicalconditionor
both;abletogive
informedconsent;
motivatedto
participatein12
weekintensive
physiotherapy
programme.

INTERVENTION
circuittraining60
minutes;
evaluation/break10
minutes;groupgame
15minutes)

NationalClinicalGuidelineCentre,2013.
343

COMPARISON

OUTCOMES
MotricityIndex,
functional
ambulation,
6minwalk,
5mcomfortable
walk,
timedbalance,
timedupandgo,

StrokeRehabilitation
Movement

Comparison:Cardiorespiratorytrainingversususualcare
Table92:CardiorespiratorytrainingendofinterventionversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings.
Subgroupsareinitalics.

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

Confidence
(ineffect)

Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)

Seesubgroupsfor
means

Seesub
groupsfor
means

0.21(
0.10,
0.52)

SMD0.21 Low
higher
(0.1
lowerto
0.52
higher)

100.38
(18.92)

0.23(
0.32,
0.78)

SMD0.23 Moderate
higher
(0.32
lowerto
0.78
higher)

DisabilityFunctionalIndependenceMeasure(Betterindicatedbyhighervalues)
3
Seesub
groups
below
(next4
rows)

RCTsingle
blind

Serious
limitations(
a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(b
)

DisabilityFunctionalIndependenceMeasureDuringusualcare(Betterindicatedbyhighervalues)
1
Bateman
200119

RCTsingle
blind

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(b
)

104.74(17.7)

DisabilityFunctionalIndependenceMeasureAfterusualcare(Betterindicatedbyhighervalues)

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

2
Cuviello
Palmer
198852;
Katz
Leurer
2003134

RCTsingle
blind

Summaryoffindings
Limitations

Serious
limitations(
a)

Inconsistency

Noserious
inconsistency

Indirectness

Noserious
indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

Serious
imprecision(b
)

CuvielloPalmer:
44.79(8.77)
KatzLeurer:
105.8(12.5)

Cuviello
0.17(
Palmer:
0.29,
47.18(9.88) 0.63)
KatzLeurer:
101.4(16)

SMD0.17 Low
higher
(0.29
lowerto
0.63
higher)

Serious
imprecision(c
)

Seesubgroups
below

See
subgroups
below

MD0.57
higher
(0.03
lowerto
1.17
higher)

Bateman10.06
(3.6)
Jin10.5(1.7)
VandePort13.47
(1.44)

Bateman9.9 0.41
(3.65)
(0.01,
Jin10.4(1.6) 0.81)
VandePort
12.82(1.44)

Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)

Confidence
(ineffect)

DisabilityRivermeadMobilityIndex(Betterindicatedbyhighervalues)
4
Seesub
groups
below
(next4
rows)

RCTssingle
blind

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

0.57(
0.03,
1.17)

Moderate

DisabilityRivermeadMobilityIndexDuringusualcare(Betterindicatedbyhighervalues)
3
Bateman
200119
Jin
2012125
VanDe
Port267

RCTssingle
blind

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision

NationalClinicalGuidelineCentre,2013.

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MD0.41 Moderate
higher
(0.01
higherto
0.81
higher)

StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

Confidence
(ineffect)

Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)

13.3(1.7)

11.3(2.7)

2(0.53,
3.47)

MD2
Low
higher
(0.53
higherto
3.47
higher)

DisabilityRivermeadMobilityIndexAfterusualcare(Betterindicatedbyhighervalues)
1
Globas
201294

RCTssingle
blind

Serious
limitations(
d)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

DisabilityPhysicalActivityandDisabilityScaleAfterusualcare(Betterindicatedbylowervalues)
1
Mudge
2009180

RCTsingle
blind

Serious
limitations(
d)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

77.8(55.7)

60.9(67.2)

16.9(
15.15,
48.95)

MD16.9
higher
(15.15
lowerto
48.95
higher)

Low

Noserious
imprecision

Seesubgroupsfor
means

Seesub
groupsfor
means

0.4(
8.38,
9.18)

MD0.4
higher
(8.38
lowerto
9.18
higher)

Low

Riskfactorsbloodpressure,systolic(Betterindicatedbylowervalues)
4
Seesub
groups
below
(next4
rows)

RCTsingle
blind

Serious
limitations(
a)

Serious
inconsistency(
e)

Noserious
indirectness

Riskfactorsbloodpressure,systolicDuringusualcare(Betterindicatedbylowervalues)

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

1
daCunha
200253

RCTsingle
blind

Summaryoffindings
Limitations

Serious
limitations(
a)

Inconsistency

Noserious
inconsistency

Indirectness

Noserious
indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect
Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)

daCunha:191.33
(9.93)

DaCunha:
165(28.81)

26.33
(1.95to
50.71)

MD26.33 Low
higher
(1.95to
50.71
higher)

Noserious
imprecision

KatzLeurer:130.3
(15.7)
Lennon:136(13.3)
Potempa:127.3
(18.31)

KatzLeurer: 2.69(
136.2(19.5) 8.03,
2.66)
Lennon:
133.5(16.7)
Potempa:
131.5
(22.54)

MD2.69
lower
(8.03
lowerto
2.66
higher)

Moderate

Noserious
imprecision

Seesubgroupsfor
means

Seesub
groupsfor
means

MD0.33
lower
(2.97
lowerto
2.31
higher)

Moderate

Serious
imprecision(c
)

Confidence
(ineffect)

Riskfactorsbloodpressure,systolicAfterusualcare(Betterindicatedbylowervalues)
3
Katz
Leurer
2003134;
Lennon
2008152;
Potempa
1995211

RCTsingle
blind

Serious
limitations(
a)

Noserious
inconsistency

Noserious
indirectness

Riskfactorsbloodpressure,diastolic(Betterindicatedbylowervalues)
4
Seesub
groups
below
(next4
rows)

RCTsingle
blind

Serious
limitations(
a)

Noserious
inconsistency

Noserious
indirectness

Riskfactorsbloodpressure,diastolicDuringusualcare(Betterindicatedbylowervalues)

NationalClinicalGuidelineCentre,2013.

347

0.33(
2.97,
2.31)

StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

1
daCunha
200253

RCTsingle
blind

Summaryoffindings
Limitations

Serious
limitations(
a)

Inconsistency

Noserious
inconsistency

Indirectness

Noserious
indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Veryserious 95.33(9.69)
imprecision(j)

Usualcare
Mean(SD)

Effect

Confidence
(ineffect)

Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)

94.33
(10.54)

1(
10.46,
12.46)

MD1
higher
(10.46
lowerto
12.46
higher)

Verylow

Riskfactorsbloodpressure,diastolicAfterusualcare(Betterindicatedbylowervalues)
3
Katz
Leurer
2003134;
Lennon
2008152;
Potempa
1995211

RCTsingle
blind

Serious
limitations(
a)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

KatzLeurer:79
(9.7)
Lennon:81.4(8.4)
Potempa:78.4
(9.15)

KatzLeurer:
80.8(10.2)
Lennon:82
(9)
Potempa:
76.4(7.67)

0.41(
3.12,
2.31)

MD0.41
lower
(3.12
lowerto
2.31
higher)

Moderate

Serious
imprecision(c
)

Seesubgroupsfor
means

Seesub
groupsfor
means

2.73
(1.29to
4.17)

MD2.14
higher
(0.5to
3.78
higher)

Low

PhysicalfitnesspeakVO2(ml/kg/min)(Betterindicatedbyhighervalues)
6
Seesub
groups
below
(next4
rows)

RCTsingle
blind

Serious
limitations(
a)

Noserious
inconsistency

Noserious
indirectness

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

Confidence
(ineffect)

Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)

DaCunha11.55
(2.76)
Jin16.8(1)

DaCunha
8.12(2.3)
Jin13.3(1)

3.50
(3.16,
3.84)

MD3.50
higher
(3.16to
3.84
higher)

Moderate

Lennon:12(2.2)
Moore:18(5.4)
Potempa:18.8
(4.79)
Globas24.4(6.6)

Lennon:
11.1(1.9)
Moore:16
(7.1)
Potempa:
15.2(4.32)
Globas20.9
(7.8)

1.85
(0.31,
3.39)

MD1.85
higher
(0.31to
3.39
higher)

Low

0.371
(0.234)

0.08(
0.28,
0.12)

MD0.08
lower
(0.28
lowerto

Verylow

PhysicalfitnesspeakVO2(ml/kg/min)Duringusualcare(Betterindicatedbyhighervalues)
2
daCunha
200253;
Jin
2012125

RCTsingle
blind

Serious
limitations(
a)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

PhysicalfitnesspeakVO2(ml/kg/min)Afterusualcare(Betterindicatedbyhighervalues)
4
Lennon
2008152;
Moore
2010177;
Potempa
1995
211
;
Globas
201294

RCTsingle
blind

Serious
limitations(
a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

Physicalfitnessgaiteconomy,VO2(ml/kg/metre)Afterusualcare(Betterindicatedbyhighervalues)
1
Moore
2010177

RCTsingle
blind

Serious
limitations(f
)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision(g
)

0.291(0.228)

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

Confidence
(ineffect)

Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)
0.12
higher)

Seesubgroupsfor
means

Seesub
groupsfor
means

0.6
(0.18,
1.02

SMD0.6
higher
(0.18to
1.02
higher)

Bateman:
4.13(0.59)
DaCunha:
41.67
(12.91)

0.32(
0.34,
0.98)

SMD0.32 Moderate
higher
(0.34
lowerto
0.98
higher)

KatzLeurer:
12.9(12.6)
Potempa:

0.83
(0.47to
1.18)

SMD0.83 Low
higher
(0.47to
1.18

Physicalfitnessmaximumcyclingworkrate(Watts)(Betterindicatedbyhighervalues)
4
Seesub
groups
below
(next4
rows)

RCTsingle
blind

Serious
limitations(
a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

Low

Physicalfitnessmaximumcyclingworkrate(Watts)Duringusualcare(Betterindicatedbyhighervalues)
2
Bateman
200119;
daCunha
200253

RCTsingle
blind

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

Bateman:4.22
(0.72)
daCunha:62.5
(26.22)

Physicalfitnessmaximumcyclingworkrate(Watts)Afterusualcare(Betterindicatedbyhighervalues)
2
Katz
Leurer

RCTsingle
blind

Serious
limitations(
a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

KatzLeurer:25.2
(14.9)
Potempa:94.2

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

2003134;
Potempa
1995211

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

(46.64)

66.1(30.69)

80.79(15.78)

Effect

Confidence
(ineffect)

Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)
higher)

75.41
(14.58)

5.38(
1.69,
12.45)

MD5.38
higher
(1.69
lowerto
12.45
higher)

Moderate

DaCunha:
1.86(1.77)
Pohl:4.3
(0.7)
Pohl*:4.3
(0.7)Vande
Port4.74
(0.55)

0.33[0.0
1,0.65]

MD0.33
higher
(0.01to
0.65
higher)

Low

Seesub

8.66

MD8.66

Moderate

PhysicalfitnessDuringusualcareBodyMass(Kg)(Betterindicatedbylowervalues)
1
Bateman
200119

RCTsingle
blind

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

MobilityfunctionalambulationcategoriesDuringusualcare(Betterindicatedbyhighervalues)
3
RCTsingle
daCunha blind
200253;
Pohl2002
208
;Pohl
2002
208
*Van
dePort267

Serious
limitation(a
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

daCunha:2.33
(1.37)
Pohl:5(0.01)
Pohl*:4.6(0.6)
VandePort4.87
(0.36)

Mobilitymaximalgaitspeed(m/minover5to10metres)(Betterindicatedbyhighervalues)
7

RCTsingle

Noserious

Noserious

Noserious

Serious

Seesubgroupsfor

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Seesub
groups
below
(next4
rows)

blind

Summaryoffindings
Limitations

limitations

Inconsistency

inconsistency

Indirectness

indirectness

Imprecision

imprecision(f)

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

means

groupsfor
means

(2.98,
14.34)

daCunha:
16.2(13.8)
Pohl*:58.2
(38.4)
Bateman:
16.22
(19.49)
Eich:36
(13.2)
Pohl:58.2
(38.4)

10(
0.05,
20.05

MD10
higher
(0.05
lowerto
20.05
higher)

Moderate

Salbach:48
(29.4)

9.93
(3.38,

MD9.93
higher

Low

Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)
higher
(2.98to
14.34
higher)

Confidence
(ineffect)

Mobilitymaximalgaitspeed(m/minover5to10metres)Duringusualcare(Betterindicatedbyhighervalues)
4
RCTsingle
daCunha blind
200253;
Pohl2002
208
*;
Bateman
200119;
Eich2004
74
;Pohl
2002208

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
daCunha:35.5
imprecision(f) (17.4)
Pohl*:73.2(44.4)
Bateman:16
(11.06)
Eich:42.6(18)
Pohl:97.8(48)

Mobilitymaximalgaitspeed(m/minover5to10metres)Afterusualcare(Betterindicatedbyhighervalues)
3
Salbach

RCTsingle
blind

Serious
limitation(a

Noserious
inconsistency

Noserious
indirectness

Serious
Salbach:59.4
imprecision(f) (33.6)

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352

StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

2004229;
Moore
2010177;
Mudge
2009180

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect
Mean
differen
ce(95%
CI)

Moore:54.6(26.4) Moore:46.2 16.48)

Mudge:47.4(16.8) (19.2)
Mudge:37.8
(15)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)
(3.38to
16.48
higher)

Confidence
(ineffect)

Mobilitypreferredgaitspeed(m/min)(Betterindicatedbyhighervalues)
4
Seesub
groups
below
(next4
rows)

RCTsingle
blind

Serious
limitation(a
)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

Seesubgroupsfor
means

Seesub
groupsfor
means

4.68
(1.4,
7.96)

MD4.68
higher
(1.4to
7.96
higher)

Moderate

12.07(6.41)

6.04(
MD6.04
0.92,13) higher
(0.92
lowerto
13
higher)

Low

KatzLeurer:
27(9.6)

29(0.57, MD4.29
8.01)
higher

Moderate

Mobilitypreferredgaitspeed(m/min)Duringusualcare(Betterindicatedbyhighervalues)
1
Cuviello
Palmer
198852

RCTsingle
blind

Serious
limitation(a
)

Noserious
inconsistency

Noserious
indirectness

Serious
18.11(9.22)
imprecision(f)

Mobilitypreferredgaitspeed(m/min)Afterusualcare(Betterindicatedbyhighervalues)
3
Katz

RCTsingle
blind

Serious
limitation(a

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

KatzLeurer:30.6
(10.8)

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Leurer
2003134;
Moore
2010177;
Salbach
2004229

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Moore:37.8(18)
Salbach:46.8(24)

Moore:34.8
(13.8)
Salbach:
38.4(22.2)

Seesubgroupsfor
means

Effect

Confidence
(ineffect)

Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)
(0.57to
8.01
higher)

Seesub
groupsfor
means

39.39
(13.53,
65.25)

MD39.39 VeryLow
higher
(13.53to
65.25
higher)

Eich164.4
(69.3)
Jin213.5
(50.6)
VandePort
354(145)

30.25(
4.70,
65.21)

MD30.25 Verylow
higher
(4.70
lowerto
65.21hig
her)

Mobilitygaitendurance(6MWTmetres)(Betterindicatedbyhighervalues)
7
Seesub
groups
below
(next4
rows)

RCTsingle
blind

Serious
limitation(a
)

Serious
inconsistency()

Noserious
indirectness

Serious
imprecision(n
)

Mobilitygaitendurance(6MWTmetres)Duringusualcare(Betterindicatedbyhighervalues)
3
RCTsingle
Eich2004 blind
74
;Jin
2012125
vande
Port
2012267

Serious
limitation

Veryserious
inconsistency(
h)

Noserious
indirectness

Serious
imprecision(n
)

Eich198.8(81.1)
Jin218.5(63.7)
VandePort412
(117)

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354

StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

Confidence
(ineffect)

Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)

Moore:201
(134)
Mudge:200
(99)
Salbach:209
(132)
Globas
265.9(189)

58.10
(23.02,
93.17)

MD58.10 Low
higher
(23.02to
93.17
higher)

0.87(0.62)

0.15(
0.19,
0.49)

MD0.15
lower
(0.19
lowerto
0.49
higher)

Low

See
subgroups
below

0.20
(0.12,
0.28)

MD0.20
higher
(0.12to

Low

Mobilitygaitendurance(6MWTmetres)Afterusualcare(Betterindicatedbyhighervalues)
4
Moore
2010177;
Mudge
2009180;
Salbach
2004229;
Globas
201294

RCTsingle
blind

Serious
limitation(a
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(n
)

Moore:226(130)
Mudge:282(117)
Salbach:249(136)
Globas332.1(138)

Mobilitymaximalgaitspeed(m/secover10metres)Afterusualcare(Betterindicatedbyhighervalues)
1
Globas
201294

RCTsingle
blind

Serious
limitation(a
)

Noserious
inconsistency

Noserious
indirectness

Serious
1.02(0.38)
imprecision(f)

Mobilitycomfortablegaitspeed(m/secover5to10metres)(Betterindicatedbyhighervalues)
2
See
subgroup

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
Seesubgroups
imprecision(f) below

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355

StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect
Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)
0.28
higher)

0.89(0.36)

0.21
(0.13,
0.29)

MD0.21
higher
(0.13to
0.29
higher)

Low

Serious
0.79(0.29)
imprecision(f)

0.70(0.46)

0.09(
0.16,
0.34)

MD0.09
higher
(0.16
lowerto
0.34
higher)

Low

Serious
imprecision(h
)

Seesub
groupsfor
means

8.87
(1.35,
16.4)

MD8.87
higher
(1.35to
16.4
higher)

Low

sbelow

Confidence
(ineffect)

Mobilitycomfortablegaitspeed(m/secover10metres)Duringusualcare(Betterindicatedbyhighervalues)
Vande
Port
2012267

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
1.1(0.3)
imprecision(f)

Mobilitycomfortablegaitspeed(m/secover10metres)Afterusualcare(Betterindicatedbyhighervalues)
1
Globas
201294

RCTsingle
blind

Serious
limitation(a
)

Noserious
inconsistency

Noserious
indirectness

Mobilitygaitendurance(m/min)(Betterindicatedbyhighervalues)
3
Seesub
groups
below
(next4
rows)

RCTsingle
blind

Serious
limitation(a
)

Noserious
inconsistency

Noserious
indirectness

Seesubgroupsfor
means

NationalClinicalGuidelineCentre,2013.

356

StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

Confidence
(ineffect)

Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)

daCunha:34.17
(17.17)
Eich:33.13(13.52)

daCunha:
12.14
(10.87)
Eich:27.4
(11.55)

12.24(
3.41,
27.89)

MD12.24 Moderate
higher
(3.41
lowerto
27.89
higher)

41.4(22.8)

34.8(22.2)

6.6(
2.66,
15.86)

MD6.6
higher
(2.66
lowerto
15.86
higher)

Low

Serious
9.98(3.03)
imprecision(i)

13.3(7.82)

3.32(
8.52,
1.88)

MD3.32
lower
(8.52
lowerto
1.88
higher)

Low

Mobilitygaitendurance(m/min)Duringusualcare(Betterindicatedbyhighervalues)
2
RCTsingle
daCunha blind
200253;
Eich2004
74

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(h
)

Mobilitygaitendurance(m/min)Afterusualcare(Betterindicatedbyhighervalues)
1
Salbach
2004229

RCTsingle
blind

Serious
Noserious
limitation(c) inconsistency

Noserious
indirectness

Serious
imprecision(h
)

Mobility6metrewalkingtime(sec)Duringusualcare(Betterindicatedbylowervalues)
1
Glasser
198693

RCTsingle
blind

Serious
limitation(a
)

Noserious
inconsistency

Noserious
indirectness

MobilityStrokeImpactScale(mobilitydomain)(Betterindicatedbylowervalues)

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357

StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

2See
subgroup
sbelow

Summaryoffindings
Limitations

Noserious
limitation

Inconsistency

Noserious
inconsistency

Indirectness

Noserious
indirectness

Imprecision

Serious
imprecision(c
)

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

Confidence
(ineffect)

Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)

Seesubgroups
below

See
subgroups
below

3.20
(0.04,
6.35

MD3.20
(0.04to
6.35
higher)

Moderate

83.73
(13.25)

3.54
(0.30,
6.78)

MD3.54
higher
(0.30to
6.78
higher)

Moderate

68(15.4)

3.2(
17.14,
10.74)

MD3.2
lower
(17.14
lowerto
10.74
higher)

Verylow

49(17.5)

18.1
(7.71,
28.49)

MD18.1
higher
(7.71to
28.49

Low

MobilityStrokeImpactScale(mobilitydomain)Duringusualcare(Betterindicatedbylowervalues)
1
RCTsingle
blind
Vande
Port2012
267

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

87.27(12.38)

MobilityStrokeImpactScale(mobilitydomain)Afterusualcare(Betterindicatedbylowervalues)
1
Smith
2008244

RCTsingle
blind

Very
serious
limitations(
a)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision(g
)

64.8(16.4)

Mobilitypeakactivityindex(steps/min)Afterusualcare(Betterindicatedbyhighervalues)
1
Mudge
2009180

RCTsingle
blind

Serious
limitation(d

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

67.1(22.8)

NationalClinicalGuidelineCentre,2013.

358

StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

Confidence
(ineffect)

Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)
higher)

Serious
imprecision(c
)

90.7(21.9)

75.2(20.5)

15.5
(4.58,
26.42)

MD15.5
higher
(4.58to
26.42
higher)

Low

Serious
imprecision(c
)

Seesubgroupfor
means

Seesub
groupfor
means

1.28(
1.74,
3.30)

MD1.28
higher
(1.74
lowerto
3.30
higher)

Low

Bateman45(11.9)
Jin48.6(2.9)

Bateman
0.27(
45.3(11.3)
0.87,
Jin48.3(3.9) 1.41)

MD0.27
higher
(0.87
lowerto
1.41
higher)

Moderate

Mobilitymaxstepratein1minAfterusualcare(Betterindicatedbyhighervalues)
1
Mudge
2009180

RCTsingle
blind

Serious
limitation(d
)

Noserious
inconsistency

Noserious
indirectness

PhysicalfunctionBergBalancescale(Betterindicatedbyhighervalues)
5
Seesub
group
below
(next4
rows)

RCTsingle
blind

Serious
limitation(a
)

Noserious
inconsistency

Noserious
indirectness

PhysicalfunctionBergBalancescaleDuringusualcare(Betterindicatedbyhighervalues)
2
Bateman
200119;
Jin
2012125

RCTsingle
blind

Serious
limitation(a
)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

PhysicalfunctionBergBalancescaleAfterusualcare(Betterindicatedbyhighervalues)

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359

StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

3
Moore
2010177;
Salbach
2004229;
Globas
201294

RCTsingle
blind

Summaryoffindings
Limitations

Serious
limitation(a
)

Inconsistency

Noserious
inconsistency

Indirectness

Noserious
indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

Confidence
(ineffect)

Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)

Serious
imprecision(c
)

Moore:48(10)
Salbach:44(11)
Globas51.1(6.4)

Moore:46
(10)
Salbach:41
(13)Globas
44.3(11.9)

4.06
(0.52,
7.60)

MD4.06
higher
(o.52to
7.60
higher)

Low

Noserious
imprecision

Seesubgroups
below

See
subgroups
below

3.99(
6.91,
1.08)

MD3.99
lower
(6.91to
1.08
lower)

High

15(16)

4.00(
7.15,
0.85)

MD4.00
lower
(7.15to
0.85
lower)

High

Moore:24
(16)

3.94(
11.65,

MD3.94
lower

Low

PhysicalfunctionTimedUpandGo(sec)(Betterindicatedbylowervalues)
3
See
subgroup
sbelow

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

PhysicalfunctionTimedUpandGo(sec)Duringusualcare(Betterindicatedbylowervalues)
1
Vande
Port
2012267

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

11(7)

PhysicalfunctionTimedUpandGo(sec)Afterusualcare(Betterindicatedbylowervalues)
2
Moore

RCTsingle
blind

Serious
limitation(a

Noserious
inconsistency

Noserious
indirectness

Serious
Moore:20(12)
imprecision(j) Salbach:23.2

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360

StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

2010177;
Salbach
2004229

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

(20.6)

Salbach:
27.1(27.1)

3.77)

Aidar59.3
(6.9)
Globas43.7
(8.3)
Holmgren
45.8.(26.6)

0.82(
0.13,
1.77)

58.2(8.3)

11(6.15, MD11
15.85)
higher
(6.15to
15.85
higher)

Low

86(32)

14.6(
39.54,
10.34)

Low

Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)
(11.65
lowerto
3.77
higher)

Confidence
(ineffect)

HealthrelatedQoLSF36orSF12physicalfunctioningAfterusualcare(Betterindicatedbyhighervalues)
3
RCTsingle
blind
Aidar
3
2007 ;
Globas
201294;
Holmgren
2010113

Serious
limitation(a
)

Veryserious
inconsistency(k
)

Noserious
indirectness

Serious
imprecision(c
)

Aidar69.9(3.2)
Globas46.5(5)
Holmgren52.1
(22.2)

SMD0.82 Verylow
higher
(0.13
lowerto
1.77
higher)

HealthrelatedQoLSF36emotionalrolefunctioningAfterusualcare(Betterindicatedbyhighervalues)
1
Aidar
20073

RCTsingle
blind

Very
serious
limitation(a
)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

69.2(3.5)

HealthrelatedQoLSF36emotionalrolefunctioningPostintervention(Betterindicatedbyhighervalues)
1
RCTsingle
Holmgren blind
2010113

Serious
limitation(d
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

71.4(38.9)

NationalClinicalGuidelineCentre,2013.

361

MD14.6
lower
(39.54

StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

Confidence
(ineffect)

Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)
lowerto
10.34
higher)

79.4(20.8)

5.2(
6.19,
16.59)

MD5.2
higher
(6.19
lowerto
16.59
higher)

Low

33.2(12)

1(
8.74,
6.74)

MD1
lower
(8.74
lowerto
6.74
higher)

Verylow

54.8(10)

0.4(
7.42,
6.62)

MD0.4
lower
(7.42
lowerto

Verylow

HealthrelatedQoLSF36mentalhealthPostintervention(Betterindicatedbyhighervalues)
1
RCTsingle
Holmgren blind
2010113

Serious
limitation(d
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

86.4(12.4)

HealthrelatedQoLSF36PhysicalComponentScalePostintervention(Betterindicatedbyhighervalues)
1
RCTsingle
Holmgren blind
2010113

Serious
limitation(d
)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision(g
)

32.2(10.6)

HealthrelatedQoLSF36MentalComponentScalePostintervention(Betterindicatedbyhighervalues)
1
RCTsingle
Holmgren blind
2010113

Serious
limitation(d
)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision(g
)

54.4(10.3)

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

Confidence
(ineffect)

Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)
6.62
higher)

9.4(1.9)

8.8(3)

0.6(
1.6,2.8)

MD0.6
higher
(1.6
lowerto
2.8
higher)

Verylow

0.87(
2.52,
0.78)

MD0.78
lower
(2.58
lowerto
078
higher)

Moderate

MoodBeckDepressionIndexAfterusualcare(Betterindicatedbylowervalues)
1
Smith
2008244

RCTsingle
blind

Very
serious
limitation(a
)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision(g
)

MoodHospitalAnxietyandDepressionScale(HADS)anxietyscoreDuringusualcare(Betterindicatedbylowervalues)
2
Bateman
200119;
Vande
Port
2012267

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

Bateman4.42
(3.69)
VandePort3.8
(3.4)

6.36(3.47)
VandePort
4.01(3.6)

MoodHospitalAnxietyandDepressionScale(HADS)andGeriatricDepressionscoredepression(Betterindicatedbylowervalues)
1
Bateman
200119
Vande
Port

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

serious
imprecision

Bateman5.54
(3.26)
VandePort4.92
(3.62)

Bateman
6.94(3.82)
VandePort
4.42(3.69)

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0.25(
0.77,
0.27)

SMD0.25 Moderate
lower
0.77
lowerto
0.27

StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
intervention
Mean(SD)

Usualcare
Mean(SD)

2012267;
Holmgren
2010113
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
(k)
(l)

Effect
Mean
differen
ce(95%
CI)

Mean
Differenc
e(MD)
/Standar
dised
Mean
Differenc
e(SMD)
(95%CI)
higher)

Confidence
(ineffect)

Unclear allocation concealment and blinding (outcome assessor). Limitations were considered by study weights in the meta-analysis
Mean difference did not reach the agreed MID of 17 points for the motor scale between the intervention and control group
Confidence interval crosses default MID (0.5) for single studies or default 0.5*median control SD for 2 or more studies
Unclear allocation concealment
2
Heterogeneity: I = 59%
Unclear blinding (outcome assessor)
Confidence interval crosses both ends of default MID (0.5) for single studies or default 0.5*(median control SD) for 2 or more studies
Mean difference did not reach agreed MID of 0.16m/sec for the walking speed between the intervention and control group for acute stroke patients or 0.2 m/sec for chronic stroke
patients
Mean difference did not reach agreed MID of 28m for the 6 MWT between the intervention and control group
Mean difference did not reach the agreed MID of 10 secs. for the Time Up and Go between the intervention and control group
2
Heterogeneity: I = 74%
Pohl 2002*: Pohl 2002 data were subdivided into two relevant comparisons. Half of the controls (10 participants) were used for each comparison

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StrokeRehabilitation
Movement

Comparison:Cardiorespiratorytrainingversususualcare
Table93:CardiorespiratorytrainingendofretentionfollowupversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings
Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
retentionfollow
up
Mean(SD)/
Frequency

Usualcare Effect
Mean(SD)/ Relative
Frequency risk/mean
difference
(95%CI)

1/42
(2.40%)

2/39
(5.10%)

0.46(0.04,
4.92)

28fewer
per1000
(from49
fewerto
201
more)

Verylow

10.72(3.3)

10.97
(3.35)

0.25(
1.85,1.35)

MD0.25
lower
(1.85
lowerto
1.35
higher)

Moderate

31.59
(17.17)

2.64(
5.57,
10.85)

MD2.64
higher
(5.57
lowerto
10.85
higher)

Moderate

Absolute
effect/
Mean
differenc
e(MD)
(95%CI)

Confidence
(ineffect)

Casefatality
1
Katz
Leurer
2003
134

RCTsingle Serious
Noserious
blind
limitation(a) inconsistency

Noserious
indirectness

Veryserious
imprecision(
b)

DisabilityRivermeadMobilityIndexDuringusualcare(Betterindicatedbyhighervalues)
1
Bateman
200119

RCTsingle Noserious
blind
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

DisabilityNottinghanExtendedADLsDuringusualcare(Betterindicatedbyhighervalues)
1
Bateman
200119

RCTsingle Noserious
blind
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

34.23(16.3)

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
retentionfollow
up
Mean(SD)/
Frequency

Usualcare Effect
Mean(SD)/ Relative
Frequency risk/mean
difference
(95%CI)

Absolute
effect/
Mean
differenc
e(MD)
(95%CI)

Confidence
(ineffect)

DisabilityPhysicalActivityandDisabilityScaleAfterusualcare(Betterindicatedbylowervalues)
1
Mudge
2009180

RCTsingle Serious
Noserious
blind
limitation(a) inconsistency

Noserious
indirectness

Serious
imprecision(c
)

82.1(72.8)

62.2(72.5)

19.9(
17.58,
57.38)

MD19.9
higher
(17.58
lowerto
57.38
higher)

Low

26(5)

1(1.55,
3.55)

MD1
higher
(1.55
lowerto
3.55
higher)

Low

84.06(75.52)

77.94
(44.76)

6.12(
24.06,
36.3)

MD6.12
higher
(24.06
lowerto
36.3
higher)

Moderate

80.39(15.83)

77.58
(14.43)

2.81(
4.63,
10.25)

MD2.81
higher
(4.63

Moderate

DisabilityFrenchayActivitiesIndex(FAI)Afterusualcare(Betterindicatedbyhighervalues)
1
Katz
Leurer
2003134

RCTsingle Serious
Noserious
blind
limitation(a) inconsistency

Noserious
indirectness

Serious
imprecision(c
)

27(6.5)

Physicalfitnessmaximumcyclingworkrate(Watts)Duringusualcare(Betterindicatedbyhighervalues)
1
Bateman
200119

RCTsingle Noserious
blind
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

PhysicalfitnessBodyMass(Kg)Duringusualcare(Betterindicatedbylowervalues)
1
Bateman
200119

RCTsingle Noserious
blind
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
retentionfollow
up
Mean(SD)/
Frequency

Usualcare Effect
Mean(SD)/ Relative
Frequency risk/mean
difference
(95%CI)

Seesubgroupsfor
means

Seesub
groupsfor
means

8.21(3.38,
13.05)

MD8.21
higher
(3.38to
13.05
higher)

Moderate

Bateman:21.04
(12.31)
Eich:46.2(21)

Bateman:
15(21.86)
Eich:34.8
(13.2)

8.1(1.98,
14.22)

MD8.1
higher
(1.98to
14.22
higher)

Moderate

46.2(15.6)

37.8(15)

8.4(0.52,
16.28)

MD8.4
higher
(0.52to
16.28
higher)

Low

Seesubgroupsfor

Seesub

69.3

MD69.3

High

Absolute
effect/
Mean
differenc
e(MD)
(95%CI)
lowerto
10.25
higher)

Confidence
(ineffect)

Mobilitymaximalgaitspeed(m/min)(Betterindicatedbyhighervalues)
3
Seesub
groups
below
(next4
rows)

RCTsingle Noserious
blind
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
d)

Mobilitymaximalgaitspeed(m/min)Duringusualcare(Betterindicatedbyhighervalues)
2
Bateman
200119;
Eich2004
74

RCTsingle Noserious
blind
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
d)

Mobilitymaximalgaitspeed(m/min)Afterusualcare(Betterindicatedbyhighervalues)
1
Mudge
2009180

RCTsingle Serious
Noserious
blind
limitation(a) inconsistency

Noserious
indirectness

Serious
imprecision(
d)

Mobilitygaitendurance(6MWTmetres)(Betterindicatedbylowervalues)
2

RCTsingle Noserious

Noserious

Noserious

Noserious

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Seesub
groups
below
(next4
rows)

blind

Summaryoffindings
Limitations

limitation

Inconsistency

inconsistency

Indirectness

indirectness

Imprecision

imprecision

Cardiorespiratory
trainingendof
retentionfollow
up
Mean(SD)/
Frequency

Usualcare Effect
Mean(SD)/ Relative
Frequency risk/mean
difference
(95%CI)

means

groupsfor
means

(33.38,
105.23)

163(70.2)

61.8
(16.48,
107.12)

MD61.8
higher
(16.48to
107.12
higher)

Moderate

195(104)

82(23.05,
140.95)

MD82
higher
(23.05to
140.95
higher)

Low

51.5(20.5)

12.2(1.38,
23.02)

MD12.2
higher
(1.38to
23.02
higher)

Low

Absolute
effect/
Mean
differenc
e(MD)
(95%CI)
higher
(33.38to
105.23
higher)

Confidence
(ineffect)

Mobilitygaitendurance(6MWTmetres)Duringusualcare(Betterindicatedbyhighervalues)
1
Eich2004
74

RCTsingle Noserious
blind
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(f
)

224.8(90)

Mobilitygaitendurance(6MWTmetres)Afterusualcare(Betterindicatedbyhighervalues)
1
Mudge
2009180

RCTsingle Serious
Noserious
blind
limitation(a) inconsistency

Noserious
indirectness

Serious
imprecision(f
)

277(125)

Mobilitypeakactivityindex(steps/min)Afterusualcare(Betterindicatedbyhighervalues)
1
Mudge
2009180

RCTsingle Serious
Noserious
blind
limitation(a) inconsistency

Noserious
indirectness

Serious
imprecision(c
)

63.7(21.5)

Mobilitymaxstepratein1minAfterusualcare(Betterindicatedbyhighervalues)

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StrokeRehabilitation
Movement

Qualityassessment

Summaryoffindings

Noof
studies

Design

Limitations

Inconsistency

1
Mudge
2009180

RCTsingle Serious
Noserious
blind
limitation(a) inconsistency

Indirectness

Noserious
indirectness

Imprecision

Serious
imprecision(c
)

Cardiorespiratory
trainingendof
retentionfollow
up
Mean(SD)/
Frequency

Usualcare Effect
Mean(SD)/ Relative
Frequency risk/mean
difference
(95%CI)

87.7(21)

75.6(22.2)

12.1(0.93,
23.27)

MD12.1
higher
(0.93to
23.27
higher)

Low

78.3(13.3)

72.4(18)

5.9(7.97,
19.77)

MD5.9
higher
(7.97
lowerto
19.77
higher)

Verylow

46.16(12.09)

49.09
(8.01)

2.93(
7.91,2.05)

MD2.93
lower
(7.91
lowerto
2.05
higher)

Moderate

7.3(2.5)

8.6(2.9)

1.3(3.67, MD1.3
1.07)
lower
(3.67
lowerto
1.07

Absolute
effect/
Mean
differenc
e(MD)
(95%CI)

Confidence
(ineffect)

MobilityStrokeImpactScale(mobilitydomain)Afterusualcare(Betterindicatedbylowervalues)
1
Smith
2008244

RCTsingle Veryserious Noserious

blind
limitation(a) inconsistency

Noserious
indirectness

Veryserious
imprecision(
e)

PhysicalfunctionBergBalancescaleDuringusualcare(Betterindicatedbyhighervalues)
1
Bateman
200119

RCTsingle Noserious
blind
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

MoodBeckDepressionIndexAfterusualcare(Betterindicatedbylowervalues)
1
Smith
2008244

RCTsingle Veryserious Noserious

blind
limitation(a) inconsistency

Noserious
indirectness

Serious
imprecision(c
)

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369

Verylow

StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
retentionfollow
up
Mean(SD)/
Frequency

Usualcare Effect
Mean(SD)/ Relative
Frequency risk/mean
difference
(95%CI)

Absolute
effect/
Mean
differenc
e(MD)
(95%CI)
higher)

Confidence
(ineffect)

MoodHospitalAnxietyandDepressionScale(HADS)anxietyscoreDuringusualcare(Betterindicatedbylowervalues)
1
Bateman
200119

RCTsingle Noserious
blind
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

3.57(3.36)

5.17(3.99)

1.6(3.58, MD1.6
0.38)
lower
(3.58
lowerto
0.38
higher)

Moderate

2.7(4.4,
1)

Moderate

MoodHospitalAnxietyandDepressionScale(HADS)depressionscoreDuringusualcare(Betterindicatedbylowervalues)
1
Bateman
200119

RCTsingle Noserious
blind
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c
)

3.3(2.36)

6(3.92)

MD2.7
lower
(4.4to1
lower)

HealthrelatedQoLSF36PhysicalComponentScale6monthspostintervention(Betterindicatedbyhighervalues)
1
RCTsingle Serious
Noserious
limitation(a) inconsistency
Holmgren blind
2010113

Noserious
indirectness

Veryserious
imprecision(
e)

35.3(13.3)

35.4(12.9)

0.1(9.47, MD0.1
9.27)
lower
(9.47
lowerto
9.27
higher)

Verylow

5(14.22,
4.22)

Low

HealthrelatedQoLSF36MentalComponentScale6monthspostintervention(Betterindicatedbyhighervalues)
1
RCTsingle Serious
Noserious
limitation(a) inconsistency
Holmgren blind
2010113

Noserious
indirectness

Serious
imprecision(c
)

50.4(15)

55.4(9.3)

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370

MD5
lower
(14.22
lowerto

StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
trainingendof
retentionfollow
up
Mean(SD)/
Frequency

Usualcare Effect
Mean(SD)/ Relative
Frequency risk/mean
difference
(95%CI)

Absolute
effect/
Mean
differenc
e(MD)
(95%CI)
4.22
higher)

Confidence
(ineffect)

HealthrelatedQoLSF36physicalfunctioning6monthspostintervention(Betterindicatedbylowervalues)
1
RCTsingle Serious
Noserious
blind
limitation(a)
inconsistency
Holmgren
113
2010

Noserious
indirectness

Veryserious
imprecision(
e)

51.5(18.6)

46.7(26.9)

4.8(
11.22,
20.82)

MD4.8
higher
(11.22
lowerto
20.82
higher)

Verylow

90.7(27.6)

18.9(
44.34,
6.54)

MD18.9
lower
(44.34
lowerto
6.54
higher)

Low

77.3(21.2)

3.9(7.84,
15.64)

MD3.9
higher
(7.84
lowerto
15.64
higher)

Verylow

3.7(2.9)

0.7(2.27, MD0.7

HealthrelatedQoLSF36emotionalrolefunctioning6monthspostintervention(Betterindicatedbylowervalues)
1
RCTsingle Serious
Noserious
blind
limitation(a)
inconsistency
Holmgren
113
2010

Noserious
indirectness

Serious
imprecision(c
)

71.8(40.5)

HealthrelatedQoLSF36mentalhealth6monthspostintervention(Betterindicatedbylowervalues)
1
RCTsingle Serious
Noserious
limitation(a) inconsistency
Holmgren blind
2010

Noserious
indirectness

Veryserious
imprecision(c
)

81.2(11.9)

MoodGeriatricDepressionScale156monthspostintervention(Betterindicatedbylowervalues)
1

RCTsingle Serious

Noserious

Noserious

Serious

3(1.5)

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371

Low

StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Holmgren blind
2010

(a)
(b)
(c)
(d)
(e)
(f)

Summaryoffindings
Limitations

Inconsistency

limitation(a) inconsistency

Indirectness

indirectness

Imprecision

Cardiorespiratory
trainingendof
retentionfollow
up
Mean(SD)/
Frequency

Usualcare Effect
Mean(SD)/ Relative
Frequency risk/mean
difference
(95%CI)

imprecision(c
)

0.87)

Unclear allocation concealment/unclear assessor blinding. Limitations were considered by study weights in the meta-analysis
Confidence interval crosses one end of default MID (0.75, 1.25)
Confidence interval crosses one end of default MID (0.5)
Mean difference did not reach agreed MID of 0.16m/sec for the walking speed between the intervention and control group
Confidence interval crosses both ends of default MID (0.5)
Mean difference did not reach agreed MID of 28m for the 6 MWT between the intervention and control group

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372

Absolute
effect/
Mean
differenc
e(MD)
(95%CI)
lower
(2.27
lowerto
0.87
higher)

Confidence
(ineffect)

StrokeRehabilitation
Movement

Comparison:Resistancetrainingversususualcare
Table94:ResistancetrainingendofinterventionversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings
Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Resistance
trainingend
of
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

Confidence
(ineffect)

Meanor
Standard
ised
Mean
Differen
ce
(95%CI)

Mean
Differenc
e(MD)/
Standardi
sedMean
Differenc
e(SMD)
(95%CI)

Seesubgroup
formeans

Seesubgroup
formeans

0.58
(0.06,
1.1)

SMD0.58
higher
(0.06to
1.1
higher)

Low

220.58
(260.26)

0.47(
0.16,
1.1)

SMD0.47
higher
(0.16
lowerto
1.1
higher)

Low

142(193)

0.84(
0.09,
1.76)

SMD0.84
higher
(0.09
lowerto
1.76

Low

Physicalfitnesscompositemeasureofmusclestrength(Betterindicatedbyhighervalues)
2
Seesub
group
below
(next4
rows)

RCTsingle
anddouble
blind

Serious
limitation(d)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(b
)

PhysicalfitnesscompositemeasureofmusclestrengthDuringandafterusualcare(Betterindicatedbyhighervalues)
1
Winstein
2004285

RCTsingle
blind

Serious
limitation(a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(b
)

353.53
(296.25)

PhysicalfitnesscompositemeasureofmusclestrengthAfterusualcare(Betterindicatedbyhighervalues)
1
Kim2001
136

RCTdouble
blind

Serious
limitation(c)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(b
)

507(559)

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Resistance
trainingend
of
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

Confidence
(ineffect)

Meanor
Standard
ised
Mean
Differen
ce
(95%CI)

Mean
Differenc
e(MD)/
Standardi
sedMean
Differenc
e(SMD)
(95%CI)
higher)

Seesubgroup
formeans

Seesubgroup
formeans

12.01(
4.46,
28.47)

MD12.01
higher
(4.46
lowerto
28.47
higher)

Verylow

12.9(13.5)

4.8(
5.98,
15.58)

MD4.8
higher
(5.98
lowerto
15.58
higher)

Verylow

41.3(20.9)

21.8
(4.92,
38.68)

MD21.8
higher
(4.92to
38.68
higher)

Low

Physicalfitnessmusclestrength,kneeextension(Nm)(Betterindicatedbyhighervalues)
2
Seesub
group
below
(next4
rows)

RCTsingle
blind

Veryserious
limitation(c)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(e
)

Physicalfitnessmusclestrength,kneeextension(Nm)Duringusualcare(Betterindicatedbyhighervalues)
1
Bale
200814

RCTsingle
blind

Veryserious
limitation(c)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(e
)

17.7(9.8)

Physicalfitnessmusclestrength,kneeextension(Nm)Afterusualcare(Betterindicatedbyhighervalues)
1
Flansbjer
200884

RCTsingle
blind

Serious
limitation(c)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(e
)

63.1(19.6)

Physicalfitnessmusclestrength,kneeflexion(Nm)(Betterindicatedbyhighervalues)

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

2
Seesub
group
below
(next4
rows)

RCTsingle
blind

Summaryoffindings
Limitations

Veryserious
limitation(c)

Inconsistency

Noserious
inconsistency

Indirectness

Noserious
indirectness

Imprecision

Resistance
trainingend
of
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect
Meanor
Standard
ised
Mean
Differen
ce
(95%CI)

Mean
Differenc
e(MD)/
Standardi
sedMean
Differenc
e(SMD)
(95%CI)

Seesubgroup
formeans

9.61(
5.01,
24.24)

MD9.61
higher
(5.01
lowerto
24.24
higher)

Verylow

2.8(4.8)

4.5(
1.13,
10.13)

MD4.5
higher
(1.13
lowerto
10.13
higher)

Verylow

Serious
74(27.7)
imprecision(f)

53.5(21.1)

20.5
(0.84,
40.16)

MD20.5
higher
(0.84to
40.16
higher)

Low

Serious
imprecision(g
)

Seesubgroup
formeans

3.98(
4.88,
12.85)

MD3.98
higher
(4.88

Verylow

Serious
Seesubgroup
imprecision(f) formeans

Confidence
(ineffect)

Physicalfitnessmusclestrength,kneeflexion(Nm)Duringusualcare(Betterindicatedbyhighervalues)
1
Bale
200814

RCTsingle
blind

Veryserious
limitation(c)

Noserious
inconsistency

Noserious
indirectness

Serious
7.3(6.9)
imprecision(f)

Physicalfitnessmusclestrength,kneeflexion(Nm)Afterusualcare(Betterindicatedbyhighervalues)
1
Flansbjer
200884

RCTsingle
blind

Serious
limitation(c)

Noserious
inconsistency

Noserious
indirectness

Mobilitymaximalgaitspeed(m/min)(Betterindicatedbyhighervalues)
2
Seesub
group

RCTsingle
blind

Veryserious
limitation(c)

Noserious
inconsistency

Noserious
indirectness

Seesubgroup
formeans

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Resistance
trainingend
of
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect
Meanor
Standard
ised
Mean
Differen
ce
(95%CI)

Mean
Differenc
e(MD)/
Standardi
sedMean
Differenc
e(SMD)
(95%CI)
lowerto
12.85
higher)

17.4(6)

9(6)

8.4
(2.82,
13.98)

MD8.4
higher
(2.82to
13.98
higher)

Verylow

3.98(7.89)

4.63(7.29)

0.65(
6.86,
5.56)

MD0.65
lower
(6.86
lowerto
5.56
higher)

Low

13.8(6)

4.8(6)

9(3.42,
14.58)

MD9
higher
(3.42to
14.58
higher)

Verylow

below
(next4
rows)

Confidence
(ineffect)

Mobilitymaximalgaitspeed(m/min)Duringusualcare(Betterindicatedbyhighervalues)
1
Bale
200814

RCTsingle
blind

Veryserious
limitation(c)

Veryserious
Noserious
inconsistency(j) indirectness

Serious
imprecision(g
)

Mobilitymaximalgaitspeed(m/min)Afterusualcare(Betterindicatedbyhighervalues)
1
Flansbjer
200884

RCTsingle
blind

Serious
limitation(c)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(g
)

Mobilitypreferredgaitspeed(m/min)Duringusualcare(Betterindicatedbyhighervalues)
1
Bale
200814

RCTsingle
blind

Veryserious
limitation(c)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(g
)

MobilityRivermead(Betterindicatedbyhighervalues)

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

1
Cooke
201047

RCTsingle
blind

Summaryoffindings
Limitations

Noserious
limitation

Inconsistency

Noserious
inconsistency

Indirectness

Noserious
indirectness

Imprecision

Serious
imprecision(b
)

Resistance
trainingend
of
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

Confidence
(ineffect)

Meanor
Standard
ised
Mean
Differen
ce
(95%CI)

Mean
Differenc
e(MD)/
Standardi
sedMean
Differenc
e(SMD)
(95%CI)

37.7(8.6)

34.6(10.8)

3.1(
1.58,
7.78)

MD3.1
higher
(1.58
lowerto
7.78
higher)

Moderate

11.8
(0.89,
22.71)

MD11.8
higher
(0.89to
22.71
higher)

Verylow

SMD0.04
lower
(0.86
lowerto
0.77
higher)

Verylow

MD1.2
lower
(11.84

Low

Physicalfunctionweightbearing(%bodyweightaffectedside)Duringusualcare(Betterindicatedbyhighervalues)
1
Bale
200814

RCTsingle
blind

Veryserious
limitation(c)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(b
)

17.4(8.8)

5.6(14.6)

Physicalfunctionstairclimbing,maximal(sec/step)Afterusualcare(Betterindicatedbyhighervalues)
2
Kim2001
136
;
Ouellette
2004195

RCTsingle
anddouble
blind

Serious
limitation(c)

Serious
inconsistency(k
)

Noserious
indirectness

Veryserious
imprecision(h
)

Kim:0.03
Kim:0.08(0.1) 0.04(
(0.08)
Ouellette:0.53 0.86,
0.77)
Ouellette:0.65 (0.34)
(0.41)

PhysicalfunctionTimedUpandGo(sec)Afterusualcare(Betterindicatedbyhighervalues)
1
Flansbjer
200884

RCTsingle
blind

Serious
limitation(c)

Noserious
inconsistency

Noserious
indirectness

Serious
23.1(10.3)
imprecision(i)

24.3(14.2)

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1.2(
11.84,
9.44)

StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Resistance
trainingend
of
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

Confidence
(ineffect)

Meanor
Standard
ised
Mean
Differen
ce
(95%CI)

Mean
Differenc
e(MD)/
Standardi
sedMean
Differenc
e(SMD)
(95%CI)
lowerto
9.44
higher)

0.74(7.15)

0.73(5.81)

1.47(
4.24,
7.18)

MD1.47
higher
(4.24
lowerto
7.18
higher)

Verylow

Veryserious
imprecision(h
)

1.73(7.34)

1.07(10.13)

2.8(
4.95,
10.55)

MD2.8
higher
(4.95
lowerto
10.55
higher)

Verylow

Serious
imprecision(b
)

69.9(18.9)

60.8(19.6)

9.1(
0.14,
18.34)

MD9.1
higher
(0.14
lowerto
18.34

Moderate

HealthrelatedQoLSF36physicalfunctioningAfterusualcare(Betterindicatedbyhighervalues)
1
Kim2001
136

RCTdouble
blinded

Serious
limitation(c)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision(h
)

HealthrelatedQoLSF36mentalhealthAfterusualcare(Betterindicatedbyhighervalues)
1
Kim2001
136

RCTdouble
blinded

Serious
limitation(c)

Noserious
inconsistency

Noserious
indirectness

EuroQolSelfperceivedhealth(Betterindicatedbyhighervalues)
1
Cooke
201047

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Resistance
trainingend
of
intervention
Mean(SD)

Usualcare
Mean(SD)

Effect

Confidence
(ineffect)

Meanor
Standard
ised
Mean
Differen
ce
(95%CI)

Mean
Differenc
e(MD)/
Standardi
sedMean
Differenc
e(SMD)
(95%CI)
higher)

5.49(
9.78,
1.2)

MD5.49
Verylow
lower
(9.78to
1.2lower)

MoodCentreforEpidemiologicStudiesforDepressionscale(CESD)Afterusualcare(Betterindicatedbylowervalues)
1
Sims
2009238

(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
(k)

RCTsingle
blind

Veryserious
limitation(a);
(c)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(b
)

15.13(8.49)

20.62(11.79)

Unclear blinding. Limitations were considered by study weights in the meta-analysis

Confidence interval crosses one end of default MID (0.5) for single studies and default 0.5 *median control SD for 2 or more studies.
Unclear allocation concealment. Limitations were considered by study weights in the meta-analysis
Unclear blinding and allocation concealment. Limitations were considered by study weights in the meta-analysis
Confidence interval crosses MID (8.6)
Confidence interval crosses MID (6.47)
Mean difference did not reach agreed MID of 0.16m/sec for the walking speed between the intervention and control group
Confidence interval crosses both ends of default MID (0.5)
Mean difference did not reach the agreed MID of 10 secs. for the Time Up and Go between the intervention and control group
2
Heterogeneity: I = 78%
2
Heterogeneity: I = 57%

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StrokeRehabilitation
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Comparison:Resistancetrainingversususualcare
Table95:ResistancetrainingendofretentionfollowupversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings
Qualityassessment
Noof
studies

Design

Summaryoffindings
Limitations

Inconsistency

Indirectness

Imprecision

Resistance
training
endof
retention
followup
Mean(SD)

Control
Mean
(SD)

Effect
Mean
differenc
e
(95%CI)

Mean
Difference
(MD)(95%
CI)

Confidence
(ineffect)

Physicalfitnessmusclestrength,kneeextension(Nm)Afterusualcare(Betterindicatedbyhighervalues)
1
Flansbjer
200884

RCTsingle
blind

Serious
limitation(c)

Noserious
inconsistency

Noserious
indirectness

Serious
59.4(22.6)
imprecision(b)

42(20.1) 17.4(
0.01,
34.81)

MD17.4
higher
(0.01
lowerto
34.81
higher)

Low

53(22.1) 17.6(
2.17,
37.37)

MD17.6
higher
(2.17
lowerto
37.37
higher)

Low

Physicalfitnessmusclestrength,kneeflexion(Nm)Afterusualcare(Betterindicatedbyhighervalues)
1
Flansbjer
200884

RCTsingle
blind

Serious
limitation(c)

Noserious
inconsistency

Noserious
indirectness

Serious
70.6(26.7)
imprecision(b)

Mobilitymaximalgaitspeed(m/min)Afterusualcare(Betterindicatedbyhighervalues)
1
Flansbjer
200884

RCTsingle
blind

Serious
limitation(c)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

96.6(59.4)

116.4
(106.8)

19.8(
95.77,
56.17)

MD19.8
lower
(95.77
lowerto
56.17
higher)

Moderate

Noserious

Veryserious

39.9(7.2)

39.7

0.2(

MD0.2

Low

MobilityRivermead(Betterindicatedbylowervalues)
1

RCTsingle

Noserious

Noserious

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StrokeRehabilitation
Movement

Qualityassessment
Noof
studies

Design

Cooke
201047

blind

Summaryoffindings
Limitations

limitation

Inconsistency

inconsistency

Indirectness

indirectness

Imprecision

Resistance
training
endof
retention
followup
Mean(SD)

imprecision(d)

Control
Mean
(SD)

Effect

Confidence
(ineffect)

Mean
differenc
e
(95%CI)

Mean
Difference
(MD)(95%
CI)

(5.7)

3.34,
3.74)

higher
(3.34
lowerto
3.74
higher)

26.7
(18.9)

3.1(
16.67,
10.47)

MD3.1
lower
(16.67
lowerto
10.47
higher)

Low

PhysicalfunctionTimedUpandGo(sec)Afterusualcare(Betterindicatedbylowervalues)
1
Flansbjer
200884

RCTsingle
blind

Serious
limitation(c)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision

23.6(11.1)

MoodCentreforEpidemiologicStudiesforDepressionscale(CESD)Afterusualcare(Betterindicatedbylowervalues)
1
RCTsingle
Sims2009 blind
238

Veryserious
limitation(a);(
c)

Noserious
inconsistency

Noserious
indirectness

Serious
13.78(8.02)
imprecision(b)

22.7
(11.17)

8.92(
13.03,
4.81)

MD8.92
lower
(13.03to
4.81
lower)

Verylow

Noserious
indirectness

Serious
69.6(19.3)
imprecision(b)

66.2
(18.9)

3.4(
7.31,
14.11)

MD3.4
higher
(7.31
lowerto
14.11
higher)

Moderate

EuroQolSelfperceivedhealth(Betterindicatedbyhighervalues)
1
Cooke
201047

RCTsingle
blind

Noserious
limitation

Noserious
inconsistency

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StrokeRehabilitation
Movement

(a)
(b)
(c)
(d)

Unclear blinding.
Confidence interval crosses one end of default MID (0.5)
Unclear allocation concealment
Confidence interval crosses both ends of default MID (0.5)

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StrokeRehabilitation
Movement

Comparison:Cardiorespiratoryversusresistancetraining
Table96:CardiorespiratoryversusresistancetrainingClinicalstudycharacteristicsandclinicalsummaryoffindings
Qualityassessment
Noof
studies

Design

Noofpatients
Limitations

Inconsistency

Indirectness

Imprecision

Cardiorespiratory
versusresistance
training
Mean(SD)

Usual
care
Mean
(SD)

Effect
Mean
differenc
e(95%
CI)

Mean
Differenc
e(MD)
(95%CI)

Confidence
(ineffect)

Mobilitygaitpreferredspeed(m/min)Cardiorespiratorytraining(Betterindicatedbylowervalues)
4
Cuviello
Palmer
198852;
Katz
Leurer
2003134;
Moore
2010177;
Salbach
2004229

RCTsingle
blind

Serious
limitation(a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(b
)

CuvielloPalmer:
18.11(9.22)
KatzLeurer:30.6
(10.8)
Moore:37.8(18)
Salbach:46.8(24)

Cuviello
4.68
Palmer:
(1.4,
12.07
7.96)
(6.41)
Katz
Leurer:27
(9.6)
Moore:
34.8
(13.8)
Salbach:
38.4
(22.2)

MD4.68
higher
(1.4to
7.96
higher)

Low

Bale:4.8 2.34(
(6)
6.77,
11.45)
Kim:5.4
(4.2)
Ouellette:
38.4
(24.75)

MD2.34
higher
(6.77
lowerto
11.45
higher)

Verylow

Mobilitygaitpreferredspeed(m/min)Resistancetraining(Betterindicatedbylowervalues)
3
RCTsingle
anddouble
Bale
blind
200814;
Kim2001
136
;
Ouellette
2004195
(a)
(b)

Serious
limitation(c)

Veryserious
inconsistency(d
)

Noserious
indirectness

Serious
imprecision(b
)

Bale:13.8(6)
Kim:2.4(7.8)
Ouellette:38.4(22)

Unclear blinding and unclear allocation concealment. Limitations were considered by study weights in the meta-analysis
Mean difference did not reach agreed MID of 0.16m/sec for the walking speed between the intervention and control group

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StrokeRehabilitation
Movement

(c)
(d)

Unclear allocation concealment

2
Heterogeneity: I = 78%

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13.2.1.2

Economicevidence
Literaturereview
Norelevanteconomicevaluationswereidentifiedoncardiorespiratoryorresistancefitnesstraining.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
Cardiorespiratorytrainingisdeliveredaspartofusualrehabilitationprogrammesby
physiotherapists.Thecostperhourofacommunitybasedphysiotherapistis30.51TheGDG
acknowledgedthatadditionalcostswouldbeincurredifpeoplearereferredfortrainingprogrammes
postrehabilitation.

13.2.1.3

Evidencestatements
Clinicalevidencestatements
Endofintervention:
Functionalindependencemeasure
Threestudies1952134of162participantsfoundnosignificantdifferenceinFIMDisabilitybetween
theparticipantswhoreceivedcardiorespiratorytrainingandthosewhoreceivedusualcareatthe
endofintervention(LOWCONFIDENCEINEFFECT)
Onestudy19of52participantsfoundnosignificantdifferenceinFIMDisabilitybetweenthe
participantswhoreceivedcardiorespiratorytrainingandthosewhoreceivedusualcareat
theendofintervention(MODERATECONFIDENCEINEFFECT)
Twostudies52134of110participantsfoundnosignificantdifferenceinFIMDisability
betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewhoreceived
usualcareattheendofintervention(LOWCONFIDENCEINEFFECT)
RivermeadMobilityIndex
Fourstudies19,125,26794of488participantsfoundthatcardiorespiratorytrainingwasassociatedwitha
significantimprovementinthelevelofdisabilityasmeasuredbyRivermeadMobilityIndex,
comparedtousualcareattheendofintervention(MODERATECONFIDENCEINEFFECT).Rivermead
MobilityIndexwasthensubdividedintogroupsofstudieswhereparticipantsinthecontrolgroup
stillreceivedusualcarerehabilitation(duringusualcare)andthosewhereparticipantswere
recruitedwhomaynotcurrentlyreceiveusualcarerehabilitation(afterusualcare).
Duringusualcare:Threestudies19,125,26794comprising452participantsfoundthat
cardiorespiratorytrainingwasassociatedwithasignificantimprovementinthelevelof
disability,asmeasuredbytheRivermeadMobilityIndex,comparedtousualcareattheend
ofintervention(MODERATECONFIDENCEINEFFECT).
Afterusualcare:Onestudy94,94of36participantsfoundthatcardiorespiratorytraining
significantlyimprovedlevelofdisabilityasassessedwiththeRivermeadMobilityIndex,
comparedtousualcareattheendofintervention(LOWCONFIDENCEINEFFECT)
PhysicalActivityandDisabilityscale

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Onestudy180of58participantsfoundnosignificantdifferenceinthePhysicalActivityandDisability
scalebetweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewhoreceivedusual
careattheendofintervention(LOWCONFIDENCEINEFFECT)
Systolicbloodpressure
Fourstudies53134152211of190participantsfoundnosignificantdifferenceinsystolicbloodpressure
Riskfactorsbetweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewho
receivedusualcareattheendofintervention(LOWCONFIDENCEINEFFECT)
Onestudy53of12participantsfoundthatusualcarewasassociatedwithstatistically
significantimprovementinsystolicbloodpressureRiskfactorscomparedtothe
cardiorespiratorytrainingattheendofintervention(LOWCONFIDENCEINEFFECT)
Threestudies134152211of178participantsfoundnosignificantdifferenceinsystolicblood
pressureRiskfactorsbetweentheparticipantswhoreceivedcardiorespiratorytrainingand
thosewhoreceivedusualcareattheendofintervention(MODERATECONFIDENCEIN
EFFECT)
Diastolicbloodpressure
Fourstudies53134152211of190participantsfoundnosignificantdifferenceindiastolicbloodpressure
Riskfactorsbetweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewho
receivedusualcareattheendofintervention(MODERATECONFIDENCEINEFFECT)
Onestudy53of12participantsfoundnosignificantdifferenceindiastolicbloodpressure
Riskfactorsbetweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewho
receivedusualcareattheendofintervention(VERYLOWCONFIDENCEINEFFECT)
Threestudies134152211of178participantsfoundnosignificantdifferenceindiastolicblood
pressureRiskfactorsbetweentheparticipantswhoreceivedcardiorespiratorytrainingand
thosewhoreceivedusualcareattheendofintervention(MODERATECONFIDENCEIN
EFFECT)
PeakVO2
Sixstudies5315217794,125,211comprising289participantsfoundasignificantimprovementinpeak
oxygenuptake(VO2)Physicalfitnessinfavouroftheparticipantsthatreceivedcardiorespiratory
trainingcomparedtotheparticipantsthatreceivedusualcareattheendofintervention(LOW
CONFIDENCEINEFFECT)
Twostudies53,125of145participantsfoundasignificantdifferenceinpeakoxygenuptake
(VO2)Physicalfitnessinfavouroftheparticipantsthatreceivedcardiorespiratorytraining
comparedtotheparticipantsthatreceivedusualcareattheendofintervention
(MODERATECONFIDENCEINEFFECT)
Fourstudies15217794,211of144participantsfoundasignificantimprovementinpeakoxygen
uptake(VO2)Physicalfitnessinfavouroftheparticipantsthatreceivedcardiorespiratory
trainingcomparedtotheparticipantsthatreceivedusualcareattheendofintervention
(LOWCONFIDENCEINEFFECT)
Gaiteconomy,VO2
Onestudy177of20participantsfoundnosignificantdifferenceinGaiteconomy,VO2Physicalfitness
betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewhoreceivedusualcare
attheendofintervention(VERYLOWCONFIDENCEINEFFECT)
Maximumcyclingworkrate
Fourstudies1953134211of221participantsfoundthatcardiorespiratorytrainingwasassociatedwitha
statisticallysignificantdifferenceinmaximumcyclingworkratePhysicalfitnesscomparedtousual
careattheendofintervention(LOWCONFIDENCEINEFFECT)

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Twostudies1953of89participantsfoundnosignificantdifferenceinmaximumcyclingwork
ratePhysicalfitnessbetweentheparticipantswhoreceivedcardiorespiratorytrainingand
thosewhoreceivedusualcareattheendofintervention(MODERATECONFIDENCEIN
EFFECT)
Twostudies134211of132participantsfoundthatthecardiorespiratorytrainingwasassociated
withstatisticallysignificantimprovementinmaximumcyclingworkratePhysicalfitness
comparedtousualcareattheendofintervention(LOWCONFIDENCEINEFFECT)

Bodymass(KG)
Onestudy19of72participantsfoundnosignificantdifferenceinBodymass(KG)Physicalfitness
betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewhoreceivedusualcare
attheendofintervention(MODERATECONFIDENCEINEFFECT)
FunctionalAmbulationCategories
Twostudies53208of73participantsfoundthatcardiorespiratorytrainingwasassociatedwith
statisticallysignificantimprovementinFunctionalAmbulationCategoriesMobilitycomparedtothe
usualcareattheendofintervention(LOWCONFIDENCEINEFFECT)
Maximalgaitspeed
Sevenstudies5320819,74229177180of365participantsfoundthatcardiorespiratorytrainingwas
associatedwithstatisticallysignificantimprovementinmaximalgaitspeedMobilitycomparedto
theusualcareattheendofintervention,althoughthisdifferencewasnotofclinicalsignificance
(MODERATECONFIDENCEINEFFECT)
Fourstudies5320819,74of196participantsfoundnosignificantdifferenceinmaximalgaitspeed
Mobilitybetweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewho
receivedusualcareattheendofintervention(MODERATECONFIDENCEINEFFECT)
Threestudies229177180of169participantsfoundthatcardiorespiratorytrainingwas
associatedwithstatisticallysignificantimprovementinmaximalgaitspeedMobility
comparedtotheusualcareattheendofintervention.Thisdifferencewasnotclinically
significant(LOWCONFIDENCEINEFFECT)
Preferredgaitspeed
Fourstudies52134177229of221participantsfoundthatcardiorespiratorytrainingwasassociatedwith
statisticallysignificantimprovementinpreferredgaitspeedMobilitycomparedtotheusualcareat
theendofintervention.Thisdifferencewasofclinicalsignificance(MODERATECONFIDENCEIN
EFFECT)
Onestudy52of20participantsfoundnosignificantdifferenceinpreferredgaitspeed
Mobilitybetweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewho
receivedusualcareattheendofintervention(LOWCONFIDENCEINEFFECT)
Threestudies134177229of201participantsfoundthatcardiorespiratorytrainingwas
associatedwithstatisticallysignificantimprovementinpreferredgaitspeedMobility
comparedtotheusualcareattheendofintervention.Thisdifferencewasofclinical
significance(MODERATECONFIDENCEINEFFECT)
Gaitendurance(6MWTmetres)
Sevenstudies7417718094,125,229,267of630participantsfoundthatcardiorespiratorytrainingwas
associatedwithstatisticallysignificantimprovementingaitendurance(6MWTmetres)Mobility
comparedtotheusualcareattheendofintervention.(VERYLOWCONFIDENCEINEFFECT)
Threestudies74,125,267of425participantsfoundnosignificantdifferenceingaitendurance(6
MWTmetres)Mobilitybetweentheparticipantswhoreceivedcardiorespiratorytraining

NationalClinicalGuidelineCentre,2013.
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andthosewhoreceivedusualcareattheendofintervention(VERYLOWCONFIDENCEIN
EFFECT)
Fourstudies17718022994of205participantsfoundthatcardiorespiratorytrainingwas
associatedwithstatisticallysignificantimprovementingaitendurance(6MWTmetres)
Mobilitycomparedtotheusualcareattheendofintervention.Thisdifferencewasnot
clinicallysignificant(LOWCONFIDENCEINEFFECT)

Maximalgaitspeed(m/secover10meters)
Onestudy94of36participantsfoundthatcardiorespiratorytrainingwasassociatedwithstatistically
significantimprovementinmaximalgaitspeedMobility(m/secover10meters)comparedtothe
usualcareattheendofintervention,althoughthisdifferencewasnotofclinicalsignificance(Low
CONFIDENCEINEFFECT)
Comfortablegaitspeed(m/secover5to10meters)
Twostudies94,267of278participantsfoundthatcardiorespiratorytrainingwasassociatedwith
statisticallysignificantimprovementincomfortablegaitspeedMobilitycomparedtotheusualcare
attheendofintervention.(LOWCONFIDENCEINEFFECT)
Onestudy267of242participantsfoundthatcardiorespiratorytrainingwasassociatedwith
statisticallysignificantimprovementincomfortablegaitspeedMobilitycomparedtothe
usualcareattheendofintervention.(LOWCONFIDENCEINEFFECT)
Onestudy94of36participantsfoundcardiorespiratorytrainingwasnotassociatedwith
statisticallysignificantimprovementincomfortablegaitspeedMobilitycomparedtothe
usualcareattheendofintervention.(LOWCONFIDENCEINEFFECT)
Gaitendurance(m/min)
Threestudies5374229of154participantsfoundthatcardiorespiratorytrainingwasassociatedwith
statisticallysignificantimprovementingaitendurance(m/min)Mobilitycomparedtotheusualcare
attheendofintervention,althoughthisdifferencewasnotofclinicalsignificance(LOWCONFIDENCE
INEFFECT)
Twostudies5374of63participantsfoundnosignificantdifferenceingaitendurance(m/min)
Mobilitybetweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewho
receivedusualcareattheendofintervention(MODERATECONFIDENCEINEFFECT)
Onestudy229of91participantsfoundnosignificantdifferenceingaitendurance(m/min)
Mobilitybetweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewho
receivedusualcareattheendofintervention(LOWCONFIDENCEINEFFECT)
6metrewalkingtime(sec)
Onestudy93of20participantsfoundnosignificantdifferencein6metrewalkingtime(sec)Mobility
betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewhoreceivedusualcare
attheendofintervention(LOWCONFIDENCEINEFFECT)
StrokeImpactScale
Twostudies244,267of262participantsfoundthatcardiorespiratorytrainingwasassociatedwitha
statisticallysignificantimprovementintheimpactofthestroke,asmeasuredbythestrokeimpact
scaleMobility,comparedtotheusualcareattheendofintervention.(MODERATECONFIDENCEIN
EFFECT)
Onestudy267of242participantsfoundthatcardiorespiratorytrainingwasassociatedwith
statisticallysignificantimprovementintheimpactofthestroke,asmeasuredbythestroke
impactscaleMobility,comparedtotheusualcareattheendofintervention.(MODERATE
CONFIDENCEINEFFECT)

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Onestudy244of20participantsfoundnosignificantdifferenceinStrokeImpactScale(mobility
domain)betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewho
receivedusualcareattheendofintervention(VERYLOWCONFIDENCEINEFFECT)

Peakactivityindex(steps/min)
Onestudy180of58participantsfoundthatcardiorespiratorytrainingwasassociatedwithstatistically
significantimprovementinPeakactivityindex(steps/min)mobilitycomparedtotheusualcareat
theendofintervention(LOWCONFIDENCEINEFFECT)
Maximumsteprate
Onestudy180of58participantsfoundthatcardiorespiratorytrainingwasassociatedwithstatistically
significantimprovementinMaximumstepratemobilitycomparedtotheusualcareattheendof
intervention(LOWCONFIDENCEINEFFECT)
BergBalancescale
Fivestudies1922994,177125of357participantsfoundnosignificantdifferenceinBergBalancescale
Physicalfunctionbetweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewho
receivedusualcareattheendofintervention(LOWCONFIDENCEINEFFECT)
Duringusualcare:Twostudies19,125of210participantsfoundnosignificantdifferencein
BergBalancescalePhysicalfunctionbetweentheparticipantswhoreceived
cardiorespiratorytrainingandthosewhoreceivedusualcareattheendofintervention
(MODERATECONFIDENCEINEFFECT)
Afterusualcare:Threestudies22994,177of147participantsfounddifferencesignificant
improvementinBergBalancescalePhysicalfunctionassociatedwithcardiorespiratory
trainingcomparedtousualcare.(LOWCONFIDENCEINEFFECT)
TimeUpandGomeasure
Threestudies229177,267of353participantsfoundthatcardiorespiratorytrainingsignificantlyimproved
TimedUpandGoresponsePhysicalfunctioncomparedtousualcareattheendofintervention.
Thisimprovementwasnotlargeenoughtoindicateclearclinicalbenefit(HIGHCONFIDENCEIN
EFFECT).
Duringusualcare:Onestudy267of142participantsthatcardiorespiratorytraining
significantlyimprovedTimedUpandGoresponsePhysicalfunctioncomparedtousual
careattheendofintervention.Thisimprovementwasnotlargeenoughtoindicateclear
clinicalbenefit(HIGHCONFIDENCEINEFFECT)
Twostudies177229of111participantsfoundnosignificantdifferenceintheTimeUpandGo
measurePhysicalfunctionbetweentheparticipantswhoreceivedcardiorespiratory
trainingandthosewhoreceivedusualcareattheendofintervention(LOWCONFIDENCEIN
EFFECT)
HealthrelatedQoL
Onestudy3of28participantsfoundthatcardiorespiratorytrainingwasassociatedwithstatistically
significantimprovementinHealthrelatedQoL(SF36Emotionalrolefunctioningdomain)compared
totheusualcareattheendofintervention(LOWCONFIDENCEINEFFECT)
Threestudies3,94,113of97participantsfoundnosignificantdifferenceinHealthrelatedQoL(SF36or
SF12Physicalfunctioningdomain)betweentheparticipantswhoreceivedcardiorespiratory
trainingandthosewhoreceivedusualcareattheendofintervention(VERYLOWCONFIDENCEIN
EFFECT)

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Onestudy113of33participantsfoundnosignificantdifferenceinHealthrelatedQoL(SF36
Emotionalrolefunctioningdomain)betweentheparticipantswhoreceivedcardiorespiratorytraining
andthosewhoreceivedusualcareattheendofintervention(LOWCONFIDENCEINEFFECT)
Onestudy113of33participantsfoundnosignificantdifferenceinHealthrelatedQoL(SF36Mental
healthdomain)betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewho
receivedusualcareattheendofintervention(LOWCONFIDENCEINEFFECT)
Onestudy113of33participantsfoundnosignificantdifferenceinHealthrelatedQoL(SF36Physical
Componentscale)betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewho
receivedusualcareattheendofintervention(VERYLOWCONFIDENCEINEFFECT)
Onestudy113of33participantsfoundnosignificantdifferenceinHealthrelatedQoL(SF36Mental
Componentscale)betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewho
receivedusualcareattheendofintervention(VERYLOWCONFIDENCEINEFFECT)
Mood
Onestudy244of20participantsfoundnosignificantdifferenceinMood(BeckDepressionIndex)
betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewhoreceivedusualcare
attheendofintervention(VERYLOWCONFIDENCEINEFFECT)
Twostudies19,267of302participantsfoundthatcardiorespiratorytrainingwasnotassociatedwith
statisticallysignificantimprovementinanxiety(HADSanxietyscore)comparedtotheusualcareat
theendofintervention(MODERATECONFIDENCEINEFFECT)
Threestudies19,113,267of60participantsfoundnosignificantdifferenceindepression(measuredby
HADSdepressionscoreortheGeriatricDepressionScale)betweentheparticipantswhoreceived
cardiorespiratorytrainingandthosewhoreceivedusualcareattheendofintervention(MODERATE
CONFIDENCEINEFFECT)
Endofretentionfollowup:
Casefatality
Onestudy134of81participantsfoundnosignificantdifferenceincasefatalitybetweenthe
participantswhoreceivedcardiorespiratorytrainingandthosewhoreceivedusualcareattheendof
retentionfollowup(VERYLOWCONFIDENCEINEFFECT)
RivermeadMobilityIndex
Onestudy19of66participantsfoundnosignificantdifferenceintheRivermeadMobilityIndex
betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewhoreceivedusualcare
attheendofretentionfollowup(MODERATECONFIDENCEINEFFECT)
NottinghamExtendedADL
Onestudy19of64participantsfoundnosignificantdifferenceintheNottinghamExtendedADL
betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewhoreceivedusualcare
attheendofretentionfollowup(MODERATECONFIDENCEINEFFECT)
PhysicalActivityandDisabilityScale
Onestudy180of58participantsfoundnosignificantdifferenceinthePhysicalActivityandDisability
Scalebetweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewhoreceivedusual
careattheendofretentionfollowup(LOWCONFIDENCEINEFFECT)
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Onestudy134of79participantsfoundnosignificantdifferenceinFrenchayActivitiesIndexbetween
theparticipantswhoreceivedcardiorespiratorytrainingandthosewhoreceivedusualcareatthe
endofretentionfollowup(LOWCONFIDENCEINEFFECT)
Maximumcyclingworkrate
Onestudy19of66participantsfoundnosignificantdifferenceinmaximumcyclingworkratebetween
theparticipantswhoreceivedcardiorespiratorytrainingandthosewhoreceivedusualcareatthe
endofretentionfollowup(MODERATECONFIDENCEINEFFECT)
Bodymass(Kg)
Onestudy19of64participantsfoundnosignificantdifferenceinBodymass(Kg)betweenthe
participantswhoreceivedcardiorespiratorytrainingandthosewhoreceivedusualcareattheendof
retentionfollowup(MODERATECONFIDENCEINEFFECT)
Maximalgaitspeed
Threestudies19,74180of186participantsfoundthatcardiorespiratorytrainingwasassociatedwith
statisticallysignificantimprovementinmaximalgaitspeedMobilitycomparedtotheusualcareat
theendofretentionfollowup,althoughthisdifferencewasnotofclinicalsignificance(MODERATE
CONFIDENCEINEFFECT)
Twostudies19,74of128participantsfoundthatcardiorespiratorytrainingwasassociatedwith
statisticallysignificantimprovementinmaximalgaitspeedMobilitycomparedtotheusual
careattheendofretentionfollowup,althoughthisdifferencewasnotofclinical
significance(MODERATECONFIDENCEINEFFECT)
Onestudy180of58participantsfoundthatcardiorespiratorytrainingwasassociatedwith
statisticallysignificantimprovementinmaximalgaitspeedMobilitycomparedtotheusual
careattheendofretentionfollowup,althoughthisdifferencewasnotofclinical
significance(LOWCONFIDENCEINEFFECT)
6MinuteWalkTest
Twostudies74180of107participantsfoundthatcardiorespiratorytrainingwasassociatedwith
statisticallysignificantimprovementin6MinuteWalkTestMobilitycomparedtotheusualcareat
theendofretentionfollowup.Thisdifferencewasofclinicalsignificance(HIGHCONFIDENCEIN
EFFECT)
Onestudy74of49participantsfoundthatcardiorespiratorytrainingwasassociatedwith
statisticallysignificantimprovementin6MinuteWalkTestMobilitycomparedtotheusual
careattheendofretentionfollowup.Thisdifferencewasnotclinicallysignificant
(MODERATECONFIDENCEINEFFECT)
Onestudy180of58participantsfoundthatcardiorespiratorytrainingwasassociatedwith
statisticallysignificantimprovementin6MinuteWalkTestMobilitycomparedtotheusual
careattheendofretentionfollowup.Thisdifferencewasnotclinicallysignificant(LOW
CONFIDENCEINEFFECT)
Peakactivityindex(steps/min)
Onestudy180of58participantsfoundthatcardiorespiratorytrainingwasassociatedwithstatistically
significantimprovementinpeakactivityindex(steps/min)Mobilitycomparedtotheusualcareat
theendofretentionfollowup(LOWCONFIDENCEINEFFECT)
Maximumsteprate

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Onestudy180of58participantsfoundthatcardiorespiratorytrainingwasassociatedwithstatistically
significantimprovementinmaximumsteprateMobilitycomparedtotheusualcareattheendof
retentionfollowup(LOWCONFIDENCEINEFFECT)
StrokeImpactScale
Onestudy244of20participantsfoundnosignificantdifferenceinStrokeImpactScale(mobility
domain)betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewhoreceived
usualcareattheendofretentionfollowup(VERYLOWCONFIDENCEINEFFECT)
BergBalancescale
Onestudy19of66participantsfoundnosignificantdifferenceinBergBalancescalePhysical
functionbetweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewhoreceived
usualcareattheendofretentionfollowup(MODERATECONFIDENCEINEFFECT)
Mood
Onestudy244of20participantsfoundnosignificantdifferenceinMood(BeckDepressionIndex)
betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewhoreceivedusualcare
attheendofretentionfollowup(VERYLOWCONFIDENCEINEFFECT)
Onestudy19of53participantsfoundnosignificantdifferenceinMood(HADSanxietyscore)
betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewhoreceivedusualcare
attheendofretentionfollowup(MODERATECONFIDENCEINEFFECT)
Onestudy19of53participantsfoundthatcardiorespiratorytrainingwasassociatedwithstatistically
significantimprovementinMood(HADSdepressionscore)comparedtotheusualcareattheend
ofretentionfollowup(MODERATECONFIDENCEINEFFECT)
Onestudy113of31participantsfoundnosignificantdifferenceinMood(GeriatricDepressionScale)
betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewhoreceivedusualcare
at6monthspostintervention(LOWCONFIDENCEINEFFECT)
HealthrelatedQoL
Onestudy113of31participantsfoundnosignificantdifferenceinHealthrelatedQoL(SF36Physical
Componentscale)betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewho
receivedusualcareat6monthspostintervention(VERYLOWCONFIDENCEINEFFECT)
Onestudy113of31participantsfoundnosignificantdifferenceinHealthrelatedQoL(SF36Mental
Componentscale)betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewho
receivedusualcareat6monthspostintervention(LOWCONFIDENCEINEFFECT)
Onestudy113of31participantsfoundnosignificantdifferenceinHealthrelatedQoL(SF36Physical
functioningdomain)betweentheparticipantswhoreceivedcardiorespiratorytrainingandthose
whoreceivedusualcareat6monthspostintervention(VERYLOWCONFIDENCEINEFFECT)
Onestudy113of31participantsfoundnosignificantdifferenceinHealthrelatedQoL(SF36
Emotionalrolefunctioningdomain)betweentheparticipantswhoreceivedcardiorespiratorytraining
andthosewhoreceivedusualcareat6monthspostintervention(LOWCONFIDENCEINEFFECT)
Onestudy113of31participantsfoundnosignificantdifferenceinHealthrelatedQoL(SF36Mental
healthdomain)betweentheparticipantswhoreceivedcardiorespiratorytrainingandthosewho
receivedusualcareat6monthspostintervention(VERYLOWCONFIDENCEINEFFECT)
Resistancetraining:Endofintervention

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Musclestrength
Twostudies285136of60participantsfoundthatresistancetrainingwasassociatedwithstatistically
significantimprovementincompositemeasureofmusclestrengthcomparedtousualcareattheend
ofintervention(LOWCONFIDENCEINEFFECT)
Onestudy285of40participantsfoundnosignificantdifferenceincompositemeasureof
musclestrengthbetweentheparticipantswhoreceivedresistancetrainingandthosewho
receivedusualcareattheendofintervention(LOWCONFIDENCEINEFFECT)
Onestudy136of20participantsfoundnosignificantdifferenceincompositemeasureof
musclestrengthbetweentheparticipantswhoreceivedresistancetrainingandthosewho
receivedusualcareattheendofintervention(LOWCONFIDENCEINEFFECT)
Kneeextension(Nm)
Twostudies1484of42participantsfoundnosignificantdifferenceinkneeextension(Nm)between
theparticipantswhoreceivedresistancetrainingandthosewhoreceivedusualcareattheendof
intervention(VERYLOWCONFIDENCEINEFFECT)
Onestudy14of18participantsfoundnosignificantdifferenceinkneeextension(Nm)
betweentheparticipantswhoreceivedresistancetrainingandthosewhoreceivedusualcare
attheendofintervention(VERYLOWCONFIDENCEINEFFECT)
Onestudy84of24participantsfoundthatresistancetrainingwasassociatedwithstatistically
significantimprovementinkneeextension(Nm)comparedtousualcareattheendof
intervention(LOWCONFIDENCEINEFFECT)
Kneeflexion(Nm)
Twostudies1484of42participantsfoundnosignificantdifferenceinkneeflexion(Nm)betweenthe
participantswhoreceivedresistancetrainingandthosewhoreceivedusualcareattheendof
intervention(VERYLOWCONFIDENCEINEFFECT)
Onestudy14of18participantsfoundnosignificantdifferenceinkneeflexion(Nm)between
theparticipantswhoreceivedresistancetrainingandthosewhoreceivedusualcareatthe
endofintervention(VERYLOWCONFIDENCEINEFFECT)
Onestudy84of24participantsfoundthatresistancetrainingwasassociatedwithstatistically
significantimprovementinkneeflexion(Nm)comparedtousualcareattheendof
intervention(LOWCONFIDENCEINEFFECT)
Maximalgaitspeed
Twostudies1484of42participantsfoundnosignificantdifferenceinmaximalgaitspeedbetweenthe
participantswhoreceivedresistancetrainingandthosewhoreceivedusualcareattheendof
intervention(VERYLOWCONFIDENCEINEFFECT)
Onestudy14of18participantsfoundthatresistancetrainingwasassociatedwithstatistically
significantimprovementinmaximalgaitspeedcomparedtousualcareattheendof
intervention,althoughthisdifferencewasnotofclinicalsignificance(VERYLOW
CONFIDENCEINEFFECT)
Onestudy84of24participantsfoundnosignificantdifferenceinmaximalgaitspeedbetween
theparticipantswhoreceivedresistancetrainingandthosewhoreceivedusualcareatthe
endofintervention(LOWCONFIDENCEINEFFECT)
Preferredgaitspeed
Onestudy14of18participantsfoundthatresistancetrainingwasassociatedwithstatistically
significantimprovementinpreferredgaitspeedcomparedtousualcareattheendofintervention,
althoughthisdifferencewasnotofclinicalsignificance(VERYLOWCONFIDENCEINEFFECT)
RivermeadMobilityIndex

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Onestudy47of68participantsfoundnosignificantdifferenceinRivermeadMobilityIndexbetween
theparticipantswhoreceivedresistancetrainingandthosewhoreceivedusualcareattheendof
intervention(MODERATECONFIDENCEINEFFECT)
Weightbearing(affectedside)
Onestudy14of18participantsfoundthatresistancetrainingwasassociatedwithstatistically
significantimprovementinweightbearing(affectedside)comparedtousualcareattheendof
intervention(VERYLOWCONFIDENCEINEFFECT)
Stairclimbing
Twostudies136195of61participantsfoundnosignificantdifferenceinstairclimbingbetweenthe
participantswhoreceivedresistancetrainingandthosewhoreceivedusualcareattheendof
intervention(VERYLOWCONFIDENCEINEFFECT)
TimedUpandGo(sec)
Onestudy84of24participantsfoundnosignificantdifferenceinTimedUpandGo(sec)betweenthe
participantswhoreceivedresistancetrainingandthosewhoreceivedusualcareattheendof
intervention(LOWCONFIDENCEINEFFECT)
HealthrelatedQoL
Onestudy136of20participantsfoundnosignificantdifferenceinHealthrelatedQoL(SF36Physical
functioningdomain)betweentheparticipantswhoreceivedresistancetrainingandthosewho
receivedusualcareattheendofintervention(VERYLOWCONFIDENCEINEFFECT)
Onestudy136of20participantsfoundnosignificantdifferenceinHealthrelatedQoL(SF36Mental
healthdomain)betweentheparticipantswhoreceivedresistancetrainingandthosewhoreceived
usualcareattheendofintervention(VERYLOWCONFIDENCEINEFFECT)
EuroQoL
Onestudy47of67participantsfoundnosignificantdifferenceinEuroQoL(Selfperceivedhealth)
betweentheparticipantswhoreceivedresistancetrainingandthosewhoreceivedusualcareatthe
endofintervention(MODERATECONFIDENCEINEFFECT)
Mood
Onestudy238of88participantsfoundthatresistancetrainingwasassociatedwithstatistically
significantimprovementinMood(CentreforEpidemiologyStudiesforDepressionscale)compared
tousualcareattheendofintervention(VERYLOWCONFIDENCEINEFFECT)

Endofretentionfollowup:
Kneeextension(Nm)
Onestudy84of24participantsfoundnosignificantdifferenceinkneeextension(Nm)betweenthe
participantswhoreceivedresistancetrainingandthosewhoreceivedusualcareattheendof
retentionfollowup(LOWCONFIDENCEINEFFECT)
Kneeflexion(Newtonmetre)
Onestudy84of24participantsfoundnosignificantdifferenceinkneeflexion(Nm)betweenthe
participantswhoreceivedresistancetrainingandthosewhoreceivedusualcareattheendof
retentionfollowup(LOWCONFIDENCEINEFFECT)

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Maximalgaitspeed
Onestudy84of24participantsfoundnosignificantdifferenceinmaximalgaitspeedbetweenthe
participantswhoreceivedresistancetrainingandthosewhoreceivedusualcareattheendof
retentionfollowup(MODERATECONFIDENCEINEFFECT)
RivermeadMobilityIndex
Onestudy47of51participantsfoundnosignificantdifferenceinRivermeadMobilityIndexbetween
theparticipantswhoreceivedresistancetrainingandthosewhoreceivedusualcareattheendof
retentionfollowup(LOWCONFIDENCEINEFFECT)
TimedUpandGo(sec)
Onestudy84of24participantsfoundnosignificantdifferenceinTimedUpandGo(sec)betweenthe
participantswhoreceivedresistancetrainingandthosewhoreceivedusualcareattheendof
retentionfollowup(LOWCONFIDENCEINEFFECT)
Mood
Onestudy238of86participantsfoundthatresistancetrainingwasassociatedwithstatistically
significantimprovementinMood(CentreforEpidemiologyStudiesforDepressionscale)compared
tousualcareattheendofretentionfollowup(VERYLOWCONFIDENCEINEFFECT)
EuroQoL
Onestudy47of49participantsfoundnosignificantdifferenceinEuroQoL(Selfperceivedhealth)
betweentheparticipantswhoreceivedresistancetrainingandthosewhoreceivedusualcareatthe
endofretentionfollowup(MODERATECONFIDENCEINEFFECT)

CardiorespiratoryversusResistancetraining:
Preferredgaitspeed
Fourstudies52134177229of221participantsfoundthatcardiorespiratorytrainingwasassociatedwith
statisticallysignificantimprovementinpreferredgaitspeedMobilitycomparedtotheusualcare,
althoughthisdifferencewasnotofclinicalsignificance(LOWCONFIDENCEINEFFECT)
Threestudies14136195of80participantsfoundnosignificantdifferenceinpreferredgaitspeed
Mobilitybetweentheparticipantswhoreceivedresistancetrainingandthosewhoreceivedusual
careattheendofintervention(VERYLOWCONFIDENCEINEFFECT)
Economicevidencestatement
Nocosteffectivenessevidencewasidentified.

13.2.2

Recommendationsandlinkstoevidence
81.Encouragepeopletoparticipateinphysicalactivityafterstroke.

82.Assesspeoplewhoareabletowalkandaremedicallystableaftertheir
strokeforcardiorespiratoryandresistancetrainingappropriatetotheir
individualgoals.

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83.Cardiorespiratoryandresistancetrainingforpeoplewithstrokeshould
bestartedbyaphysiotherapistwiththeaimthatthepersoncontinues
theprogrammeindependentlybasedonthephysiotherapists
instructions(seerecommendation84).
84.Forpeoplewithstrokewhoarecontinuinganexerciseprogramme
independently,physiotherapistsshouldsupplyanynecessary
informationaboutinterventionsandadaptationssothatwherethe
personisusinganexerciseprovider,theprovidercanensuretheir
programmeissafeandtailoredtotheirneedsandgoals.This
informationmaytaketheformofwritteninstructions,telephone
conversationsorajointvisitwiththeproviderandthepersonwith
stroke,dependingontheneedsandabilitiesoftheexerciseprovider
andthepersonwithstroke.
85.Tellpeoplewhoareparticipatinginfitnessactivitiesafterstrokeabout
commonpotentialproblems,suchasshoulderpain,andadvisethemto
seekadvicefromtheirGPortherapistiftheseoccur.

Relativevaluesof
differentoutcomes

TheGDGagreedthatbeingfithasanimpacton:cardiovascularmortality,obesity,
speed,enduranceandmood.
TheGDGconsideredthoseoutcomesmeasuringfitness,mobilityandmoodtobe
important.

Tradeoffbetween
clinicalbenefitsand
harms

Thereisageneralagreementthatphysicalactivityisbeneficial.TheCochrane
reviewdemonstratedimprovementsinphysicalfitness,mobilityandmoodandthat
respiratorytrainingimprovedspeed,toleranceandindependenceinwalking.The
GDGnotedthatallpeopleincludedwithinthestudieshadsomewalkingcapacityat
baseline.Thestudiesdidnotcommentonharmorpotentialsideeffects.Adverse
eventswerenotconsistentlyreportedwithinthesestudiesbutrequireserious
consideration.
TheGDGagreedthatpeopleneedtobecardiovascularlystable(theirtreatmentis
notchangingandtheirsymptomsarenotgettingworse),buthavingsymptomsdoes
notmeanthattheycannotexercise.
TheGDGagreedthatcardiovascularexercisewassafeundersupervisionforcertain
people.Itwasagreedthatanassessmentshouldbeundertakenbyahealth
professionaltoestablishsuitabilityforthistypeofinterventionbutthatthebenefits
ofexerciseinpreventingfurtherdeteriorationwereestablished.Thegroupagreed
thatmostfitnesstrainingisdoneinthecommunityandasoutpatients,andthere
arenowprogrammesavailableofadaptedfitnessprogrammessuitableforastroke
populationthatwouldbesafe.Ideallypeoplewouldstarttheirexerciseprogramme
undersupervisionofacommunityphysiotherapistandthenapersonaltrainerwho
hadknowledgeandexperienceofworkingwithpeoplewithdisabilitieswhowould
continuetheprogramme.
ShoulderpainisthemostlikelyharmpeopleexperienceandthereforetheGDG
agreedthatarecommendationtodirectpeopletoseekmedicaladviceshouldbe
made.

Economic
considerations

Cardiorespiratorytrainingisdeliveredaspartofusualrehabilitationprogrammesby
physiotherapists.Fitnesstrainingisdoneinthecommunityandthecostperhourof
acommunitybasedphysiotherapistis30.TheGDGacknowledgedthatadditional
costswouldbeincurredifpeoplearereferredfortrainingprogrammespost
rehabilitation;theGDGfeltthatthepotentialcostsofcardiorespiratoryandfitness
trainingarelikelytobeoutweighedbythebenefits.

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Qualityofevidence

Theconfidenceintheeffectofspecifiedoutcomesrangefromhightoverylow.
Significanteffectswerefoundinthedomainswheresuchchangesmightbe
anticipatedwithcardiorespiratoryandresistanceinterventions(i.e.physicalfitness
andmobilityoutcomes).Thesefindingsareconsistentwithresultsinotherpatient
groupsforsimilarfitnessinterventionstudies.Inthegroupswhoreceived
cardiorespiratorytrainingsignificantimprovementswerefoundforgaitspeed,gait
enduranceandmeasuresofphysicalfitnessattheendofintervention(timepoint
whenatrainingprogrammefinishes)andwereretainedattheendoffollowup
(anytimepointoccurringaftertheendoftheintervention).Tworecentlargescale
studies125,267contributedtomanymobilityoutcomesandresultedinlarger
improvementsofhightolowqualityfortheseoutcomes.Thisalsoincludes
measuresofstrokeimpacttheevidenceofwhichwasratedasmoderatequality.

Otherconsiderations

Thegroupfeltthatparticipatinginexerciseshouldgenerallybeencouraged.The
GDGalsonotedthatthefindingsofthereviewwereuncontroversialinthatthey
highlightmobilityandfitnessasthemainhealthgains.
Therewasadiscussionaboutmedicalsuitabilityandtheroleofmedicaladvicewith
regardstocardiorespiratory/resistancetraining.Itwasfeltthattherecould
potentiallybeseriousmedicalrisksassociatedwithfitnesstrainingsincemany
peoplewhohavehadastrokealsohavecardiacconditions.Sincetherewouldbea
tradeoffbetweenbenefitsandpotentialharms,cliniciansshouldassessanddiscuss
thesewithpeoplewhohavehadastrokewhoareconsideringtakingpartinsuch
activities.TheGDGalsodebatedtheissueofindividualpreferenceandpersonal
history.Whetherapersonwantstotakepartinexercisetrainingcoulddependon
previousactivitylevelsandwork/lifecommitments.Thegroupacknowledgeda
distinctionbetweenthegoalsofthosewantingtoregainfunctionalabilityandthose
whowanttocommittoprogressivecardiorespiratoryexerciserequiringsignificant
timeandeffort.Whilstfitnesstrainingmaynotbesuitableorwantedbyeveryone,
itwasagreedphysicalactivityatwhateverlevelshouldbeofferedandpromoted.
TheGDGhighlightedtheStartactivestayactivereportpromotingregularphysical
activitythroughoutapersonslife62.Althoughfitnesstrainingtendstobedonemore
commonlyinthecommunitysettingratherthanintheacutesetting,studieshave
beendonesafelyintheacutesetting.

13.3 Handandarmtherapies:orthosesfortheupperlimb
Handorthoses,orsplints,areusuallylightweight,formedsupportsforprovidingprotection,rest,or
alignmentforthefingers,handandwrist.Afterstroke,ifhandfunctiondoesnotreturn,softtissue
tightnessandcontracturesoftenoccurleadingtosecondaryproblemsoffurtherlimitedfunction,
pain,oedemaandpossibly,worseningspasticity.Handsplintsaresometimesprovidedtoaidin
maintainingthelengthofsofttissuesandthustherangeofmotionofthejoints.Theyarealso
thoughttoreducetheeffectsofspasticity.However,thereisdifferingopinionwithregardstothe
design,schedulesandclinicalaimsforupperlimbsplinting,aswellasbothbiomechanicaland
neurophysiologicalclinicalrationales.Additionally,therearerespectedmembersofthetherapy
professionswhobothsupportandcontesttheuseofthisclinicaltool(LanninNA,2003145).

13.3.1

Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessof
orthosesforpreventionoflossofrangeofmovementintheupperlimbversususualcare?
ClinicalMethodologicalIntroduction

Population:

Adultsandyoungpeople16orolderwhohavehadastroke.

Intervention:

Orthosesfortheupperlimbincluding:
softandscotchcasts,
splint,brace,lowtemperaturesplints,palmprotector,lycra
splinting

NationalClinicalGuidelineCentre,2013.
397


ClinicalMethodologicalIntroduction

alltheaboveinterventionswithorwithoutbotulinumtoxin,

13.3.1.1

Comparison:

UsualCare

Outcomes:

Rangeofmovementassessedbygoniometry

Clinicalevidence
SearcheswereconductedforsystematicreviewsandRCTscomparingtheeffectivenessofdifferent
typesoforthosesasinterventionsforpreventionoflossofrangeofmovementintheupperlimbfor
adultsandyoungpeopleover16yearswhohadapreviousstroke.Onlystudieswithaminimum
samplesizeof20participants(10ineacharm)wereselected.TwoRCTs18,144wereidentified.Table
97summarisesthepopulation,intervention,comparisonandoutcomesofthestudy.
Table97: Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
Author
Year

POPULATION

INTERVENTION

COMPARISON

OUTCOME

Lannin,
2007144

Adultswhohadastroke
withintheprevious8
weeksandhadnoactive
wristextension.

Twosplintinginterventions
werestudied.Inboth
groups,custommade,
static,palmarmittsplints
forupto12hoursovernight
for4weekswereused.
Neutralsplint;participants
woreahandsplintwhich
positionedthewristin00to
100extension.(N=21)
Extensionsplint:
participantsworeahand
splint,whichpositionedthe
wristinacomfortableend
ofrangeposition(>450wrist
extension)withthe
metacarpophalangealand
interphalangealjoints
extended.(N=21)

Controlgroupdid
notwearahand
splintforthestudy
period.(N=21)

Wrist
extensibility
(indegrees)
at4and6
weeks

Basaran
201218

N=39participantswitha
historyofsinglestroke
andwristMASscore1+;
iftakingantispasticity
drugs,dosagehadtobe
stableduringprevious
month

Twosplintinginterventions
werestudied:staticdorsal
splintwornforupto10
hoursovernightfor5weeks
orstaticvolarsplintworn
forupto10hoursovernight
for5weeks

Allpatientshad
Passive
homeexercise
rangeof
programincluding
motion
motortrainingand
(PROM)of
stretching,reaching
wrist
andgrasping3
extension
timesadayand
(goniometer
advisedtouse
)
handsasmuchas
possibleduringthe
dayfor5weeks

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398

StrokeRehabilitation
Movement

Comparison:Neutralsplintversususualcare
Table98: NeutralsplintversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings
Qualityassessment
Noof
studies

Design

Limitations

Inconsistency

Indirectness

Imprecision

Neutral
splint
Mean(sd)

Effect

Usual
care
Mean
(sd)

Mean
difference
(95%ci)

Mean
Difference
Confidence
(MD)(95%CI) (ineffect)

Wristextensibility(indegrees)(4weeksfollowup)(Betterindicatedbyhighervalues)
Lanninet RCT
al,
2007144

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b)

53.1(14.9)

47.3
(16.9)

1.40(8.20,
5.40)

Wristextensibility(indegrees)(6weeksfollowup)(Betterindicatedbyhighervalues)
Lanninet RCT
al,
2007144

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b)

Moderate

48.8(14.5)

39.4
(17.8)

4.20(
11.65,3.25)

O
(a) MeandifferencedidnotreachtheagreedMIDof5 .

NationalClinicalGuidelineCentre,2013.

MD1.4lower
(8.2lowerto
5.4higher)

399

MD4.2lower Moderate
(11.65lower
to3.25higher)

StrokeRehabilitation
Movement

Comparison:Extensionsplintversususualcare
Table99: ExtensionsplintversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings
Qualityassessment
Noof
studies

Design

Limitations

Inconsistency

Indirectness

Imprecision

Extension
splint
Mean(sd)

Effect

Usual
care
Mean
(sd)

Mean
difference
(95%CI)

Mean
Difference
(MD)(95%CI)

Wristextensibility(indegrees)(4weeksfollowup)(Betterindicatedbyhighervalues)
Lanninet RCT
al,
2007144

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b)

45.5(15.4)

47.3
(16.9)

1.30(2.58,
5.18)

MD1.3higher
(2.58lowerto
5.18higher)

Wristextensibility(indegrees)(6weeksfollowup)(Betterindicatedbyhighervalues)
Lanninet RCT
al,
2007144
(a)

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b)

42.5(14.9)

39.4
(17.8)

0.80(5.05,
3.45)

MeandifferencedidnotreachtheagreedMIDof5 .

NationalClinicalGuidelineCentre,2013.

Moderate

Confidence
(ineffect)

400

MD0.8lower
(5.05lowerto
3.45higher)

Moderate

StrokeRehabilitation
Movement

Comparison:Dorsal/Volarsplintversususualcare
Table100:Dorsal/VolarsplintversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings

SummaryofFindings
Qualityassessment

Noof
studies

Design

Riskofbias

Inconsistency

Indirectness

Imprecisio
n

Static
dorsal/
volarsplint
Mean
change
from
baseline
(SD)

Effectsize
Usual
care
Mean
change
from
baseline
(SD)

Mean
difference
between
interventi
onand
control
(95%CI)

Mean
difference
(95%CI)

Confidence
ineffect

Passiverangeofmotion(PROM)ofwristextensionDorsalsplint(followup5weeks;measuredwith:meanchangescores;Betterindicatedbyhighervalues)
Basaran
2012

randomised
trials

noserious
riskofbias

noserious
inconsistency

noserious
indirectness

very
serious(a)

2.31(8.07)

0.42(4.5) 1.89(
3.18,6.96)

MD1.89higher Low
(3.18lowerto
6.96higher)

Passiverangeofmotion(PROM)ofwristextensionVolarsplint(followup5weeks;measuredwith:Meanchangescores;Betterindicatedbyhighervalues)
Basaran
2012
(a)
(b)

randomised
trials

noserious
riskofbias

noserious
inconsistency

noserious
indirectness

serious(b)

3.46(7.18)

0.42(4.5) 3.04(
1.62,7.70)

The confidence interval reaches from appreciable harm to appreciable benefit of the intervention (i.e. crosses both default MIDs)
The confidence interval ranges from appreciable benefit to no effect (crosses one default MID)

NationalClinicalGuidelineCentre,2013.

401

MD3.04higher Moderate
(1.62lowerto
7.7higher)

StrokeRehabilitation
Movement

13.3.1.2

Economicevidence
Literaturereview
Norelevanteconomicevaluationscomparingorthosesforpreventionoflossofrangeoftheupper
limbwithusualcarewereidentified.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
Thecostofprovidingwrist/handorthoseswasbasedontheRCTincludedinclinicalreview.InLannin
etal(2007)144,theyusedcustommadestatic,palmarmittsplints.AnexpertadvisortotheGDG
providedthecostforaprefabricatedsplint:Restingpanpositionsplint,33.93excludingVAT,
thoughcostswillvaryaccordingtotypeanddesignofprefabricatedsplint.
Custommadeorthoseswouldbemadebyamemberofspecialistmultidisciplinaryorthoticsteam
andwouldincurextracosts.Inaddition,therewouldbepersonnelcostsrelatedtothetimerequired
tomakeandadjusttheULOtotakeintoaccountthespecificpatientsneeds.Adjustmentsmaybe
madebyeitherorthotistsandexperiencedphysiotherapistsoroccupationaltherapists(band6or7),
dependingontherequirements(forexampleorthotiststendtomakepermanentandmorecomplex
adjustments).Theestimatedcostsrangefrom45to59perhourofclientcontactr.

13.3.1.3

Evidencestatements
Clinicalevidencestatements
Neutralsplint
Onestudy144comprising42participantsfoundnosignificantdifferenceonthewristextensibilityat4
and6weeksfollowupforparticipantswearingneutralsplintfor4weekscomparedtoparticipants
whoreceivedusualcare.(MODERATECONFIDENCEINEFFECT)
Extensionsplint
Onestudy144comprising42participantsfoundnosignificantdifferenceonthewristextensibilityat4
and6weeksfollowupforparticipantswearingextensionsplintfor4weekscomparedtoparticipants
whoreceivedusualcare.(MODERATECONFIDENCEINEFFECT)
Dorsalsplint
Onestudy18comprising26participantsfoundnosignificantdifferenceonthepassiverangeof
motion(PROM)ofwristextensionafter5weeksofinterventionforparticipantswearingastatic
dorsalsplintcomparedtoparticipantswhoreceivedusualcare.(LOWCONFIDENCEINEFFECT)
Volarsplint

r EstimatedbasedondataandmethodsfromPersonalSocialServicesResearchUnitUnitcostsofhealthandsocialcare
reportandAgendaforChangesalaryband6and751(typicalsalarybandidentifiedbyclinicalGDGmembers).Assumed
thatanorthotistiscostedsimilartoaphysiotherapist.

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StrokeRehabilitation
Movement
Onestudy18comprising26participantsfoundnosignificantdifferenceonthepassiverangeof
motion(PROM)ofwristextensionafter5weeksofinterventionforparticipantswearingastaticvolar
splintcomparedtoparticipantswhoreceivedusualcare.(MODERATECONFIDENCEINEFFECT)
Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

13.3.2

Recommendationsandlinktoevidence
86.Donotroutinelyofferwristandhandsplintstopeoplewith
upperlimbweaknessafterstroke.
87.Considerwristandhandsplintsinpeopleatriskafterstroke
(forexample,peoplewhohaveimmobilehandsdueto
weakness,andpeoplewithhightone),to:
maintainjointrange,softtissuelengthandalignment
increasesofttissuelengthandpassiverangeofmovement
facilitatefunction(forexample,ahandsplinttoassistgrip
orfunction)
aidcareorhygiene(forexample,byenablingaccesstothe
palm)
increasecomfort(forexample,usingasheepskinpalm
protectortokeepfingernailsawayfromthepalmofthe
hand).
88.Wherewristandhandsplintsareusedinpeopleafterstroke,
theyshouldbeassessedandfittedbyappropriatelytrained
healthcareprofessionalsandareviewplanshouldbe
established.
89.Teachthepersonwithstrokeandtheirfamilyorcarerhowto
putthesplintonandtakeitoff,careforthesplintand
monitorforsignsofrednessandskinbreakdown.Providea
pointofcontactforthepersonifconcerned.
Recommendations:

Relativevaluesofdifferent
outcomes

Wristsplintsareusedtoensurethatrangeofmovementisnotlost
followingstroke.Shouldlossofrangeofmovementoccurthiswould
haveanimpactonupperlimbfunctionshouldmovementatthehand
andwristrecover.Forthisreasontheoutcomeofinterestincludedin
thereviewwasrangeofmovement.TheGDGnotedthatrangeof
movementisoneofanumberofpotentialoutcomeswhichinclude
functionandamountofmuscletone

Tradeoffbetweenclinical
benefitsandharms

Anassessmentoftheuseofsplintsincludescheckingifitfitsandisworn
properly,andareviewplanestablished.TheGDGagreedthat
informationandtrainingforthepatientandcarerswasimportantfor
themtoensurethesplintwasusedcorrectlyandtorecogniseany
adverseeffectsthatwouldneedprofessionalcareandadvice.
Potentialcontraindicationsmayincludesensoryimpairment,spasticity,
poorskinconditionincludinginflammation,oedema,andpoorvascular

NationalClinicalGuidelineCentre,2013.
403

StrokeRehabilitation
Movement
supply,eachofwhich maycontribute toskinbreakdownafterstroke.
TheGDGagreeditwasessentialthatthesplintisassessed,fittedand
monitoredbystafftrainedinthisarea.
Economicconsiderations

Nocosteffectivenessstudieswereidentifiedforthisquestion.Thecost
ofaprefabricatedsplintwasestimatedataround34excludingVAT
thoughcostsvaryconsiderably.Inaddition,thereissomepersonneltime
requiredtoassessandmakeadjustmentsforthepatientaswellasto
ensureitscorrectuse.
Custommadeorthoseswouldbemadebyamemberofspecialist
multidisciplinaryorthoticsteamandwouldincurextracosts.Inaddition,
therewouldbepersonnelcostsrelatedtothetimerequiredtomakeand
adjusttheULOtotakeintoaccountthespecificpatientsneeds.
Basedontheresultsoftheclinicalreview,theGDGdidnotconsider
wristandhandsplintingtobecosteffectiveasaroutinetreatmentin
themajorityofpatients.

Qualityofevidence

Onlytwosmallstudies,oneinearlypostacutestrokeandoneinlater
strokerehabilitationwereidentified18,144.Confidenceintheresultsseen
inthewristextensibilityoutcomewasmoderatetolowduetonot
reachingtheminimalimportantdifferenceof5degreesaspreviously
agreedwiththeGDG(seethemethodchapter)orthedefaultMID.
HowevertheGDGconsideredbothofthesestudiestobearobust
rehabilitationstudiesandacknowledgedthedifficultiesofdouble
blindinginthistypeofintervention.

Otherconsiderations

TheGDGconsensuswasthatroutinesplintingearlyafterstrokewould
probablynotbeofbenefit,exceptinselectedpatientswheresplinting
maybeusedtohelpmanagetone,reducepainandimprovefunction.
Whetherornottousesplintslateronintherehabilitationpathwayswas
seenasunclearsincetheresultscanbeinterpretedasbeing
inconclusive.
Furtherresearchisneededtoassesswhetherupperlimbsplintingin
conjunctionwithothermodalitiesaidsthemanagementofspasticity.
Todate,thedetailsarenotknownastowhetherupperlimbsplintingis
usefulinreducingproblemsinthepoorlyfunctioninghandafterstroke
eitherasasingleinterventionorincombinationwithotherinterventions
suchasbotulinumtoxininjectionsorelectricalstimulation.

13.4 Electricalstimulation:upperlimb
Functionalelectricalstimulation(FES)andneuromuscularelectricalstimulation(NMES),usedhereto
indicateagenericformoftherapeuticelectricalstimulation(ES)tomuscles,areanadjuncttoa
comprehensiverehabilitationprogramtoimprovearmandhandfunctionafterstroke.Itmaybe
usedfortherapeuticpurposesorforfunctionalpurposes.ESisseldomusedinisolation,butmost
recentlyintandemwithorinadditiontoanactivetaskoriented,exerciseprogram.ES,applied
usuallyviasurfaceelectrodes,butalsooccasionallythroughimplantedelectrodes,activatesmuscle
contractionperipherallyusuallythroughstimulatingnervestomuscles.Withcurrenttechnology,ES
devicesaresmallandeasytouseandcanbepreprogrammedtoprescribedcyclesandduration,
includemultiplemusclegroups,bepassivelyoractivelytriggeredandbeusedinsomefunctional
activities.Oncesetupbytheappropriatehealthprofessional,thetreatmentcanoftenbecontinued
athome,enhancingthepracticeeffect.

13.4.1

Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessof
electricalstimulation(ES)forhandfunctionversususualcare?
ClinicalMethodologicalIntroduction

NationalClinicalGuidelineCentre,2013.
404

StrokeRehabilitation
Movement

13.4.1.1

ClinicalMethodologicalIntroduction

Population

Adultsandyoungpeople16orolderwhohavehadastroke

Intervention

FunctionalElectricalStimulation(FES)withorwithoutrobotics,
ESwithorwithouttranscranialmagneticstimulationor
neuromuscularelectricalstimulation(NMS)

Comparison

Usualcare

Outcomes

Anyoutcomereportedinthepaper.
UpperLimboutcomesincluding:
ActionResearchArmTest(ARAT),
FuglMeyerAssessment(FMA),
9holepegtest,
gripstrength.

Clinicalevidence
SearcheswereconductedforsystematicreviewsandRCTscomparingtheeffectivenessofelectrical
stimulation(ES)toimprovehandfunctionforpatientsover16yearsoldwithstroke.Eighteen(18)
RCTswereidentified.Table101summarisesthepopulation,intervention,comparisonandoutcomes
foreachofthestudies.
Table101:Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
STUDY

POPULATION

INTERVENTION

COMPARISON

OUTCOMES

Alon,2007

Patientswith
unilateralacute
stroke(24weeks
ago)whowere
medicallystablewith
aparesisofupper
limb(FuglMeyer
score1140)without
limitedrangeof
passivemotionand
atleast60%finger
flexion/extension
withstimulation.

FESplusstandard
rehabilitation
training(usualcare);
electricalstimulation
andinduced
contractionof
wrist/finger
extensors.FESwas
providedinitiallyfor
10min/4timesdaily
in2sessionsaspart
oftheirstandard
exerciseand2
sessionsasnot;the
durationincreased
by5min/dayto1
hourpersession4
timesdaily(FESwas
synchronisedwith
exercisefor2
sessions,eachlasted
30minandtherest
ofFEStrainingwas
notsynchronized).
(N=7)

Usualcare;standard
rehabilitation
exercise(duration3
hours)included
physical,
occupational(30min
twicedaily5daysa
weekduring
hospitalisation)and
speechtherapy
within12daysof
admission.After
discharge,patients
practised30min
twicedaily
unsupervised
rehabilitation
exercisefor12visits
perweek.(N=8)

BoxandBlocks
test
JebsenTaylor
HandFunction
test(lightcans)
ModifiedFugl
Meyer
Assessment

Alon,20087

Patientswith
unilateralacute
stroke(24weeks
ago)whowere
medicallystablewith

FESplusindividually
tailoredexercise
regimen(usualcare).
FESdurationwas
increasedby5min/

Usualcare:
BoxandBlocks
individuallytailored
test,
exerciseregimenfor JebsenTaylor
30minsessionstwice
HandFunction
dailyfor5days/week
test(lightcans),

NationalClinicalGuidelineCentre,2013.
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StrokeRehabilitation
Movement
STUDY

POPULATION
aparalysis/paresisof
upperlimb(Fugl
Meyerscore210)no
limitedrangeof
passivemotion;at
least60%finger
flexion/extension
withstimulation

INTERVENTION
dayto1hour
practicedfor4times/
day.(N=13)

COMPARISON
during
hospitalisation;after
discharge,usualcare
wasprovidedfor30
mintwicedaily
withoutsupervision
(occupation
therapists/physiother
apistswereinvolved
in12sessionsper
week).(N=13)

OUTCOMES

Cauraugh,
200038

Patientswithchronic
stroke(longerthana
yearago)with
chronicupper
extremity
impairment(upper
limitcutoffof75%
motorrecoveryand
forlowerlimitcutoff
point);subjectshad
tobecapableof
voluntarilyextending
thewrist20against
gravityfroma90
flexionposition.

Electromyography
triggered
Neuromuscular
Stimulation(EMG):
subjectswere
instructedtoinitiate
finger/wrist
extensionsothata
targetthresholdof
EMGactivitywas
voluntarilyachieved;
EMGwasprovidedin
2sessionsof30
movementtrials
(around60min)
during3daysaweek
for2weeks.(N=7)

Usualcare:patients
followedthesame
procedureasthe
experimentalgroup
exceptthattheydid
notreceivethe
neuromuscular
electricalstimulation.
(N=4)

BoxandBlocks
test
Motor
AssessmentScale
FuglMeyer
Assessment
2force
generationtasks

Cauraugh,
200239

Patientswithatleast
onecerebrovascular
accident(CVA)and
nomorethan2CVAs
onthesamesideof
thebrain(upperlimit
cutoffof80%motor
recovery;forlower
limitcutoffpoint;
subjectshadtobe
capableofvoluntarily
extendingthe
fingers/wrist10
againstgravityfroma
90flexionposition.

Unilateraltraining
group:EMG
triggeredstimulation
toassistwristand
fingerextension
(unilateral
movement).(N=10)

Bilateraltraining
group:EMG
triggeredstimulation
plusassistancefrom
unimpairedlimbas
wrist/finger
extensionexecuted
simultaneouslyon
bothlimbs(bilateral
movement).3setsof
30successfulEMG
triggeredtrials
(around1.5hours);
totalof6hoursof
trainingon4days
during2weeks.
(N=10)

Usualcare:subjects
triedtovoluntarily
extendwrist/fingers
for5seconds
followedby25
secondsrest,
repeatedlyfor90
min.persession.
(N=5)

BoxandBlocks
test
Sustained
muscle
contraction

Chae,1998
41

Strokesurvivors
admittedtoanacute

15sessionsof
stimulatingthe

15sessionsofsurface FuglMeyer
stimulation,butthe
Upperextremity

NationalClinicalGuidelineCentre,2013.
406

ModifiedFugl
Meyer
Assessment

StrokeRehabilitation
Movement
STUDY

POPULATION
inpatient
rehabilitationservice
within4weeksof
theirunilateral
stroke.Patientswere
18yrsoldorolder
withmoderateto
severeupper
extremityparesis
(FuglMeyerscore
lessthan44),withno
historyofpotentially
fatalcardiac
arrhythmias.

INTERVENTION
extensordigitorum
communisandthe
extensorcarpi
radialis(ECR)through
circular2.5cm
surfaceelectrodesin
additiontostandard
physical,
occupational,and
speechtherapy
interventions.The
stimulationcurrent
intensitywassetto
producefullwrist
andfingerextension
withadutycycleof
10secondsonand10
secondsoff.
(N=14)

COMPARISON
electrodeswere
placedawayfromall
motorpoints,
producingonly
cutaneous
stimulationjust
beyondsensory
thresholdand
withoutmotor
activationinaddition
tostandardphysical,
occupational,and
speechtherapy
interventions.
(N=14)

OUTCOMES
assessment
Functional
Independence
Measure

Chan,
200942

Patientswithfirst
timestrokelonger
than6weeksago
withascoreof0on
fingermassextension
subitemofFugl
MeyerAssessment.

FESwithmuscle
movement(20min)
plus10min
stretching/passive
mobilization
activitiestofacilitate
activemovement
plus60min
conventional
occupationaltherapy
training.EachFES
sessionlasted20
min,with2training
activitiesoutof4
tasks.(N=10)

Usualcare:
stretching/passive
mobilization
activitiestofacilitate
activemovement(10
min)plusplacebo
electricalstimulation
withsensationonly
(20min)plus
conventional
occupationaltherapy
training(60min).
(N=10)

FunctionalTest
forthe
Hemiplegic
UpperExtremity,
FuglMeyer
Upperextremity
assessment
GripPower
ActiveRangeof
Motionwrist
extension
Functional
Independence
Measure
Modified
AshworthScale
ofshoulder,
elbow,wrist
Forwardreaching
distance

Hara,
2008105

Patientswithchronic
stroke(1or2strokes
onsamesideofbrain
longerthanayear
ago)andchronic
spasticupper
extremity
impairments(Stroke
Impairment
AssessmentSet
[SIAS]scores05)
withpassiverangeof
motioninwrist
extensionto45from
neutralandshoulder

FESforwrist
extensionduring
coordinated
movement(triggered
byvoluntary
movementby
patient)for30
minute/sessionfor5
daysaweekathome.
FEStraining
increasedover10
daystoamaximum
of1hourpersession.
Supervisionwas
providedbyan
occupational

Supervisionbya
rehabilitationtrainer
inextendingthe
impairedwristsand
fingersduring
rehabilitation
sessionsonceaweek
forabout5months.
Eachsessionlasted
approximately40
min.(N=10)

ActiveRangeOf
Movement
(ROM)
electromyographi
cmeasures
(maximum
isometric
contraction)
modified
Ashworthscale
(MAS)
9holepegtest

NationalClinicalGuidelineCentre,2013.
407

StrokeRehabilitation
Movement
STUDY

POPULATION
flexionto140.

INTERVENTION
therapistfor40min
onceaweekfor5
months.(N=10)

COMPARISON

OUTCOMES

Hsu,2010117 Acutestrokepatients
withunilateral
stroke,onsetwithin3
months,Brunnstrom
stageIVwithno
contraindicationfor
NMES.
Patientswere
randomisedto3
groups:high
Neuromuscular
ElectricalStimulation
(NMES),lowNMES,
orcontrol.
(N=22)

4weeksofNMES,5
timesperweekin
additiontoregular
inpatient
rehabilitation.
30minutesper
sessionwaschosen
asthelowdose
NMESand60
minutesasthehigh
doseNMES.
(N=22)

Regularinpatient
rehabilitation

FuglMeyer
Upperextremity
assessment
ActionResearch
ArmTest
MotorActivity
Log

Kimberley,
2004137

Patientswithchronic
stroke(longerthan6
monthsago)
experiencingatleast
10active
flexion/extensionat
metacarpophalangeal
jointofindexfinger;
MiniMentalState
Examinationscore25
ormoreoutof
possible30.

Intensivehomeuse
ofFES:60hourstotal
use;6hoursperday
for10daysover3
weeks;halfofthe
timeusingactive
effortbysubjectto
triggerstimulated
responsethenFES
contractingmuscles;
otherhalfmachine
automatically
stimulatingmuscles
tocontractcyclically
withouttriggerfrom
patient.(N=8)

Shamtreatment;
lightcameonbutno
deliveredby
machine.(N=8)

BoxandBlocks
test
MotorActivity
Log:amountof
usescore(AS),
howwellscored
(HW)
JebsenTaylor
HandFunction
Test:pageturn,
smallobjects,
feeding,stacking,
lightcans,heavy
cans(all
measuredinsec).
Strengthof
fingerextension,
Fingertracking
accuracytest

Mangold,
2009167

Firsttimestroke
patients(218weeks
ago)withsevere
hemiparesistototal
hemiplegiaofarm
and/orhand
(maximumvalueof
ChedokeMcMaster
StrokeAssessment
[CMSA]forarmand
hand3points).

FESlasted45
min/sessionincluding
1520minofputting
onandtakingoffFES
/treatingspasticity
and2530minof
functionaltraining
andwasofferedin3
sessions/weekIf
necessary,therapists
treatedspasticityand
providedmanual
assistance.FES
triggeredbypatient
ortherapist.(N=12)

Conventionaltraining Nottingham
providedfor35
Activitiesofdaily
occupationaltherapy
Living
sessionsperweek;
Chedoke
eachsessionlasted
McMasterStroke
45min.Mobilisation
Assessment(arm,
andexercises
hand)
supportedby
Modified
therapistor
AshworthScale
performed
(fingerflexors,
bimanually)(N=11).
wristflexors)

Mann,
2005168

Firsttimestroke
patients(112

FES:stimulationto
givefullelbow,wrist

Passiveextension
exercisesofelbow,

NationalClinicalGuidelineCentre,2013.
408

ActionResearch
ArmTest

StrokeRehabilitation
Movement
STUDY

POPULATION
monthspoststroke)
withhemiplegia
(medicallystable)
andabletotake
hemiplegichandto
mouth.

INTERVENTION
andfingerextension
withoutdiscomfort;
increasedfrom10to
30mintwiceaday
overaround1week.
(N=11)

COMPARISON
wristandfingersto
bepractisedforthe
sameperiodeach
day.Ondischarge,
continuedwithhelp
ofcaregiveror
independently.
(N=11)

OUTCOMES

Popovic,
2003210

Firsttimestroke
patients(2weeks6
monthspoststroke)
abletounderstand
howtoapplyFESto
controlgrasp.
Patientswere
groupedtoeither
higherfunctioning
group(ableto
activelyextendthe
pareticwristmore
than20oandextend
their
metacarpophalangeal
andinterphalangeal
jointsofalldigits
morethan20o)orto
thelowerfunctioning
group(patientscould
extendtheparetic
wristbetween10o
20o).

FESincluded
reaching,grasping
andusingobjectsand
returningthemto
theirplacesduring
thefirst3weeks.FES
exerciseincluded30
minlongtreatment
sessionsofexercise
withstimulationfor7
days/week.
HighfunctioningFES:
(N=8)
LowfunctioningFES:
(N=6)

Usualcare:
conventionaldaily
therapyfor26weeks.
Forthefirst3weeks,
controlgrouphad30
minlongtreatment
sessionsofexercise
only.
Highfunctioning
usualcare:(N=8)
Lowfunctioning
usualcare:
(N=6)

UpperExtremity
FunctionTest
(UEFT)
DrawingTest(%
ofareaofsquare
correctly
captured)
Modified
Ashworthscale
ReducedUpper
ExtremityMotor
ActivityLog
questionnaire
(RUE/MAL);
maximumscore,
howwellscale
was

Powell,
1999212

Acutestrokepatients
(24weeksafter
stroke)withMedical
ResearchCouncil
powerofwrist
extensiongrade4/5
orworseat.

FESplusstandard
physiotherapy:3
halfhourperiods
daily(total90mins.
daily)for8weeks.
(N=30)

Usualcare:standard
physiotherapy
includingdiscussing
progressin
rehabilitationupto
10minfor3times
weeklytocontrolfor
similarcontact
beforeandafterFES
sessions.
(N=30)

Gripstrength
activeand
passiverangeof
motion
AshworthScale
ActionResearch
ArmTest
Numberofpegs
persecond
Rankinscale
BarthelIndex

Thrasher,
2008257

Hemiplegicpatients
hospitalisedfor
recentstroke(27
weekspoststroke)
withascoreof1or2
forcombinedarm
andhandon
ChedokeMcMaster
StagesofMotor
Recovery(CMSMR,
i.e.spasticorflaccid
paralysisofarmand

FESplusconventional
occupationaltherapy
andphysiotherapyto
shoulder,elbow,
wristandhand5
daysperweekfor12
16weeks;each
sessioncombined
withFESfor45mins.
ofthesession;
stimulatorresponded
topushbutton

Conventional
occupationaltherapy
andphysiotherapyto
shoulder,elbow,
wristandhand5
daysperweekfor12
16weeks;each
sessionlasted45min
(musclefacilitation,
repetitivefunctional
training,
strengtheningagainst

Object
manipulation
Palmargrip
torque
Pinchgrippulling
force
BarthelIndex
UpperExtremity
FuglMeyer
Assessment
UpperExtremity

NationalClinicalGuidelineCentre,2013.
409

StrokeRehabilitation
Movement
STUDY

POPULATION
handwithlittleorno
voluntary
movement).

INTERVENTION
commandby
therapistwhen
patienttried
unsuccessfullyto
performtask;
therapistguidedarm
toensureanormal
movement.Inearly
stages,all
movements
performedwithFES;
inlatertreatments
FESusedless.(N=10)

COMPARISON
resistance,electrical
stimulationfor
isolatedmuscle
strengthening(not
forfunctional
training),activitiesof
dailylivingincluding
selfcareand
caregivertraining.
(N=11)

OUTCOMES
Chedoke
McMasterstages
ofMotion
Recovery

Lin,2011155

Firststrokepatients
(within3months
postonset)with
hemiplegiaofone
upperlimband
shoulderflexor
strengthbefore
treatmentwasgrade
3orless(outof5).
Patientsdidnothave
severecognitive
dysfunction(they
scored7orbetteron
theabbreviated
mentaltest).

Standardtreatment
plusNeuromuscular
ElectricalStimulation
(NES)lastingfor30
minutes,5
days/weekfor3
weeks.The2channel
RespondSelectII
stimulator(Texas,
USA)wasused.
(N=23)

Standardtreatment,
includingphysical
therapyand
occupational
therapy,for30
minuteson5days
/weekfor3weeks.
(N=23)

Modified
AshworthScale
(MAS)
Upperlimb
sectionofthe
FuglMeyer
Assessment
(FMAU)
ModifiedBarthel
Index(MBI)

Sahin,2012
227

Patientsbetween45
65yearsofage,who
haddeveloped
forearmflexor
spasticityfollowinga
stroke.Hemiplegia
waslongerthanone
year;score2or3
spasticityaccording
toModified
AshworthScale
(MAS)andastable
neurologicalstate.

Neuromuscular
ElectricalStimulation
(NMES)and
stretchingwith
Proprioceptive
Neuromuscular
facilitation(PNF)
appliedtotheupper
extremityafterhot
treatmentwith
infrared:5daysa
weekfor20sessions.
(N=21)

Stretchingwith
Proprioceptive
Neuromuscular
facilitation(PNF)
appliedtotheupper
extremityafterhot
treatmentwith
infrared:5daysa
weekfor20sessions.
(N=21)

Wristspasticity
(MAS)
Wristextension
RangeofMotion
(degrees)
Brunnstrom
motorscale
(upper)
Functional
Independence
Measure(FIM)
Electrophysiologi
calevaluation:
Fmax/Mmax,
Hmax/Mmax

Shindo
2011237

Participantswithfirst
timeunilateral
supratentorialstroke;
strokeonsetwithin
60days;age2080
years;muscle
activitiesinthe
affectedextensor
digitorumcommunis
(EDC)detectablewith
surfaceelectrodes;
couldnotfullyextend

3weeksofHybrid
Assistive
Neuromascular
DynamicStimulation
(HANDS)therapy:
neuromuscular
electricalstimulation
withintegrated
volitionalelectrical
stimulator(IVES)plus
wristsplintfor8
hoursadayplus

Worethesamewrist FuglMeyer
splintfor8hoursa
Assessment
dayplusstandard
(proximaland
rehabilitation(1hour
distal),
physicaltherapyand ActionResearch
1houroccupational
ArmTest,
therapyperday,5
MotorActivity
daysaweekplus
LogModified
speechtherapyif
AshworthScale
indicated);instructed
tousetheaffected
handasmuchas

NationalClinicalGuidelineCentre,2013.
410

StrokeRehabilitation
Movement
STUDY

POPULATION
pareticfingersand
couldnotextend
pareticfingers
individually;passive
rangeofmotion>0
fortheaffectedwrist
extensionand10
for
metacarpophalangeal
jointextension;Mini
MentalState
Examinationscore
>23

INTERVENTION
COMPARISON
standard
possibleinactivities
rehabilitation(1hour ofdailyliving(N=12)
physicaltherapyand
1houroccupational
therapyperday,5
daysaweekplus
speechtherapyif
indicated);instructed
tousetheaffected
handasmuchas
possibleinactivities
ofdailyliving(N=12)

OUTCOMES

Rosewilliam
2012220

Adultpatientswitha
firststrokewhohad
noarmfunction
(score0intheGrasp
subsectionofthe
ActionResearchArm
Test)within6weeks
ofonsetandno
contraindicationsto
surface
neuromuscular
electricalstimulation
(sNMES).

sNMESfor6weeks:
electricalstimulators
towristandfinger
extensorsatleast
twiceadayfor30
minutesessionsfor5
daysaweekplusa
definedmoduleof
upperlimb
physiotherapyfor6
weeksinadditionto
routinetreatmenton
thestrokeunit
(N=45)

ARAT

NationalClinicalGuidelineCentre,2013.
411

Adefinedmoduleof
upperlimb
physiotherapyfor6
weeksinadditionto
routinetreatmenton
thestrokeunitonly
(N=45)

StrokeRehabilitation
Movement

Comparison:Electricalstimulationversususualcare
Table102:ElectricalstimulationversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings
SummaryofFindings
Qualityassessment

Noof
studies

Design

Riskofbias

Inconsistency

Indirectness

Imprecision

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values

Absoluteeffect
Confide
/Mean
Difference
nce(in
(MD)(95%CI) effect)

BoxandBlocks(numberofblocksmovedin1minute)Postintervention(Betterindicatedbyhighervalues)usualcare
2
Alon
20076,
Alon
20087

RCTs
unblinded

Veryserious Noserious
limitations( inconsistency
a)

Noserious
indirectness

Noserious
imprecision

Alon2007:
42.3(16.6)
Alon2008:
10.5(12)

Alon
9.53(3.20,
2007:
15.87)
26.3(11)
Alon
2008:2.5
(4.9)

MD9.53higher Low
(3.2to15.87
higher)

BoxandBlocks(numberofblocksmovedin1minute)Postintervention(Betterindicatedbyhighervalues)shamintervention
1
Kimberl
ey
2004137

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c)

27(4.8)

24.3(6.1) 2.70(
2.68,8.08)

MD2.70(2.68
lowerto8.08
higher)

Low

MD5.22lower
(9.66to0.78
lower)

Low

JebsenTaylorHandFunctiontest(timetomove5lightcans)(posttreatmenteffect)(Betterindicatedbylowervalues)usualcare
2
Alon
20076,
Alon
20087

RCTs
unblinded

Veryserious Noserious
limitations( inconsistency
a)

Noserious
indirectness

Noserious
imprecision

Alon2007:
6.7(2.9)
Alon2008:
40.5(22.8)

Alon
2007:
11.8(5.4)
Alon
2008:
52.9

NationalClinicalGuidelineCentre,2013.

412

5.22(
9.66,
0.78)

StrokeRehabilitation
Movement

SummaryofFindings
Qualityassessment

Noof
studies

Design

Riskofbias

Inconsistency

Indirectness

Imprecision

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)
(17.3)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values

Absoluteeffect
/Mean
Confide
Difference
nce(in
(MD)(95%CI) effect)

JebsenTaylorHandFunctiontest(timetomovefivelightcans)(posttreatmenteffect)(Betterindicatedbylowervalues)shamintervention
1
Kimberl
ey
2004137

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

10.8(2.1)

34.9
(25.8)

24.10(
42.04,
6.16)

MD24.10
lower(42.04to
6.16lower)

Modera
te

Alon
2007:
40.6(8.2)
Alon
2008:
14.5
(10.3)

8.85(3.35,
14.36)

MD8.85higher Very
(3.35to14.36
low
higher)

ModifiedFuglMeyerAssessment(posttreatmenteffect)(Betterindicatedbyhighervalues)
2
Alon
20076,
Alon
20087

RCTs
unblinded

Veryserious Serious
limitations( inconsistency
a)

Serious
indirectness(n)

Noserious
imprecision

Alon2007:
49(5.1)
Alon2008:
24.2(13.7)

FunctionalTestfortheHemiplegicUpperExtremity(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Chan
200942

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

3.7(0.5)

3.1(0.6)

0.60(0.12,
1.08)

MD0.6higher
(0.12to1.08
higher)

Modera
te

11.9
(12.4)

8.50(
1.30,
18.30)

MD8.5higher
(1.3lowerto
18.3higher)

Low

Forwardreachingdistance(cm)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Chan
200942

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c)

20.4(9.8)

Rangeofmotionwristextension(O)(posttreatmenteffect)(Betterindicatedbyhighervalues)

NationalClinicalGuidelineCentre,2013.

413

StrokeRehabilitation
Movement

SummaryofFindings
Qualityassessment

Noof
studies
2
Chan
200942,
Sahin
2012227

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values

Absoluteeffect
/Mean
Confide
Difference
nce(in
(MD)(95%CI) effect)

Design

Riskofbias

Inconsistency

Indirectness

Imprecision

RCTdouble
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

Chan:21
(28.5)
Sahin:25
(6.2)

Chan:6.5 1.57(
(18.9)
1.96,5.09)
Sahin:
23.8(5.6)

MD1.57higher

(1.96lowerto
LOW
5.09higher)

Serious
imprecision(f)

2.2(2)

2.2(2.1)

MD0.2higher
(1.6lowerto2
higher)

Chae:11.3
(3.0)
Chan:80.2
(6.8)
Sahin:109.8
(18.8)

Chae:
1.40(
10.6(5.9) 1.69,4.50)
Chan:
77.6(12)
Sahin:
102.7
(19.6)

MD1.40higher Modera
(1.69lowerto
te
4.50higher)

13.9(5.5)

13.6(6.5) 0.30(
4.16,4.76)

MD0.30higher Modera
(4.16lowerto
te
4.76higher)

15.8(5.8)

16.1(6.7) 0.30(

MD0.30lower

Grippower(kg)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Chan
200942

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

0.20(
1.60,2.00)

Low

FunctionalIndependenceMeasure(FIM)(postintervention)(Betterindicatedbyhighervalues)
3
Chae
199841,
Chan
200942,
Sahin
2012227

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

FunctionalIndependenceMeasure(FIM)(4weeksfollowup)(Betterindicatedbyhighervalues)
1Chae
199841

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

FunctionalIndependenceMeasure(FIM)(12weeksfollowup)(Betterindicatedbyhighervalues)
1Chae

RCTdouble

Serious

Noserious

Noserious

Noserious

NationalClinicalGuidelineCentre,2013.

414

Modera

StrokeRehabilitation
Movement

SummaryofFindings
Qualityassessment

Noof
studies
199841

Design
blinded

Riskofbias
limitations(
b)

Inconsistency
inconsistency

Indirectness
indirectness

Imprecision
imprecision

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values
4.94,4.34)

Absoluteeffect
/Mean
Difference
(MD)(95%CI)
(4.94lowerto
4.34higher)

Confide
nce(in
effect)
te

ModifiedAshworthScaleofshoulder(posttreatmenteffect)(Betterindicatedbylowervalues)
1
Chan
200942

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c)

0.3(0.5)

0.5(0.6)

0.20(
0.68,0.28)

MD0.2lower
(0.68lowerto
0.28higher)

Low

1.3(0.8)

1.6(1.1)

0.30(
1.14,0.54)

MD0.30lower
(1.14lowerto
0.54higher)

Low

0.9(0.9)

1.4(1)

0.50(
1.33,0.33)

MD0.50lower Low
(1.33lowerto
0.33higher)

12.9(7.9)

8.9(2.3)

4.00(
1.70,9.70)

MD4higher
(1.7lowerto
9.7higher)

Low

1.9(0.82)

1.3(0.71) 0.60(
0.15,1.35)

MD0.6higher
(0.15lowerto

Low

ModifiedAshworthScaleelbowPostintervention(Betterindicatedbylowervalues)
1
Chan
200942

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c)

ModifiedAshworthScalewristPostintervention(Betterindicatedbylowervalues)
1
Chan
200942

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c)

Strengthoffingerextension(Newtons)Postintervention(Betterindicatedbyhighervalues)
1
Kimberl
ey
2004137

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c)

MotorActivityLogAmountofusescorePostintervention(Betterindicatedbyhighervalues)
1
Kimberl

RCTdouble
blinded

Serious
limitations(

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c)

NationalClinicalGuidelineCentre,2013.

415

StrokeRehabilitation
Movement

SummaryofFindings
Qualityassessment

Noof
studies
ey
2004137

Design

Riskofbias
b)

Inconsistency

Indirectness

Imprecision

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values

Absoluteeffect
/Mean
Confide
Difference
nce(in
(MD)(95%CI) effect)
1.35higher)

MotorActivityLogHowwellusedscorePostintervention(Betterindicatedbyhighervalues)
1
Kimberl
ey
2004137

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c)

2.1(0.84)

1.4(0.73) 0.70(
0.07,1.47)

MD0.7higher
(0.07lowerto
1.47higher)

Low

Serious
imprecision

0.6(1)

0.11
(0.29)

0.49(0.05,
0.93)

MD0.49higher Low
(0.05to0.93
higher)

Serious
imprecision

0.56(0.87)

0.11
(0.29)

0.45(0.07,
0.83)

MD0.45higher Low
(0.07to0.83
higher)

0.74(1.22)

0.12
(0.32)

0.62(0.09,
1.15)

MD0.62higher Low
(0.09to1.15
higher)

0.69(1.1)

0.12
(0.32)

0.57(0.09,
1.05)

MD0.57higher Low
(0.09to1.05

MotorActivityLog:Amountofuse:Lowdose(Betterindicatedbyhighervalues)
1
Hsu,
2010117

RCTSingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

MotorActivityLog:Amountofuse:Highdose(Betterindicatedbyhighervalues)
1
Hsu,
2010117

RCTSingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

MotorActivityLog:Qualityofmovement:Lowdose(Betterindicatedbyhighervalues)
1
Hsu,
2010117

RCTSingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision

MotorActivityLog:Qualityofmovement:Highdose(Betterindicatedbyhighervalues)
1
Hsu,

RCTSingle
blinded

Serious
limitations(

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision

NationalClinicalGuidelineCentre,2013.

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StrokeRehabilitation
Movement

SummaryofFindings
Qualityassessment

Noof
studies
2010117

Design

Riskofbias
b)

Inconsistency

Indirectness

Imprecision

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values

Absoluteeffect
/Mean
Confide
Difference
nce(in
(MD)(95%CI) effect)
higher)

JebsenTaylorpageturntest(s)Postintervention(Betterindicatedbylowervalues)
1
Kimberl
ey
2004137

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c)

17.1(5.7)

19.5(4.3) 2.40(
7.35,2.55)

MD2.4lower
(7.35lowerto
2.55higher)

Low

25(5.3)

41.4
(12.6)

16.40(
25.87,
6.93)

MD16.4lower
(6.93to25.87
lower)

Modera
te

6.7(2.52)

27.9(6.9) 21.20(
26.29,
16.11)

MD21.2lower
(16.11to26.29
lower)

Modera
te

25.3(7.6)

56.7
(26.6)

MD31.4lower
(12.23to50.57
lower)

Modera
te

JebsenTaylorsmallobjectstest(s)Postintervention(Betterindicatedbylowervalues)
1
Kimberl
ey
2004137

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

JebsenTaylorfeedingtest(s)Postintervention(Betterindicatedbylowervalues)
1
Kimberl
ey
2004137

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

JebsenTaylorstackingtest(s)Postintervention(Betterindicatedbylowervalues)
1
Kimberl
ey
2004137

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

JebsenTaylorheavycanstest(s)Postintervention(Betterindicatedbylowervalues)

NationalClinicalGuidelineCentre,2013.

417

31.40(
50.57,
12.23)

StrokeRehabilitation
Movement

SummaryofFindings
Qualityassessment

Noof
studies
1
Kimberl
ey
2004137

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values

Absoluteeffect
/Mean
Confide
Difference
nce(in
(MD)(95%CI) effect)

Design

Riskofbias

Inconsistency

Indirectness

Imprecision

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision(e)

42.4(35)

30.8(21) 11.60(
16.68,
39.88)

MD11.6higher Very
(16.68lowerto low
39.88higher)

Noserious
indirectness

Serious
imprecision(c)

30(2.1)

6.2(16)

23.80(
42.09,
5.51)

MD23.80
lower(42.09to
5.51lower)

Low

9.6(6.3)

9.2(0.48,
17.92)

MD9.2higher
(0.48to17.92
higher)

Modera
te

0.2(0.1)

1.7(0.82,
2.58)

MD1.7higher
(0.82to2.58
higher)

Modera
te

Fingertrackingaccuracytest(posttreatmenteffect)
1
Kimberl
ey
2004137

RCTdouble
blinded

Serious
limitations(
b)

Noserious
inconsistency

UpperExtremityFunctionTestPostinterventionhighfunctiongroup(Betterindicatedbyhighervalues)
1
Popovic
2003210

RCTsingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

18.8(10.9)

UpperExtremityFunctionTestPostinterventionlowfunctiongroup(Betterindicatedbyhighervalues)
1
Popovic
2003210

RCTsingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

1.9(1.1)

UpperExtremityFunctionTestFollowup(26weeks)highfunctiongroup(Betterindicatedbyhighervalues)
1
Popovic
2003210

RCTsingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

29.9(9.7)

15.4(7.6) 14.5(5.96,
23.04)

UpperExtremityFunctionTestFollowup(26weeks)lowfunctiongroup(Betterindicatedbyhighervalues)

NationalClinicalGuidelineCentre,2013.

418

MD14.5higher Modera
(5.96to23.04
te
higher)

StrokeRehabilitation
Movement

SummaryofFindings
Qualityassessment

Noof
studies
1
Popovic
2003210

Design

Riskofbias

Inconsistency

Indirectness

Imprecision

RCTsingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)
4.9(3.1)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)
1.5(0.9)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values
3.4(0.82,
5.98)

Absoluteeffect
/Mean
Confide
Difference
nce(in
(MD)(95%CI) effect)
MD3.4higher
(0.82to5.98
higher)

Modera
te

Drawingability(%areacomparedwithtargetsquare)Postinterventionhighfunctiongroup(rangeofscores:0100;Betterindicatedbyhighervalues)
1
Popovic
2003210

RCTsingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c)

83.8(5.6)

68.7
(11.7)

15.10
(6.11,
24.09)

MD15.1higher Low
(6.11to24.09
higher)

Drawingtest(%areacomparedwithtargetsquare)(higherfunctioninggroupversususualcare)(26weeksfollowup)(Betterindicatedbyhighervalues)
1
Popovic
2003210

RCTsingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c)

39.9(8.1)

25.9(8.6) 14.00
(5.81,
22.19)

MD15.1higher Low
(6.11to24.09
higher)

Drawingability(%areacomparedwithtargetsquare)Postinterventionlowfunctiongroup(rangeofscores:0100;Betterindicatedbyhighervalues)
1
Popovic
2003210

RCTsingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c)

24(9.9)

16(2.8)

8.0(0.23,
16.23)

MD8.0higher
(0.23lowerto
16.23higher)

Low

Drawingability(%areacomparedwithtargetsquare)Followup(26weeks)highfunctiongroup(followupmean26weeks;rangeofscores:0100;Betterindicated
byhighervalues)
1
Popovic
2003210

RCTsingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c

49.8(9.6)

36.7(6.9) 13.10
(3.64,
22.56)

MD13.1higher Low
(3.64to22.56
higher)

ModifiedAshworthScale(higherfunctioninggroupversususualcare)(26weeksfollowup)(Betterindicatedbylowervalues)
1

RCTsingle

Serious

Noserious

Noserious

Noserious

1.25(0.5)

2.25

NationalClinicalGuidelineCentre,2013.

419

1.00(

MD1lower

Modera

StrokeRehabilitation
Movement

SummaryofFindings
Qualityassessment

Noof
studies
Popovic
2003210

Design
blinded

Riskofbias
limitations(
b)

Inconsistency
inconsistency

Indirectness
indirectness

Imprecision
imprecision

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)
(0.75)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values
1.62,
0.38)

Absoluteeffect
/Mean
Difference
(MD)(95%CI)
(0.38to1.62
lower)

Confide
nce(in
effect)
te

ModifiedAshworthScale(lowerfunctioninggroupversususualcare)(26weeksfollowup)(Betterindicatedbylowervalues)
1
Popovic
2003210

RCTsingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(f)

2.5(0.75)

2.25
(0.75)

0.25(
0.60,1.10)

MD0.25higher Low
(0.6lowerto
1.1higher)

ReducedUpperExtremityMotorActivityLogquestionnaireAmountscale(higherfunctioninggroupversususualcare)(26weeksfollowup)(Betterindicatedbyhigher
values)
1
Popovic
2003210

RCTsingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c)

59.7(2.5)

28.7
(11.7)

31.00
(19.14,
42.86)

MD31higher
(19.14to42.86
higher)

Low

ReducedUpperExtremityMotorActivityLogquestionnaireAmountscale(lowerfunctioninggroupversususualcare)(26weeksfollowup)(Betterindicatedbyhigher
values)
1
Popovic
2003210

RCTsingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c)

16.7(8.3)

3.3(1.7)

13.40
(6.62,
20.18)

MD
13.40
higher
(6.62to
20.18
higher)

Low

ReducedUpperExtremityMotorActivityLogquestionnaireHowwellscale(higherfunctioninggroupversususualcare)(26weeksfollowup)(Betterindicatedby
highervalues)
1
Popovic

RCTsingle
blinded

Serious
limitations(

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c)

66.7(11.4)

32.5
(10.6)

NationalClinicalGuidelineCentre,2013.

420

34.20
(23.41,

MD
34.20

Low

StrokeRehabilitation
Movement

SummaryofFindings
Qualityassessment

Noof
studies
2003210

Design

Riskofbias
b)

Inconsistency

Indirectness

Imprecision

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values
44.99)

Absoluteeffect
/Mean
Confide
Difference
nce(in
(MD)(95%CI) effect)
higher
(23.41to
44.99
higher)

ReducedUpperExtremityMotorActivityLogquestionnaireHowwellscale(lowerfunctioninggroupversususualcare)(26weeksfollowup)(Betterindicatedby
highervalues)
1
Popovic
2003210

RCTsingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(c)

11.5(6.1)

2.3(1.2)

9.20(4.23,
14.17)

MD9.20
higher
(4.23to
14.17
higher)

Low

5.10(
0.52,
10.72)

MD5.1
higher
(0.52
lowerto
10.72
higher)

Low

5.00[
1.39,
11.39]

MD5.0
higher
(1.39
lowerto
11.39

Low

ChangeinActionResearchArmTest(totalscore)(4weeksfollowup:LowdoseFES)(Betterindicatedbyhighervalues)
1
Hsu,
2010117

RCTSingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(h)

8.6(11.3)

3.5(8.2)

ChangeinActionResearchArmTest(totalscore)(4weeksfollowup:HighdoseFES)(Betterindicatedbyhighervalues)
1
Hsu,
2010117

RCTSingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(h)

8.5(13.2)

3.5(8.2)

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StrokeRehabilitation
Movement

SummaryofFindings
Qualityassessment

Noof
studies

Design

Riskofbias

Inconsistency

Indirectness

Imprecision

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values

Absoluteeffect
/Mean
Confide
Difference
nce(in
(MD)(95%CI) effect)
higher)

ChangeinActionResearchArmTest(totalscore)(12weeksfollowup:LowdoseFES)(Betterindicatedbyhighervalues)
1
Hsu,
2010117

RCTSingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(h)

17.2(19.1)

4(9.5)

13.20
(5.19,
21.21)

MD5.1
higher
(0.52
lowerto
10.72
higher)

Low

Hsu:4
(9.5)
Mann:
24.4

10.68
(5.68,
15.68)

MD10
higher
(3.77to
16.23
higher)

Low

34.4

24.7

9.70(2.35,
17.05)

MD9.70
higher
(2.35to
17.05
higher)

Verylow

3(1,3.3)

1.5(0.8,
2)

P=0.19(j)

(i)

Low(i)

ChangeinActionResearchArmTest(totalscore)(12weeksfollowup)(Betterindicatedbyhighervalues)
2
RCT
Hsu,
2010117;
Mann
2005168

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(h)

Hsu(high
dose):15.9
(18.4)
Mann:34.4

ChangeinActionResearchArmTest(totalscore)(24weeksfollowup)(Betterindicatedbyhighervalues)
1Mann
2005168

RCT

Veryserious Noserious
limitations( inconsistency
g)

Noserious
indirectness

Serious
imprecision(h)

ActivitiesofDailyLiving(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
RCT
Mangold

Veryserious Noserious
limitations( inconsistency

Noserious
indirectness

(i)

NationalClinicalGuidelineCentre,2013.

422

StrokeRehabilitation
Movement

SummaryofFindings
Qualityassessment

Noof
studies
2009167

Design

Riskofbias
g)

Inconsistency

Indirectness

Imprecision

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values

Absoluteeffect
/Mean
Confide
Difference
nce(in
(MD)(95%CI) effect)

0(0,1)

P=0.57(j)

(i)

Low(i)

0.3(0,
0.5)

P=1.0(j)

(i)

Low(i)

0.5(0,
1.1)

P=0.17(j)

(i)

Low(i)

0.5(0,1.3)

0.5(0,
1.1)

P=0.68(j)

(i)

Low(i)

2(0,3)

1(0,4)

(i)

(i)

Moderate(i)

GaininChedokeMcMasterStrokeAssessment(arm)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
RCT
Mangold
2009167

Veryserious Noserious
limitations( inconsistency
g)

Noserious
indirectness

(i)

1(0,1)

GaininChedokeMcMasterStrokeAssessment(hand)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
RCT
Mangold
2009167

Veryserious Noserious
limitations( inconsistency
g)

Noserious
indirectness

(i)

0(0,1)

GaininModifiedAshworthScale(fingerflexors)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
RCT
Mangold
2009167

Veryserious Noserious
limitations( inconsistency
g)

Noserious
indirectness

(i)

0(0.5,0.8)

GaininModifiedAshworthScale(wristflexors)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
RCT
Mangold
2009167

Veryserious Noserious
limitations( inconsistency
g)

Noserious
indirectness

(i)

Changeingripstrength(kg)(8weeksfollowup)(Betterindicatedbyhighervalues)
1Powell
1999213

RCTsingle
blinded

Serious
limitations
(k)

Noserious
inconsistency

Noserious
indirectness

(i)

Changeingripstrength(kg)(32weeksfollowup)(Betterindicatedbyhighervalues)

NationalClinicalGuidelineCentre,2013.

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StrokeRehabilitation
Movement

SummaryofFindings
Qualityassessment

Noof
studies

Design

Riskofbias

Inconsistency

Indirectness

Imprecision

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)

Effect

1Powell
1999213

RCTsingle
blinded

Serious
limitations
(k)

Noserious
inconsistency

Noserious
indirectness

(i)

2(0,8)

4(0,10)

(i)

(i)

Moderate(i)

(i)

0(0,1)

0(0,1)

(i)

(i)

Moderate(i)

(i)

1(0,1.5)

1(0,1)

(i)

(i)

Moderate(i)

(i)

10(0,29)

2(0,14) (i)

(i)

Moderate(i)

(i)

6(0,31)

1(0,16) (i)

(i)

Moderate(i)

(i)

0(0,13)

0(0,
0.8)

(j)

Moderate(i)

Relative
Risk
Mean
difference
(95%CI)/P
values

Absoluteeffect
/Mean
Confide
Difference
nce(in
(MD)(95%CI) effect)

Ashworthscore(8weeksfollowup)(Betterindicatedbyhighervalues)
1Powell
1999213

RCTsingle
blinded

Serious
limitations
(k)

Noserious
inconsistency

Noserious
indirectness

Asworthscore(32weeksfollowup)(Betterindicatedbyhighervalues)
1Powell
1999213

RCTsingle
blinded

Serious
limitations
(k)

Noserious
inconsistency

Noserious
indirectness

ARAT(totalscore)(8weeksfollowup)(Betterindicatedbyhighervalues)
1Powell
1999213

RCTsingle
blinded

Serious
limitations
(k)

Noserious
inconsistency

Noserious
indirectness

ARAT(totalscore)(32weeksfollowup)(Betterindicatedbyhighervalues)
1Powell
1999213

RCTsingle
blinded

Serious
limitations
(k)

Noserious
inconsistency

Noserious
indirectness

Noofpegspersecond(8weeksfollowup)(Betterindicatedbyhighervalues)
1Powell
1999213

RCTsingle
blinded

Serious
limitations
(k)

Noserious
inconsistency

Noserious
indirectness

NationalClinicalGuidelineCentre,2013.

424

(i)

StrokeRehabilitation
Movement

SummaryofFindings
Qualityassessment

Noof
studies

Design

Riskofbias

Inconsistency

Indirectness

Imprecision

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)

(i)

0(0,0.16)

(i)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values

Absoluteeffect
/Mean
Confide
Difference
nce(in
(MD)(95%CI) effect)

0(0,
0.11)

(i)

(i)

Moderate(i)

5(3,7)

4(1,6)

(i)

(i)

Moderate(i)

(i)

7(5,10)

4(2,9)

(i)

(i)

Moderate(i)

(i)

1(1,0)

1(1,0)

(i)

(i)

Moderate(i)

(i)

1(2,0)

1(1,0)

(i)

(i)

Moderate(i)

Chae:13.1

Chae:

5.72(2.79,

MD5.72

Moderate

Noofpegspersecond(32weeksfollowup)(Betterindicatedbyhighervalues)
1Powell
1999213

RCTsingle
blinded

Serious
limitations
(k)

Noserious
inconsistency

Noserious
indirectness

BarthelIndex(8weeksfollowup)(Betterindicatedbyhighervalues)
1Powell
1999213

RCTsingle
blinded

Serious
limitations
(k)

Noserious
inconsistency

Noserious
indirectness

BarthelIndex(8weeksfollowup)(Betterindicatedbyhighervalues)
1Powell
1999213

RCTsingle
blinded

Serious
limitations
(k)

Noserious
inconsistency

Noserious
indirectness

Rankinscale(8weeksfollowup)(Betterindicatedbyhighervalues)
1Powell
1999213

RCTsingle
blinded

Serious
limitations
(k)

Noserious
inconsistency

Noserious
indirectness

Rankinscalescore(32weeksfollowup)(Betterindicatedbyhighervalues)
1Powell
1999213

RCTsingle
blinded

Serious
limitations
(k)

Noserious
inconsistency

Noserious
indirectness

FuglMeyerAssessmentUpperLimb(posttreatmenteffect)(Betterindicatedbyhighervalues)
3

RCTSingle

Serious

Noserious

Noserious

Noserious

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StrokeRehabilitation
Movement

SummaryofFindings
Qualityassessment

Noof
studies
Chae
199841,
Chan
200942;
Lin,
2011155

Design
blinded

Riskofbias
limitations(
b)

Inconsistency
inconsistency

Indirectness
indirectness

Imprecision
imprecision

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)
(10.3)
Chan:25.9
(8.9)
Lin:20.3
(5.4)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)
6.5(6.1)
Chan:
22.1
(9.9)
Lin:14.5
(5.8)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values
8.65)

Absoluteeffect
/Mean
Confide
Difference
nce(in
(MD)(95%CI) effect)
higher
(2.79to
8.65
higher)

FuglMeyerAssessmentUpperLimb(total)(1weekfollowup)(Betterindicatedbyhighervalues)
4
RCTSingle
blinded
Chae
41
1998 ;C
han
200942;
Lin,
2011155;
Shindo
20011237

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

Chae:13.1
(10.3)
Chan::25.9
(8.9)
Lin:20.3
(5.4)
Shindo:12.2
(5.3)

Chae:
9.7(7.7)
Chan:
22.1
(9.9)
Lin:14.5
(5.8)
Shindo:
5.5(6)

5.98(3.45,
8.50)

MD5.98
higher
(3.45to
8.50
higher)

Moderate

Chae:17.8
(12.6)
Hsu(high
dose):25.5
(20)
Lin:22.6

Chae:
9.7(7.7)
Hsu:
14.2
(14.5)
Lin:17.7

6.11(2.85,
9.38)

MD6.11
higher
(2.85to
9.38
higher)

Moderate

FuglMeyerAssessmentUpperLimb(total)(12weeks)(Betterindicatedbyhighervalues)
3
RCTSingle
blinded
Chae
199841;
Hsu,
2010117;
Lin,
2011155

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

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StrokeRehabilitation
Movement

SummaryofFindings
Qualityassessment

Noof
studies

Design

Riskofbias

Inconsistency

Indirectness

Imprecision

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)
(5.7)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)
(6.2)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values

Absoluteeffect
/Mean
Confide
Difference
nce(in
(MD)(95%CI) effect)

FuglMeyerAssessmentUpperLimb(total)(1monthfollowup:LowdoseFES)(Betterindicatedbyhighervalues)
1
Hsu,
2010117

RCTSingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(d)

Hsu:28.1
(18)

Hsu:
14.2
(14.5)

13.90
(4.24,
23.56)

MD
13.90
higher
(4.24to
23.56
higher)

Low

Chae:
11.2
(8.7)
Hsu:17
(15.4)
Lin:18.5
(6.7)

8.45(5.05,
11.85)

MD8.45
higher
(5.05to
11.85
higher)

Moderate

19.70
(9.32,
30.08)

MD19.7
higher
(9.32to
30.08
higher)

Low

FuglMeyerAssessmentUpperLimb(total)(3monthsfollowup)(Betterindicatedbyhighervalues)
3
RCTSingle
blinded
Chae
41
1998 ;
Hsu,
2010117;
Lin,
2011155

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

Chae:20.6
(15.1)
Hsu(high
dose):32.8
(23.7)
Lin:26.0
(5.1)

FuglMeyerAssessmentUpperLimb(total)(3monthsfollowup:LowdoseFES)(Betterindicatedbyhighervalues)
1
Hsu,
2010117

RCTSingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(d)

Hsu:36.7
(19.5)

Hsu:17
(15.4)

FuglMeyerAssessmentUpperLimb(total)(6monthsfollowup)(Betterindicatedbyhighervalues)

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SummaryofFindings
Qualityassessment

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values

Absoluteeffect
/Mean
Confide
Difference
nce(in
(MD)(95%CI) effect)

Noof
studies

Design

Riskofbias

Inconsistency

Indirectness

Imprecision

Lin,
2011155

RCTSingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(d)

29.8(3.6)

20.3
(12.3)

9.5(3.59
to15.41)

MD9.5
higher
(3.59to
15.41
higher)

Low

Serious
imprecision(f)

1.16(0.50)

0.78
(0.55)

0.38(0.04
to0.72)

MD0.38
higher
(0.04to
0.72
higher)

Low

Serious
imprecision(f)

1.42(0.51)

1.11
(0.32)

0.31(0.04
to0.58)

MD0.31
higher
(0.04to
0.58
higher)

Low

1.56(0.53)

1.50
(0.53)

0.06(0.28
to0.40)

MD0.06
higher(
0.28
lowerto
0.40
higher)

Verylow

ModifiedAshworthScale(3Weeksfollowup)(Betterindicatedbyhighervalues)
Lin,
2011155

RCTSingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

ModifiedAshworthScale(1monthfollowup)(Betterindicatedbyhighervalues)
Lin,
2011155

RCTSingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

ModifiedAshworthScale(3monthsfollowup)(Betterindicatedbyhighervalues)
Lin,
2011155

RCTSingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision(n)

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SummaryofFindings
Qualityassessment

Noof
studies

Design

Riskofbias

Inconsistency

Indirectness

Imprecision

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values

Absoluteeffect
/Mean
Confide
Difference
nce(in
(MD)(95%CI) effect)

ModifiedAshworthScale(6monthsfollowup)(Betterindicatedbyhighervalues)
Lin,
2011155

RCTSingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(f)

1.67(0.52)

1.86
(0.38)

0.19(
0.48to
0.1)

MD0.19
lower
(0.48
lowerto
0.1
higher)

Low

Serious
imprecision(l)

57.0(10.7)

49.7
(11.4)

7.3(0.17
to14.43)

MD7.3
higher
(0.17to
14.43
higher)

Low

Serious
imprecision(l)

64.5(10.4)

55.7
(12.1)

8.80(1.51
to16.09)

MD8.8
higher
(1.51to
16.09
higher)

Low

Noserious

72.4(8.5)

59.3

13.10(6.37

MD13.1

Moderate

ModifiedBarthelIndex(3weeksfollowup)(Betterindicatedbyhighervalues)
Lin,
2011155

RCTSingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

ModifiedBarthelIndex(1monthfollowup)(Betterindicatedbyhighervalues)
Lin,
2011155

RCTSingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

ModifiedBarthelIndex(3monthsfollowup)(Betterindicatedbyhighervalues)
Lin,

RCTSingle

Serious

Noserious

Noserious

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SummaryofFindings
Qualityassessment

Noof
studies
2011155

Design
blinded

Riskofbias
limitations(
b)

Inconsistency
inconsistency

Indirectness
indirectness

Imprecision
imprecision

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)
(12.0)

Effect

79.2(5.2)

66.1
(11.3)

13.1(7.38
to18.82)

MD13.1
higher
(7.38to
18.82
higher)

Moderate

3.6(3.0)

3.5(2.9)

0.10(
1.68,1.88)

MD0.10
higher
(1.68
lowerto
1.88
higher)

Low

0.27(0.15)

0.25
(0.19)

0.02(
0.08,0.12)

MD0.10
higher
(1.68
lowerto
1.88
higher)

High

Relative
Risk
Mean
difference
(95%CI)/P
values
to19.83)

Absoluteeffect
/Mean
Confide
Difference
nce(in
(MD)(95%CI) effect)
higher
(6.37to
19.83
higher)

ModifiedBarthelIndex(6monthsfollowup)(Betterindicatedbyhighervalues)
Lin,
2011155

RCTSingle
blinded

Serious
limitations(
b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

ElectrophysiologicalevaluationFmax/Mmax(%)Postintervention(Betterindicatedbyhigher)
Sahin
2012227

RCTDouble Noserious
blinded
limitation

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision(o)

ElectrophysiologicalevaluationHmax/Mmax(%)Postintervention(Betterindicatedbyhigher)
Sahin
2012227

RCTDouble Noserious
blinded
limitation

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

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SummaryofFindings
Qualityassessment

Noof
studies

Design

Riskofbias

Inconsistency

Indirectness

Imprecision

ES
Number
ofevent/
TotalN
Mean
(SD)/
Median
(IQR)

Usualcare
Numberof
event/
TotalN

Mean
(SD)/Medi
an(IQR)

Effect
Relative
Risk
Mean
difference
(95%CI)/P
values

Absoluteeffect
/Mean
Confide
Difference
nce(in
(MD)(95%CI) effect)

WristspasticityModifiedAshworthScalePostintervention(Betterindicatedbyhigher)
Sahin
2012227

RCTDouble Noserious
blinded
limitation

Noserious
inconsistency

Noserious
indirectness

(i)

1.8

(i)

(i)

High

(i)

4.5

(i)

(i)

High

Brunnstrommotorscale(upper)Postintervention(Betterindicatedbyhigher)
Sahin
2012227

RCTDouble Noserious
blinded
limitation

Noserious
inconsistency

Noserious
indirectness

(a)Bothstudieswereunblindedwithunclearrandomizationandallocationconcealment.
(b)Unclearrandomizationandallocationconcealment.
(c)ConfidenceintervalcrossedoneendofdefaultMID.
(d)MeandifferencedidnotreachtheagreedMID(10%differenceinthescale).
(e)ConfidenceintervalcrossedbothendsofdefaultMID.
(f)MeandifferencedidnotreachthedefaultMID.
(g)Unclearblinding,randomizationandallocationconcealment.
(h)MeandifferencedidnotreachtheagreedMIDof12points.
(i)Imprecisioncouldnotbeassessedasauthorsreportedonlymedian(IQR).Resultscouldnotbemetaanalysedandrelative/absoluteeffectcouldnotbeestimated.
(j)Pvalueasreportedbyauthors.
(k)Inadequateallocationconcealment.
(l)MeandifferencedidnotreachtheagreedMID(9.25).
(m)ConfidenceintervalcrossedbothendsofthedefaultMID.
(n)Itemsoftheoriginalscalenotincluded.
(o)ConfidenceintervalcrossesbothendsofdefaultMID

Narrativesummaries
ThefollowingstudiesaresummarisedasanarrativebecausetheresultswerenotpresentedinnumericaldatathatcouldbeincludedintheGRADEtable:

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Cauraughetal,200038foundthattheexperimentalgroupwhoreceivedtheFEStrainingmovedsignificantlymoreblocksanddisplayedahigherisometric
forceimpulseaftertherehabilitationtreatmentcomparedtousualcaregroup.NeitherMotorAssessmentScalenorFuglMeyertestsweresignificantly
differentbetweenthetwogroups.
Cauraughetal,200239foundsignificantfindingsfavouringthecoupledbilateralmovementtrainingandEMGtriggeredneuromuscularstimulationgroup.
Inaddition,theunilateralmovement/stimulationgroupexceededthecontrolacrossthecategoriesoftasks.
Thrasheretal,2008257foundthattheFESgroupimprovedsignificantlymorethanthecontrolgroupintermsofobjectmanipulation,palmergriptorque,
andpinchgrippullingforce,BarthelIndex,UpperExtremityFuglMeyerscoresandUpperExtremityChedokeMcMasterstagesofMotorRecovery.
Haraetal,2008104reportedthattheFESgroupdisplayedsignificantlygreaterimprovementsintheactiveRangeofMovementofwristandfinger
extensionandshoulderflexion,modifiedAshworthscale(MAS)andfunctionalhandtestsandwasabletosmoothlyperformactivitiesofdailylifeusing
thehemiplegicupperextremities.

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13.4.1.2

Economicevidence
Literaturereview
NorelevanteconomicevaluationscomparingESwithusualcarewereidentified.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
TypicalcostsforFESwereobtainedfromOdstockMedicalLimitedatSalisburyDistrictHospital(by
email,2021stDecember2010)whosupplytheFESsystemdescribedintheRCTreportedbyMannet
al(2005)168includedintheclinicalreview(theMicrostim2[MS2v2],aselfcontainedtwochannel
exercisestimulator).ThecostoftheMS2v2kitis267(excludingVAT).Thedeviceisguaranteedfor
2yearsandsparepartsandservicemaintenanceareofferedforaminimumof5years.The
electrodesaresinglepatientuseandlastaroundfourweeks.Electrodescostbetween6and10
perpackoffour(excludingVAT)dependingonsizeandquality.Thedevicewillrunonstandardor
rechargeablePP3batteries(suppliedinkit).Thecostofastandard6monthtreatmentpackageusing
theMS2v2systemconsistingofoneinitialassessmentandfivetreatmentsessionsischargedat
840;eachsessionis140.Thisincludesthecostofallequipment,consumables,physiotherapyand
hospitaloverheadsandisdeliveredasanoutpatientservice.PatientscanalsousetheMS2v2dailyin
theirownhomes.Basedonthestandardtreatmentpackagecost,forFEStobejudgedcosteffective
itwouldneedtoprovidebenefitstopatientsthattranslatedtoatleastanadditional0.042QALYsper
person.

13.4.1.3

Evidencestatements
Clinicalevidencestatements
Twostudies6,7comprisingof41participantsfoundthatparticipantswhoreceivedtheElectrical
StimulationexperiencedastatisticallysignificantimprovementintheBoxandBlocstestattheendof
thetrialcomparedtoparticipantswhoreceivedusualcare(LOWCONFIDENCEINEFFECT).
Onestudy137comprisingof16participantsfoundnosignificantdifferenceintheBoxandBlockstest
attheendofthetrialbetweenparticipantswhoreceivedtheElectricalStimulationandthosewho
receivedshamtreatment(LOWCONFIDENCEINEFFECT).
Twostudies6,7comprisingof41participantsfoundthatparticipantswhoreceivedtheElectrical
StimulationexperiencedastatisticallysignificantimprovementintheJebsenTaylorHandFunction
test(lightcans)attheendofthetrialcomparedtoparticipantswhoreceivedusualcare(LOW
CONFIDENCEINEFFECT).
Onestudy137comprisingof16participantsfoundastatisticallysignificantimprovementinthe
JebsenTaylorHandFunctiontest(lightcans)attheendofthetrialforparticipantswhoreceivedthe
ElectricalStimulationcomparedtothosewhoreceivedshamtreatment(MODERATECONFIDENCEIN
EFFECT).
Twostudies6,7comprisingof41participantsfoundthatparticipantswhoreceivedtheElectrical
StimulationexperiencedastatisticallysignificantimprovementintheModifiedFuglMeyer

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Assessmentattheendofthetrialcomparedtoparticipantswhoreceivedusualcare(VERYLOW
CONFIDENCEINEFFECT).
Onestudy42comprisingof20participantsfoundthatparticipantsreceivedtheElectricalStimulation
hadsignificantlyhigherscoresintheFunctionalTestfortheHemiplegicUpperExtremityattheend
ofthetrialcomparedtotheusualcaregroup(MODERATECONFIDENCEINEFFECT).
Onestudy42comprisingof20participantsfoundnosignificantdifferenceonthefollowingoutcomes
betweentheElectricalStimulationandtheusualcaregroupsattheendofthetrial:
forwardreachdistance(cm)(LOWCONFIDENCEINEFFECT),
activerangeofmotioninwristextension(VERYLOWCONFIDENCEINEFFECT),
grippower(kg)(LOWCONFIDENCEINEFFECT),
FunctionalIndependenceMeasure(LOWCONFIDENCEINEFFECT),
ModifiedAshworthScaleofshoulder(LOWCONFIDENCEINEFFECT),
ModifiedAshworthScaleofelbow(LOWCONFIDENCEINEFFECT),
ModifiedAshworthScaleofwrist(LOWCONFIDENCEINEFFECT)
Twostudies42,227comprising62participantsfoundnosignificantdifferencewiththerangeofmotion
inwristextensionbetweentheElectricalStimulationandtheusualcaregroupsattheendofthe
intervention(HIGHCONFIDENCEINEFFECT)
Threestudies41;42;227comprisingof90participantsfoundnosignificantdifferenceintheFunctional
IndependenceMeasurebetweentheElectricalStimulationgroupandtheusualcaregrouppost
treatment(MODERATECONFIDENCEINEFFECT)
Onestudy41comprisingof28participantsfoundnosignificantdifferenceintheFunctional
IndependenceMeasurebetweentheElectricalStimulationgroupandtheusualcaregroupat4and
12weeksfollowup(MODERATECONFIDENCEINEFFECT)
Onestudy137comprisingof16participantsfoundnosignificantdifferenceonthefollowingoutcomes
betweentheElectricalStimulationandtheusualcaregroupsattheendofthetrial:
Strengthoffingerextension(LOWCONFIDENCEINEFFECT),
MotorActivityLog;amountofusescore(LOWCONFIDENCEINEFFECT),
MotorActivityLog;howwellusedscore(LOWCONFIDENCEINEFFECT),
JebsenTaylorHandFunctiontest(pageturn)(LOWCONFIDENCEINEFFECT),
JebsenTaylorHandFunctiontest(heavyscans)(VERYLOWCONFIDENCEINEFFECT).
Onestudy117comprisingof66participantsfoundstaticallysignificantimprovementinthefollowing
outcomesbetweentheElectricalStimulationandtheusualcaregroups
MotorActivityLog:amountofusescorelowdose(LOWCONFIDENCEINEFFECT),
MotorActivityLog:amountofusescorehighdose(LOWCONFIDENCEINEFFECT),
MotorActivityLog:qualityofmovementlowdose(LOWCONFIDENCEINEFFECT),
MotorActivityLog:qualityofmovementhighdose(LOWCONFIDENCEINEFFECT)

Onestudy137comprisingof16participantsfoundastatisticallysignificantimprovementinthe
followingoutcomesattheendofthetrialforparticipantswhoreceivedtheElectricalStimulation
comparedtothosewhoreceivedshamtreatment:
JebsenTaylorHandFunctiontest(smallobjects)(MODERATECONFIDENCEINEFFECT),
JebsenTaylorHandFunctiontest(feeding)(MODERATECONFIDENCEINEFFECT),
JebsenTaylorHandFunctiontest(stacking)(MODERATECONFIDENCEINEFFECT),

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StrokeRehabilitation
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Fingertrackingaccuracytest(LOWCONFIDENCEINEFFECT).

Onestudy210comprisingof16participantsfoundastatisticallysignificantimprovementinthe
followingoutcomesforthehigherfunctioningparticipantswhoreceivedtheElectricalStimulation
comparedtothosewhoreceivedusualcare:
UpperExtremityFunctionTest(attheendofthetrialandat26weeksfollowup)(MODERATE
CONFIDENCEINEFFECT),
Drawingtest(attheendofthetrialandat26weeksfollowup)(LOWCONFIDENCEINEFFECT),
Ashworthgrade(at26weeksfollowup)(MODERATECONFIDENCEINEFFECT),
ReducedUpperExtremityMotorActivityLogQuestionnaireamountscale(at26weeksfollowup)
(LOWCONFIDENCEINEFFECT),
ReducedUpperExtremityMotorActivityLogQuestionnairehowwellscale(at26weeksfollow
up)(LOWCONFIDENCEINEFFECT).

Onestudy210comprisingof12participantsfoundastatisticallysignificantimprovementinthe
followingoutcomesforthelowerfunctioningparticipantswhoreceivedtheElectricalStimulation
comparedtothosewhoreceivedusualcare:
UpperExtremityFunctionTest(attheendofthetrialandat26weeksfollowup)(MODERATE
CONFIDENCEINEFFECT),
Drawingtest(at26weeksfollowup)(LOWCONFIDENCEINEFFECT),
ReducedUpperExtremityMotorActivityLogQuestionnaireamountscale(at26weeksfollowup)
(LOWCONFIDENCEINEFFECT),
ReducedUpperExtremityMotorActivityLogQuestionnairehowwellscale(at26weeksfollow
up)(LOWCONFIDENCEINEFFECT).

Onestudy117comprising66participantsfoundnodifferenceinthechangescoresofActionResearch
ArmTest(totalscore)betweenthegroupthatreceivedlowdoseESandtheusualcaregroupat4
weeksfollowup(LOWCONFIDENCEINEFFECT).

Onestudy117comprising66participantsfoundnodifferenceinthechangescoresofActionResearch
ArmTest(totalscore)betweenthegroupthatreceivedhighdoseESandtheusualcaregroupat4
weeksfollowup(LOWCONFIDENCEINEFFECT).

Onestudy117comprising66participantsfoundastatisticallysignificantimprovementinthechange
scoresofActionResearchArmTest(totalscore)betweenthegroupthatreceivedlowdoseESand
theusualcaregroupat12weeksfollowup(LOWCONFIDENCEINEFFECT).

Twostudies168;117comprisingof88participantsfoundastatisticallysignificantimprovementinthe
changescoresofActionResearchArmTest(totalscore)at12weeksfollowupfortheparticipants
whoreceivedtheElectricalStimulationcomparedtothosewhoreceivedusualcare(LOW
CONFIDENCEINEFFECT).

Onestudy168comprisingof22participantsfoundastatisticallysignificantimprovementinthechange
scoresofActionResearchArmTest(totalscore)at24weeksfollowupfortheparticipantswho
receivedtheElectricalStimulationcomparedtothosewhoreceivedusualcare(VERYLOW
CONFIDENCEINEFFECT).

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Threestudies41,42;155comprisingof85participantsfoundthatparticipantswhoreceivedthe
ElectricalStimulationexperiencedastatisticallysignificantimprovement(posttreatment)intheFugl
MeyerAssessmentcomparedtoparticipantswhoreceivedusualcare.Thisdifferencewasofclinical
importance(MODERATECONFIDENCEINEFFECT).
Threestudies41;117;155comprisingof109participantsfoundthatparticipantswhoreceivedthe
ElectricalStimulationexperiencedastatisticallysignificantimprovementintheFuglMeyer
Assessmentcomparedtoparticipantswhoreceivedusualcareatonemonthfollowup.This
differencewasofclinicalimportance(MODERATECONFIDENCEINEFFECT).
Onestudy117comprisingof66participantsfoundthatparticipantswhoreceivedlowdoseElectrical
StimulationexperiencedastatisticallysignificantimprovementintheFuglMeyerAssessment
comparedtoparticipantswhoreceivedusualcareatonemonthfollowup.Thisdifferencewasnotof
clinicalimportance(LOWCONFIDENCEINEFFECT).
Threestudies41;117;155comprisingof109participantsfoundthatparticipantswhoreceivedthe
ElectricalStimulationexperiencedastatisticallysignificantimprovementintheFuglMeyer
Assessmentcomparedtoparticipantswhoreceivedusualcareat3monthsfollowup.Thisdifference
wasofclinicalimportance(MODERATECONFIDENCEINEFFECT).
Onestudy117comprisingof66participantsfoundthatparticipantswhoreceivedlowdoseElectrical
StimulationexperiencedastatisticallysignificantimprovementintheFuglMeyerAssessment
comparedtoparticipantswhoreceivedusualcareat3monthsfollowup.Thisdifferencewasnotof
clinicalimportance(LOWCONFIDENCEINEFFECT).
Onestudy155comprisingof46participantsfoundthatparticipantswhoreceivedtheElectrical
StimulationexperiencedastatisticallysignificantimprovementintheFuglMeyerAssessmentat6
monthsfollowupcomparedtoparticipantswhoreceivedusualcare.Thisdifferencewasnotof
clinicalimportance(LOWCONFIDENCEINEFFECT).
Onestudy155comprisingof46participantsfoundthatparticipantswhoreceivedtheElectrical
Stimulationexperiencedastatisticallysignificantimprovementposttreatmentand1monthfollow
upwiththemodifiedAshworthscalecomparedtoparticipantswhoreceivedusualcare(LOW
CONFIDENCEINEFFECT).
Onestudy155comprisingof46participantsfoundnosignificantimprovementwiththemodified
Ashworthscaleat3monthsfollowupbetweentheElectricalStimulationandtheusualcaregroups
(VERYLOWCONFIDENCEINEFFECT).
Onestudy155comprisingof46participantsfoundnosignificantimprovementwiththemodified
Ashworthscaleat6monthsfollowupbetweentheElectricalStimulationandtheusualcaregroups
(LOWCONFIDENCEINEFFECT).
Onestudy155comprisingof46participantsfoundthatparticipantswhoreceivedtheElectrical
StimulationexperiencedastatisticallysignificantimprovementinthemodifiedBarthelIndexatpost
treatmentand1monthfollowupcomparedtoparticipantswhoreceivedusualcare.Thisdifference
wasnotofclinicalimportance(LOWCONFIDENCEINEFFECT).
Onestudy155comprisingof46participantsfoundthatparticipantswhoreceivedtheElectrical
StimulationexperiencedastatisticallysignificantimprovementinthemodifiedBarthelIndexat3and
6monthsfollowupcomparedtoparticipantswhoreceivedusualcare(MODERATECONFIDENCEIN
EFFECT).
Onestudy227comprising42participantsfoundnosignificantdifferenceinelectrophysiological
evaluation(Fmax/Mmax)betweentheElectricalStimulationandtheusualcaregroup(LOW
CONFIDENCEINEFFECT)

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Onestudy227comprising42participantsfoundnosignificantdifferenceinelectrophysiological
evaluation(Hmax/Mmax)betweentheElectricalStimulationandtheusualcaregroup(HIGH
CONFIDENCEINEFFECT)
Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

13.4.2

Recommendationsandlinktoevidence

90.Donotroutinelyofferpeoplewithstrokeelectrical
stimulationfortheirhandandarm.
91.Consideratrialofelectricalstimulationinpeoplewhohave
evidenceofmusclecontractionafterstrokebutcannotmove
theirarmagainstresistance.
92.Ifatrialoftreatmentisconsideredappropriate,ensurethat
electricalstimulationtherapyisguidedbyaqualified
rehabilitationprofessional.
93.Theaimofelectricalstimulationshouldbetoimprove
strengthwhilepractisingfunctionaltasksinthecontextofa
comprehensivestrokerehabilitationprogramme.
94.Continueelectricalstimulationifprogresstowardsclear
functionalgoalshasbeendemonstrated(forexample,
maintainingrangeofmovement,orimprovinggraspand
release).

Relativevaluesofdifferent
outcomes

AwiderangeofmeasureswereusedinthesestudiesandtheGDGnoted
thattherewasnopsychometricallyrobustpatientreportedoutcome
measureusedforassessmentofreducedupperlimbfunction.
Thewiderangeofmeasuresreportedwithinthetrialsreviewedmakes
interpretingthedatadifficult.

Tradeoffbetweenclinical
benefitsandharms

TherearefewrisksassociatedwithElectricalStimulation.The
commonestisaskinreactionwhenselfadhesiveelectrodesareused.
BenefitsarisefromtheincreasedrangeofmovementsproducedbyES
withtheassociatedincreasedeaseofperformanceoffunctionaltask.ES
wastypicallytargetedatfingerandwristextensorsbutwasalsousedfor
elbowextensionandshoulderflexion.TheGDGwerealsoawareofthe
useofelectricalstimulationformanagementofspasticityhoweverthis
wasnotincludedinreview.

Economicconsiderations

Nocosteffectivenessstudieswerefoundforthisquestion.
ESforhandfunctionsarenotroutinelyusedintheUKNHScurrently.
AtypicalcostperpatientofdeliveringESwasestimatedtobearound
840(oneinitialassessmentfollowedbyfivesessionsinhospital).Based
onthesecosts,forEStobejudgedcosteffectiveitwouldneedto
providebenefitstopatientsthattranslatedtoatleastanadditional
0.042QALYsperperson.TheGDGconsideredthisadditionalbenefit
achievableinaselectedpopulationforwhomthetreatmentis
consideredappropriate(forexamplepeoplewhohaveevidenceof

NationalClinicalGuidelineCentre,2013.
437

StrokeRehabilitation
Movement
musclecontractionafterstrokebutcannotmovetheirarmagainst
resistance).
Qualityofevidence

Themajorityofthestudiesreportedbenefitbutthiswasnotalways
significant.TheGDGconsideredthattheresultsshouldbeinterpreted
withcautionduetothesmallsamplesizeofthestudies.Veryfewstudies
reportedfollowupresultsbutPopovic210,Mann168,Powell213,Lin155did
reportstatisticalsignificanceinfavourofESbetween1andsixmonths
followupforarangeofoutcomesincludingFuglMeyerAssessmentand
modifiedBarthelIndex.
Thestudiescouldbedividedintothosethatlookedatearlyafterstroke,
lateafterstrokeandthosethatincorporatedphysiotherapyguided
functionalexerciseandthosethatdidnot.TheGDGobservedthatthe
Kimberleystudy137wastheonlyonethatdidnothavephysiotherapyas
thecomparatoranditwasnotedthatgenerallythepatientsincludedin
thestudiestendedtobetheyoungeragegroup(between4570years
old).
TheGDGconsideredthatwhenusedearlyafterstrokeinhigh
functioningpeoplethereappearedtobelimitedevidenceofbenefit6,210
butalargerstudyisneeded.
TheGDGalsonotedthatthestudiesbyAlon6,7usedamodifiedFugl
MeyerAssessmentoutcomeandthereforetheresultsshownwould
needtoberegardedwithcaution.

Otherconsiderations

TheGDGnotedthatthestudybyAlon6,7waspartiallysponsoredbythe
manufacturersofthedeviceandthattheresultswereconsistentwith
otherstudieswhichwerepubliclyorcharityfunded.Electrical
stimulationisnotwidelyavailable,andifatrialoftreatmentisofferedto
apatientitshouldonlybedeliveredbyahealthprofessionalwiththe
appropriateskillset.TheGDGagreedthatanassessmentofthosewho
maybenefitfromtheinterventionshouldbecarriedoutandatrialof
useconductedtoestablishifanimprovementinrangeofmovementor
functionofthehandorwristisclearlydemonstrated.

13.5 Constraintinducedmovementtherapy
Constraintinducedmovementtherapyisanapproachtopromoteincreasedactivityintheimpaired
upperlimbinpatientsafterstroke.Inordertoovercomelearnednonuseintheaffectedlimbthe
unaffectedlimbisrestrainedusuallybyahandmittenorarmslingforlongperiodsoftheday,
therebypromotingtheuseoftheaffectedlimbineverydaysituations.Inadditiontotherestraint,
treatmentincludesperiodsofintensivefocusedexerciseoractivityusuallyundertheguidanceofa
therapist.Becauseofthenatureoftheinterventionconstraintinducedmovementtherapyisnot
suitablefor,oracceptableto,allpatientsafterstroke.

13.5.1

Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessof
constraintinducedtherapyversususualcareonimprovingfunctionandreducing
disability?
ClinicalMethodologicalIntroduction
Population

Adultsandyoungpeople16orolderwhohavehadastroke

Intervention

Constraintinducedmovementtherapy(CIMT)forupperlimb
Subgroupanalysis
Lessthan5hours
Morethan5hours
Anyconstraintegslings

Comparison

Usualcare

NationalClinicalGuidelineCentre,2013.
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StrokeRehabilitation
Movement
ClinicalMethodologicalIntroduction

Outcomes

FunctionalIndependenceMeasure(FIM)
BarthelIndex
FuglMeyerAssessment
ActionResearchArmTest(ARAT)
WolfMotorFunctionTest(WMFT)
9holepegtest
Anyadverseevent

13.5.1.1

Clinicalevidencereview
SearcheswereconductedforsystematicreviewsandRCTscomparingConstraintInducedMovement
Therapies(CIMTs)withusualcareforimprovingupperlimbfunctionandreducingdisabilityinpeople
afterstroke.Onlystudieswithaminimumsamplesizeof20participants(10ineacharm)and
includingatleast50%ofparticipantswithstrokewereselected.Fifteen(15)RCTswereidentified.
Table1summarisesthepopulation,intervention,comparisonandoutcomesforeachofthestudies.
Table103:Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
STUDY
54

Dahl,2008

Dromerick,
200072

POPULATION
Inpatientsafter
stroke(2weeks
8yearspost
stroke)with
unilateralhand
impairmentbut
morethan
20degrees
activewrist
extensionand
10degrees
activefinger
extension.

INTERVENTION

COMPARISON

OUTCOMES

CIMT:amitten
immobilisedthenon
paretichandfortarget
90%ofwakinghours
(actually13
hours/day).Training
providedingroupsof4
participantsledby
physicaland
occupationaltherapists
andassistedbytrained
nursesfor6hours/day
for10consecutive
weekdays;exercises
andactivitieschosen
from150in10fields
(includingpersonal
care,
kitchen/household
etc.).(N=18)

Usualcare:
communitybased
followupaccording
topatient'sneeds,
involvingbothupper
andlowerlimb
trainingandcould
includeinpatient
rehabilitation
(physiotherapyplus
occupational
therapy)following2
outpatientsessions
perweek.(N=12)

Inpatientsin
acutestroke&
braininjury
rehabilitation
service
(admission
within14days
ofischemic
stroke)with
persistent
hemiparesis
leadingto

CIMT:apaddedmitten
immobilisedthenon
paretichandforat
least6hours/day
duringthe14day
treatmentperiod.
Treatmentwas
directedtowards
subjectattentionand
efforttowardthe
hemipareticupper
extremityand

Usualcare:

traditional
occupationaltherapy
plusacircuittraining

programallowing
patientstoperform
bilateralselfrangeof
motionand
functionalactivities
inasupervised
settingfor2
hours/day,5

NationalClinicalGuidelineCentre,2013.
439

WolfMotor
FunctionTest
(WMFT)
Functional
Independence
Measure(FIM)

ActionResearch
ArmTest(ARAT)
BarthelIndex
Functional
Independence
Measure(FIM)

StrokeRehabilitation
Movement
STUDY

POPULATION
impairedupper
extremity
function.Details
onpatients
wristandfinger
extensionability
werenot
reported.

INTERVENTION
minimisedtheuseof
theuninvolvedupper
extremityduring
functionalactivities.All
subjectsalsoreceived
routine
interdisciplinarystroke
rehabilitation;
individualisedcircuit
trainingtechniques2
hours/day,5
days/weekfor2
consecutiveweeks.
(N=11)

COMPARISON
days/weekfor2
consecutiveweeks.
(N=9)

Hammer,
2009102

Patientsafter
stroke(16
monthspost
stroke)with
abilitytomove
theshoulder
andelbow
voluntarilyand
extend20
degreesinthe
wristand10
degreesinthe
fingersofthe
pareticarmand
hand.

Forcedusedsling:
arestrainingsling
immobilisedthe
unaffectedarmwitha
targetof6hours/day
(actuallyachieved3.7
hours/day)for5
days/weekfor2
weeks.Patientsalso
receivedindividualised
physicaland
occupationaltherapy
fortheupperand
lowerlimbtraining
basedonandtask
orientatedapproach.
(N=15)

Usualcare:standard
interdisciplinary
rehabilitationofdaily
training5days/week
(withoutforced

use).(N=15)

Lin,2009153

Chronic
unilateralstroke
patients(>6
monthspost
onsetof
ischemicor
hemorrhagic
stroke)with
Brunnstrom
abovestageIII
forproximal
anddistalpart
ofupperlimb;
anamountof
usescore<2.5
onthemotor
Activitylogof
theupperlimb
andModified
Ashworthscale
score2inany
jointofthe
shoulder,elbow
wrist,orfingers.

DistributedCIMT:
amittenrestrictedthe
movementof
unaffectedhandfor6
hours/day.Patients
alsoreceivedintensive
trainingofaffected
upperlimbin
functionaltasksfor2
hours/weekdayfor3
weeks.(N=20)

Usualcare:training
inhandfunction,
coordination,
balance,movements
ofaffectedupper
limbandpracticeon
functionaltaskswith
unaffectedorboth
limbs.(N=20)

NationalClinicalGuidelineCentre,2013.
440

OUTCOMES

FuglMeyer
Assessment
ActionResearch
ArmTest(ARAT)

FuglMeyer
Assessment(FMA)
Functional
Independence
Measure(FIM)

StrokeRehabilitation
Movement
STUDY

POPULATION

INTERVENTION

COMPARISON

Lin,2007

Chronicstroke
patients(1326
monthspost
first
cerebrovascular
incident)with
Brunnstrom
abovestageIII
forproximal
anddistalpart
ofarm;an
amountofuse
score<2.5on
themotor
Activitylogof
theaffected
armand
Modified
Ashworthscale
score=2inany
jointofthe
shoulder,elbow
wrist,orfingers.

ModifiedCIMT:amitt
restrictedthe
movementof
unaffectedhandfora
targetof6hours/day
(actual6.2hours/day)
for3weeksplus
intensivetrainingof
affectedarm
supervisedbytrained
occupationaltherapists
for2hours/weekday.
(N=17)

Usualcare:involving
strength,balanceand
finemotordexterity
training,functional
taskpracticewhen
possible,and
stretching/weight
bearingbythe
affectedarm.(N=17)

Functional
Independence
Measure(FIM)

Myint,
2008182

Strokepatients
(216weeks
afterstroke)
with
hemiparesisof
theaffected
limbandwith
minimal
movementof
20degreeswrist
extensionand
10degrees
extensionofall
digits

CIMT:patientswearing
apaddedshoulder
slingfor90%ofwaking
hours).Patientsalso
received4hours/day
for5days/weekfor2
weekssupervised
activitiesincluding
shaping(abehavioural
methodtoimprove
motorperformancein
smallstepsand
encouragingpositive
feedback).(N=28)

Usualcare:

conventional
occupationaland

physicaltherapy

involving
neurodevelopmental
techniques,bimanual
tasks,compensatory
techniques,strength,
rangeofmotion,
positioning,mobility
for4hours/dayfor5
days/weekfor2
weeks.(N=20)

ActionResearch
ArmTest(ARAT)
BarthelIndex
9holepegtest

Page,
2008197

Chronicstroke
patients(>12
monthspost
stroke)ableto
selectively
activelyextend
atleast10
degreesatthe
metacarpophala
ngealand
interphalangeal
jointsand20
degreesatthe
wrist.

ModifiedCIMT:sling
andhandinmesh
polystyrenefilledmitt
restrictedtheuseof
unaffectedarmfor5
hours/weekdayduring
atimeoffrequentarm
use.Patientsalso
receivedtrainingofthe
moreaffectedarm
therapyusingshaping
techniquesforhalf
houronetoone
sessionsfor3daysper
weekfor10weeks
assistedbytherapists.
(N=13)

Usualcare:time
matched
rehabilitation
focusingon
proprioceptive
neuromuscular
facilitation
techniques,
stretchingand
compensatory
techniques.(N=12)

Inorout

ForceduseCIMT:

Usualcare:

154

Ploughman,

NationalClinicalGuidelineCentre,2013.
441

OUTCOMES

ActionResearch
ArmTest(ARAT)
FuglMeyer
assessment(FMA)

ActionResearch

StrokeRehabilitation
Movement
STUDY
2004206

POPULATION
patientswith
firststroke(less
than16weeks
poststroke)
showing
minimal
movementof
thearmand
hand(intertiary
mixed
rehabilitation
centre).Motor
controlofthe
upperextremity
ofmorethan
stage2butnot
morethanstage
6onthe
Chedoke
McMaster
Impairment
Inventory(CMII)
ofthearmand
hand.

INTERVENTION
patientswearingthick
constraintknitted
acrylicthumbless
mittentodiscourage
useofunaffectedarm
andhand;wornfor1
hourperdayincreasing
to6hoursby2weeks
and6hourstowards
theendoftreatment.
(N=13)

COMPARISON
OUTCOMES
conventionaltherapy
ArmTest(ARAT)
byfacilitatingthe
Functional
proximalmotor
Independent
controlprogressing
Measure(FIM)
toskilledtask
training,strengthand
endurancetraining,
functionalelectrical
stimulation,gait
training,education.
(N=14)

Taub,
2006254

Chronicstroke
patients
(mean=4.5
yearsafter
stroke)with
motordeficit;
abilityto
activelyextend
10degreesat
metacarpophala
ngealand
interphalangeal
jointsand20
degreesat
wrist.

CIMT:arestinghand
splint/slingonthe
unaffectedupper
extremityprevented
useofthatarmfora
targetof90%of
wakinghoursfor6
hours/dayfor10
consecutiveweekdays.
Trainingontheparetic
armconsistedof
'shaping'(a
behaviouralmethodto
improvemotor
performanceinsmall
stepsandencouraging
positivefeedback).
(N=21)

Usualcare:program
ofphysicalfitness,
cognitive,and
relaxationexercises
forthesamelength
oftimeandwiththe
sameamountof
interactionwiththe
therapistsasthe
interventiongroup.
(N=20)

vanderLee,
1999270

Patientsafter
singlestroke(at
least1yearpost
stroke)with
hemiparesison
thedominant
sideandwitha
minimumof20
degreesof
activewrist
extensionand
10degreesof
fingerextension

Forcedusetreatment:
unaffectedarmwas
immobilisedusing
splint(wornathome)
for6hours/dayfor5
days/weekduring12
daysoftreatmentplus
aclosedarmslingwas
attachedtothewaist
duringthetreatment
hours.(N=33)

Usualcare:involving
neurodevelopmental
bimanualtraining
providedingroupsof
4participants
(housekeeping
activities,
handicrafts,games)
(N=33)

FuglMeyer
Assessment(FMA)
ActionResearchArm
Test(ARAT)

Wolf,

Patientswith

CIMT:mittrestricted

Usualcare:ranged

NationalClinicalGuidelineCentre,2013.
442

WolfMotor
FunctionTest
(WMFT)

WolfMotor

StrokeRehabilitation
Movement
STUDY
2006286

POPULATION
firsttime
clinicalischemic
orhemorrhagic
cerebrovascular
accident(36
monthsafter
stroke).Lower
functioning
participantshad
atleast10
degreesof
activewrist
extension,at
least10degrees
ofthumb
abduction/exte
nsion,andat
least10degrees
ofextensionin
atleast2
additional
digits.These
movementshad
toberepeated
3timesin1
minute.

INTERVENTION
theuseofunaffected
handforagoalof90%
ofwakinghoursfora
totalof14days
(treatmentdaysplus
weekends);the
patientsalsoreceived
adaptivetaskpractice
andstandardtask
trainingofpareticlimb
for6hours/dayon
weekdays(N=106)

COMPARISON
OUTCOMES
fromnotreatmentto
FunctionTest
applicationof
(WMFT)
mechanical

interventions
(orthotics)orvarious
occupationaland
physicaltherapy
approachesathome
asadaypatientoras
anoutpatient.
(N=116)

Wu,2007(a) Firsttimestroke CIMT:mittrestricted

291

patients(3
theuseoflessaffected
weeksto37
handfor6hours/day
monthspost
for5days/weekfor3
onsetwith
weeksandpatients
Brunnstrom
alsoreceivedtypical
abovestageIII
trainingactivitiesfor
forproximal
dailytasksinvolving
partofupper
theuseofmore
limb;anamount affectedlimb(2
ofusescore
hours/day).Also
<2.5onthe
received
MotorActivity
interdisciplinary
logoftheupper rehabilitation(1.5
limb;noserious hours/dayfor5
cognitive
days/week).(N=24)
deficits.

Usualcare:
neurodevelopmental
therapyemphasising
functionaltask
practice,stretching
andweightbearing
withmoreaffected
armandfinemotor
dexterityfor2
hours/day.Also
received
interdisciplinary
rehabilitation(1.5
hours/dayfor5
days/week).(N=23)

FuglMeyer
Assessment(FMA)

Wu,2007(b) Elderlystroke
292
patients(mean

age72years)
with0.531
monthspost
onsetofafirst
everstrokewith
considerable
nonuseofthe
affectedlimb
(anamountof
usescore<2.5
ontheMotor

Usualcare:
2hourtherapy
sessionwith75%of
timespenton
neurodevelopmental
techniques
emphasising
functionaltask
practice,stretching,
weightbearing,fine
motordexterityand
25%on
compensatory

FuglMeyer
Assessment(FMA)
Functional
Independence
Measure(FIM)

ModifiedCIMT:amitt
wasappliedinthe
unaffectedhandfor6
hours/weekdayat
timeoffrequentarm
usefor3weeks.
Patientsalsoreceived
individualised2hour
therapysessionsfor5
times/weekinvolving
shapingandadaptive
repetitivetasks
focusingondaily

NationalClinicalGuidelineCentre,2013.
443

StrokeRehabilitation
Movement
STUDY

POPULATION
Activitylog);
Modified
Ashworthscale
score2inany
joint

INTERVENTION
activitiesand15
minutesoftherapyon
normalisingmuscle
tone.(N=13)

COMPARISON
techniques.(N=13)

OUTCOMES

Wu,2007(c
)293

Poststroke
patients(1236
monthspost
strokeofafirst
ever
cerebrovascular
accident)with
anabilityto
activelyextend
atleast10
degreesatthe
metacarpophala
ngealand
interphalangeal
jointsand20
degreesatthe
wrist.

ModifiedCIMT:amitt
wasappliedinthe
unaffectedhandfor6
hours/weekdayat
timeoffrequentarm
usefor3weeks.
Trainingadministered
intensively2hoursper
day,5daysperweek,
for3weeks.Training
tookplaceduring
scheduled
occupationaltherapy
sessions,andother
routine
interdisciplinarystroke
rehabilitation
proceededasusual.
(N=15)

Usualcare:patients
receivedtraining
matchedtothe
mCIMTinduration
andintensityof
occupationaltherapy
activities.(N=15)

Functional
Independence
Measure(FIM)

Wu,2011294

Patientsafter
stroke(mean
poststroke16.2
months)and
mildto
moderate
motor
impairment
with
Brunnstrom
abovestageIII
forproximal
partofupper
extremity;an
amountofuse
score<2.5on
theMotor
Activitylog.

1)DistributedCIMT:
amittrestrictedthe
unaffectedhandfor6
hours/dayand
intensivelytrainedthe
affectedupper
extremityinfunctional
tasks.(N=22)
2)Bilateralarm
trainingfocusingon
thesimultaneous
movementsin
symmetricor
alternatingpatternsof
bothupperextremities
infunctionaltasks.
(N=22)
Studyduration:2
hours/day,5
days/weekfor3weeks

Usualcare:
patientsreceived
compensatory
practiceon
functionaltaskswith
theunaffectedupper
extremityorboth
upperextremities.
(N=22)

WolfMotor
FunctionTest
(WMFT)

NationalClinicalGuidelineCentre,2013.
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StrokeRehabilitation
Movement

Comparison:constraintInducedmovementtherapiesversususualcare
Table104:Constraintinducedmovementtherapy(CIMT)versususualcareclinicalstudycharacteristicsandclinicalsummaryoffindings

Summaryoffindings
Qualityassessment

Noof
studies

Design

Effect

Limitations

Inconsistency

Indirectness

Imprecision

CIMT
Mean
(SD)/
Frequencie
s(%)

Absolute
Effect/
Usualcare Mean
Mean
Mean(SD)/ difference/ Difference
Frequencie RiskRatio (MD)(95%
s(%)
(95%CI)
CI)

Confidence
(ineffect)

ActionResearchArmTest(posttreatment)(Betterindicatedbyhighervalues)
4
Dromerick
200072;
Myint
2008182;
Page
2008197;
VanderLee
1999270

RCTssingle
blinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b)

Dromerick
2000:52.8
(5.9)
Myint
2008:47.1
(10.2)
Page2008:
40.54
(8.18)
Vander
Lee:39.2
(13.1)

Dromerick
2000:44.3
(11.1)
Myint
2008:33.6
(12.5)
Page2008:
29.17(10)
Vander
Lee:30
(13.9)

10.78
(7.27,
14.30)

MD10.78
higher
(7.27to
14.30
higher)

Low

38(12.3)

30.8(13.6)

MD7.20
(0.94,
13.46)

MD7.20
higher
(0.94to
13.46
higher)

Moderate

ActionResearchArmTest(4weeksfollowup)(Betterindicatedbyhighervalues)
1Vander
Lee1999270

RCTsingle
blinded

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b)

ActionResearchArmTest(12weeksfollowup)(Betterindicatedbyhighervalues)

NationalClinicalGuidelineCentre,2013.

445

StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Effect

Noof
studies

Design

Limitations

Inconsistency

Indirectness

Imprecision

1Myint
2008182

RCTsingle
blinded

Serious
limitations(a
)

Noserious
indirectness

Noserious
indirectness

Noserious
imprecision

CIMT
Mean
(SD)/
Frequencie
s(%)

Absolute
Effect/
Usualcare Mean
Mean
Mean(SD)/ difference/ Difference
Frequencie RiskRatio (MD)(95%
s(%)
(95%CI)
CI)

Confidence
(ineffect)

49.6(9.9)

39.9(14.1)

MD9.7
(2.51,
16.89)

MD9.7
higher
(2.51to
16.89
higher)

Moderate

38.5(13.6)

30.7(14.2)

MD7.80
(1.09,
14.51)

MD7.80
higher
(1.09to
14.51
higher)

Moderate

Dahl2008:
2.03(0.82)
Taub
2010:4.6
(4.4)
Wu
2011:5.83
(4.65)

MD0.53(
0.91,0.16
)

MD0.53
lower(0.91
to0.16
lower)

Low

1.77(0.92)

MD0.05(
0.59,0.69)

MD0.05
higher
(0.59lower
to0.69

Low

ActionResearchArmTest(10monthsfollowup)(Betterindicatedbyhighervalues)
1Vander
Lee1999270

RCTsingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(b)

WolfMotorFunctionTest(performancetime)(posttreatment)(Betterindicatedbylowervalues)
3Dahl
RCTssingle
200854;
blinded
Taub
2006254;Wu
2011294

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
e)

Dahl2008:
1.56(0.57)
Taub
2010:3
(1.1)
Wu
2011:4.02
(2.49)

WolfMotorFunctionTest(performancetime)(6monthsfollowup)(Betterindicatedbylowervalues)
1Dahl
200854

RCTsingle
blinded

Serious
limitations(d
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
e)

1.82(0.8)

NationalClinicalGuidelineCentre,2013.

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noof
studies

Design

Effect

Limitations

Inconsistency

Indirectness

Imprecision

CIMT
Mean
(SD)/
Frequencie
s(%)

Absolute
Effect/
Usualcare Mean
Mean
Mean(SD)/ difference/ Difference
Frequencie RiskRatio (MD)(95%
s(%)
(95%CI)
CI)
higher)

(f)

(f)

MD34.00
(14.50,
53.50)

MD34.00
higher
(14.50to
53.50
higher)

High

Dahl
2008:3.47(
0.6)
Taub
2010:2.9(0.
5)
Wu
2011:3.66
(0.87)

MD0.46
(0.08,0.
83)

MD
0.46higher
(0.08to0.
83higher)

Low

3.73(0.58)

MD0.22(
0.21,0.65)

MD0.22
higher
(0.21lower
to0.65
higher)

Low

Confidence
(ineffect)

ChangeinWolfMotorFunctionTest(performancetime)(12monthsfollowup)
1Wolf
2006286

RCTsingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

WolfMotorFunctionTest(functionalability)(posttreatment)(Betterindicatedbyhighervalues)
3Dahl2008 RCTssingle
54
;Taub
blinded
2006254;Wu
2011294

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
e)

Dahl
2008:3.85
(0.5)
Taub2010:
3.2(0.4)
Wu
2011:3.78
(0.71)

WolfMotorFunctionTest(functionalability)(6monthsfollowup)(Betterindicatedbyhighervalues)
1Dahl
200854

RCTsingle
blinded

Serious
limitations(d
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
e)

3.95(0.61)

ChangeinWolfMotorFunctionTest(functionalability)(12monthsfollowup)

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StrokeRehabilitation
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Summaryoffindings
Qualityassessment

Effect
CIMT
Mean
(SD)/
Frequencie
s(%)

Absolute
Effect/
Usualcare Mean
Mean
Mean(SD)/ difference/ Difference
Frequencie RiskRatio (MD)(95%
s(%)
(95%CI)
CI)

Confidence
(ineffect)

Noof
studies

Design

Limitations

Inconsistency

Indirectness

Imprecision

1Wolf
2006286

RCTsingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
e)

(f)

(f)

MD0.11(
0.05,0.27)

MD0.11
higher
(0.05lower
to0.27
higher)

Moderate

Serious
imprecision(
e)

(f)

(f)

MD0.67(
1.51,2.85)

MD0.67
higher
(1.51lower
to2.85
higher)

Moderate

Serious
imprecision(
e)

(f)

(f)

MD2.64(
6.27,0.99)

MD2.64
lower
(6.27lower
to0.99
higher)

Moderate

Dahl
2008:107.3
3(8.8)
Lin
2007:113.0
6(10.55)
Lin

Dahl
2008:111.6
7(6.49)
Lin
2007:105.6
7(15.85)
Lin

MD2.87( MD2.87
0.12,5.87) (0.12lower
to5.87
higher)

ChangeinWolfMotorFunctionTest(weight)(12monthsfollowup)
1Wolf
2006286

RCTsingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

ChangeinWolfMotorFunctionTest(grip)(12monthsfollowup)
1Wolf
2006286

RCTsingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

FunctionalIndependenceMeasure(posttreatment)(Betterindicatedbyhighervalues)
5
Dahl200854;
Lin2007154;
Lin2009153;
Wu
2007(b)292
Wu2007

RCTS4
Serious
single
limitations(c
blinded1
)
double
blinded

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
g)

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Low

StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noof
studies
(c)293

Design

Effect

Limitations

Inconsistency

Indirectness

Imprecision

CIMT
Mean
(SD)/
Frequencie
s(%)
2009:122.0
5(5.6)
Wu
2007:104.8
5(12.13)

Absolute
Effect/
Usualcare Mean
Mean
Mean(SD)/ difference/ Difference
Frequencie RiskRatio (MD)(95%
s(%)
(95%CI)
CI)
2009:116.6
5(8.34)
Wu2007:
100.85
(20.08)

Confidence
(ineffect)

FunctionalIndependenceMeasure(totalscore)(6monthsfollowup)(Betterindicatedbyhighervalues)
1Dahl
200854

RCTsingle
blinded

Serious
limitations(d
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
g)

109.56
(8.25)

112.92
(6.75)

MD3.36
MD3.36
(8.762.04) lower(8.76
lowerto
2.04
higher)

Low

6.27(0.78)

6(0.92)

MD0.27(
0.49,1.03)

MD0.27
higher
(0.49lower
to1.03
higher)

Low

5.62(0.52)

MD0.47
(0.01,0.93)

MD0.47
higher
(0.01to
0.93
higher)

Low

FunctionalIndependencemeasure(eating)(posttreatment)(Betterindicatedbyhighervalues)
1Dromerick RCTsingle
200072
blinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
g)

FunctionalIndependencemeasure(grooming)(posttreatment)(Betterindicatedbyhighervalues)
1Dromerick RCTsingle
200072
blinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
g)

6.09(0.53)

FunctionalIndependencemeasure(bathing)(posttreatment)(Betterindicatedbyhighervalues)

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noof
studies

Design

1Dromerick RCTsingle
200072
blinded

Effect

Limitations

Inconsistency

Indirectness

Imprecision

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
g)

CIMT
Mean
(SD)/
Frequencie
s(%)

Absolute
Effect/
Usualcare Mean
Mean
Mean(SD)/ difference/ Difference
Frequencie RiskRatio (MD)(95%
s(%)
(95%CI)
CI)

Confidence
(ineffect)

5.27(1.1)

5.25(0.46)

MD0.02(
0.70,0.74)

MD0.02
(0.70lower
to0.74
higher)

Low

FunctionalIndependencemeasure(upperextremitydressing)(posttreatment)(Betterindicatedbyhighervalues)
1Dromerick RCTsingle
200072
blinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
g)

6(0.77)

5.25(0.71)

MD0.75
(0.10,1.40)

MD0.75
(0.10to
1.40
higher)

Low

Serious
imprecision(l
)

Lin2009:
52.3(7.17)
Page2008:
48.23
(8.06)Wu
2007(a):
46.75
(11.58)Wu
2007(b:
49.54
(12.84))

Lin2009:
51.25(12.59
)
Page2008:
42.42(12)
Wu2007
(a);:44.78
(13.08)Wu
2007(b):
49.38
(10.18)

MD2.15(
1.56,5.86)

MD2.15
higher
(1.56lower
to5.86
higher)

Low

Noserious
imprecision

51.6(8)

45(10.6)

MD6.60
(2.07,11.13
)

MD6.60
higher
(2.07to

High

FuglMeyerAssessment(posttreatment)(Betterindicatedbyhighervalues)
4Lin
RCTssingle
2009153;
blinded
Page
2008197;Wu
2007(a)291;
Wu2007
(b)292

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

FuglMeyerAssessment(3weeksfollowup)(Betterindicatedbyhighervalues)
1Vander
Lee1999270

RCTsingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

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StrokeRehabilitation
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Summaryoffindings
Qualityassessment

Noof
studies

Design

Effect

Limitations

Inconsistency

Indirectness

Imprecision

CIMT
Mean
(SD)/
Frequencie
s(%)

Absolute
Effect/
Usualcare Mean
Mean
Mean(SD)/ difference/ Difference
Frequencie RiskRatio (MD)(95%
s(%)
(95%CI)
CI)
11.13
higher)

Confidence
(ineffect)

FuglMeyerAssessment(6weeksfollowup)(Betterindicatedbyhighervalues)
1Vander
Lee1999270

RCTsingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(l
)

52.3(8.3)

46.7(9.6)

MD5.60
MD5.60
(1.27,9.93) higher
(1.27to
9.93
higher)

Moderate

Serious
imprecision(l
)

50.9(9.9)

45.5(9.7)

MD5.4
(0.67,
10.13)

MD5.4
higher
(0.67to
10.13
higher)

Moderate

Serious
imprecision
(h)

Dromerick
2000:100
(1.1)
Myint
2008:92.6
(8.5)

Dromerick
2000:98.5
(3.77)
Myint
2008:85.3
(13.6)

MD3.53(
1.89,8.95)

MD3.53
higher
(1.89lower
to8.95
higher)

Low

Serious
imprecision

97.6(4.2)

93.4(7.7)

MD4.2
MD4.2
(0.48,7.92) higher

FuglMeyerAssessment(1yearfollowup)(Betterindicatedbyhighervalues)
1Vander
Lee1999270

RCTsingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

BarthelIndex(posttreatment)(Betterindicatedbyhighervalues)
2Dromerick RCTssingle
200072;
blinded
Myint
2008182

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

BarthelIndex(12weeksfollowup)(Betterindicatedbyhighervalues)
1Myint
2008182

RCTsingle
blinded

Serious
limitations(a

Noserious
inconsistency

Noserious
indirectness

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Low

StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noof
studies

Design

Effect

Limitations
)

Inconsistency

Indirectness

Imprecision
(i)

CIMT
Mean
(SD)/
Frequencie
s(%)

Absolute
Effect/
Usualcare Mean
Mean
Mean(SD)/ difference/ Difference
Frequencie RiskRatio (MD)(95%
s(%)
(95%CI)
CI)
(0.48to
7.92
higher)

Confidence
(ineffect)

9holepegtest(posttreatment)(Betterindicatedbyhighervalues)
1Myint
2008182

RCTsingle
blinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision
(j)

16/28
(57.1%)

9/20(45%)

RR1.27
(0.71to
2.27)

121more
per1000
(from131
fewerto
572more)

VeryLow

Serious
imprecision(
k)

18/28
(64.2%)

10/20
(50%)

RR1.29
(0.77to
2.16)

145more
per1000
(from115
fewerto
580more)

Low

4/18
(22.2%)

0/12

RR6.16
(0.36to
104.90)

145more
per1000
(from115
fewerto
580more)

VeryLow

9holepegtest(3monthsfollowup)(Betterindicatedbyhighervalues)
1Myint
2008182

RCTsingle
blinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Adverseevent(muscletendernessintheaffectedarm)(Betterindicatedbylowervalues)
1Dahl
200854

(a)
(b)
(c)
(d)
(e)

RCTsingle
blinded

Serious
limitations(d
)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision
(j)

Unclearallocationconcealmentandunclearallocationconcealment
MeandifferencedidnotreachtheagreedMIDof12points.
Unclearrandomizationandunclearallocationconcealment
unclearrandomization
MeandifferencedidnotreachtheagreedMIDof19points.

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StrokeRehabilitation
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(f)
(g)
(h)
(i)
(j)
(k)
(l)

Nomeans(SD)pergroupwerereportedbyauthors.
MeandifferencedidnotreachtheagreedMIDof22pointsforthetotalscore,17pointsonthemotorscaleand3pointsforthecognitivescale.
MeandifferencedidnotreachtheagreedMIDof6.6points.
MeandifferencedidnotreachtheagreedMIDof9.25points.
ConfidenceintervalcrossedbothendsofdefaultMID.
ConfidenceintervalcrossesoneendofdefaultMID.
MeandifferencedidnotreachagreedMID(10%differenceoftotalscore)

Narrativesummaries
ThefollowingstudiesaresummarisedasanarrativebecausetheresultswerenotpresentedinnumericaldatathatcouldbeincludedintheGRADEtable:
Onestudy102randomisedaconvenientsampleof30participantsintoforcedusetraining(N=15)andstandardrehabilitationprogramme(N=15).Thestudy
foundthatthechangesintheforcedusegroupdidnotdifferfromthechangesinthestandardrehabilitationgroupforanyoftheoutcomemeasures
(FuglMeyerAssessmentandActionResearchArmTest).Bothgroupsimprovedovertime(posttreatment3monthsfollowup),withstatistically
significantchangesintheFuglMeyerAssessment(meanscorechangedfrom52to57).Thetrialwasunblindedandofasmallsamplesize.
Inonestudy206,30participantswererandomlyallocatedtoforcedusetherapyandconventionaltherapy.Participantsintheforcedusegrouphadan85%
improvement(baseline=20.7(15.49))inARATscore,whereasthosewhoreceivedconventionaltherapyhada74%improvement(baseline=16.0(13.64))
(p=0.20).NosignificantdifferenceinFIMwasobserved(datanotpresented).Noneoftheparticipantsintheforcedusegroupachieved6hoursof
constraintwearingaday(averagetime=2.7hours/day).Datawerepresentedasgraphsandtheycouldnotbeextracted/usedformetaanalysis.The
analysiswasnotdonebasedonITTandthestudyhadunclearrandomisationandallocationconcealment.

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StrokeRehabilitation
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13.5.1.2

Economicevidence
Literaturereview
Norelevanteconomicevaluationscomparingconstraintinducedmovementtherapywithusualcare
wereidentified.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
Lookingatresourcesusedinthestudiesincludedintheclinicalreview,themaindifferencein
resourcesusedbetweeninterventionandusualcarewasoftheconstraintused,withnosubstantial
differenceinpersonneltime.TheGDGadvisedthatthecostofconstraintwasminimalforexample
itmayinvolveusingbandaging.However,thecostsattributabletoCIMTwilldependonhowand
whenitisoffered.IfCIMTactivitiesareincorporatedaspartoftheusualrehabilitation,costsmay
notbesubstantiallyhigherthanusualcare;if CIMTisofferedinadditiontousualrehabilitationcare
thatpatientsreceive,additionalcostswouldbeincurredduetoadditionalresourceuse(forexample,
stafftime).

13.5.1.3

Evidencestatements
Clinicalevidencestatements
Fourstudies72,182,197,270of159participantsfoundthatpatientswhoreceivedconstraintinduced
movementtherapyshowedstatisticallysignificantimprovementinActionResearchArmtest
comparedtopatientswhoreceivedusualcareatpostintervention,althoughitwasnotofclinical
significance(LOWCONFIDENCEINEFFECT).
Onestudy270of66participantsfoundthatpatientswhoreceivedconstraintinducedmovement
therapyshowedstatisticallysignificantimprovementinActionResearchArmtestcomparedto
patientswhoreceivedusualcareat4weeksfollowup,althoughitwasnotofclinicalsignificance
(MODERATECONFIDENCEINEFFECT).
Onestudy182of66participantsfoundthatpatientswhoreceivedconstraintinducedmovement
therapyshowedstatisticallysignificantimprovementinActionResearchArmtestcomparedto
patientswhoreceivedusualcareat12weeksfollowup(MODERATECONFIDENCEINEFFECT).
Onestudy270of66participantsfoundthatpatientswhoreceivedconstraintinducedmovement
therapyshowedstatisticallysignificantimprovementinActionResearchArmtestcomparedto
patientswhoreceivedusualcareat10monthsfollowup,althoughitwasnotofclinicalsignificance
(MODERATECONFIDENCEINEFFECT).
Threestudies54,254,294of115participantsfoundthatpatientswhoreceivedconstraintinduced
movementtherapyshowedstatisticallysignificantimprovementinWolfMotorFunctiontest
performancetimecomparedtopatientswhoreceivedusualcareatpostintervention,althoughit
wasnotofclinicalsignificance(LOWCONFIDENCEINEFFECT).
Onestudy54of30participantsshowedthattherewasnosignificantdifferenceinperformancetime
oftheWolfMotorFunctiontestbetweenthosepatientswhoreceivedconstraintinducedmovement
therapyandthosewhoreceivedusualcareat6months(LOWCONFIDENCEINEFFECT).

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StrokeRehabilitation
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Onestudy286of222participantsshowedthatpatientswhoreceivedconstraintinducedmovement
therapyshowedstatisticallysignificantimprovementinchangeintheWolfMotorFunctiontest
performancetimecomparedtopatientswhoreceivedusualcareat12months(HIGHCONFIDENCE
INEFFECT).
Threestudies54,254,294of115participantsfoundthatpatientswhoreceivedconstraintinduced
movementtherapyshowedstatisticallysignificantimprovementinfunctionalabilityofWolfMotor
Functiontestcomparedtopatientswhoreceivedusualcareatpostintervention,althoughitwasnot
ofclinicalsignificance(LOWCONFIDENCEINEFFECT).
Onestudy54of30participantsshowednosignificantdifferenceinthefunctionalabilityoftheWolf
MotorFunctiontestbetweenthosewhoreceivedconstraintinducedmovementtherapyandthose
whoreceivedusualcareat6months(LOWCONFIDENCEINEFFECT).
Onestudy286of222participantsshowednosignificantdifferenceinthechangeoftheWolfMotor
Functiontestbetweenthosewhoreceivedconstraintinducedmovementtherapyandthosewho
receivedusualcareat12monthsforthefollowingscales:
Functionalability(MODERATECONFIDENCEINEFFECT)
Weight(MODERATECONFIDENCEINEFFECT)
Grip(MODERATECONFIDENCEINEFFECT)

Fivestudies153,197,154,292(Lin2009,Page2008,Lin2007Wu2007(b))of160participantsshowedthat
therewasnostatisticallysignificantdifferenceintheFunctionalIndependenceMeasure(totalscore)
betweenthosepatientswhoreceivedconstraintinducedmovementtherapyandthosewhoreceived
usualcareatpostintervention(LOWCONFIDENCEINEFFECT).
Onestudy54of30participantsshowednosignificantdifferenceintheFunctionalIndependence
Measure(totalscore)betweenthosewhoreceivedconstraintinducedmovementtherapyandthose
whoreceivedusualcareat6months(LOWCONFIDENCEINEFFECT).
Onestudy72of20participantsshowednosignificantdifferenceinthefollowingscalesofthe
FunctionalIndependenceMeasurebetweenthosewhoreceivedconstraintinducedmovement
therapyandthose197whoreceivedusualcareatpostintervention:
eating(LOWCONFIDENCEINEFFECT)
Bathing(LOWCONFIDENCEINEFFECT).

Onestudy72of20participantsshowedthatpatientswhoreceivedconstraintinducedmovement
therapyshowedstatisticallysignificantimprovementinthefollowingscalesoftheFunctional
IndependenceMeasurecomparedtopatientswhoreceivedusualcareatpostintervention,although
thesedifferenceswerenotofclinicalsignificance:
grooming(LOWCONFIDENCEINEFFECT)
upperextremitydressing(LOWCONFIDENCEINEFFECT

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StrokeRehabilitation
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Fourstudies153,197,291,292of138participantsshowedthattherewasnostatisticallysignificant
differenceinFuglMeyerassessmentbetweenthosepatientswhoreceivedconstraintinduced
movementtherapyandthosewhoreceivedusualcareatpostintervention(LOWCONFIDENCEIN
EFFECT).
Onestudy270of66participantsfoundthatpatientswhoreceivedconstraintinducedmovement
therapyshowedstatisticallysignificantimprovementinFuglMeyerassessmentcomparedto
patientswhoreceivedusualcareat3weeksfollowup(HIGHCONFIDENCEINEFFECT).
Onestudy270of66participantsfoundthatpatientswhoreceivedconstraintinducedmovement
therapyshowedstatisticallysignificantimprovementinFuglMeyerassessmentcomparedtopatients
whoreceivedusualcareat6weeksfollowup,althoughitwasnotofclinicalsignificance(MODERATE
CONFIDENCEINEFFECT).
Onestudy270of66participantsfoundthatpatientswhoreceivedconstraintinducedmovement
therapyshowedstatisticallysignificantimprovementinFuglMeyerassessmentcomparedtopatients
whoreceivedusualcareat1yearfollowupalthoughitwasnotofclinicalsignificance(MODERATE
CONFIDENCEINEFFECT).
Twostudies72,182of68participantsshowedthattherewasnostatisticallysignificantdifferencein
BarthelIndexbetweenthosepatientswhoreceivedconstraintinducedmovementtherapyandthose
whoreceivedusualcareatpostintervention(LOWCONFIDENCEINEFFECT).
Onestudy182of48participantsfoundthatpatientswhoreceivedconstraintinducedmovement
therapyshowedstatisticallysignificantimprovementinBarthelIndexbetweenthosepatientswho
receivedconstraintinducedmovementtherapyandthosewhoreceivedusualcareat12weeks
followup,althoughitwasnotofclinicalsignificance(LOWCONFIDENCEINEFFECT).
Onestudy182of48participantsshowedthattherewasnostatisticallysignificantdifferenceinNine
holePegtestbetweenthosepatientswhoreceivedconstraintinducedmovementtherapyandthose
whoreceivedusualcareatpostintervention(VERYLOWCONFIDENCEINEFFECT).
Onestudy182of48participantsshowedthattherewasnostatisticallysignificantdifferenceinNine
holePegtestbetweenthosepatientswhoreceivedconstraintinducedmovementtherapyandthose
whoreceivedusualcareat3monthsfollowup(LOWCONFIDENCEINEFFECT).
Onestudy54of30participantsshowedthattherewasnostatisticallysignificantdifferenceinthe
experienceofmuscletendernessintheaffectedarmbetweenpatientswhoreceivedconstraint
inducedmovementtherapyandthosewhoreceivedusualcare(VERYLOWCONFIDENCEINEFFECT).
Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

13.5.2

Recommendationsandlinktoevidence
95.Considerconstraintinducedmovementtherapyforpeople
withstrokewhohavemovementof20degreesofwrist
extensionand10degreesoffingerextension.Beawareof
potentialadverseevents(suchasfalls,lowmoodand
fatigue).

Relativevaluesofdifferent
outcomes

TheoutcomesofinterestincludedtheFunctionalIndependence
Measure(FIM),BarthelIndex,FuglMeyerscore,ActionResearchArm
test(ARAT),WolfMotorFunctionTest(WMFT)and9holepegtest.The
9holepegtestmaybeinsensitiveasitisameasureoffinefinger

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StrokeRehabilitation
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movementsaswellastheabilitytoreach.SimilarlytheFIMandBarthel
Indexasmeasuresofdependencemaybeunresponsivetochangesin
upperlimbfunction.TheGDGnotedthatthereisnopsychometrically
robustpatientreportedoutcomemeasuresfocussingonupperlimb
activity.Anyadverseeventwasalsoincludedwherereported.
Tradeoffbetweenclinical
benefitsandharms

Participantswhoreceivedconstraintinducedmovementtherapy(CIMT)
demonstratedaclinicallysignificantimprovementinFuglMeyerscores
atashorttermof3weeksandinARATscoresandfunctionalabilityof
WMFTat12weeksfollowup.Althoughtheimprovementin
performancetimeofWMFTforthosewhoreceivedCIMTwasnotof
clinicalsignificanceatpostinterventionandat6monthsfollowup,the
differenceinthisoutcomebecameclinicallysignificantbetweenthe
participantsintheCIMTandtheusualcaregroupsat1yearfollowup.
Onlyonestudyreportedadverseevents,theexperienceofmuscle
tendernessintheaffectedarm(Dahl,2008)54duringconstraintinduced
movementtherapy,thoughitsprevalencewasnotsignificantlydifferent
betweenthetwogroups.HowevertheGDGconsideredtherewere
possibleharmsassociatedwiththistherapyandagreedthatwhen
selectingpatientsforCIMT,attentionneedstobemadetopotential
adverseeventssuchasfallinganddeteriorationinmood.

Economicconsiderations

Nocosteffectivenessstudieswereidentifiedforthisquestion.IfCIMT
activitiesareincorporatedaspartoftheusualrehabilitation,costsmay
notbesubstantiallyhigherthanusualcare.However,offeringCIMT
mightrepresentachangeintheusualactivitiesthatarepartofthe
rehabilitation.TheGDGagreedthatitisunlikelythatCIMTisofferedin
additiontousualrehabilitationcareandthereforenoadditionalcosts
wouldbeincurredduetoadditionalresourceuse.

Qualityofevidence

TheconfidenceintheeffectfortheoutcomesofFunctional
IndependenceMeasure,Barthelindex,WolfMotorFunctionTest,and9
holepegtestrangedfromhightoverylowduetolimitationsinstudy
design(unclearallocationconcealmentandunclearrandomisation)and
imprecisionaroundtheeffectestimate.TheGDGacknowledgedthat
duetothenatureoftheinterventionitwasdifficulttorecruitpeople
intostudies.Themeanageofstrokesurvivorsis7374245anditwas
notedthatthepatientswithinthesestudies,withtheexceptionofthe
Wustudy2007(b)292,wererelativelyyoungforastrokepopulationand
arelikelytoreflectthosewhoareadmittedintospecialistrehabilitation
units.
Inpatientswithmovementof20degreeswristand10degreesinfingers
ConstraintInducedMovementTherapywithrepetitivetaskpracticemay
beofbenefitforpatientsbothearly(2weeksafteronset)andlateafter
stroke.

Otherconsiderations

TheGDGagreedthattheactiveelementofconstrainttherapyisthe
amountofpracticeperformedbytheweakarmandthisneedstobe
carefullystructuredandtailoredtotheindividualpatientneeds.The
GDGwereunsurewhatvaluepatientsplaceonsmallimprovementsin
upperlimbfunction.Whilstthistypeofinterventionmaynotbesuitable
ortoleratedbysomepatients,theGDGagreedthatitisanintervention
thattendstobeusedwiththosepatientswhoarehighlymotivatedto
gettheirmovementsbackanditisthesewhowouldvaluethistypeof
interventionmost.

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StrokeRehabilitation
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13.6 Shoulderpain
Therewasalackofdirectevidenceforthetreatmentofshoulderpain.Thereforerecommendations
inthissectionwerebasedonmodifiedDelphiconsensusstatementsderivedfrompublishednational
andinternationalguidance.ThissectionoftheDelphisurveywasaimedatthoseDelphipanel
memberswhofelttheyhadtherelevantexperiencetocommentonshoulderpain.OtherDelphi
panelmemberscouldoptoutofthissection.Responserateswerethereforelowerinthissection.
Belowweprovidetablesofstatementsthatreachedconsensusandstatementsthatdidnotreach
consensusandgiveasummaryofhowtheywereusedtodrawuptherecommendations.Fordetails
ontheprocessandmethodologyusedforthemodifiedDelphisurveyseeAppendixF.

13.6.1

Howshouldpeoplewithshoulderpainafterstrokebemanagedtoreducepain?
Population

Adultsandyoungpeople16orolderwhohavehadastrokeandhavesymptomsof
shoulderpain

Components

Assessment

Painmanagement
FES
Physicaltherapies

Outcomes

13.6.2

Mobility
Function
pain

Delphistatementswhereconsensuswasachieved
Table105:Tableofconsensusstatements,resultsandcomments(percentageintheresultscolumn
indicatestheoverallrateofresponderswhostronglyagreedwithastatementand
amountofcommentsinthefinalcolumnreferstorateofresponderswhousedthe
openendedcommentsboxes,i.e.No.peoplecommented/No.peoplewhoresponded
tothestatement)

Number

1.

Results
%

Statement

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes

Informationshouldbeprovidedbythe
healthcareprofessionalonhowto
preventpain/traumatotheshoulder.

77.6

7/49(14%)panelmembers
commented

Mostpanelmemberswho
commentedonthisquestionqueried
whotogivetheinformationto
(patient,carer,otherstaff)and
underwhichconditions(ifthereis
weaknessintheshoulder).

Itwasstatedinonecommentthat
therewasnoinformationavailable
onthistopic.

Whenmanagingshoulderpainthe
followingtreatmentsshouldbe
considered:
Positioning

70.7

Inround223/49(47%)panel
memberscommented;13/42(31%)
inround3

Noneoftheothertreatment

NationalClinicalGuidelineCentre,2013.
458

StrokeRehabilitation
Movement

Number

Statement

Results
%

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes
optionsgainedconsensus the
optionswere:
Armsslings,
Shouldersupport,
Highintensitytranscutaneous
nervestimulation,and
FunctionalElectricalStimulation
Analgesics
Physicaltherapies
Strapping

Commentsweredivided:
Anumberofpanelmembers
statedthatshoulderpainhastobe
treatedinaflexiblemannerand
accordingtoindividualneeds.
Somestatedthattreatmentshould
beevidencebased.
Othersstatedthattheevidence
formostoftheoptionswaspoor

13.6.3

Delphistatementwhereconsensuswasnotreached
Table106:Tableofnonconsensusstatementswithqualitativethemesofpanelcomments
Number

Statement

Results
%

Amountandcontentofpanel
commentsorthemes

1.

Thepersonwhohashadastroke
shouldbeassessedforshoulderpain

63.6

Inround213/48(27%)panel
memberscommented;7/42(17%)in
round3

Therewasageneralopinionthat
thisshouldbeeasilyascertainedand
thereforeafullassessmentisnot
needed.

2.

Thereisaneedforanalgorithmto
assessandtreatshoulderpain

31.0

Inround223/49(47%)panel
memberscommented;13/42(31%)
inround3

Somecommentsweremadethat
therearealgorithmsalreadyin
existence.

Otherscommentedthatthe
evidencefortreatmentswaspoor
andthereforethereisnotenough
informationtocreateanalgorithm.

Therewerealsocommentsthatthis

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StrokeRehabilitation
Movement

Number

13.6.4

Results
%

Statement

Amountandcontentofpanel
commentsorthemes
wouldbeuseful.

RecommendationsandlinkstoDelphiconsensussurvey
Statements

Recommendation

32.Informationshouldbeprovidedbythehealthcareprofessionalon
howtopreventpain/traumatotheshoulder.
33.Whenmanagingshoulderpainthefollowingtreatmentsshouldbe
Whenmanagingshoulderpainthefollowingtreatmentsshouldbe
considered:
Positioning

96.Provideinformationforpeoplewithstrokeandtheirfamiliesand
carersonhowtopreventpainortraumatotheshoulderiftheyare
atriskofdevelopingshoulderpain(forexample,iftheyhaveupper
limbweaknessandspasticity).
97.Manageshoulderpainafterstrokeusingappropriatepositioningand
othertreatmentsaccordingtoeachpersonsneed.
98.ForguidanceonmanagingneuropathicpainfollowNeuropathicpain
(NICEclinicalguideline96).

Economicconsiderations Thereisaminorcostofstafftimeassociatedwiththeprovisionof
information.HowevertheGDGconsideredthesetobelargelyoffsetby
thebenefits.
Otherconsiderations

TheGDGagreedthiswasacommonproblemamongstpeopleafter
strokeandthatpreventionshouldbehighlighted.However,themeansof
preventingshoulderpainisnotuniversallyagreedandthismaybedue,
tothelargearrayofidentifiedcauses,includingspasticity,thalamic
(central)pain,complexregionalpainsyndromes(CRPS),(forexample:
shoulderhandsyndrome),fractureandsofttissueproblems.Itis
generallyagreedthatoneofthemajorcausesofinjuringtheshoulderis
poormanualhandlingandsupportoftheatriskarmbyhealth
professionals,carers,orthepatientthemselves.
Inthesurveyconsensuswasreachedonlyforprovidinginformationto
preventshoulderpain.TheGDGclarifiedthisstatementbyindicatingthe
peoplelikelytodevelopshoulderpainwerethosewithchangesintone
orpowerintheirarms.Algorithmsandassessmentsdidnotreach
consensusintheDelphiandtheGDGdiscussedtheprosandconsof
includingthisinalistofassessmentsroutinelycarriedout.Itwasfeltthat
askingpeoplewhodisplaydiscomfortwhenmovingtheirarmswouldbe
sufficientinthemajorityofcases.
Whilsttherewasconsensusthatpositioningtheshouldermayhelpto
alleviatesymptoms,overalltheviewfromthesurveyshowedtherewas
noevidencebasetorecommendanyparticulartreatment.TheGDG

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StrokeRehabilitation
Movement
agreedthiswasanareawherefurtherresearchwasneededtoassessthe
effectivenessofthevariousmanagementstrategiescurrentlyused,and
agreedthataresearchrecommendationbeincludedintheguideline.
TheGDGweresurprisedthattherewasnoagreementabouttheuseofa
simpletreatmentsuchasanalgesicstoalleviatepain.Thegroupagreed
thatwhilstitwasnotpossibletomakearecommendation,health
professionalsshouldconsiderothertreatmentsaccordingtoindividual
need.TheGDGacknowledgedthatavariedrangeoftherapieswere
currentlybeingusedinpracticethatinclude:upperlimbsupport
includingslingsandorthotics,strappingoftheshoulder,rangeofmotion
exercises,ultrasound,electricalstimulation,steroidandbotulinumtoxin
injections,acupunctureandmassagetherapy.Theuseofshoulderslings
maybeassociatedwithsomerisks,includingholdingthelimbinapoor
positionthatislikelytocausesofttissuecontracture,inhibitinguseofa
recoveringlimb,andhaveanadverseeffectonsymmetryandbalance,
makingfallsmorelikely.

13.7 Repetitivetasktraining
Rehabilitationisintegraltothecarepathwayafterstroke.Howevertheoptimumcomponentsof
physicalrehabilitationareuncertain.Repetitivetasktrainingpromotestherepetitionofmotor
movementrelatedtopurposefultasks.Thismightforexampleincludereachingforacuporcombing
hair.Thefocusisgenerallyontheimpairedlimbandisoneapproachtoincreasetheamountof
physicalrehabilitation.

13.7.1

Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessof
repetitivetasktrainingversususualcareonimprovingfunctionandreducingdisability?
ClinicalMethodologicalIntroduction
Population

Adultsandyoungpeople16orolderwhohavehadastroke

Intervention

Repetitivetasktraining
Lowerlimbfunctionaltasksand/or
Upperlimbfunctionaltasks

Comparison

Usualcare

Outcomes

Lowerlimb
Anytimedwalk;6minutewalktest,5metre,10metretimedwalk
Changeinwalkingdistance
Rivermeadmobilityindex
Upperlimb
Arm:
FuglMeyerAssessment,
ActionResearchArmTest(ARAT)
Hand:
Anypegholetest,
FrenchayArmTest,
MotorAssessmentScale(MAS)

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StrokeRehabilitation
Movement
13.7.1.1

Clinicalevidence
SearcheswereconductedforsystematicreviewsandRCTscomparingtheclinicaleffectivenessof
repetitivetasktrainingwithusualcaretoimprovefunctionandreducedisabilityforadultsandyoung
people16orolderwhohavehadastroke.Onlystudieswithaminimumsamplesizeof20
participants(10ineacharm)wereselected.FiveRCTswereidentified.
Table107summarisesthepopulation,intervention,comparisonandoutcomesforeachofthe
studies.
Table107:Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
STUDY

POPULATION

INTERVENTION

COMPARISON

OUTCOMES

Blennerhassett,
200427

Inpatientswith
aprimary
diagnosisof
strokeandwho
areabletowalk
10metreswith
supervision
(withorwithout
walkingaids)

Lowerlimbtraining:
therapistassistedfunctional
tasksincludedsittostand,
stepups,obstaclecourse,
plus
stretching/strengthening
exercise,andsome
endurancetraining
(stationary,bikesand
treadmill)for1hour/day,5
days/weekfor4weeks.
(N=15)

Therapist
assisted
functionaltasks
toimprove
reachand
grasp,handeye
coordination,
stretchingand
strengthening
for1hour/day,
5days/weekfor
4weeks.(N=15)

Higgins,
2006111

Patientswitha
firstor
recurrentstroke
(lessthan1year
poststrokeat
studyentry);
whohadthe
abilitytowalk
10m
independently
usinganaideor
orthosis
with/without
supervision.

Armtraining:
90minutepersession(total
18sessions)3timesaweek
for6weekswithatherapist
torepetitivelyperformtasks
thatthepatientsfound
difficult.Taskswere
changedortheirlevelof
difficultywasincreased
whenpatientsmaximised
theirperformance.
(N=47)

18sessionsof
walking
intervention
consistedof10
functionaltasks
3timesaweek
for6weeks.
(N=44)

Kwakkel,
1999140

Severely
disabled
patientswith
primaryfirst
everstroke
(within14days
afterstroke
onset);withan
inabilitytowalk
atfirst
assessment.

Upperlimbtraining:
functionalexercisesthat
facilitatedforcedarmand
handactivity.(N=33)

Lowerlimbtraining:
emphasisonachieving
stabilityandimprovinggait
velocity(N=31).
Bothinterventionswere
assistedbytherapistsfor30
minutes,5days/weekfora
totalof20weeks,plus
1.5hour/weekactivitiesof
dailylivingtrainingbyan
occupationaltherapist.

Armandleg
were
immobilised
withan
inflatable
pressuresplint
(30min,5
days/week).
(N=37)

NationalClinicalGuidelineCentre,2013.
462

Motor
assessment
Scale(MAS)
hand
6minute
walktest(m)
Timeupand
gotest(sec)

9hole
pegtest

Action
Research
Armtest
(ARAT)
10metre
timed
walkingtest:
comfortable
and
maximum
walking
speed
(m/sec)

StrokeRehabilitation
Movement
STUDY

POPULATION

INTERVENTION

COMPARISON

Salbach,
2004229

Patientswith
walkingdeficit
withinoneyear
ofafirstor
recurrent
stroke;ableto
walk
independently
usinganaideor
orthosis
with/without
supervision.

Lowerlimbtraining:10
walkingrelatedtasks(total
18sessions)supervisedbya
physicaloroccupational
therapist,for3times/week
for6weeks,inrehabilitation
orhospitalsetting.(N=44)

Functional
upperextremity
tasks(total18
sessions/3
timesperweek
for6weeks)
thatweredone
whilesittingand
patientswere
recommended
topractiseat
home.(N=47)

Patientswith
recentfirsttime
stroke(2to35
dayspostonset)
frominfarction
intheanterior
circulation.

Upperlimbtaskfunctional
trainingfor1hour/day,5
days/weekfor4weeks:
repetitivepracticeoftasks
withinthelevelofavailable
voluntarymotion.Alltasks
aredesignedtobestandard,
repeatable,andtohave
somefunctionalgoal(for
examplepointing,grasping
andstirring).(N=22)

Winstein,2004285

NationalClinicalGuidelineCentre,2013.
463

Muscle
facilitation
exercises,
neuromuscular
electric
stimulation
applied
primarilyfor
shoulder
subluxation,
stretching
exercises,
activitiesof
dailyliving(self
carewherethe
upperlimbwas
usedasan
assist)and
caregiver
training.(N=21)

OUTCOMES

6minute
walktest
(m)
5metre
timed
walk:
comfortable
and
maximum
walking
speed(m/s)
Timedup&
gotest(sec)

FuglMeyer
Assessment:
rangeofmotion
pain
sensory
motorfunction

StrokeRehabilitation
Movement

Comparison:lowerlimbtraining(repetitivetaskorfunctional)versususualcare
Table108:Lowerlimbtraining(repetitivetaskorfunctional)versususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings
Qualityassessment

Noofstudies

Design

Limitation
s

Inconsistenc
y

Indirectnes
s

Imprecision

Lowerlimb
training
Mean(SD)or
median(IQR)

Effect
Usual
care
Mean
(SD)or Mean
median differenc
(IQR)
e(95%CI)

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)

Confidence
(ineffect)

6minutewalktest(m)(posttreatmenteffect)(Betterindicatedbyhighervalues)
Blennerhassett
200427;Salbach
2004229

RCTs
single
blinded

Serious
limitations
(a,b)

Noserious
Noserious Serious
inconsistency indirectness imprecision(
c)

Blennerhassett
:404(101)
Salbach:
249(136)

Blenne
rhasset
t:288
(124)
Salbach
:
209
(132)

64.09
(18.52,
109.65)

MD64.09
higher
(18.52to
109.65
higher)

Low

416(171)

313
(154)

103(
13.46,
219.46)

MD103
higher
(13.46
lowerto
219.46
higher)

Low

Blennerhassett
:11.5(3.8)
Salbach:

Blenne
rhasset
t:19.1

6.23(
12.22,
0.25)

MD6.23
lower
(12.22low

Low

6minutewalktest(m)(6monthsfollowup)(Betterindicatedbyhighervalues)
Blennerhassett
200427

RCT
single
blinded

Serious
limitations
(a)

Noserious
Noserious Serious
inconsistency indirectness imprecision(
c)

Timedupandgotest(sec)(posttreatmenteffect)(Betterindicatedbylowervalues)
Blennerhassett
200427;Salbach
2004229

RCTs
single
blinded

Serious
limitations
(a)

Noserious
Noserious Serious
inconsistency indirectness imprecision(
d)

NationalClinicalGuidelineCentre,2013.

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitation
s

Inconsistenc
y

Indirectnes
s

Imprecision

Lowerlimb
training
Mean(SD)or
median(IQR)
23.2(20.6)

Usual
care
Mean
(SD)or Mean
median differenc
(IQR)
e(95%CI)
(14.4)
Salbach
:
27.1
(27.1)

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)
erto0.25
lower)

21.3
(30.3)

10.50(
26.0,5.0)

MD10.50
lower
(26.0
lowerto
5.0
higher)

Low

Kwakke
l:0.37
(0.41)
Salbach
:
0.64
(0.37)

0.48
(0.16,
0.79)

SMD0.48
higher
(0.16
higherto
0.79
higher)

Moderate

Kwakke
l:0.52
(0.58)

0.45
(0.13,
0.77)

SMD0.45
higher
(0.13
higherto

Moderate

Confidence
(ineffect)

Timedupandgotest(sec)(6monthsfollowup)(Betterindicatedbylowervalues)
Blennerhassett
200427

RCT
single
blinded

Serious
limitations
(a)

Noserious
Noserious Serious
inconsistency indirectness imprecision(
d)

10.8(4.5)

5and10metretimedwalk:comfortablespeed(m/sec)(posttreatmenteffect)(Betterindicatedbyhighervalues)
Kwakkel1999140
Salbach2004229

RCTs
single
blinded

Serious
limitations
(a,b)

Noserious
Noserious Noserious
inconsistency indirectness imprecision

Kwakkel:
0.65(0.46)
Salbach:
0.78(0.40)

5and10metretimedwalk:maximumspeed(m/sec)(posttreatmenteffect)(Betterindicatedbyhighervalues)
Kwakkel1999140
Salbach2004229

RCTs
single
blinded

Serious
limitations
(a,b)

Noserious
Noserious Noserious
inconsistency indirectness imprecision

Kwakkel:
0.88(0.66)
Salbach:

NationalClinicalGuidelineCentre,2013.

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitation
s

Inconsistenc
y

Indirectnes
s

Imprecision

Lowerlimb
training
Mean(SD)or
median(IQR)
0.99(0.56)

Usual
care
Mean
(SD)or Mean
median differenc
(IQR)
e(95%CI)
Salbach
:
0.80
(0.49)

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)
0.77
higher)

0.44
(0.44)

0.19(
0.03,
0.41)

MD0.19
higher
(0.03
lowerto
0.41
higher)

Low

0.57
(0.60)

0.28(
0.02,
0.58)

MD0.28
higher
(0.02
lowerto
0.58
higher)

Low

Confidence
(ineffect)

10metretimedwalking:comfortablespeed(m/sec)(6monthsfollowup)(Betterindicatedbyhighervalues)
Kwakkel1999140

RCT
single
blinded

Serious
limitations
(a)

Noserious
Noserious Serious
inconsistency indirectness imprecision
(e)

0.63(0.47)

10metretimedwalking:maximumspeed(m/sec)(6monthsfollowup)(Betterindicatedbyhighervalues)
Kwakkel1999140

RCT
single
blinded

Serious
limitations
(a)

Noserious
Noserious Serious
inconsistency indirectness imprecision
(e)

0.85(0.65)

(a)

Unclearallocationconcealment
7patientswithdrawnfromtrial;4patientswithmissingbaseline/followupdata(Salbach2004).
(c)
ConfidenceintervalcrossedthelowerlimitofagreedMID(28m)
(d)
MeandifferencedidnotreachtheagreedMIDof10sec.
(e)
ConfidenceintervalscrossedoneendofdefaultMID.
(b)

NationalClinicalGuidelineCentre,2013.

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StrokeRehabilitation
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Comparison:Upperlimbtraining(repetitivetaskorfunctional)versususualcare
Table109:

Upperlimbtraining(repetitivetaskorfunctional)versususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings

Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectness

Imprecision

Absolute
effect/
Mean
Differenc
e(MD)
Confidence
(95%CI)
orpvalue (ineffect)

Upperlimb
training
Mean
(SD)/median
(IQR)

Usualcare
Mean
(SD)/
median
(IQR)

1(1)

1(1)

0.00(
0.41,0.41)

MD0.00
(0.41
lowerto
0.41
higher)

Moderate

6(56)

6(56)

(c)

(d)

Moderate
(b)

6(4.26.0)

6(36)

(c)

(d)

Moderate
(b)

6(4.26.0)

6(36)

(c)

p<0.01(e) Moderate
(b)

Mean
difference
(95%CI)

9holepegtest(1monthsfollowup)(Betterindicatedbyhighervalues)
Higgins
2006111

RCT
single
blinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

Motorassessmentscale(MAS)hand(posttreatmenteffect)(Betterindicatedbyhighervalues)
Blennerhasset
t200427

RCT
single
blinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

(b)

Motorassessmentscale(MAS)hand(6monthsfollowup)(Betterindicatedbyhighervalues)
Blennerhasset
t200427

RCT
single
blinded

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

(b)

ActionResearchArmtest(posttreatmenteffect)(Betterindicatedbyhighervalues)
Kwakkel
1999140

RCT
single
blinded

Serious
limitations(
e)

Noserious
inconsistency

Noserious
indirectness

(b)

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectness

Imprecision

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)
Confidence
orpvalue (ineffect)

Upperlimb
training
Mean
(SD)/median
(IQR)

Usualcare
Mean
(SD)/
median
(IQR)

Mean
difference
(95%CI)

4(038)

0(02.25)

(c)

p<0.001(e
)

Moderate
(b)

1.9(2.02)

0.6(1.93)

1.30(
2.48,
0.12)

MD1.30
lower
(2.48
lowerto
0.12
lower)

Verylow

1.6(2.8)

0.6(1.79)

1.00(
2.40,0.40)

MD1.00
lower
(2.40
lowerto
0.40
higher)

Verylow

0.75(2.99)

0.75(1.33)

0.00(
1.37,1.37)

MD0.00
(1.37
lowerto
1.37
higher)

Verylow

ActionResearchArmtest(6monthsfollowup)(Betterindicatedbyhighervalues)
Kwakkel
1999140

RCT
single
blinded

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

(b)

FuglMeyerAssessmentrangeofmotion(posttreatmenteffect)(Betterindicatedbyhighervalues)
Winstein
2004285

RCT
unblinded

Serious
limitations(f
)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision
(g)

FuglMeyerAssessmentpain(posttreatmenteffect)(Betterindicatedbyhighervalues)
Winstein
2004285

RCT
unblinded

Serious
limitations(f
)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision
(g)

FuglMeyerAssessmentsensory(posttreatmenteffects)(Betterindicatedbyhighervalues)
Winstein
2004285

RCT
unblinded

Serious
limitations(f
)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision
(g)

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectness

Imprecision

Upperlimb
training
Mean
(SD)/median
(IQR)

Usualcare
Mean
(SD)/
median
(IQR)

Mean
difference
(95%CI)

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)
Confidence
orpvalue (ineffect)

FuglMeyerAssessmentmotorfunction(posttreatmenteffect)(Betterindicatedbyhighervalues)
Winstein
2004285

RCT
unblinded

Serious
limitations(f
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(h)

16.5(13.74)

9.05(7.6)

7.45(0.85,
14.05)

MD7.45
higher
(0.85
lowerto
14.05
higher)

Low

0.46(2.76)

0.33(1.45) 0.13(
1.44,1.18)

MD0.13
lower
(1.44
lowerto
1.18
higher)

Verylow

1.23(2.42)

1.00(2.88) 0.23(
1.82,1.36)

MD0.23
lower
(1.82
lowerto
1.36
higher)

Verylow

0.69(2.36)

0.07(1.03)

MD0.62
higher

Verylow

FuglMeyerAssessmentrangeofmotion(9monthsfollowup)(Betterindicatedbyhighervalues)
Winstein
2004285

RCT
unblinded

Serious
limitations(f
,i)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision
(g)

FuglMeyerAssessmentpain(9monthsfollowup)(Betterindicatedbyhighervalues)
Winstein
2004285

RCT
unblinded

Serious
limitations(f
,i)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision
(g)

FuglMeyerAssessmentsensory(9monthsfollowup)(Betterindicatedbyhighervalues)
Winstein
2004285

RCT
unblinded

Serious
limitations(f

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision

NationalClinicalGuidelineCentre,2013.

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0.62(
0.46,1.70)

StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations
,i)

Inconsistency

Indirectness

Imprecision
(g)

Upperlimb
training
Mean
(SD)/median
(IQR)

Usualcare
Mean
(SD)/
median
(IQR)

Mean
difference
(95%CI)

8.33
(11.26)

2.56(
7.73,2.61)

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)
Confidence
orpvalue (ineffect)
(0.46
lowerto
1.70
higher)

FuglMeyerAssessmentmotorfunction(9monthsfollowup)(Betterindicatedbyhighervalues)
Winstein
2004285

RCT
unblinded

Serious
limitations(f
,i)

(a)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision
(g)

5.77(4.49)

Unclearallocationconcealment(Blennerhassett2004)
Imprecisioncouldnotbeassessedasresultswerepresentedinmediananditsinterquartilerangeandcouldnotbemetaanalysed.
(c)
Resultswerepresentedasmedian(IQR)andcouldntestimaterelative/absoluteeffect.
(d)

AuthorsreportedthattherewasnosignificantdifferenceontheMAS(hand)betweenthelowerlimbtraininggroupandtheusualgroup.
(e)

Pvalueasreportedbyauthors

(f)
Studywasnotblinded,unclearrandomizationandinadequateallocationconcealment.

(g)
ConfidenceintervalcrossedbothendsofagreedMID(differenceby10%).
(h)
MeandifferenceanditsconfidenceintervalsdidnotreachtheagreedMID(differenceby10%ofthescale).
(i)
Highrateoflosstofollowupat9months(7inthefunctionaltaskgroupand5instandardcaregroup).
(b)

NationalClinicalGuidelineCentre,2013.

470

MD2.56
lower
(7.73
lowerto
2.56
higher)

Verylow

StrokeRehabilitation
Movement

13.7.1.2

Economicevidence
Literaturereview
Norelevanteconomicevaluationscomparingrepetitivetasktrainingwithusualcarewereidentified.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
IntheRCTsincludedintheclinicalreviewasubstantialdifferenceintermsofpersonneltimewasnot
seenbetweenusualcareandrepetitivetasktraining.Somenegligiblecostswouldbelinkedwiththe
useofcardsthatpatientswereaskedtomanipulate(forexample,inHiggins2002111).However,the
GDGnotedthatthiswasduetothestudiesmatchingtheintensityofinput;inreallifeitwas
expectedthatrepetitivetasktrainingmightinvolvesomeadditionaltherapytimeorthatcarers
wouldbetrainedtoassist.

13.7.1.3

Evidencestatements
Clinicalevidencestatements
Twostudies27,229of121participantsshowedthattherewasastatisticallysignificantimprovementin
locomotorperformanceassessedbythe6minutewalktest(m)inthegroupthatreceivedmobility/
lowerlimbtraining,comparedwiththeusualcaregroupattheendofthetreatment(LOW
CONFIDENCEINEFFECT).
Onestudy27of30participantsshowednosignificantdifferenceinlocomotorperformanceassessed
bythe6minutewalktest(m)betweenthemobility/lowerlimbtraininggroupandtheusualcare
groupat6monthsfollowup(LOWCONFIDENCEINEFFECT).
Twostudies27,229of121participantsshowedastatisticallysignificantimprovementintheTimedUp
andGoTest(sec)forthegroupreceivedthelowerlimbtrainingcomparedtotheusualcaregroupat
theendofthetreatment(LOWCONFIDENCEINEFFECT).
Onestudy27of30participantsshowednosignificantdifferenceinlocomotorperformanceassessed
bytheTimedUpandGoTest(sec)betweenthemobility/lowerlimbtraininggroupandtheusual
caregroupat6monthsfollowup(LOWCONFIDENCEINEFFECT).
Twostudies140,229of159participantsfoundasignificantdifferenceincomfortableandmaximum
walkingspeedmeasuredby5and10mtimedwalk(m/sec)betweenthosewhoreceived
mobility/lowerlimbtrainingandtheusualcaregroupattheendofthetreatment(MODERATE
CONFIDENCEINEFFECT).
Onestudy140of68participantsshowednosignificantdifferenceincomfortableandmaximum
walkingspeedmeasuredby5and10mtimedwalk(m/sec)betweenthosewhoreceived
mobility/lowerlimbtrainingandtheusualcaregroupat6monthsfollowup(LOWCONFIDENCEIN
EFFECT).
Onestudy111of91participantsfoundnosignificantdifferenceinthe9holepegtestscoresbetween
thearmtraininggroupandtheusualcaregroupattheendofthetreatment(MODERATE
CONFIDENCEINEFFECT).

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StrokeRehabilitation
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Onestudy285of33participantsshowedthatthestandardcaregroupwasassociatedwitha
statisticallysignificantimprovementintheFuglMeyerassessment(rangeofmotion),comparedwith
thosewhoreceivedfunctionaltaskarmtrainingattheendoftreatment(VERYLOWCONFIDENCEIN
EFFECT).
Onestudy285of33participantsshowednosignificantdifferencebetweenthefunctionaltaskarm
traininggroupandtheusualcaregroupattheendofthetreatmentonthefollowingoutcomes:
FuglMeyerassessment(pain)(VERYLOWCONFIDENCEINEFFECT)
FuglMeyerassessment(sensory)(VERYLOWCONFIDENCEINEFFECT)
Onestudy285of33participantsshowedthatthefunctionaltaskarmtraininggroupwasassociated
withastatisticallysignificantimprovementintheFuglMeyerassessment(motorfunction)compared
withthosewhoreceivedusualcareattheendofthetreatment(LOWCONFIDENCEINEFFECT).
Onestudy285of33participantsfoundnosignificantdifferencebetweenthefunctionaltaskarm
traininggroupandtheusualcaregroupat9monthsfollowuponthefollowingoutcomes:
FuglMeyerassessment(rangeofmotion(VERYLOWCONFIDENCEINEFFECT)
FuglMeyerassessment(pain)(VERYLOWCONFIDENCEINEFFECT)
FuglMeyerassessment(sensory)(VERYLOWCONFIDENCEINEFFECT)
FuglMeyerassessment(motorfunction)(VERYLOWCONFIDENCEINEFFECT)
Evidencestatementscouldnotbeproducedforthefollowingoutcome(s)asresultswerenot
presentedinawaythatenabledthesizeoftheinterventionseffecttobeestimated:
Actionresearcharmtest(upperlimbtrainingversusstandardcare)140
Motorassessmentscale(hand)(upperlimbtrainingversusstandardcare)27
Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

13.7.2

Recommendationsandlinktoevidence
99.Offerpeoplerepetitivetasktrainingafterstrokeonarangeof
tasksforupperlimbweakness(suchasreaching,grasping,
pointing,movingandmanipulatingobjectsinfunctional
tasks)andlowerlimbweakness(suchassittostand
transfers,walkingandusingstairs).
Recommendations:
Relativevaluesofdifferent
outcomes

Alltherepetitivetasksconsideredinthereviewcomprisedofcircuittype
tasksforupperandlowerlimb.Othertypesofrepetitivetasksuchas
dressingpracticeortreadmillwerenotidentifiedbythesearch.
Theoutcomesofinterestforthelowerlimbwereanytimedwalk,
changeinwalkingdistanceandRivermeadMobilityIndex.Astherewere
avarietyofdifferenttimedwalkmeasurestheGDGrequestedthatthe
resultsbepresentedtogetherasnogreateremphasiswouldbeplaced
ononeoveranother.
TheGDGagreedtousethefollowingminimalimportantdifferences
(MIDs)publishedintheliteratureforthefollowingoutcomesreported;
20cm/secforthewalkingspeed,12and17pointsfortheaffected
dominantandnondominantsidesrespectivelywhenassessingthe
outcomeofActionResearchArm(ARAT)anddifferenceby10%ofthe
totalscalefortheFuglMeyerassessment(FMA)(pleaserefertoTable
5inthemethodologychapterformoredetailsonthepublishedsources

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StrokeRehabilitation
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oftheagreedminimalimportantdifferences).
Tradeoffbetweenclinical
benefitsandharms

TheGDGagreedtherewerenosignificantharmsassociatedwiththese
interventions.TheconsensusoftheGDGwasthatrepeatedpracticefor
bothupperandlowerlimbfunctionswaslikelytobebeneficialinterms
ofpatientsqualityoflifeandsocialinclusion.

Economicconsiderations

Norelevantcosteffectivenessevidencewasidentified.Theclinical
studiesincludedinthereviewdidnotindicateadifferenceinresource
usebetweenrepetitivetasktrainingandusualcare;however,itwas
consideredthatinrealitytheremaybesomeadditionalpersonneltime,
thereforecostsassociatedwithrepetitivetasktraining.TheGDG
consideredthesecoststobeoffsetbythebenefits.

Qualityofevidence

TheGDGnotedthattwoofthestudiesincludedinthereview(Salbach,
2004andHiggins2002)arethesamestudywithonereportingupper
extremityinterventionresultsandtheothermobility.
Twostudiesshowedasignificantimprovementinthe6minutewalktest
(Blennerhassett,2004andSalbach,200527,229)andtwointhetimed
metreswalks(Kwakkel,1999andSalbach,2004140,229).TheGDGnoted
thatthisimprovementwasfoundattheendofthestudy(post
treatmenteffect)butnotat6monthsfollowup(Kwakkel,1999140),
howeveritwouldusuallybeexpectedthatoncepatientswerewalking
thiswouldbemaintained.Thelowerlimboutcomesweregraded
betweenlowandmoderateduetostudylimitationsandimprecision
aroundtheeffectestimate.
TheWinstein(2004)studydemonstratedthatfunctionaltaskarm
trainingwasassociatedwithasignificantimprovementwithmotor
functioncomparedtousualcaregroupattheendoftreatment.
Confidenceintheresultsfortheseoutcomeswasgradedasverylowdue
tolimitationsinstudydesign(inadequateallocationconcealmentand
randomisation)andtheeffectestimatenotreachingtheminimal
importantdifferenceof10%ofthescale.Howeverthisimprovementin
themotorabilityoutcomeswasnotpreservedat9monthsfollowup.It
wasnotpossibletoestimatethesizeofeffectoftheupperlimb
interventionswithintheKwakkelandBlennerhassettstudiesasresults
werepresentedonlyasmedians(IQR).

Otherconsiderations

TheGDGconsideredthattheinterventionsusedforupperlimbwhich
includedtaskssuchasmanipulatingplayingcardsandhandwritingare
notrepresentativeofusualtherapeuticinterventions.HowevertheGDG
believedsuchtasksareimportantintermsofenablingthepatientto
undertakeactivitiesthemselvesandpromotingparticipationandself
esteem.TheGDGagreedthatalthoughusefulforsomepatientsthese
arehighleveltasks.TheGDGagreedthatthetrialsincludedthose
peoplewhoalreadyhadsomeupperlimbfunction,andthatthisisthe
groupwhoaremostlikelytobenefitfromtheinterventions.

13.8 Walkingtherapies:treadmillandtreadmillwithbodyweight
support
Therearetwotypesoftreadmilltrainingthatarecurrentlyusedtoassistwiththereeducationof
gaitfollowingastroke.Thefirstisaconventionaltreadmillthatrequiresthestrokesurvivorto
mobilisebearingthefullweightoftheirbody.Thesecondisatreadmillwithbodyweightsupport
thatallowsthestrokesurvivortomobilisewithoutrequiringthattheycarrythefullweightoftheir
body.Astheybecomestrongertheyareabletograduallyreducethebodyweightsupport.Theuse
oftreadmilltrainingbothwithandwithoutbodyweightsupporthasbeenshowntoassistwiththe

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StrokeRehabilitation
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reeducationofgaitfollowingstroke,asanadjuncttoconventionalphysiotherapy.Ithasnotbeen
demonstratedtobeofbenefitinsteadofroutinephysiotherapyintervention.

13.8.1

Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessofall
treadmillversususualcareonimprovingwalking?

13.8.2

Evidencereview:Inpeopleafterstrokewhocanwalk,whatistheclinicalandcost
effectivenessoftreadmillplusbodysupportversustreadmillonlyonimprovingwalking?

13.8.2.1

ClinicalMethodologicalIntroduction

Population

Adultsandyoungpeople16orolderwhohavehadastroke

Intervention

Anytreadmilltraining(withorwithoutbodysupport)

Comparison

Usualcare(otherphysiotherapy)
Treadmillwithoutbodysupport

Outcomes

Walkingspeeds(5m/10m/30m)
Anytimedwalk
Walkingendurance
FunctionalIndependenceMeasure(FIM)
BarthelIndex
RivermeadMobilityIndex

Clinicalevidencereview
Searcheswereconductedforsystematicreviews(ofrandomizedcontrolledtrials(RCTs)andcohort
studies)andRCTsthatcomparedtheeffectivenessofalltreadmilltherapieswithusualcareto
improvewalkingforadultsandyoungpeople16orolderwhohavehadastroke.Onlystudieswitha
minimumsamplesizeof20participants(10ineacharm)andincludingatleast50%ofparticipants
withstrokewereselected.Sixteen(16)RCTswereidentified.Onestudy190includedtreadmill
trainingexercisewithbodysupportcomparedtousualcareandthreestudies15,115,272compared
treadmilltrainingexercisewithbodysupportwithtreadmilltrainingexercisewithoutbodysupport.
Alltheotherstudiescomparedtreadmillwithoutbodyweightsupportversususualcare.Table110
summarisesthepopulation,intervention,comparisonandoutcomesforeachofthestudiesincluded
intheclinicalevidencereview.
Table110:Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
STUDY

POPULATION

INTERVENTION

COMPARISON

OUTCOMES

Barbeau
200315

Strokepatients
(onset<6
monthsago)
referredina
hospitalfor
physical
rehabilitation
whocouldnt
walkinanormal
gaitpattern.

Treadmilltrainingwith
bodywhilean
overheadharness
supporteda
percentageoftheir
bodyweightwiththe
assistanceof1or2
therapistsasneeded.
Patientswere
providedupto40%
bodyweightsupport

Treadmilltraining
withoutabody
supportwiththe
assistanceof1or2
therapistsasneeded
(N=50).

Proportionof
participants
achievedover
groundwalking
speedover0.2m/s
Proportionof
participants
achievedover
groundwalking
enduranceover20m

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StrokeRehabilitation
Movement
STUDY

POPULATION

INTERVENTION
COMPARISON
atthebeginningofthe
training,andthat
percentagewas
progressively
decreasedastheir
abilitytowalk
improved(N=50)

OUTCOMES

Duncan
201173

Inpatientswho
hadstroke
within45days
beforestudy
entryandthe
abilityto
undergo
randomisation
within2months
afterstroke;
patients
experienced
residualparesis
inthelegbut
wereableto
walk3mwith
assistance.

Earlytreadmilltraining
withpartialbody
weightsupportand
manualassistanceas
neededfor2030
minutesat3.2kmper
hour,followedbya
progressiveprogram
ofwalkingoverground
for15minutes.Study
duration:1216weeks.
(N=139)

Homeexercise
programtask
specificwalking
program,managed
byaphysical
therapistinthe
home,withthegoals
ofenhancing
flexibility,rangeof
motioninjoints,
strengthofarmsand
legs,coordination,
andstaticand
dynamicbalance.
(N=126)

10metrewalktime
(m/sec)
6minutewalktest
(m)

Eich,200474

Patientswith
firsttimestroke
(<6weeksof
strokeonset)
referredto
inpatient
rehabilitation
centre.
Followuptime=
3months

Treadmilltrainingwith
nobodyweight
supportfor30minutes
andotherindividual
physiotherapyfor30
minutesfor6weeks
(N=25).

Usualcareincluded
60minutesof
individual
physiotherapydaily
for6weeks(N=25).

10metretimedwalk
(m/sec)
6minutewalktest
(m)
RivermeadMotor
AssessmentScore

Franceschini
,200986

Patientswith
subacutestroke
(<6weeksof
strokeonset)
whowere
unabletowalk.
Followuptime=
6months.

Treadmilltrainingwith
bodyweightsupport
for20minutes
followedby40
minutesof
conventionaltraining
for5timesaweekfor
20sessions.The
trainingshouldhave
beencompleted
within5weeksof
inclusioninthestudy.
(N=52)

Usualcareincluded
20sessionsof
conventional
treatment(consisting
ofovergroundgait
training)of60
minuteseach
session.5timesper
weekfor20sessions,
whichshouldhave
beencompleted
within5weeksof
inclusioninthe
study.(N=50)

10metretimedwalk
test(m/sec)

6minutewalktest
(m)
BarthelIndex

Kosak,
2000138

Patients
admittedto
inpatientstroke
rehabilitation
unit.(timesince

Partialbodyweight
supporttreadmill
training(with
overheadmotorised
hoistattachedtoa

Aggressivebracing
assistedwalking
(usinghemibarand
kneeanklefoot
orthosisifnecessary)

Walkingspeed(2
minutetestperiod)
(m/minute)
Walkingendurance
(m)

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StrokeRehabilitation
Movement
STUDY

POPULATION
stroke(mean
days);39forthe
intervention
groupand40for
thecontrol
group).The
sampleincluded
someseverely
affectedpatients
with
hemiparesis
hemisensory
hemianopic
visualdeficits

INTERVENTION
parachutetypebody
harness;assistedby
physicaltherapistand
physicaltherapyaide)
forupto45minutes
astolerated,and45
minutesoftraditional
physicaltherapy5
daysaweek.(N=22)

COMPARISON
forupto45minutes
astolerated,and45
minutesof
traditionalphysical
therapy5daysa
week.(N=34)

Kuys2011139 Patientswith
firsttimestroke
(timesince
strokemean
days52forthe
intervention
groupand48for
thecontrol
group)
Patientswere
followedupat6
and18weeks
post
intervention.

Treadmilltrainingfor
30minutes(excluding
rests),threetimesa
weekfor6weeks,at
anintensityof4060%
heartratereserveora
BorgRatingof
PerceivedExertionof
1114.Alsoreceived
usualphysiotherapyof
approximatelyone
hourperday.(N=15)

Usualphysiotherapy Walkingendurance
ofapproximatelyone
(m)
hourperdayof
Comfortablewalking
comprehensive
speed(m/sec)
therapyusingatask
Fastwalkingspeed
orientedapproach
(m/sec)
targeting
impairmentsand
activitylimitations
specifictoeach
participant.(N=15)

Langhamme
r,2010143

Patientswith
strokeata
private
rehabilitation
centre.(<8
weeksofstroke
onset)
Nofollowup.

Treadmilltraining
exercisewithnobody
supportforupto30
minutesforfivedays
perweek.
Thetreadmillhad
handrailingstohold
onto,otherwisethere
werenosafety
precautions(N=21).

Outdoorwalking
6minutewalktest
exerciseincluded
(m)
walkingata
10metretimedwalk
comfortablespeed
(m/sec)
fivedaysaweekwith
theuseofordinary
assistivedevices
whennecessary.(N
=18)

Laufer,20011
47

Firststroke
patients(onset
ofstroke<=90
day)withan
abilitytowalkon
treadmillata
speedofatleast
0.2km/hr.with
minimalto
moderate
assistancefor2
minuteswithout
rest.
Nofollowup.

Treadmilltraining
exerciseconsistedof
ambulatingona
motordriventreadmill
whichwasadjustedto
thesubjects
comfortablewalking
speedfor5sessionsa
weekfor3weeks.
Actualwalkingtime
duringtraining
sessionsincluded4
minperdaythefirst
week,6minperdayin
2ndweekand8min
perdayin3rdweek.
(N=13)

Floorwalking
exerciseconsistedof
ambulatingonfloor
surfaceata
comfortablespeed
usingwalkingaids,
assistance,and
restingperiodsas
needed.Actual
walkingtime
included4minper
daythefirstweek,6
minperdayin2nd
weekand8minper
dayin3rdweek.
(N=12).

NationalClinicalGuidelineCentre,2013.
476

OUTCOMES

10metretimedwalk
(m/sec)

StrokeRehabilitation
Movement
STUDY

POPULATION

INTERVENTION

COMPARISON

Luft,2008 Patientswith
chronic
hemipareticgait
(>=6months
aftertheirfirst
stroke).
Nofollowup.

Treadmilltraining
exerciseincluded
threeexercisesof40
minuteseachper
weekatanaerobic
intensityof60%of
heartratereserve,for
6months.(N=57)

Usualcareincluded
10metretimedwalk
13supervised
(m/sec)
traditionalstretching 6minutestimed
movements(actively
walk(m)
ifpossibleor

passively)onaraised
mattablewitha
therapistsassistance
for6months(N=56)

Nilsson,
2001190

Patientswitha
firststroke(<8
weeksfrom
onsetofstroke)
withresidual
hemiparesis
afterstroke.
Followuptime=
10months.

Treadmilltrainingwith
bodyweightsupport
wasprovidedfor30
minutesforfivedaysa
week.Thebodyweight
supportwasgradually
reducedasfastas
possibleasthegoal
wastoattainwalking
onthetreadmillwith
fullweightbearing.
(N=36)

Usualcareincluded
individualwalking
trainingbya
physiotherapistfor
30minutesfivedays
aweek.(N=37)

FIM
10metretimedwalk
(m/sec)

Olawale
2011193

Patients(from
anAfrican
population)with
chronicstroke
(324months)in
anoutpatient
stroke
rehabilitation
unitinatertiary
hospital;who
wereableto
walk10m
independently
withorwithouta
walkingaid.

Treadmillwalking
trainingand
conventional
physiotherapyfor12
weeks.(N=20)

Group1:
Overgroundwalking
exerciseand
conventional
physiotherapyfor12
weeks(N=20)
Group2:
Usualcare
conventional
physiotherapyonly
for12weeks(N=20)

10metretimedwalk
(m/sec)
6minutewalktest
(m)

Pohl,
2002208

Patientswith
hemiparesis
causedby
stroke,admitted
toapoststroke
inpatient
rehabilitation
centre(>4weeks
poststroke).
Nofollowup.

Structuredspeed
dependenttreadmill
training(STT);
12x30minofSTT,8x
45minconventional
physiotherapy(gait
trainingallowed)in
total12hoursof
treatment.
Thetotalwalking
distancevariedfrom
sessiontosession.
(N=20)

Usualcareincluded
12sessionsof45min
conventionalgait
training,8sessionsof
45minconventional
physiotherapy(gait
trainingallowed).
Totaldurationof
training:15hoursof
treatmentfor4
weeks.(N=20)

10metretimedwalk
(m/sec)

160

NationalClinicalGuidelineCentre,2013.
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OUTCOMES

StrokeRehabilitation
Movement
STUDY

POPULATION

INTERVENTION

COMPARISON

Visintin1998
272

Patients
admittedto
hospitalwith
stroke(<6
monthsago),not
walkingwitha
normalgait
patternandnot
ambulating
beforestroke.
Followuptime=
3months.

Treadmillgaittraining
whileanoverhead
harnesssupporteda
percentageoftheir
bodyweight.
Individualsinthebody
weightsupportgroup
wereprovidedupto
40%bodyweight
supportatthe
beginningoftraining,
andthepercentageof
bodyweightsupport
wasprogressively
decreasedasthe
subjectsgaitpattern
andabilitytowalk
improved.Body
weightsupport
treadmilltrainingwas
givenatafrequencyof
fourtimesperweek
for6weeks(nomore
than20minutesper
session).(N=50)

Thecontrolgroup
10metretimedwalk
receivedgaittraining
(m/sec)
onatreadmillwith
Walkingendurance
nobodyweight
(m)
support,i.e.while

bearingfullweight
ontheirlower
extremities.
Treadmillwithout
bodysupportwas
givenfor6weeksat
afrequencyoffour
timesperweek(no
morethan20
minutespersession).
(N=50)

Hoyer,2012
115

Patientsmainly
<6monthsafter
onsetofstroke,
useofwheel
chair,
dependenceon
assistancefor
walkingwithor
withoutwalking
aids,medically
stable,no
neurologicalor
orthopaedic
contraindication
sforwalking.

Treadmilltrainingwith
bodyweightsupport
(TTBWS),plus
conventionalgait
trainingandfunctional
trainingforaperiodof
minimum10weeks.
TTBWSwasdailyfor
the1st4weeks(20
sessions),andthen12
timesaweek(10
sessions)forthe
remaining6weeks.
(N=30)

Intensivegait
training(30min)and
functionaltraining
(30min)dailyfor
minimum10weeks.
(N=30)

Globas
201294

38patientswith
stroke(>6
months)aged
>60yearswith
residual
hemipareticgait
(atleast1clinical
signforparesis,
spasticityor
circumductionof
affectedleg
whilewalking);
abilitytowalkon
treadmillat
0.3km/hr.for3
minuteswith

Highintensityaerobic
treadmillexercise
(TAEX)for3months
(39sessions)starting
with1020minutesat
4050%heartrate
reserve(HRR)building
upto3050minutesat
6080%HRR

ConventionalCare
Sustainedwalking
Physiotherapy(13
ability(6minute
sessionsof1hour
walk).
each/week)including 10mtimedwalkat
passivemuscletone
comfortableand
regulatingexercises
maximalspeeds;
forupperandlower

extremity,balance
training

NationalClinicalGuidelineCentre,2013.
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OUTCOMES

Functional
Independence
Measure(FIM)
10mwalktest(m/s)
6minwalktest(m)

StrokeRehabilitation
Movement
STUDY

POPULATION
INTERVENTION
handrailsupport.

COMPARISON

OUTCOMES

Kang
2012131

30Patientswith
hemiparetic
stroke6months
afterdiagnosis;
whocouldwalk
unaidedfor>15
minutes;without
visualdisability
orhemianopia;
MiniMental
State
Examination
score21or
higher;
Brunnstrum
stage>4.

Generalstretching
addingrangeof
motiontobothsides
oftrunk,armsand
legs.Allpatients
received
conventional
physiotherapy5
timesaweekfor4
weeks

10mwalktest,
6minutewalktest

Treadmilltraining3
timesaweekfor4
weeks,30minutes
eachdayspeed
increasedby0.1kmhr
eachtimepatients
couldwalkstablyfor
20seconds;2x15
minuteswith5minute
break

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StrokeRehabilitation
Movement

Comparison:Treadmilltraining(withorwithoutbodysupport)versususualcare
Table111:Alltreadmilltraining(withorwithoutbodysupport)versususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings

Summaryoffindings
Qualityassessment

Noof
studies

Design

Effect

Limitations

Inconsistency

Indirectness Imprecision

All
treadmill
training
Mean(SD)
ormedian
(range)

Usual
care
Mean
(SD)or
median
(range)

Mean
difference
(95%CI)

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)

Confidence
(ineffect)

6minutewalktest(m)(acutestrokepatients)(posttreatmenteffect)(Betterindicatedbyhighervalues)
2
Eich200474
Langhamme
r2010143

RCTssingle
blinded

Serious
limitations(a)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

Eich2004:
198.8
(81.1)
Langhamm
er2010:
320.6
(153.8)

Eich
2004:
164.4
(69.3)
Langham
mer
2010:
310.1
(164.4)

31.9
(8.18,
70.56)

MD31.19 Moderate
higher
(8.18
lowerto
70.56
higher)

Olawale
155.27
(66.37)
Globas
265.9
(189)
Kang
240.9

1.07
(17.60,
19.75)

MD1.07
lower
(17.60
lowerto
19.75
higher)

6minutewalktest(m)(chronicstrokepatients)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Olawale
2011193
Globas
201294Kang
2012131

RCTunclear
blinding

Veryserious
limitations(b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

Olawale
145.32
(74.97)
Globas
332.1
(138)Kang
242.3(26)

NationalClinicalGuidelineCentre,2013.

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Low

StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noof
studies

Design

Effect

Limitations

Inconsistency

All
treadmill
training
Mean(SD)
ormedian
(range)

Usual
care
Mean
(SD)or
median
(range)
(22.4)

(c)

Franceschi
ni2009:
160(118
231)
Luft2008:
0.63(0.52
0.73)

Noserious
imprecision

(c)

Indirectness Imprecision

Mean
difference
(95%CI)

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)

Francesc
hini
2009:
170
(90.5
250)
Luft
2008:
0.57
(0.46
0.69)

(c)

(c)

Low(c)

224.8(90)

163
(70.2)

61.8
(16.48,
107.12)

MD61.8
higher
(16.48to
107.12
higher)

Moderate

217
(108.8
332.5)

210
(140
335)

(c)

(c)

High(f)

Confidence
(ineffect)

6minutewalktest(m)(posttreatment)(e)(Betterindicatedbyhighervalues)
2
Franceschini
200986
Luft2008160

RCTssingle
blinded

Veryserious
limitations(a)

Noserious
inconsistency

Noserious
indirectness

6minutewalktest(m)(18weeksfollowup)(Betterindicatedbyhighervalues)
1
Eich200474

RCTssingle
blinded

Serious
limitations(a)

Noserious
inconsistency

Noserious
indirectness

6minutewalktest(m)(6monthsfollowup)(d)(Betterindicatedbyhighervalues)
1
Franceschini
200986

RCTssingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

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Movement

Summaryoffindings
Qualityassessment

Noof
studies

Design

Effect

Limitations

Inconsistency

Indirectness Imprecision

All
treadmill
training
Mean(SD)
ormedian
(range)

Usual
care
Mean
(SD)or
median
(range)

Mean
difference
(95%CI)

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)

Confidence
(ineffect)

10metretimedwalk(m/sec)(acutestrokepatients)(posttreatmenteffect)(Betterindicatedbyhighervalues)
4
Eich200474
Langhamme
r2010143
Laufer
2001147
Pohl2002208

RCTssingle
blinded

Veryserious
limitations(a,h)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

Eich2004:
0.7(0.3)
Langhamm
er2010:
1.0(0.4)
Laufer
2001:
0.47(0.4)
Pohl2002:
1.63(0.8)

Eich
2004:
0.6
(0.22)
Langham
mer
2010:
0.9(0.5)
Laufer
2001:
0.33
(0.24)
Pohl
2002:
0.97
(0.64)

0.14(0.03,
0.26)

MD0.14
higher
(0.03
lowerto
0.26
higher)

Low

Olawale
9.28
(0.4)
Globas
0.87(0.6
2)
Kang0.5

0.41
(0.29,
0.53)

MD0.41
higher
(0.29to
0.53
higher)

Moderate

10metretimedwalk(m/sec)(chronicstrokepatients)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Olawale
2011193
Globas
201294Kang
2012131

RCTunclear
blinding

Serious
limitations(b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

Olawale
6.71(0.6)
Globas
1.02(0.38)
Kang0.5
(0.2)

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Movement

Summaryoffindings
Qualityassessment

Noof
studies

Design

Effect

Limitations

Inconsistency

Indirectness Imprecision

All
treadmill
training
Mean(SD)
ormedian
(range)

Usual
care
Mean
(SD)or
median
(range)
(0.1)

Franceschi
ni2009:
0.5(0.3
0.9)
Luft2008:
0.82(0.69
0.95)

Mean
difference
(95%CI)

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)

Francesc
hini
2009:
0.6(0.3
0.9)
Luft
2008:
0.71
(0.58
0.84)

(g)

(g)

Moderate
(f)

Eich2004:
0.77(0.35)
Nilsson
2001:
0.7(0.3)

Eich
2004
0.58
(0.22)
Nilsson
2001:
0.8(0.4)

0.07
(0.06,
0.19)

MD0.07
higher
(0.06
lowerto
0.19
higher)

Moderate

0.7(0.3
1.0)

0.8(0.5
1.1)

(g)

(g)

High(f)

Confidence
(ineffect)

10metretimedwalktest(m/sec)(posttreatmenteffect)(e)(Betterindicatedbyhighervalues)
2
Franceschini
200986
Luft,2008160

RCTssingle
blinded

Serious
limitations(e)

Noserious
inconsistency

Noserious
indirectness

(f)

10metretimedwalk(m/sec)(mean29weeksfollowup)(Betterindicatedbyhighervalues)
2
Eich200474
Nilsson
2001190

RCTssingle
blinded

Serious
limitations(a)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

10metretimedwalk(m/sec)(6monthsfollowup)(c)(Betterindicatedbyhighervalues)
1
Franceschini
200986

RCTsingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

(f)

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Movement

Summaryoffindings
Qualityassessment

Noof
studies

Design

Effect

Limitations

Inconsistency

All
treadmill
training
Mean(SD)
ormedian
(range)

Usual
care
Mean
(SD)or
median
(range)

Serious
imprecision
(i)

11(9.38)

11(5.83)

0.00(
4.38,4.38)

MD0.00
higher
(4.38
lowerto
4.38
higher)

Verylow

Serious
imprecision(i
)

74(70.36)

72
(64.14)

2.00(
34.46,
38.46)

MD2.00
higher
(34.46
lowerto
38.46
higher)

Verylow

Veryserious
imprecision(
k)

284(139)

279
(163)

5.00(
106.86,11
6.86)

MD5
higher
(106.86
lowerto
116.86
higher)

Low

Veryserious
imprecision(
k)

291(157)

293
(180)

2.00(
137.14,
133.14)

MD2
lower
(137.14

Low

Indirectness Imprecision

Mean
difference
(95%CI)

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)

Confidence
(ineffect)

Walkingspeed(2minutes)(m/min)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Kosak
2000138

RCTssingle
blinded

Veryserious
limitations(b)

Noserious
inconsistency

Serious
indirectness
(j)

Walkingendurance(m)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Kosak
2000138

RCTsingle
blinded

Veryserious
limitations(b)

Noserious
inconsistency

Serious
indirectness
(j)

Walkingendurance(m)(6weeksfollowup)(Betterindicatedbyhighervalues)
1Kuys
2011139

RCTsingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Walkingendurance(m)(18weeksfollowup)(Betterindicatedbyhighervalues)
1Kuys
2011139

RCTsingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noof
studies

Design

Effect

Limitations

Inconsistency

All
treadmill
training
Mean(SD)
ormedian
(range)

Usual
care
Mean
(SD)or
median
(range)

0.63(0.3)

0.68
(0.37)

0.05(0.3, MD0.05
0.2
lower
(0.3
lowerto
0.2
higher)

Low

Veryserious
imprecision(
k)

0.72(0.35)

0.66
(0.41)

0.06(
0.25,0.37)

MD0.06
higher
(0.25
lowerto
0.37
higher)

Low

Veryserious
imprecision(
k)

0.86(0.43)

0.86
(0.47)

0(0.33,
0.33)

MD0
higher
(0.33
lowerto
0.33
higher)

Low

Indirectness Imprecision

Mean
difference
(95%CI)

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)
lowerto
133.14
higher)

Confidence
(ineffect)

Comfortablewalkingspeed(m/sec)(6weeksfollowup)(Betterindicatedbyhighervalues)
1Kuys
2011139

RCTsingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision(
k)

Comfortablewalkingspeed(m/sec)(18weeksfollowup)(Betterindicatedbyhighervalues)
1Kuys
2011139

RCTsingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Fastwalkingspeed(m/sec)(6weeksfollowup)(Betterindicatedbyhighervalues)
1Kuys
2011139

RCTsingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Fastwalkingspeed(m/sec)(18weeksfollowup)(Betterindicatedbyhighervalues)

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Movement

Summaryoffindings
Qualityassessment

Effect
All
treadmill
training
Mean(SD)
ormedian
(range)

Usual
care
Mean
(SD)or
median
(range)

Mean
difference
(95%CI)

Veryserious
imprecision(
k)

0.91(0.46)

0.82
(0.49)

0.09(
0.29,0.47)

MD0.09
higher
(0.29
lowerto
0.47
higher)

Low

Serious
imprecision(l
)

81.9(9.6)

80.3
(15.9)

1.6(4.96,
8.16)

MD1.6
higher
(4.96
lowerto
8.16
higher)

Low

Serious
imprecision(
m)

32(5)

31.5
(6.6)

0.50
(2.44,
3.44)

MD0.50
higher
(2.44
lowerto
3.44
higher)

Low

(f)

3(24)

2(13.5)

(g)

(g)

High(f)

Noof
studies

Design

Limitations

Inconsistency

Indirectness Imprecision

1
Kuys2011139

RCTsingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)

Confidence
(ineffect)

FIMmotoritems(10monthsfollowup)(Betterindicatedbyhighervalues)
1
Nilsson
2001190

RCTsingle
blinded

Serious
limitations(a)

Noserious
inconsistency

Noserious
indirectness

FIMcognitiveitems(10monthsfollowup)(Betterindicatedbyhighervalues)
1
Nilsson
2001190

RCTsingle
blinded

Serious
limitations(a)

Noserious
inconsistency

Noserious
indirectness

BarthelIndex(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Franceschini
200986

RCTssingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

BarthelIndex(6monthsfollowup)(Betterindicatedbyhighervalues)

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noof
studies
1
Franceschini
200986

Effect
All
treadmill
training
Mean(SD)
ormedian
(range)

Usual
care
Mean
(SD)or
median
(range)

(f)

4(45)

(f)

Design

Limitations

Inconsistency

Indirectness Imprecision

RCTssingle
blinded

Noserious
limitation

Noserious
inconsistency

Noserious
indirectness

Mean
difference
(95%CI)

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)

Confidence
(ineffect)

4(35)

(g)

(g)

High(f)

11(11)

11(10
11)

(g)

(g)

Low(f)

11(11)

11(10
11)

(g)

(g)

Low(f)

Rivermeadgrossfunction(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Eich200474

RCTsingle
blinded

Veryserious
limitations(a)

Noserious
inconsistency

Noserious
indirectness

RivermeadMotorAssessmentScore(18weeksfollowup)(Betterindicatedbyhighervalues)
1
Eich200474

RCTsingle
blinded

Veryserious
limitations(a)

Noserious
inconsistency

(a)

Noserious
indirectness

(f)

Inadequaterandomisation(Eich2004;Langhammer2010;Laufer2001;Nilsson2001;Kang2012)
Unclearblinding(Globas2012),randomisationmethodandallocationconcealment(Olawale2011;Kossak2000)
(c)
Thisoutcomeispresentedseparatelyforthestudiesthatcouldnotbemetaanalysedastheresultswerenotpresentedwiththemeanandstandarddeviation
(d)

Highdropoutrate35%inexperimentalgroupand39%incontrolgroup(Luft2008)
(e)
Imprecisioncouldnotbeassessedbecauseonlymedianandinterquartilerangesofdatawerereported.
(f)

Relativeandabsoluteeffectcouldnotbeassessedbecausemedianandinterquartilerangesofdatareported

(g)
Unclearallocationconcealment(Laufer2001;Pohl2002)
(h)

ConfidenceintervalcrossedoneendofdefaultMID.
(i)
Controlgroupreceivedaggressivebracingassistedwalkingexercise.
(j)
ConfidenceintervalcrossedbothendsofdefaultMID.
(k)
ConfidenceintervalcrossedoneendofagreedMID(17points).
(l)
ConfidenceintervalcrossedoneendofagreedMID(3points).
(b)

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StrokeRehabilitation
Movement

Comparison:Earlytreadmilltrainingexercise(2monthsafterstroke)withbodyweightsupportversushomeexerciseprogram
Table112:Earlytreadmilltrainingexercise(2monthsafterstroke)withbodyweightsupportversushomeexerciseprogramClinicalstudy
characteristicsandclinicalsummaryoffindings
Summaryoffindings
Qualityassessment

Noof
studies

Design

Limitations

Inconsistency

Indirectness Imprecision

Early
body
weight
support
treadmill
Mean
(SD)

Effect
Home
exercise
program
Mean
(SD)

Mean
difference
(95%CI)

Mean
Differenc
e(MD)
(95%CI)

Confidence
(ineffect)

10metretimedwalktest(m/sec)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Duncan
201173

RCTSingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(a)

0.25(0.21
)

0.23(0.20
)

0.02
(0.03,
0.07)

MD0.02
higher
(0.03
lowerto
0.07
higher)

Moderate

Serious
imprecision
(a)

0.23
(0.20)

0.25(0.22
)

0.02
(0.07,
0.03)

MD0.02
lower
(0.07
lowerto
0.03
higher)

Moderate

Serious
imprecision
(b)

81.8
(62.8)

75.9
(69.3)

5.9
(10.08,
21.88)

MD5.9
higher
(10.08
lowerto
21.88
higher)

Moderate

10metretimedwalktest(m/sec)(6monthsfollowup)(Betterindicatedbyhighervalues)
1
Duncan
201173

RCTSingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

6minutewalktest(m)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Duncan
201173

RCTSingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

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Movement

Summaryoffindings
Qualityassessment

Noof
studies

Design

Limitations

Inconsistency

Indirectness Imprecision

Early
body
weight
support
treadmill
Mean
(SD)

Effect
Home
exercise
program
Mean
(SD)

Mean
difference
(95%CI)

Mean
Differenc
e(MD)
(95%CI)

Confidence
(ineffect)

6minutewalktest(m)(6monthsfollowup)(Betterindicatedbyhighervalues)
1
Duncan
201173

RCTSingle
blinded

Noserious
limitations

Noserious
inconsistency

Noserious
indirectness

Veryserious 73.2
imprecision (69.4)
(b)

85.2
(72.9)

12.0
(29.18,
5.18)

(a)

ConfidenceintervalbothendsofdefaultMID.
MeandifferencedidnotreachtheagreedMIDof28m.

(b)

NationalClinicalGuidelineCentre,2013.

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MD12.0
lower
(29.18
lowerto
5.18
higher)

Moderate

StrokeRehabilitation
Movement

Comparison:Treadmilltrainingexercisewithbodysupportversustreadmilltrainingexercisewithoutbodysupport
Table113:TreadmillplusbodyweightsupportversustreadmillonlyClinicalstudycharacteristicsandclinicalsummaryoffindings

Summaryoffindings
Qualityassessment

Noof
studies

Design

Limitations

Inconsistency

Indirectness Imprecision

Body
weight
support
treadmill
Mean
(SD),
Frequenc
y(%)

Effect
Treadmill
only
Mean
(SD),
Frequenc
y(%)

Mean
difference
/Risk
Ratio
(95%CI)

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)

Confidence
(ineffect)

10metretimedwalk(m/sec)(posttreatmenteffect)(Betterindicatedbyhighervalues)
2
Hoyer2012
115
,
Visintin
1998272

RCTSingle
blinded

Serious
limitations(a)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

Hoyer:
0.33
(0.24)
Visintin:
0.34
(0.26)

Hoyer:
0.32
(0.22)
Visintin:
0.25
(0.36)

0.04(
0.05,
0.13)

MD0.04
higher
(0.05
lowerto
0.13
higher)

Moderate

Hoyer:
0.4(0.27)
Visintin:
0.52
(0.32)

Hoyer:
0.36
(0.24)
Visintin:
0.30
(0.29)

0.11
(0.01,
0.21)

MD0.11
higher
(0.01to
0.21
higher)

Verylow

105
(112.2)

42.4(
8.75,
93.55)

MD42.4
higher
(8.75
lowerto
93.55

Verylow

10metretimedwalk(m/sec)(1112weeksfollowup)(Betterindicatedbyhighervalues)
2
Hoyer2012
115
,
Visintin
1998272

RCTSingle
blinded

Veryserious
limitations(a,
b)

Serious
inconsistency(
i)

Noserious
indirectness

Noserious
imprecision

Walkingendurance(m)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Visintin
1998272

RCTSingle
blinded

Serious
limitations(a)

Noserious
inconsistency

Noserious
indirectness

Veryserious 147.4
imprecision( (119.35)
c)

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Movement

Summaryoffindings
Qualityassessment

Noof
studies

Design

Limitations

Inconsistency

Indirectness Imprecision

Body
weight
support
treadmill
Mean
(SD),
Frequenc
y(%)

Effect
Treadmill
only
Mean
(SD),
Frequenc
y(%)

Mean
difference
/Risk
Ratio
(95%CI)

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)
higher)

Confidence
(ineffect)

Walkingendurance(m)(3monthsfollowup)(Betterindicatedbyhighervalues)
1
Visintin
1998272

RCTSingle
blinded

Veryserious
limitations
(a,b)

Noserious
inconsistency

Noserious
indirectness

Veryserious 202.4
imprecision (122.78)
(c)

152.3
(141)

50.10(
22.82,
123.02)

MD50.1
higher
(22.82
lowerto
123.02
higher)

Verylow

13/50
(26%)

RR1.31
(0.71to
2.4)

81more
Verylow
per1000
(from75
fewerto
364more)

Proportionofparticipantsachievedovergroundwalkingspeedover0.2m/s(posttreatmenteffect)
1Barbeau15

RCTDouble
blinded

Serious
limitations(d)

Noserious
inconsistency

Noserious
indirectness

Veryserious 17/50
imprecision
(e)

Proportionofparticipantsachievedovergroundwalkingenduranceover20m(posttreatmenteffect)
15

1Barbeau

RCTDouble
blinded

Serious
limitations(d)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(f)

24/50
(48%)

19/50
(38%)

RR1.26
(0.8to
1.99)

99more
Low
per1000
(from76
fewerto
376more)

Serious
imprecision(
g)

108.39
(76.84)

98.03
(61.90)

10.36(
24.95,
45.67)

MD10.36
higher
(24.95

6metrewalktest(m)(posttreatmenteffect)(betterindicatedbyhighervalues)
1
Hoyer2012
115

RCTsingle
blinded

Serious
limitations(a)

Noserious
inconsistency

Noserious
indirectness

NationalClinicalGuidelineCentre,2013.

491

Low

StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noof
studies

Design

Limitations

Inconsistency

Indirectness Imprecision

Body
weight
support
treadmill
Mean
(SD),
Frequenc
y(%)

Effect
Treadmill
only
Mean
(SD),
Frequenc
y(%)

108.39
(76.84)

98.03
(61.90)

Mean
difference
/Risk
Ratio
(95%CI)

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)
lowerto
45.67
higher)

Confidence
(ineffect)

6metrewalktest(m)(11weeksfollowup)(Betterindicatedbyhighervalues)
1
Hoyer2012
115

RCTsingle
blinded

Serious
limitations(a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision(
g)

22.23(
22.91,
67.37)

MD22.23
higher
(22.91
lowerto
67.37
higher)

Low

5.35(
19.92,
9.22)

MD5.35
lower
(19.92
lowerto
9.22
higher)

Verylow

6.83(
21.35,
7.69)

MD6.83
lower
(21.35
lowerto
7.69
higher)

Verylow

FunctionalIndependenceMeasure9,shortertransfer(sec):(Postintervention)(Betterindicatedbylowervalues)
1
Hoyer2012
115

RCTsingle
blinded

Serious
limitations(a)

Noserious
inconsistency

Noserious
indirectness

Very
serious
imprecision(
h)

40.32
(28.98)

45.67
(28.61)

FunctionalIndependenceMeasure9,shortertransfer(sec):(11weeksfollowup)(Betterindicatedbylowervalues)
1
Hoyer2012
115

RCTsingle
blinded

Serious
limitations(a)

Noserious
inconsistency

Noserious
indirectness

Very
serious
imprecision(
h)

33.02
(25.07)

39.85
(31.89)

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StrokeRehabilitation
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Summaryoffindings
Qualityassessment

Noof
studies

Design

Limitations

Inconsistency

Indirectness Imprecision

Body
weight
support
treadmill
Mean
(SD),
Frequenc
y(%)

Effect
Treadmill
only
Mean
(SD),
Frequenc
y(%)

Mean
difference
/Risk
Ratio
(95%CI)

Absolute
effect/
Mean
Differenc
e(MD)
(95%CI)

Confidence
(ineffect)

FunctionalIndependenceMeasure13,StairsNinestepsupdowntransfer(sec):(Postintervention)(Betterindicatedbylowervalues)
1
Hoyer2012
115

RCTsingle
blinded

Serious
limitations(a)

Noserious
inconsistency

Noserious
indirectness

Very
serious
imprecision(
h)

61.31
(43.04)

80.79
(61.55)

19.48(
46.36,
7.40)

MD19.48
lower
(46.36
lowerto
7.40
higher)

Verylow

FunctionalIndependenceMeasure13,StairsNinestepsupdowntransfer(sec):(11weeksfollowup)(Betterindicatedbylowervalues)
1
Hoyer2012
115

RCTsingle
blinded

Serious
limitations(a)

Noserious
inconsistency

Noserious
indirectness

Very
serious
imprecision(
h)

48.4
(31.82)

67.03
(51.70)

(a)

Unclearallocationconcealment.
Highdropoutrate(34%)duringfollowupforVinsintin
(c)
ConfidenceintervalcrossedbothendsofdefaultMID.
(d)
Unclearallocationconcealment.28%ofthecontrolgroupdidnotcompletethestudy.
(e)
ConfidenceintervalcrossedbothendsofdefaultMID(0.75,1.25).
(f)
ConfidenceintervalcrossedtheupperlimitofMID(1.25).
(g)
ConfidenceintervalcrossesoneendofagreedMID(28m)
(h)
ConfidenceintervalcrossesbothendsofdefaultMID(0.5)
(i)
Heterogeneity:I=64%
(b)

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18.63[
40.35,
3.09]

MD18.63
lower
(40.35
lowerto
3.09
higher)

Verylow

StrokeRehabilitation
Movement

13.8.2.2

Economicevidence
Literaturereview
Norelevanteconomicevaluationswereidentifiedcomparingtreadmilltrainingwithusualcare,or
treadmilltrainingwithbodysupportwithtreadmilltrainingwithoutbodysupport.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
Inmoststudiesidentifiedintheclinicalreviewthemaindifferenceintermsofresourcesuse
betweentreadmilltrainingandusualcarewastheuseofthetreadmillandtherewasnosubstantial
differenceinpersonneltime.Illustrativetreadmillcostsarepresentedbelow.
AGDGmembersuppliedpricedataonaspecifictypeoftreadmillwithoutbodysupportunit.This
datawasobtainedfromthemanufacturerofthetreadmill(Cranlea&CoMedical).Thetreadmill
modelwasaWoodwaymodeldesmohip,anditscostamountedto9,421(2011prices),withan
additional500estimatedasdeliveryandinstallationcosts.TheGDGalsosupplieddataregarding
therateofutilisationofatreadmillwithoutbodyweightsupportforanNHSTrustwithaninpatient
subacutestrokerehabilitationservice(basedatGuysandStThomasNHSFoundationTrust)where
patientsareusually060dayspoststroke.Thetreadmillaloneisusedtothelevelofapproximately2
4treatmentsessionseachday,whereeachsessionlastsforabout1hour.Annuitisingthiscost
assumingausefullifetimeof5years,noresalevalueandadiscountrateof3.5%,andassuming
usageof3sessionsperday,thiswouldequatetoacostpersessionof1.94.
Theestimateforthecostofatreadmillwithbodyweightsupportwasobtainedbycontactingthe
authorofaUSstudy(Walker,2010279).Theoverallcostquotedbytheauthorwasof$20,000(of
which$2,000wasthecostofthetreadmillalone),equivalentto13,029(at2009prices).The
manufacturerofthetreadmillandoftheBSWunitwasBiodex(aUScompany).AGDGmember
supplieddataregardingtherateofutilisationofatreadmillwithbodyweightsupportforanNHS
Trustwithaninpatientsubacutestrokerehabilitationservice(basedatGuysandStThomasNHS
FoundationTrust)wherepatientsareusually060dayspoststroke.ThetreadmillwithBWSunitis
usedforapproximately1patientpermonthforapproximately46treatmentsoverall.Annuitising
thiscostassumingausefullifetimeof5years,noresalevalueandadiscountrateof3.5%,and
assumingusageof5sessionspermonth,thiswouldequatetoacostpersessionof46.47.

13.8.2.3

Evidencestatements
Clinicalevidencestatements
Twostudies74,143of83participantswithacutestrokefoundthattherewasnosignificantdifferencein
walkingcapacity(6minutewalktest)(m)betweentheparticipantswhoreceivedtreadmilltraining
withnobodyweightsupportandthosewhohadusualcareattheendofthestudy(MODERATE
CONFIDENCEINEFFECT).
Threestudies19394,131of100participantswithchronicstroke(upto24monthspoststroke)found
thattherewasnosignificantdifferenceinwalkingcapacity(6minutewalktest)(m)betweenthose
whoreceivedtreadmilltrainingwithoutbodyweightsupportandtheusualcaregroupattheendof
thestudy(LOWCONFIDENCEINEFFECT).

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Onestudy74of49participantsfoundthattreadmilltrainingwithnobodyweightsupportwas
associatedwithastatisticallysignificantimprovementinwalkingcapacity(6minutewalktest)(m)
comparedtothosereceivingusualcareattheendofthe18weeksfollowup(MODERATE
CONFIDENCEINEFFECT).
Fourstudies74,143,147,208comprisingof148participantswithacutestrokefoundastatistically
significantimprovementingaitspeed(10metretimedwalktest)(m/sec)inthosewhoreceived
treadmilltrainingwithnobodyweightsupportcomparedtothosewhoreceivedusualcareatthe
endofthestudy(LOWCONFIDENCEINEFFECT).
Threestudies19394,131of100participantswithchronicstroke(upto24monthspoststroke)founda
statisticallysignificantlargerimprovementingaitspeed(10metretimedwalktest)(m/sec)inthose
whoreceivedtreadmilltraining,comparedtothosewhoreceivedusualcareattheendofthestudy
(MODERATECONFIDENCEINEFFECT).
Twostudies74,190comprisingof102participantsfoundnosignificantdifferenceingaitspeed(10
metretimedwalktest)(m/sec)betweenthealltreadmilltraininggroup(withandwithoutbody
weightsupport)andthosewhoreceivedusualcareattheendofthefollowup(average29weeks)
(MODERATECONFIDENCEINEFFECT).
Onestudy138comprisingof56participantsfoundnosignificantdifferencebetweenthepartialbody
weightsupporttreadmillgroupandthosewhoreceivedaggressivebracingassistedwalkingatthe
endofthestudyonthefollowingoutcomes:
walkingspeedovera2minutetestperiod(m/minute)(VERYLOWCONFIDENCEINEFFECT)
walkingendurance(m)(VERYLOWCONFIDENCEINEFFECT).
Onestudy190comprisingof60participantsfoundnosignificantdifferencebetweenthetreadmill
traininggroupwithbodyweightsupportandthosewhoreceivedusualcareat10monthsfollowup
onthefollowingoutcomes:
FIMmotoritems(LOWCONFIDENCEINEFFECT)
FIMcognitiveitems(LOWCONFIDENCEINEFFECT).
Onestudy139comprisingof30participantsfoundnosignificantdifferencebetweentheparticipants
receivedthetreadmilltraininggroupandthosewhoreceivedusualcareat6and18monthsfollow
uponthefollowingoutcomes:
walkingendurance(LOWCONFIDENCEINEFFECT)
comfortablewalkingspeed(m/sec)(LOWCONFIDENCEINEFFECT)
fastwalkingspeed(m/sec)(LOWCONFIDENCEINEFFECT).
Onestudy73comprisingof265participantsfoundthattherewassignificantdifferencebetweenthe
participantswhoreceivedearlybodyweightsupportedtreadmilltrainingandthosewhoreceived
homeexerciseprogramonthefollowingoutcomes:
10metretimedwalktest(m/sec)attheendofthestudyand6monthsfollowup(MODERATE
CONFIDENCEINEFFECT)
6minutewalktest(m)attheendofthestudyand6monthsfollowup(MODERATECONFIDENCE
INEFFECT)
Twostudies272,115comprisingof139participantsfoundnosignificantdifference(in10metretimed
walktest)betweentheparticipantswhoreceivedbodyweightsupportedtreadmilltrainingand
thosewhoreceivedonlytreadmilltrainingpostintervention(MODERATECONFIDENCEINEFFECT)
Twostudies272,115comprisingof139participantsshowedsignificantdifferencein10metretimed
walktestinfavouroftheparticipantswhoreceivedbodyweightsupportedtreadmilltraining

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StrokeRehabilitation
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comparedwiththosewhoreceivedonlytreadmilltrainingattheendoffollowup(VERYLOW
CONFIDENCEINEFFECT)

Onestudy272comprisingof100participantsfoundnosignificantdifferencebetweentheparticipants
whoreceivedbodyweightsupportedtreadmilltrainingandthosewhohadonlytreadmilltrainingon
thefollowingoutcomes:
walkingendurance(m)attheendofthestudy(VERYLOWCONFIDENCEINEFFECT)
walkingendurance(m)at3monthsfollowup(VERYLOWCONFIDENCEINEFFECT).

Onestudy15comprisingof100participantsfoundthattherewasnosignificantdifferenceonthe
proportionofparticipantsachievedovergroundwalkingspeedover0.2m/sbetweenthosewho
receivedbodyweightsupportedtreadmillandthosewhohadonlytreadmilltraining(VERYLOW
CONFIDENCEINEFFECT).
Onestudy15comprisingof100participantsfoundthattherewasnosignificantdifferenceonthe
proportionofparticipantsachievedovergroundwalkingenduranceover20mbetweenthosewho
receivedbodyweightsupportedtreadmillandthosewhohadonlytreadmilltraining(LOW
CONFIDENCEINEFFECT).
Onestudy115comprising60participantsfoundnosignificantdifference(in6metrewalktest)
betweenthegroupthatreceivedbodyweighttreadmillandthegroupthatreceivedonlytreadmill
postinterventionandattheendoffollowup(LOWCONFIDENCEINEFFECT)
Onestudy115comprising60participantsfoundnosignificantdifference(intheFunctional
Independencemeasurescales9and13)betweenthegroupthatreceivedbodyweighttreadmilland
thegroupthatreceivedonlytreadmillpostinterventionandattheendoffollowup(VERYLOW
CONFIDENCEINEFFECT)

Evidencestatementscouldnotbeproducedforthefollowingoutcome(s)asresultswerenot
presentedinawaythatenabledthesizeoftheinterventionseffecttobeestimated:
Barthelindex(treadmillwithorwithoutbodyweightsupportversususualcare)86
Rivermeadgrossfunction(treadmillwithorwithoutbodyweightsupportversususualcare)74
Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

13.8.3

Recommendationsandlinktoevidence

100. Offerwalkingtrainingtopeopleafterstrokewhoareableto
walk,withorwithoutassistance,tohelpthembuild
enduranceandmovemorequickly.

101. Considertreadmilltraining,withorwithoutbodyweight
support,asoneoptionofwalkingtrainingforpeopleafter
strokewhoareabletowalkwithorwithoutassistance.

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StrokeRehabilitation
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Relativevaluesofdifferent
outcomes

Theoutcomesconsideredintheevidencereviewwere:walkingspeeds
(5m/10m/30m),timedwalk,walkingendurance,FIM,Bartheland
RivermeadMobilityIndex.TheGDGconsideredoutcomes
demonstratingchangesinwalkingtobeofmoresignificance.
Overall,thesixteen(16)studiesincludedinthereviewshowedtherewas
animprovementinwalkingoutcomesinboththeinterventionand
controlgroups,buttreadmillprovidednogreaterimprovementthan
otherformsofphysiotherapy.

Tradeoffbetweenclinical
benefitsandharms

Thepatientrepresentativesonthegroupfeltthattoomuchemphasis
wasbeingplacedondistanceandspeed,andthatforpatients,the
primaryconcernwasthemotivationtowalkfrompointAtoBsafelyand
feelingcomfortable.Theyfeltthatspeedofwalkingwouldnotbea
significantconcernofpatients.
Groupmembersnotedthatthetrialswereconductedinagymsetting
andthiswouldnotnecessarilytranslatetowalkingoutdoors.The
consensusviewwasthatvarietywasanimportantpartofrehabilitation
treatmentforpatients,andtreadmillisareasonabletoolforuseingait
trainingforpeoplewhoarealreadywalkingandcanincreasewalking
speedandcapacity.

Economicconsiderations

Norelevantcosteffectivenessstudieswereidentified.Themain
differenceincostofusingtreadmilltrainingoverusualcarewas
consideredtobethecostofthetreadmill.Thecapitalcostofatreadmill
ishighataround10,000,howeverwhenthiscostisspreadoverthe
lifetimeoftheequipmentandtheamountofusageitgetsthecostper
patientpersessionwasestimatedat2fortreadmillwithoutbody
weightsupport,and47fortreadmillwithbodyweightsupport.The
GDGalsonotedthatatreadmillmayalreadybeavailableinmany
hospitalsandusedforpurposesotherthanstrokerehabilitation;if
currentlynotfullyutilised,useinstrokepatientscouldbe
accommodatedwithoutincurringthefullcostsestimated.

Qualityofevidence

Allthestudiesweresmall(rangeofparticipantsintheincludedstudies
25113).Thestudiesusingboththe6minutewalktestand10metre
timedwalkasmeasurementsoverdifferentfollowupperiodspresent
mixedresultsbutoverallshowednosignificantdifferencebetweenthe
interventionarm(treadmillwithorwithoutbodyweight)andthecontrol
arminwalkingcapacityorgaitspeedoutcomes.Confidenceinthe
resultsforwalkingcapacityandspeedoutcomeswasmoderatetovery
lowduetolimitationsinstudydesignorimprecisionintheeffect
estimate.
TheGDGnotedthatallthepeoplewithinthestudieshadsomewalking
capacityexceptforonetrial86.
TheGDGquestionedwhytheresultsintheVisintinstudy(1998)showed
therewaslategainachievedinthe10metrewalkoutcomewhenthere
wasnoimmediateresponseaftertheintervention.Afterdiscussion,the
GDGconcludedthatitmaybethatwithbodysupportbettergaitis
achievedandthereforethiswouldexplainthelategain.Therewerealso
differencesingaitspeedbetweenthetwogroupswhichmayhave
allowedtheinterventionarmtoreachacertainthreshold.
TheGDGconcludedthatthepatientswithinthetrialsusedintheclinical
evidencecouldalreadywalkwithsomesupport;thereforethe
recommendationshouldstatethatthisgrouparemostlikelytobenefit
fromtreadmill.

Otherconsiderations

Treadmillfacilitiesarewidelyavailableinrehabilitationunitsandthe

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StrokeRehabilitation
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GDGagreedthattreadmillwasonemethodofdeliveringanintensive
treatment.Astreadmillwasfoundtobeasgoodasconventionaltherapy
theGDGagreeditcouldbeconsideredforpatients.Patientscurrently
wouldusuallyreceivefixedamountsoftherapywhichincludestreadmill
trainingaspartoftheirrehabilitationtherapy.Ifpatientsarestablethen
treadmilluserscanworkwithminimalsupervisiononcetheyaresetup
ontheequipment.Treadmillenablespatientstogetmuchmorepractice
walkingthantheycanbywalkingoutdoorsanditalsooffersthe
opportunitytodoforcedspeedtraining.TheGDGagreedthattreadmill
wasausefultoolandofferedsomebenefittothepatientsafterstroke
evenifnogreaterthanusualcare.TheGDGagreedthatitwas
importantforeveryonetobeofferedwalkingtraining,andthiswas
backedupbytheevidencereviewedwhichshowedbotharmsofstudies
makinganimprovementfollowingwalkingexercises.

13.9 Electromechanicalgaittraining
Anelectromechanicalgaittrainerisaroboticgaitassistivedevicethatisdesignedtoprovidephysical
supportandmechanicalwalkingactionduringgaitreeducation.Thereareseveraltypesof
electromechanicalgaittraininginterventionsthatproviderepetitivelocomotortherapy.Locomat
andRehastimarethetradenamesofthetrainersusedinthestudiesconsidered.Botharerobotic,
orservocontrolledmotorassisteddevices,andprovidevariableamountsofassistanceduring
walkingtraining,includingtimingoflegmovementswiththeoptionofbodyweightsupport(upto
40%).Theadvocatesofelectromechanicalgaittrainersclaimthatitimproveswalkingbystimulating
anormal,symmetricalgaitcycle.
Asymmetricalmuscleweakness,tonalchanges,lossofsensationincludingproprioception,andpoor
balanceandcoordinationaremajorobstaclesinthesuccessfulrehabilitationofgaitintherecovering
strokepatient.Theuseofassistivedevicessuchaselectromechanicalgaittraineraimstoassistinthe
reeducationofgaitthroughsupportedrepetitionofwalkingbehaviour.
Theuseoftheaidisassumedtobeinthecontextofaprofessionallydirectedrehabilitation
programmetoimprovewalkingability.AsuitablyqualifiedPhysiotherapistandassistantwillbe
requiredtodesigntheappropriatewalkingtraining,positionthepatientcorrectlyandtoencourage
andadvisethroughoutthedurationoftheintervention.
Thistypeofinterventionmaybeusedthroughoutanystageintherehabilitationfollowingstrokeas
longasthepatientismedicallyfitandhasnocontraindicationstoexercise.
DuetothecostandscarcityoftheequipmentthisformofinterventionisrarelyseenwithinNHS
facilities.

13.9.1

Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessof
electromechanicalgaittrainingversususualcareonimprovingfunctionandreducing
disability?
ClinicalMethodologicalIntroduction

Population

Adultsandyoungpeople16orolderwhohavehadastroke

Intervention

Electromechanicalgaittraining
Locomattraining

Comparison

Usualcare

Outcomes

Walkingspeeds(5metres/10metres/30metres)
Anytimedwalk
Walkingendurance

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StrokeRehabilitation
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ClinicalMethodologicalIntroduction

FunctionalIndependenceMeasure(FIM)
BarthelIndex
RivermeadMobilityIndex

13.9.1.1

Clinicalevidencereview
SearcheswereconductedforsystematicreviewsandRCTscomparingtheeffectivenessof
electromechanicalgaittrainingwithusualcareasinterventionsforimprovingfunctionandreducing
disabilityforadultsandyoungpeople16orolderwhohavehadastroke.Onlystudieswitha
minimumsamplesizeof20participants(10ineacharm)andincludingatleast50%ofparticipants
withstrokewereselected.ElevenRCTswereidentified.Table114summarisesthepopulation,
intervention,comparisonandoutcomesforeachofthestudies.
Table114:Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
STUDY

POPULATION

INTERVENTION

COMPARISON

OUTCOMES

Dias,2007

Singleincident
chronicstroke
patients(>12months
ago)withlowerlimb
motordeficit.

Gaittrainer/RehaStim(40
minutespersession,5
times/weekfor5weeks):
patientswereharness
securedandpositionedon
twofootplatessupervised
byaphysiotherapist;a
servocontrolledmotor
assistedthegaitmovement
bycontrollingthegear
velocitywithamaxof30%
bodyweightreliefduring
thefirstsessions.(N=20)

Usualcare:
patientsfollowed
theclassicBobath
methodand
rehabilitation
management,
includinganinitial
20minutes
sessionforjoint
mobilisationand
muscle
strengthening
plus20minutes
balanceandgait
training.(N=20)

Rivermead
MobilityIndex
BarthelIndex
10metre
timedwalk
test(m/sec)
6minutewalk
test(m)

Hidler,
2009110

Firsttimestroke;time
sincestrokeonset<6
months;abilityto
ambulate5meters
withoutphysical
assistanceandaself
selectedwalking
speedbetween0.1to
0.6m/s

Lokomatgaitorrobotic
assistedtraining(3
days/weeksfor810weeks
toamaximumtotalof24
sessions(1.5hourseach
session)):
patientswereharness
securedwithupto40%
bodyweightsupportwith
thelevelofbodysupport
decreasedincrementallyper
session.Thetraining
intensitywasincreasedby
changingthespeedandthe
levelofbodyweight
supportanddurationof
continuouswalking(N=36).

Conventionalgait
training:
focusedon
therapistassisted
staticand
dynamicpostural
tasks,trunk
positioning,
improvinglower
andupperlimb
rangeofmotion,
overground
walking,then
higherlevel
balanceandgait
activities
includingstairs.
(N=36)

5metretimed
walktest
(selfselected
velocity)
(m/sec)
6minutewalk
test(m)
Rivermead
MobilityIndex

Hornby,
2008114

Patientswith
hemiparesisof
>6monthsduration
afterstroke;abilityto

Roboticassistedlocomotor
training(Lokomat)(atotal
of12sessionsfor30
minutes/session):patients

Therapistassisted 6minutewalk
locomotor
test(m)
training(atotalof 10metre
12sessionsfor30
timedwalk

64

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StrokeRehabilitation
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STUDY

POPULATION
walk>10mwithout
physicalassistanceat
speedsofatleast
0.8m/satself
selectedvelocity
usingassistivedevices
andbracingbelow
thekneeasneeded.

INTERVENTION
wereharnesssecuredto
provide3040%bodyweight
inthefirstsessionand
decreasedapproximately
10%incrementspersession
astoleratedwithout
substantialkneebucklingor
toedrag.(N=31)

COMPARISON
minutes/session):
patientswere
harnesssecured
andtrainedat
similarweight
supportand
speedstorobotic
assistedgroup.
(N=31)

Husemann,
2007118

Firsttimestroke
patientswithsevere
hemiparesiswith
lowerextremity
strengthgraded3or
lessonMRCscalein
>2musclegroups.
Intervalbetween
strokeandstartof
treatment28200
days.

Roboticassistedtraining(a
totalof40sessions(30
minutes/session)for4
weeks):patientswalkedon
atreadmillwiththehelpof
aLokomat.30%ofbody
weightofeachsubjectwas
supportedinitially.The
velocityofthetreadmillset
tothemaximumspeed
toleratedbythepatients,
forceofthedrivesregulated
andbodyweightsupport
wasreducedassoonas
patientscouldtolerateit.
Patientsalsoreceived30
minutesphysiotherapy
sessions.(N=17)

Therapistassisted 10metre
gait
timedwalk
rehabilitation:
test(m/sec)
exercisingtrunk
BarthelIndex
stabilityand
(German
symmetry,step
version)
initiationand
weightsupport.
Treadmilltraining
wasprovidedif
possiblewiththe
helpoftherapists.
Patientsalso
received30
minutes
physiotherapy
sessions.
(N=15)

Peurala
2005204

Chronicfirsttime
strokepatients(>6
months)whohad
slowordifficult
walking

Gaittrainer/RehaStim(20
minutes/sessionforatotal
of3weeks):supportedwith
aharnessandtheirfeet
wereonmotordriven
footplates+partialbody
weightsupportverballyor
manuallyguidedby
physiotherapists(N=15)

Walking
overground:
practised
overgroundor
overuneven
terrainwith
walkingaids.
(N=15)

Peurala
2009203

Firsttimestroke
patients(within10
daysofstrokeonset)

Gaittrainer/RehaStim)(in
totalof15sessionsfor3
weeks):patientswere
supportedwithaharness
andtheirfeetwere
supportedonmotordriven
footplates.Amountofbody
supportwaschosen
accordingtoindividual
needs.(N=22)

Controlgroup1
10metre
timedwalk
Walkingtraining:
(m/sec)
patientspractised
6minutewalk
walking
test(m)
overgroundwith
1or2
Rivermead
physiotherapists,
MobilityIndex
usingwalking
aids.
(N=21)
Controlgroup2
Conventional
treatment:
patientsreceived
oneor2
physiotherapy
sessionsdaily,but

NationalClinicalGuidelineCentre,2013.
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OUTCOMES
test(self
selected
velocity)
(m/sec)

10metre
timedwalk
(m/sec)
6minutewalk
test(m)
Functional
Independence
Measure
(FIM)(total
score)

StrokeRehabilitation
Movement
STUDY

POPULATION

INTERVENTION

COMPARISON
OUTCOMES
notatthesame
intensityasthe
othertwogroups.
(N=13)

Pohl,2007209

Firsttimestroke
patients(<60days);
abletosit
unsupportedwith
feetsupported,could
notwalkatall,or
requiredthehelpof
oneortwotherapists
irrespectiveofthe
useofananklefoot
orthosisorawalking
aid.

Gaittrainer/RehaStim
(everyweekdayfor4
weeks):patientsreceived20
minutesofrepetitive
locomotortherapyonthe
gaittrainer,immediately
followedby25minutesof
onetoonephysiotherapy
everyweekdayfor4weeks
(N=77)

Usualcare:
patientsreceived
45minute
physiotherapy.
(N=78)

Schwartz,
2009233

Firsttimestroke
patients(<3months)
whowere
independent
ambulatedbeforethe
stroke.

Roboticassistedgait
training(Lokomat)(30
minutes/session/workday,
3timesaweekfor6weeks):
thespeedoftreadmillsetto
maximumtoleratedbythe
patients.Approximately
50%ofbodyweight
supportedbyharness
initially,thesupportwas
graduallyreducedin
approximately10%
incrementspersessionas
toleratedwithout
substantialkneebucklingor
toedrag.Patientsalso
receivedregular
physiotherapy.(N=37)

Usualcare:
FIM
patientstreated
10metre
withadditional
timedwalk
regular
test(m/sec)
physiotherapyfor
gaittrainingfor
30minutes
(overall60
minutesof
regular
physiotherapy)3
timesaweek.In
everysessionthe
patientwalked
somestepswith
thehelpof
therapists.(N=30)

Tong,2006260

Firststrokepatients
admittedtoinpatient
rehabilitationunitin
HongKong(<6weeks
afteronsetofstroke)
withsignificantgait
deficit(FACscore<3);
abilitytostand
upright,supportedor
unsupportedfor1
min.

Electromechanicalgait
trainer/RehaStim(1
trainingsessionof
20min/weekdayovera
totalof4weeks):
gaittrainerstimulateda
normalgaitcycleina
symmetricmannerwitha
ratioof6040%betweenthe
stanceandswingphases.
Bodyweightpartially
supportedbyaharness.
Patientshadalsoregular
weekday40min
physiotherapysessionsand
1.5hourmultidisciplinary
treatments.(N=15)

Controlgait
training:
trainingbasedon
principlesof
proprioceptive
neuromuscular
facilitationand
Bobathconcepts
byaphysical
therapist.
Patientshadalso
regularweekday
40min
physiotherapy
sessionsand
1.5hourmulti
disciplinary
treatments.
(N=20)

NationalClinicalGuidelineCentre,2013.
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BarthelIndex
10metre
timedwalk
(m/sec)
6minutewalk
test(m)
Rivermead
MobilityIndex

5metretimed
walk(m/sec)
FIM
Barthelindex

StrokeRehabilitation
Movement
STUDY

POPULATION

INTERVENTION

COMPARISON

OUTCOMES

Werner
2002281

Subacute,non
ambulatory
hemipareticpatients
(412weeksafter
stroke)

Gaittrainer/RehaStim(15
20minutes/sessionfor2
weeks):harnesssecured
patientswerepositionedon
2footplates.Aservo
controlledmotorassisted
thegaitmovement;body
weightwaspartially
supportedandthesupport
wasgraduallyreduced.
(N=15)

Treadmill
training:
motordriven
treadmill,
patientsworea
modified
parachute
harnessanda
pulleyreleased
partofthebody
weight.(N=15)

10metre
timedwalk
(m/sec)
(maximum
speed)

Morone
2012179

Participantswithsub
acutestrokestratified
intogroupsaccording
tomotorimpairments
(lowmotricityand
highmotricity
groups).Theauthors
usedthemotricity
indexscorewitha
cutoffof29to
definealowmotricity
(LM)groupof
patientsversusa
groupofpatientswith
highmotricity(HM;
MI>29).

Gaittrainer/RehaStim:2
Conventionalgait
therapysessionsperday5
training(N=24)
daysperweekfor3months;
GaitTrainerforfirst4weeks
(N=24)

NationalClinicalGuidelineCentre,2013.
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Functional
ambulation
Classification
BarthelIndex
Rivermead
MobilityIndex

StrokeRehabilitation
Movement

Comparison:Electromechanicalgaittrainingversususualcare
Table115:ElectromechanicalgaittrainingversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectness

Electro
mechanicalgait
training
Mean(SD)/
Imprecision median(IQR)

Usualcare
Mean(SD)
/median
(IQR)

Mean
difference
(95%CI)

Standard
ised
Mean
Differen
ce(SMD)
/Mean
Differen
ce(MD) Confidence
(95%CI) (ineffect)

5and10metretimedwalk(m/sec)(posttreatmenteffect)(Betterindicatedbyhighervalues)
6
Hornby2008114
Husemann
2007118
Peurala2005204
Pohl2007209
Tong2006260
Werner2002281

RCTs2
Veryserious
single
limitations
blinded,3 (a)
unblinded,
1cross
overtrial

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

Changefrom
baseline
Hornby:
0.52(0.21)
Husemann:
0.2(0.12)
Pohl:
0.44(0.47)
Tong:
0.47(0.21)
Werner:
0.42(0.21)
Finalvalues
Peurala:
35.9(29.9)

Change
0.22(
from
0.00,0.43)
baseline
Hornby:
0.56(0.28)
Husemann
:0.2(0.18)
Pohl:
0.32(0.36)
Tong:
0.24(0.30)
Werner:
0.37(0.23)
Final
values
Peurala:

NationalClinicalGuidelineCentre,2013.

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SMD
0.22
higher
(0.00
lowerto
0.43
higher)

Low

StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectness

Electro
mechanicalgait
training
Mean(SD)/
Imprecision median(IQR)

Usualcare
Mean(SD) Mean
/median
difference
(IQR)
(95%CI)
32.1(15.9)

Standard
ised
Mean
Differen
ce(SMD)
/Mean
Differen
ce(MD) Confidence
(95%CI) (ineffect)

5metretimedwalk(m/sec)(posttreatmenteffect)*(Betterindicatedbyhighervalues)
1
Hidler2009110

RCT
unblinded

Veryserious
limitations
(b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

0.12(0.03)

0.25(0.03) 0.13(
MD0.13
0.14,0.12) lower
(0.14to
0.12
lower)

Low

5metretimedwalk(m/sec)(3monthsfollowup)(Betterindicatedbyhighervalues)
1
Hidler2009110

RCT
unblinded

Veryserious
limitations
(b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

0.15(0.04)

0.30
(0.03)

0.15(
0.17,
0.13)

MD0.15
lower
(0.17to
0.13
lower)

Low

0.52
(0.25)

0.02(
0.13,0.09)

MD
0.02
lower
(0.13
lowerto
0.09
higher)

Low

10metretimedwalk(m/sec)(6monthsfollowup)(>6monthsstrokeonset)^(Betterindicatedbyhighervalues)
1
Hornby2008114

RCTs
single
blinded

Veryserious
limitations
(c)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(d)

0.50(0.21)

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectness

Electro
mechanicalgait
training
Mean(SD)/
Imprecision median(IQR)

Usualcare
Mean(SD)
/median
(IQR)

Mean
difference
(95%CI)

Standard
ised
Mean
Differen
ce(SMD)
/Mean
Differen
ce(MD) Confidence
(95%CI) (ineffect)

10metretimedwalk(m/sec)(6monthfollowup)(<2monthsstrokeonset)^(Betterindicatedbyhighervalues)
1
Pohl2007209

RCTs
unclear
blinding

Serious
limitations
(e)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(d)

0.53(0.31)

0.36(0.42) 0.17(
0.05,0.29)

MD0.17
higher
(0.05
lowerto
0.29
higher)

Low

Serious
imprecision
(q)

Changefrom
baseline
Dias:
18.92
(26.33)
Finalvalues
Hornby:
186(88)
Pohl:
134.4
(125.5)
Peurala:
151.7

Change
from
baseline
Dias:
23.28
(2.16)
Final
values
Hornby:
204(96)
Pohl:
92.5
(104.9)
Peurala:

SMD
0.20
higher
(0.03
lowerto
0.44
higher)

Verylow

6minutewalktest(m)(posttreatmenteffect)(Betterindicatedbyhighervalues)
4
Hornby2008114
Peurala2005204
Pohl2007209
Dias200764

RCTs2
Veryserious
single
limitations
blinded,1 (f)
unblinded,
1trialwith
unclear
blinding

Noserious
inconsistency

Noserious
indirectness

NationalClinicalGuidelineCentre,2013.

505

0.20(
0.03,0.44)

StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectness

Electro
mechanicalgait
training
Mean(SD)/
Imprecision median(IQR)
(97.4)

Usualcare
Mean(SD)
/median
(IQR)
135.1
(67.9)

Mean
difference
(95%CI)

Standard
ised
Mean
Differen
ce(SMD)
/Mean
Differen
ce(MD) Confidence
(95%CI) (ineffect)

6minutewalktest(m)(posttreatmenteffect)(changeinscoresfromthebaseline*)(Betterindicatedbyhighervalues)
1
Hidler2009110

RCT
unblinded

Veryserious
limitations
(b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

50.17(9.906)

83.515
(10.79)

33.34
(38.13,
28.56)

MD
33.34
lower
(38.13
to28.56
lower)

Low

62.21
(14.87)

101.96
(15.18)

39.75(
46.69,
32.81)

MD
Low
39.75
lower
(46.69to
32.81
lower)

203(104)

10.00(
59.35,
39.35)

MD10
lower
(59.35
lowerto

6minutewalktest(m)(selfselected)(3monthsfollowup)(Betterindicatedbyhighervalues)
1
Hidler2009110

RCT
unblinded

Veryserious
limitation(b)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

6minutewalktest(m)(6monthsfollowup)(>6monthstrokeonset^)(Betterindicatedbyhighervalues)
1
Hornby2008114

RCTs
single
blinded

Veryserious
limitations
(c)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(q)

193(94)

NationalClinicalGuidelineCentre,2013.

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Verylow

StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectness

Electro
mechanicalgait
training
Mean(SD)/
Imprecision median(IQR)

Usualcare
Mean(SD)
/median
(IQR)

Mean
difference
(95%CI)

Standard
ised
Mean
Differen
ce(SMD)
/Mean
Differen
ce(MD) Confidence
(95%CI) (ineffect)
39.35
higher)

6minutewalktest(m)(6monthfollowup)(<60daysstrokeonset^)(Betterindicatedbyhighervalues)
1
Pohl2007209

RCTs
unclear
blinding

Serious
limitations
(g)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(d)

165.5(152.5)

112.1
(127.7)

53.40
(9.09,
97.71)

MD
53.40
higher
(9.09to
97.71
higher)

Low

Very
serious
imprecision
(i)

100.9(12.3)

102.3
(10.9)

1.40(
9.72,6.92)

MD1.40
lower
(9.72
lowerto
6.92
higher)

Verylow

(k)

91(17)

89.5(26.5) (l)

(l)

Moderate
(k)

Serious

66.9(15.6)

60.3(14.8) 6.60(

MD6.6

Low

FIM(totalscore)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Peurala2005204

RCT
unblinded

Veryserious
limitations
(h)

Noserious
inconsistency

Serious
indirectness

FIM(totalscore)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Tong2006260

RCT
unblinded

Serious
Noserious
limitations(j) inconsistency

Noserious
indirectness

FIM(motoritems)(posttreatmenteffect)(Betterindicatedbyhighervalues)
1

RCT

Serious

Noserious

Noserious

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies
Schwartz
2009233

Design
unblinded

Effect

Limitations
limitations
(m)

Inconsistency
inconsistency

Indirectness
indirectness

Electro
mechanicalgait
training
Mean(SD)/
Imprecision median(IQR)
imprecision
(n)

Usualcare
Mean(SD)
/median
(IQR)

Mean
difference
(95%CI)
0.70,
13.90)

Standard
ised
Mean
Differen
ce(SMD)
/Mean
Differen
ce(MD) Confidence
(95%CI) (ineffect)
higher
(0.70
lowerto
13.9
higher)

RivermeadMobilityIndex(posttreatmenteffect)(Betterindicatedbyhighervalues)
3
Dias200764
Pohl2007209
Hidler2009110

RCTs
2single
blind,1
unblinded

Veryserious
limitations
(o)

Noserious
inconsistency

Noserious
indirectness

Noserious Changefrom
imprecision baseline
Dias:0.35
(0.75)
Hidler:2.0(0.3)
Finalvalues
Pohl:
8.5(3.9)

Change
from
baseline
Dias:
1.26
(1.82)
Hidler:
1.6(0.3)
Pohl:
6.3(3.7)

0.83(0.35,
1.31)

SMD
0.83
higher
(0.35
lowerto
1.31
higher)

Low

2.2(0.5)

0.40(0.19,
0.61)

MD0.4
higher
(0.19to
0.61
higher)

Low

RivermeadMobilityIndex(3monthsfollowup)(Betterindicatedbyhighervalues)
1
Hidler2009110

RCT
unblinded

Veryserious
limitations
(b)

Noserious
inconsistency

Noserious
indirectness

Noserious 2.6(0.4)
imprecision

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Movement

Summaryoffindings
Qualityassessment

Noofstudies

Design

Effect

Limitations

Inconsistency

Indirectness

Electro
mechanicalgait
training
Mean(SD)/
Imprecision median(IQR)

Usualcare
Mean(SD)
/median
(IQR)

Mean
difference
(95%CI)

Standard
ised
Mean
Differen
ce(SMD)
/Mean
Differen
ce(MD) Confidence
(95%CI) (ineffect)

RivermeadMobilityIndex(6monthsfollowup)(Betterindicatedbyhighervalues)
1
Pohl2007209

RCT
single
blinded

Serious
limitations
(e)

Noserious
inconsistency

Noserious
indirectness

Noserious 10.0(4.1)
imprecision

7.8(4.8)

Noserious
imprecision

72.3(21)

(k)

Noserious
imprecision

2.20(0.80,
3.60)

MD2.20
higher
(0.80to
3.60
higher

Moderate

58.7(21.6) 13.60
(6.89,
20.31)

MD13.6
higher
(6.89to
20.31
higher)

Moderate

Tong:
84.0(19)
Husmann:
50.0(25)

Tong:
(l)
73.0(32.5)
Husmann:
50(10)

(l)

Moderate(k
)

77.5(23.1)

65.1(28.0) 12.40
(4.32,

MD12.4
higher

Moderate

BarthelIndex(posttreatmenteffect)(Betterindicatedbyhighervalues)
1
Pohl2007209

RCT
single
blinded

Serious
limitations
(e)

Noserious
inconsistency

Noserious
indirectness

BarthelIndex(posttreatmenteffect)(Betterindicatedbyhighervalues)
2
Tong2006260
Husemann
2007118

RCTs1
single
blinded,1
unblinded

Serious
limitations
(jp)

Noserious
inconsistency

Noserious
indirectness

BarthelIndex(6monthsfollowup)(Betterindicatedbyhighervalues)
1
Pohl2007209

RCT
single

Serious
limitations

Noserious
inconsistency

Noserious
indirectness

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StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noofstudies

(a)

(b)

(c)
(d)
(e)
(f)

(g)
(h)
(i)
(j)
(k)
(l)
(m)
(n)
(o)
(p)
(q)

Design
blinded

Effect

Limitations
(a)

Inconsistency

Indirectness

Electro
mechanicalgait
training
Mean(SD)/
Imprecision median(IQR)

Usualcare
Mean(SD)
/median
(IQR)

Mean
difference
(95%CI)
20.48)

Standard
ised
Mean
Differen
ce(SMD)
/Mean
Differen
ce(MD) Confidence
(95%CI) (ineffect)
(4.32to
20.48
higher)

Unclearrandomisation(Hornby2008;Peurala2005),inadequateallocationconcealment(Hornby2008;Pohl2007;Peurala2005;Tong2006),unclearallocationconcealment(Hidler2009)unclearblinding
(Hornby2008),unblindedstudies(Peurala2005;Tong2006;Hidler2009)highdropoutrateincontrolgroup(30%)(Hornby2008).

Unblindedstudywithunclearallocationconcealment.No ITTanalysis.Therewasasignificantdifferenceinagebetweengroups,reportedbyauthor.RivermeadMobilityIndexatbaselinewasstatistically
significantlyhigherincontrolgroupcomparedtotheintervention(Hidler2009).

Studywithunclearblindingandrandomisationhighdropoutrateincontrolgroup(30%)(Hornby2008).

ConfidenceintervalcrossedoneendofdefaultMID.

Singleblindedstudywithinadequateallocationconcealment(Pohl2007).
1unblinded(Peurala2007),1withunclearblinding(Hornby2008),2studieshadunclearrandomization(Hornby2008;Peurala2005)andthemajorityhadinadequateallocationconcealment(Hornby2008;
Pohl2007;Peurala2005)andunclearallocationconcealment(Dias2007).
Inadequateallocationconcealment(Pohl2007).
Unblindedstudywithunclearrandomizationandinadequateallocationconcealment(Peurala2007).
MeandifferencedidnotreachtheagreedMIDof22points.
Studywasunblindedwithunclearallocationconcealment(Tong2006).
Imprecisioncouldnotbeassessedbecauseresultswerereportedasmedianandinterquartilerange.
Relativeandabsoluteeffectscouldnotbecalculatedbecauseresultswerereportedasmedianandinterquartilerange.
Studywasnotblindedandunclearallocationconcealment;Dropoutrategreaterininterventiongroupcomparedtocontrols(Schwartz2009).
MeandifferencedidnotreachtheagreedMIDof17points.
Unblinded(Hidler2009),withonestudywithinadequateallocationconcealment(Pohl2007)andtwostudieswithunclearallocationconcealment(Dias2007,Hidler2009).
GermanversionofBarthelIndexwasusedinthestudy,Husemannetal(2007).
MeandifferencedidnotreachtheagreedMIDof28m.
2

*Walkingvelocity:5and10metretimedwalktest(posttreatmenteffect):wecouldnotmetaanalyseHidleretal.withotherstudiesastherewassubstantialheterogeneity(I :99%),thereforetheresultsofthis
studywerepresentedseparately.
^Walkingvelocity:5and10metretimedwalktest(6monthsfollowup):wecouldnotmetaanalyseHornbyetal.andPohletal.togetherduetothelargedifferenceintimebetweenstrokeonsetandstudyentry
amongtheparticipants.

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StrokeRehabilitation
Movement

OneRCT(Morone2012179)stratifiedparticipantswithstrokeaccordingtotheirinitialmotorimpairmentlevelsintoseparategroupsfromtheoutset.
ResultsofthistrialarepresentedinaseparateGRADEtablesinceoverallvalueswerenotprovided.
Comparison:Electromechanicalgaittrainingversusconventionalgaittraining(ingroupsstratifiedbylevelofmotorimpairments)
Table116:GRADEcharacteristicsandclinicalsummaryoffindings(Note.LM=lowmotricitygreaterlevelofimpairments;HM=highmotricitylower
levelofimpairment)
SummaryofFindings
Qualityassessment

Noof
studies Design

Effect

Riskof
bias

Inconsistency

Indirectness

Imprecision

Roboticgait
trainingMeans
(SD)

Mean
difference
(MD)(95% Confidence
CI)
(ineffect)

Conventional
gaittraining
Mean(SD)

Mean
difference
(95%CI)

2.1(1.2)

1.9(1.05,
2.75)

MD1.9
higher
(1.05to
2.75
higher)

Moderate

1.6(0.81,
2.39)

MD1.6
higher
(0.81to
2.39
higher)

Moderate

0.1(0.74,
0.94)

MD0.1
higher
(0.74
lowerto
0.94
higher)

VeryLow

FunctionalambulationclassificationDischargeLM(rangeofscores:05;Betterindicatedbyhighervalues)
Moron randomised Serious
e
trials
(a)
2012179 (assessor
blinded)

noserious
inconsistency

noserious
indirectness

noserious
imprecision

4(0.9)

FunctionalambulationclassificationFollowupat2yearsLM(rangeofscores:05;Betterindicatedbyhighervalues)
Moron randomised serious
e
trials
(a)
2012179 (assessor
blinded)

noserious
inconsistency

noserious
indirectness

noserious
imprecision

4.7(0.5)

3.1(1.3)

FunctionalambulationclassificationDischargeHM(rangeofscores:05;Betterindicatedbyhighervalues)
Moron randomised serious
e
trials
(a)
2012179 (assessor
blinded)

noserious
inconsistency

noserious
indirectness

very
serious(b)

3.8(1.1)

3.7(1.0)

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StrokeRehabilitation
Movement

SummaryofFindings
Qualityassessment

Noof
studies Design

Effect

Riskof
bias

Inconsistency

Indirectness

Imprecision

Roboticgait
trainingMeans
(SD)

Conventional
gaittraining
Mean(SD)

Mean
difference
(95%CI)

Mean
difference
(MD)(95% Confidence
CI)
(ineffect)

FunctionalambulationclassificationFollowupat2yearsHM(rangeofscores:05;Betterindicatedbyhighervalues)
Moron randomised serious
e
trials
(a)
2012179 (assessor
blinded)

noserious
inconsistency

noserious
indirectness

very
serious(b)

4.3(0.9)

4.0(1.0)

0.3(0.46,
1.06)

MD0.3
higher
(0.46
lowerto
1.06
higher)

VeryLow

52.1(14.1)

17.5(5.81,
29.19)

MD17.5
higher
(5.81to
29.19
higher)

Moderate

64.7(14.0)

17.5(5.81,
29.19)

MD12.2
higher
(1.95to
22.45
higher)

Moderate

74.2(14.1)

10(
26.61,
6.61)

MD10
lower
(26.61
lowerto
6.61
higher)

VeryLow

BarthelIndexDischargeLM(rangeofscores:0100;Betterindicatedbyhighervalues)
Moron randomised serious
e
trials
(a)
2012179 (assessor
blinded)

noserious
inconsistency

noserious
indirectness

noserious
imprecision

69.6(15.1)

BarthelIndexFollowupat2yearsLM(rangeofscores:0100;Betterindicatedbyhighervalues)
Moron randomised serious
e
trials
(a)
2012179 (assessor
blinded)

noserious
inconsistency

noserious
indirectness

noserious
imprecision

76.9(11.5)

BarthelIndexDischargeHM(rangeofscores:0100;Betterindicatedbyhighervalues)
Moron randomised serious
e
trials
(a)
2012179 (assessor
blinded)

noserious
inconsistency

noserious
indirectness

very
serious(c)

64.2(21.2)

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SummaryofFindings
Qualityassessment

Noof
studies Design

Effect

Riskof
bias

Inconsistency

Indirectness

Imprecision

Roboticgait
trainingMeans
(SD)

Mean
difference
(MD)(95% Confidence
CI)
(ineffect)

Conventional
gaittraining
Mean(SD)

Mean
difference
(95%CI)

77.6(20.4)

3.3(
18.96,
12.36)

MD3.3
lower
(18.96
lowerto
12.36
higher)

4.9(2.0)

4.5(2.6,
6.4)

MD4.5

higher(2.6 Moderate
to6.4
higher)

BarthelIndexFollowupat2yearsHM(rangeofscores:0100;Betterindicatedbyhighervalues)
Moron randomised serious
e
trials
(a)
2012179 (assessor
blinded)

noserious
inconsistency

noserious
indirectness

very
serious(c)

74.3(18.7)

VeryLow

RivermeadMobilityIndexDischargeLM(rangeofscores:015;Betterindicatedbyhighervalues)
Moron randomised serious
e
trials
(a)
2012179 (assessor
blinded)

noserious
inconsistency

noserious
indirectness

noserious
imprecision

9.4(2.7)

RivermeadMobilityIndexFollowupat2yearsLM(rangeofscores:015;Betterindicatedbyhighervalues)
Moron randomised serious
e
trials
(a)
2012179 (assessor
blinded)

noserious
inconsistency

noserious
indirectness

serious(d)

11.8(3.5)

7(3.6)

4.8(1.96,
7.64)

MD4.8
higher
(1.96to
7.64
higher)

Low

7.4(4.1)

10.1(4.0)

2.7(5.94, MD2.7
0.54)
lower
(5.94
lowerto
0.54
higher)

Low

RivermeadMobilityIndexDischargeHM(Betterindicatedbylowervalues)
Moron randomised serious
e
trials
(a)
2012179 (assessor
blinded)

noserious
inconsistency

noserious
indirectness

serious(e)

RivermeadMobilityIndexFollowupat2yearsHM(rangeofscores:015;Betterindicatedbyhighervalues)

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SummaryofFindings
Qualityassessment

Noof
studies Design

Effect

Riskof
bias

Moron randomised serious

e
trials
(a)
2012179 (assessor
blinded)

Inconsistency

Indirectness

Imprecision

noserious
inconsistency

noserious
indirectness

very
serious(b)

Roboticgait
trainingMeans
(SD)

Conventional
gaittraining
Mean(SD)

Mean
difference
(95%CI)

10.4(3.6)

10.6(3.9)

0.2(3.2,
2.8)

Mean
difference
(MD)(95% Confidence
CI)
(ineffect)
MD0.2

lower(3.2 VeryLow
lowerto
2.8higher)

(a)

Unclear allocation concealment, a large proportion (up to 50%) of participants in all study arms did not finish the 4 week treatment.
The confidence interval crosses both default MIDs (0.5 of standard mean difference) ranging from benefit associated with the control treatment to benefit associated with robotic gait training.
The confidence interval crosses both agreed MIDs for the Barthel Index (1.85), i.e. robotic gait training could have positive or negative effects
(d)
The confidence interval crosses one default MID (0.5 standard mean difference) from appreciable benefit to no effect associated with robotic gait training
(e)
The confidence interval crosses one default MID (0.5 standard mean difference) indicating possible benefit associated with the conventional gait training to no effect.
(b)
(c)

Narrativesummary

ThefollowingstudyissummarisedasanarrativebecausetheresultswerenotpresentedinnumericaldatathatcouldbeincludedintheGRADEtable:

Onestudy203randomised56patientstogaittrainerexercise,walkingtrainingandconventionaltreatment.Attheendof3weekstraining,meanwalking
velocity(10metretimedwalktest)andwalkingdistance(6minutewalktest)werenotdifferentbetweenthegaittrainerexerciseandwalkinggroups(10
metretimedwalktest,p=0.452;6minutewalktest,p=0.547).TheRivermeadMobilityIndeximprovedinallgroups(frombaselinetoendoftreatment)
butpvalueforgroupdifferencewasnotstatisticallysignificant(p=0.703).Analysiswasbasedonthenumberofpatientswhowereabletowalk20minutes
(differentlevelofpatientsparticipationindifferentmeasurementsatdifferenttimepoints)andreconstructeddatafor10metretimedwalktestand6
minutewalktestwasused;thereforethisstudywasnotincludedinthemetaanalysis.

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13.9.1.2

Economicevidence
Literaturereview
Norelevanteconomicevaluationscomparingelectromechanicalgaittrainingwithusualcarewere
identified.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
ThemanufacturersofLokomatandofRehaStimelectromechanicalgaittrainerswerecontactedand
theyeachsuppliedcostsfortheirproducts.TheLokomatelectromechanicalgaittrainercostsranged
between~173,000to~264,000(costsprovidedbyHocomabyemail,20thJune2011;VATis
excluded).TheRehaStimelectromechanicalgaittrainercostwasprovidedbutisnotreportedhere
asitwasdeemedcommercialinconfidence.Assumingadiscountrateof3.5%,alifeexpectancyfor
themachineof10years,autilizationrateofthemachineof208daysperyearandof4hourseach
day,foraninterventionconsistingof6hoursofuseoftheelectromechanicalgaittraining,the
attributablecostfortheinterventionusingaLokomattrainerwouldbebetween~145and~221.
Tothesecostsitmaybenecessarytoaddpersonnelcostswhenthepatientneedstobeaidedin
usingtheelectromechanicalgaittrainer.

13.9.1.3

Evidencestatements
Clinicalevidencestatements
Sixstudies114,118,204,209,260,281of344participantsfoundnosignificantdifferencein5and10metre
timedwalktest(m/sec)betweentheelectromechanicalgaittraininggroupandtheusualcaregroup
attheendoftheintervention(LOWCONFIDENCEINEFFECT).
Onestudy110of72participantsfoundthatthosewhoreceivedusualcarewasassociatedwitha
statisticallysignificantimprovementin5metretimedwalktest(m/sec)comparedwiththe
electromechanicalgaittraininggroupattheendoftheintervention(LOWCONFIDENCEINEFFECT).
Onestudy110of72participantsfoundthatthosewhoreceivedusualcarewasassociatedwitha
statisticallysignificantimprovementin5and10metretimedwalktest(m/sec)thanthe
electromechanicalgaittraininggroup,at3monthsfollowup(LOWCONFIDENCEINEFFECT).
Onestudy114of62participants(>6monthspoststroke)foundnosignificantdifferencein5and10
metretimedwalktest(m/sec)betweentheelectromechanicalgaittraininggroupandtheusualcare
groupattheendof6monthsfollowup(LOWCONFIDENCEINEFFECT).
Onestudy209of155participants(<2monthspoststroke)foundthattheelectromechanicalgait
traininggroupwasassociatedwithastatisticallysignificantimprovementin10metretimedwalktest
(selfselected)(m/sec)comparedwiththeusualcaregroupattheendof6monthsfollowup(LOW
CONFIDENCEINEFFECT).
Fourstudies64,114,204,209of287participantsfoundnosignificantdifferencein6minutewalktest(m)
betweentheelectromechanicalgaittrainingandtheusualcaregroupattheendofintervention
(LOWCONFIDENCEINEFFECT).

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Onestudy110of72participantsfoundthatthosewhoreceivedusualcarewasassociatedwitha
statisticallysignificantgreaterimprovementin6minutewalktest(m)comparedwiththe
electromechanicalgaittraininggroupattheendofintervention(LOWCONFIDENCEINEFFECT).
Onestudy110of72participantsfoundnosignificantdifferencein6minutewalktest(m)(self
selected)betweentheelectromechanicalgaittrainingandtheusualcaregroupat3monthsfollow
up(LOWCONFIDENCEINEFFECT).
Onestudy114of62participants(>6monthspoststroke)foundnosignificantdifferencein6minute
walktest(m)betweentheelectromechanicalgaittrainingandtheusualcaregroupat6months
followup(VERYLOWCONFIDENCEINEFFECT).
Onestudy209of155participants(<60dayspoststroke)foundthatthosewhoreceived
electromechanicalgaittrainingwasassociatedwithastatisticallysignificantgreaterimprovementin
6minutewalktest(m)comparedwiththosewhoreceivedusualcareat6monthsfollowup(LOW
CONFIDENCEINEFFECT).
Onestudy204of30participantsfoundnosignificantdifferenceintotalFunctionalIndependence
Measurebetweentheelectromechanicalgaittrainingandtheusualcaregroupattheendof
intervention(VERYLOWCONFIDENCEINEFFECT).
Onestudy233of67participantsfoundnosignificantdifferenceinFunctionalIndependenceMeasure
(Motoritem)betweenelectromechanicalgaittrainingandusualcareattheendofintervention
(LOWCONFIDENCEINEFFECT).
Threestudies64,110,209of267participantsfoundthatelectromechanicalgaittrainingwasassociated
withastatisticallysignificantimprovementontheRivermeadMobilityIndexcomparedwiththe
usualcaregroupattheendofintervention(LOWCONFIDENCEINEFFECT).
Onestudy110of72participantsfoundthatelectromechanicalgaittrainingwasassociatedwitha
statisticallysignificantimprovementontheRivermeadMobilityIndexcomparedwiththosewho
receivedusualcareat3months(LOWCONFIDENCEINEFFECT)
Onestudy209of155participantsfoundthatelectromechanicalgaittrainingwasassociatedwitha
statisticallysignificantimprovementontheRivermeadMobilityIndexcomparedwiththosewho
receivedusualcareat6monthsfollowup(MODERATECONFIDENCEINEFFECT).
Onestudy209of155participantsfoundthatelectromechanicalgaittrainingwasassociatedwitha
statisticallysignificantimprovementonBarthelIndexcomparedwiththosewhoreceivedusualcare
attheendofintervention(MODERATECONFIDENCEINEFFECT)and6monthsfollowup(MODERATE
CONFIDENCEINEFFECT).
Electromechanicalgaittrainingversusconventionalgaittrainingingroupsdividedbyinitialmotor
impairmentlevel
Onestudy179of48participantsfoundthatroboticgaittrainingsignificantlyimprovedfunctional
ambulatoryabilities(asmeasuredbytheFunctionalAmbulationClassificationscale)inthosewith
higherlevelsofmotorimpairments(atbaseline).Theseimprovementswereobservedbothat
dischargeandat2yearfollowupcomparedtoconventionalgaittraining.However,these
improvementswerenotobservedinparticipantswithfewerimpairments(atbaseline).
Onestudy179of48participantsfoundthatroboticgaittrainingsignificantlyimprovedperformancein
activitiesofdailyliving(asmeasuredbytheBarthelIndex)inthosewithhigherlevelsofmotor
impairments(atbaseline).Theseimprovementswereobservedbothatdischargeandat2year
followupcomparedtoconventionalgaittraining.However,theseimprovementswerenotobserved
inparticipantswithfewerimpairments(atbaseline).

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StrokeRehabilitation
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Onestudy179of48participantsfoundthatroboticgaittrainingsignificantlyimprovedmobility(as
measuredbytheRivermeadMobilityIndex)inthosewithhigherlevelsofmotorimpairments(at
baseline).Theseimprovementswereobservedbothatdischargeandat2yearfollowupcompared
toconventionalgaittraining.However,theseimprovementswerenotobservedinparticipantswith
fewerimpairments(atbaseline).
Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

13.9.2

Recommendationsandlinktoevidence

102. Offerelectromechanicalgaittrainingtopeopleafterstrokeonlyin
thecontextofaresearchstudy.

Relativevaluesof
differentoutcomes

Theoutcomesofinterestincludedinthereviewwerewalkingspeedand
endurance,theRivermeadMobilityIndexandtwomeasuresofdependencethe
FunctionalIndependenceMeasure,andtheBarthelIndex.TheGDGconsidered
theresultsofthewalkingoutcomeswereofmorerelevancetotheintervention.

Tradeoffbetween
clinicalbenefitsand
harms

Notapplicable.Theavailabilityandusageofthisequipmentiscurrently
extremelylimitedwithintheNHS.

Economicconsiderations Nocosteffectivenessstudieswereidentifiedforthisquestion.TheGDGnoted
thatthemaincostcomponentfortheseinterventionsconsistsofthecostof
acquiringandmaintainingthemachine,aswellasthepersonnelcosts(for
examplephysiotherapisttime)thatmayberequiredtoaidthepatientinusing
theelectromechanicalgaittraining.Inaddition,theGDGnotedthatthereisvery
limiteduseofelectromechanicalgaittrainingdevicescurrentlyintheUKNHS.
Consideringthehighinitialoutlaycostforelectromechanicalgaittrainersand
thelimitedevidencefortheirpotentialhealthbenefits,theGDGconcludedthat
therewasinsufficientevidencetoconcludethatelectromechanicalgaintraining
representsacosteffectiveuseofNHSresources.
Qualityofevidence

TheGDGnotedthatmanyofthestudiespresentedhadseveretoveryserious
limitationsintermsofsamplesizeandstudydesignandtherewasinsufficient
evidencetosupporttheuseofelectromechanicalgaittraining.
Manystudiesdidnotshowasignificantdifferenceforthewalkingspeedor
capacityoutcomes114,118,204,233,260,281.InonewelldesignedstudybyPohl209there
isevidencethatinpatientsearlyafterstroke(upto2monthspoststroke)with
verypoormobility,whousedtheelectromechanicalgaittrainershowedan
improvementinwalkingspeedoverusualpracticewhichwasmaintainedafter6
months.Inaddition,patientsintheelectromechanicalgaittrainergroupshowed
aclinicallysignificantimprovementinRivermeadMobilityIndex(posttreatment
andat3,6monthsfollowup)andtheBarthelIndex(6monthsfollowup).The
recentpublicationofastudybyMoroneandcolleagues(2012)179witha2year
followupshowedthatroboticgaittrainingimprovedperformanceinthe
RivermeadMobilityandtheBarthelindexaswellasintheFunctional
Ambulationcategories.However,thiseffectwasrestrictedtothosewithmore
severelyimpairedmotorfunctioningattheoutset.Itwasasmallstudywith12
participantsineacharmandtheconfidenceineffectswasveryvariableranging
frommoderatetoverylow.

Otherconsiderations

Thestudiesexaminedtwodifferentelectromechanicalgaittrainerswhichvaryin
designandmayfeedintodifferentphysiologicalmechanisms.
TheLokomatisadrivengaitorthosiswithelectricaldrivesinkneeandhipjoints
with4forcetransducerswith4amplifiersthatautomateslocomotiontherapy

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StrokeRehabilitation
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onatreadmill. Theorthosisisadaptabletosubjectsfemurlength.
RehaStimisanelectromechanicalgaittrainerwith2footplateswhose
movementssimulatedstanceandswingphases.Steplengthandwalkingspeed
arecontinuouslyadjustablebyaservomotor.
Bothuseanelementofbodyweightsupport.Futurestudiesshouldaddressthe
underlyingmechanismsofaction.Thistypeofinterventionisusedinsomeunits
butnotcommonlywithintheUK.
TherewasagreementbytheGDGthattheevidence,basedontwostudies(Pohl
etal.,2007andMoroneetal.,2012)209)179infavouroftheRehaStimtrainer
wasnotstrongenoughtomakearecommendationforusewithintheNHS,but
thattheinterventionshowedpromiseandanonlyinresearchrecommendation
shouldbemade.

13.10 Anklefootorthoses
AnAnkleFootOrthosis(AFO)isanappliancedesignedtosupportthefootandankle.Afterstroke,it
istypicallyprescribedforwalkingproblemswherethefootneedstobehelduptopreventdragging
(footdrop)and/ortogivesupporttotheankletopreventthelegfromcollapsingoverthefootand
ankleinstance.TherearemanydifferentAFOs,buttwocommontypesarethosewhicharerigid
whichoffergreaterstabilityandthosethatarehingedwhichofferhelpwithdorsiflexionbutless
stabilityatthesubtalarjoint.AFOsmaybecustommadeorofftheshelfandcanbemadefrom
widerangeofdifferentmaterials.AssessmentforuseofanAFOshouldbecarriedoutbyan
appropriatelytrainedprofessional.AnAFOisanadjuncttotherapyandthusshouldbeconsideredin
thecontextofacomprehensiverehabilitationprogramwithinputfromamultidisciplinaryteam.

13.10.1

Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessof
AnkleFootorthosesofalltypestoimprovewalkingfunctionversususualcare?
ClinicalMethodologicalIntroduction
Population:

Adultsandyoungpeople16orolderwhohavehadastroke

Intervention:

Comparison:

Usualcare

Outcomes:

Alltypesoforthosesincluding:
SoftandScotchcasts
Splint
Brace
Lowtemperaturesplints
AnkleFootOrthosis(AFO)
GroundReactionAnkleFootOrthosis(GRAFO)
DynamicAnkleFootOrthosis(DAFO)
Walkingspeed:6minutewalktest,10metretimedwalk
LowerlimbMAS(stairs)
Walkingendurance
FunctionalIndependenceMeasure(FIM)/BarthelIndex
RivermeadMobilityIndex
Cadence
Gaitsymmetry(stancetime,steplength)
QualityofLifeoutcomes

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StrokeRehabilitation
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13.10.1.1

Clinicalevidence
Searcheswereconductedforsystematicreviews(ofrandomizedcontrolledtrials(RCTs)andcohort
studies)andRCTsthatcomparedtheeffectivenessofalltypesofanklefootorthoseswithusualcare
toimprovewalkingfunctionforadultsandyoungpeople16orolderwhohavehadastroke.Only
studieswithaminimumsamplesizeof20participants(10ineacharm)andincludingatleast50%of
participantswithstrokewereselected.5RCTs(2paralleland3crossoverRCTs)wereidentified.
Table117:
Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
STUDY

POPULATION

INTERVENTION

COMPARISON

OUTCOMES

Beckerman
199621

Strokepatients
aged1875years
withwalking
problemscaused
byaspastic
equinesor
equinovarus
positionofthe
foot;atleast4
monthspost
stroke

AnkleFootOrthosis
(andplacebo
thermocoagulation):
AFO:Polypropylene
AFOwascustom
madeforeach
patient.AFOin5
dorsiflexion,
correctedforshoe
heelheight,designed
topreventanequinus
orequinovarus
positionofthefoot
duringwalkingand
inhibitthesynergistic
extensionpattern.
Placebo
thermocoagulation:
needleplacedinto
thetibialnerve,
localizedand
anesthetizedwithno
radiofrequency
output.
Studyduration:3
months.(N=16)

PlaceboAnkle
FootOrthosis
(andplacebo
thermocoagulatio
n)
PlaceboAFO:
Polypropylene
hingedAFOthat
allowsnormal
rangeofmotion
ofdorsiflexion
andplantar
flexion.
Placebo
thermocoagulatio
n:needleplaced
intothetibial
nerve,localized
andanesthetized
withno
radiofrequency
output.(N=14)

Walkingability
measuredwiththe
SicknessImpact
Profile(SIP)
Walkingspeed
(m/sec)

deWit200457

Strokepatients
aged4075years,
atleast6months
poststroke.

Walkingwithplastic, Walkingwithout
nonarticulatedAnkle AFO(N=10)
FootOrthosis(AFO)
(3types:AFOwitha
smallorlarge
posteriorsteelorwith
twocrossedposterior
heelreinforcements
andanopenheel)
Studyduration:at
least6months.
(N=10)

Walkingspeed
(cm/sec)
TimedUpandGo
(TUG)test(sec)
Stairstest

Erel,201177

Poststroke
patientsofatleast
6monthsduration
(chronichemi
pareticpatients);
atacognitivelevel
tounderstandthe

DynamicAnkleFoot
Orthoses(DAFO)
fabricatedbya
physiotherapist.
Fabricationtimewas
23daysonaverage.
DAFOwereworn

TimedUpandGo
Test(sec)
TimedUpStairs
TimedDownStairs
Walkingspeed
(m/sec)

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Controlgroup
woreonlytennis
shoes.(N=16)

StrokeRehabilitation
Movement
STUDY

POPULATION
aimofthestudy;
wereatlevel35
accordingto
Functional
Ambulation
Classification;had
amaximum
spasticitylevelof3
accordingtothe
ModifiedAshworth
Scale;hadarange
ofpassive
dorsiflexionupto
atleast90
degrees;were
above18years
old.

INTERVENTION
insidetennisshoe.
Studyduration3
months.(N=16)

COMPARISON

OUTCOMES

Tyson2001266 Strokepatients
agedover18years

withhemiplegia
(severe
impairments)

HingedAFOmadefor
eachpatientbyan
orthotistusing4mm
polypropylenewitha
metalanklejointand
adjustableplantar
flexionstopwhich
wassettoprevent
plantarflexionbut
allowedfull
dorsiflexion.
Studyduration:1
month.(N=12)

Noorthosis.
(N=13)

stridelengthofWeak
andsoundleg(cm)
steplengthofWeak
andsoundleg(cm)
Stepsymmetry
Walkingspeed
(m/sec)
Cadence(step/min))

Tyson2009265

AnkleFootOrthosis
(AFO)individually
fittedforeachpatient
(N=20)

Nodevice:
Walkingwithout
theorthosis.
(N=20)

Walkingspeed
(m/sec)
Steplengthofthe
weakleg(m)

Strokepatients
withsevere
walkingproblems
for2weekspost
stroke.

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Comparison:AnkleFootOrthosis(AFO)ofalltypesversususualcare
Table118:

AnkleFootOrthosisversususualcareClinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings

Qualityassessment

Noof
studies

Design

Limitations

Inconsistency

Indirectness

Dynamic/An
kleFoot
Orthosis
Mean
(SD)/median
Imprecision (range)

Effect
Usualcare
Mean(SD)/
median
(range)

Mean
difference
(95%CI)

Mean
Difference
(MD)(95%CI)

Confidence
(ineffect)

Walkingspeed(10mwalkway)(cm/sec)(patientsworeAFObeforetreatment)(posttreatmenteffect)(Betterindicatedbyhighervalues)
deWit,
200457

RCT
crossov
ertrial

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(c)

49.6(24.3)

44.9(24.0)

4.8(0.76,
8.84)

MD4.8higher
(0.76to8.84
higher)

Low

3.6(5.59,
1.61)

MD3.6lower
(5.59to1.61
lower)

Low

Timedupandgo(sec)(patientsworeAFObeforetreatment)(posttreatmenteffect)(Betterindicatedbylowervalues)
deWit,
200457

RCT
crossov
ertrial

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecisio
n(d)

25.6(11.7)

29.2(12.9)

Stairstest(sec)(patientsworeAFObeforetreatment)(posttreatmenteffect)(Betterindicatedbylowervalues)
deWit,
200457

RCT
crossov
ertrial

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecisio
n(e)

73.0(37.8)

81.6(44.4)

8.6(
14.46,
2.74)

MD8.6lower
(14.46to2.74
lower)

Low

39.3(13.7)

43.8(14.0)

4.5(0.91,
8.09)

MD4.5higher
(0.91to8.09
higher)

Moderate

39.4(14.3)

44.3(14.1)

4.9(1.48,
8.32)

MD4.9higher
(1.48to8.32
higher)

Moderate

SoundStridelength(cm)(1monthfollowup)(Betterindicatedbyhighervalues)
Tyson,
2001266

RCT
crossov
ertrial

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecisio
n

WeakStrideLength(cm)(1monthfollowup)(Betterindicatedbyhighervalues)
Tyson,
2001266

RCT
crossov
ertrial

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecisio
n

Soundsteplength(cm)(1monthfollowup)(Betterindicatedbyhighervalues)

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Summaryoffindings
Qualityassessment

Noof
studies
Tyson,
2001266

Design

Limitations

Inconsistency

Indirectness

RCT
crossov
ertrial

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Dynamic/An
kleFoot
Orthosis
Mean
(SD)/median
Imprecision (range)
Very
serious
imprecisio
n(h)

Effect
Usualcare
Mean(SD)/
median
(range)

Mean
difference
(95%CI)

Mean
Difference
(MD)(95%CI)

Confidence
(ineffect)

19.4(9.9)

20.8(9.6)

1.40(
1.44,4.24)

MD1.4higher
(1.44lowerto
4.24higher)

Verylow

Very
serious
imprecisio
n(h)

21.7(9.5)

23.7(11.7)

2.0(
1.81,5.81)

MD2higher
(1.81lowerto
5.81higher)

Verylow

Very
serious
imprecisio
n(h)

2.6(4.9)

3.0(7.8)

0.4(
1.34,2.14)

MD0.4higher
(1.34lowerto
2.14higher)

Verylow

Noserious
imprecisio
n

53.1(16.8)

62.5(17.2)

9.4(3.44,
15.36)

MD9.4higher
(3.44to15.36
higher)

Moderate

0.18(0.1)

0.25(0.1)

0.07(0.04,
0.10)

MD0.07higher
(0.04to0.10
higher)

Low

Weaksteplength(cm)(1monthfollowup)(Betterindicatedbyhighervalues)
Tyson,
2001266

RCT
crossov
ertrial

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

StepSymmetry(1monthfollowup)(Betterindicatedbyhighervalues)
Tyson,
2001266

RCT
crossov
ertrial

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Cadence(1monthfollowup)(Betterindicatedbyhighervalues)
Tyson,
2001266

RCT
crossov
ertrial

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Walkingspeed(m/sec)(1monthfollowup)(Betterindicatedbyhighervalues)
Tyson,
2001266

RCT
crossov
ertrial

Serious
limitations
(a)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecisio
n(c)

ImprovementinSicknessImpactProfile(SIP)ambulation(3monthsfollowup)(Betterindicatedbyhighervalues)

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Summaryoffindings
Qualityassessment

Noof
studies
Beckerman,
199621

Dynamic/An
kleFoot
Orthosis
Mean
(SD)/median
Imprecision (range)

Design

Limitations

Inconsistency

Indirectness

RCT
single
blind

Serious
limitations
(b)

Noserious
inconsistency

Noserious
Very
indirectness serious
imprecisio
n(h)

Effect
Usualcare
Mean(SD)/
median
(range)

Mean
difference
(95%CI)

Mean
Difference
(MD)(95%CI)

0.00(9.0,
15.8)

2.26(
3.37,7.89)
(f)

MD2.26higher
(3.37lowerto
7.89higher)

3.05(1.5,10)

0.84(11.2,
8.6)

0.8(3.3,
4.90)(f)

MD0.8higher
Verylow
(3.3lowerto4.9
higher)

2.52(1.9,
10.2)

1.02(9.9,
8.1)

2.27(
1.85,6.39)
(f)

MD2.27higher
(1.85lowerto
6.39higher)

Verylow

0.01(0.07,
0.19)

0.01(
0.05,0.07)
(f)

MD0.01higher
(0.05lowerto
0.07higher)

Low

0.02(0.21,
0.87)

0.06(
0.02,0.14)
(f)

MD0.06higher
(0.02lowerto
0.14higher)

Moderate

MD4.28lower
(11.2lowerto

Low

3.23(12.8,
13.2)

Confidence
(ineffect)
Verylow

ImprovementinSIPphysicaldimension(3monthsfollowup)(Betterindicatedbyhighervalues)
Beckerman,
199621

RCT
single
blind

Serious
limitations(b
)

Noserious
inconsistency

Noserious
indirect
ness

Very
serious
imprecisio
n(h)

ImprovementinSIPtotalscore(3monthsfollowup)(Betterindicatedbyhighervalues)
Beckerman,
199621

RCT
single
blind

Serious
limitations(b
)

Noserious
inconsistency

Noserious
Very
indirectness serious
imprecisio
n(h)

Walkingspeedcomfortablewithshoes(m/sec)(3monthsfollowup)(Betterindicatedbyhighervalues)
Beckerman,
199621

RCT
single
blind

Serious
limitations(b
)

Noserious
inconsistency

Noserious
Serious
indirectness imprecisio
n(c)

0.05(0.15,
0.17)

Walkingspeedmaximalsafewithshoes(m/sec)(3monthsfollowup)(Betterindicatedbyhighervalues)
Beckerman,
199621

RCT
single
blind

Serious
limitations(b
)

Noserious
inconsistency

Noserious
Noserious
indirectness imprecisio
n

0.04(0.33,
0.18)

TimedUpandGoTest(sec)(patientsneverworeAFObeforetreatment)(posttreatmenteffect)(Betterindicatedbylowervalues)
Erel,201177

RCT
not

Serious
limitations

Noserious
inconsistency

Noserious
indirectness

Serious
imprecisio

14.79(10.36)

19.07(8.19)

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4.28(
11.20to

StrokeRehabilitation
Movement

Summaryoffindings
Qualityassessment

Noof
studies

Design Limitations
blinded (g)

Inconsistency

Indirectness

Dynamic/An
kleFoot
Orthosis
Mean
(SD)/median
Imprecision (range)
n(d)

Effect
Usualcare
Mean(SD)/
median
(range)

Mean
difference
(95%CI)
2.64)

Mean
Difference
(MD)(95%CI)
2.64higher)

Confidence
(ineffect)

TimedDownStairs(sec)(patientsneverworeAFObeforetreatment)(posttreatmenteffect)(Betterindicatedbylowervalues)
Erel,201177

RCT
Serious
not
limitations
blinded (g)

Noserious
inconsistency

Noserious
indirectness

Very
serious
imprecisio
n(h)

13.29(11.21)

15.36(8.37)

2.07(
9.40to
5.26)

MD2.07lower
(9.4lowerto
5.26higher)

Verylow

TimedUpStairs(sec)(patientsneverworeAFObeforetreatment)(posttreatmenteffect)(Betterindicatedbylowervalues)
Erel,201177

RCT
Serious
not
limitations
blinded (g)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecisio
n(i)

12(10.21)

15(7.29)

3(9.57to MD3lower
3.57)
(9.57lowerto
3.57higher)

Low

Walkingspeed(m/sec)(patientsneverworeAFObeforetreatment)(posttreatmenteffect)(Betterindicatedbyhighervalues)
Erel,201177

(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)

RCT
Serious
not
limitations
blinded (g)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecisio
n

0.99(0.45)

0.72(0.20)

0.27(0.01
to0.53)

MD0.27higher
(0.01to0.53
higher)

Moderate

Randomizationnotclear.
Inadequateallocationconcealment.
MeandifferencedidnotreachtheagreedMIDof20cm/sec
MeandifferencedidnotreachtheagreedMIDof10sec
MeandifferencedidnotreachtheagreedMIDof15sec
Resultswereadjustedforbaselinedifferenceswithrespecttoage,periodpoststroke,andquadricepsstrength.
Unblinded,randomisationandallocationconcealmentnotclear
ConfidenceintervalcrossedbothendsofdefaultMID.
ConfidenceintervalcrossedoneendofdefaultMID.

Narrativesummary
ThefollowingstudyissummarisedasanarrativebecausetheresultswerenotpresentedinnumericaldatathatcouldbeincludedintheGRADEtable:

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Tyson,2009265comparedAnkleFootOrthosis(AFO)uswithnoAFOuseinacrossovertrial.Outcomesreportedwerefunctionalmobility(measuredwith
theFunctionalAmbulatoryCategory[FAC]scores)andwalkingimpairments(walkingspeedandsteplength).Thestudydesignhadseriouslimitationsas
therewasnoclearrandomization[NB:Therandomisationwastheorderofthe5differenttrialconditions]andtheoutcomeassessorswerenotblinded.
AuthorsreportedthatfunctionalmobilityimprovedsignificantlywithAFOuse(P=.0001),whilethewalkingimpairmentswereunchanged(mean
difference=0;P[speed(m/s)]=0.935,P[weaksteplength(m)]=0.998.Thestudyincludedseverelyimpairedacutestrokepatientswhowerenotwalking
outsideofPhysiotherapytreatments.

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13.10.1.2

Economicevidence
Literaturereview
NorelevanteconomicevaluationscomparingAnkleFootorthoseswithusualcarewereidentified.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
AnexpertadvisortotheGDGprovidedcostsforAFOssimilartotheonesinDeWit,2004study57
includedintheclinicalreview(thesewereprefabricated,thatisnotcustommade):
AFOwithsmallposteriorstrut,30.90+VAT
AFOwithbigposteriorstrut,35.54+VAT
AFOwithtwocrossedposteriorstruts,51.05
CustommadeAFOswouldbemadebyamemberofspecialistmultidisciplinaryorthoticsteamand
wouldincurhighercosts.Inaddition,therewouldbepersonnelcostsrelatedtothetimerequiredto
fit,trialandadjusttheAFOtotakeintoaccountthespecificpatientsneeds.TheGDGhassuggested
that,inmostcases,anorthotistwouldbeperformingthistask.Adjustmentsmaybemadebyeither
orthotistsandexperiencedphysiotherapistsoroccupationaltherapists(band6or7),dependingon
therequirements(forexampleorthotiststendtomakepermanentandmorecomplexadjustments).
Theestimatedcostsrangefrom45to59perhourofclientcontacts.

Evidencestatements

13.10.1.3

Clinicalevidencestatements
Onestudy57of20participantsfoundthattherewasastatisticallysignificantimprovementinthe
groupwithAnkleFootOrthosiscomparedwiththeusualcaregroup(posttreatmenteffect)inthe
followingoutcomes:
Walkingspeed(cm/sec)(LOWCONFIDENCEINEFFECT)
TimedUpandGo(TUG)test(sec)(LOWCONFIDENCEINEFFECT)
stairstest(LOWCONFIDENCEINEFFECT)

Onestudy266of25participantsfoundthattheAnkleFootOrthosisgroupwasassociatedwitha
statisticallysignificantimprovementcomparedwiththeusualcaregroupatonemonthinthe
followingoutcomes:
soundandweakstridelength(MODERATECONFIDENCEINEFFECT)
cadence(stepfrequency)(MODERATECONFIDENCEINEFFECT)

s EstimatedbasedondataandmethodsfromthePersonalSocialServicesResearchUnitUnitcostsofhealthandsocial
carereportandAgendaforChangesalarybands6and751(typicalsalarybandidentifiedbyclinicalGDGmembers).
Assumedthatanorthotistiscostedsimilartoaphysiotherapist.

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StrokeRehabilitation
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walkingspeed(m/sec)(LOWCONFIDENCEINEFFECT)

Onestudy266of25participantsfoundthattherewasnosignificantdifferencebetweenthegroup
withAnkleFootOrthosisandthegroupwithoutAnkleFootOrthosisatonemonthinthefollowing
outcomes:
soundandweaksteplength(VERYLOWCONFIDENCEINEFFECT)
stepsymmetry(VERYLOWCONFIDENCEINEFFECT)

Onestudy21of30participantsshowednosignificantdifferencebetweenthegroupwithAnkleFoot
Orthosisandtheusualcaregroupat12weeksinthefollowingoutcomes:
walkingabilityusingSicknessImpactProfilescores:totalscore(VERYLOWCONFIDENCEIN

EFFECT),ambulation(VERYLOWCONFIDENCEINEFFECT)andphysicaldimension(VERYLOW
CONFIDENCEINEFFECT)
walkingspeed:comfortablewithshoes(LOWCONFIDENCEINEFFECT)andmaximalsafe,with

shoes(m/sec)(MODERATECONFIDENCEINEFFECT)
Onestudy77of32participantsfoundnosignificantdifferencebetweenthegroupwithAnkle/Foot
Orthosesandtheusualcaregroup(posttreatmenteffect)inthefollowingoutcomes:
TimedUpandGo(TUG)test(sec)(LOWCONFIDENCEINEFFECT)
TimedDownStairs(sec)(VERYLOWCONFIDENCEINEFFECT)
TimedUpStairs(sec)(LOWCONFIDENCEINEFFECT)

Onestudy77of32participantsshowedastatisticalsignificantimprovementintheAnklefoot
orthosesgroupcomparedtothegroupthatreceivedusualcareinwalkingspeed(m/sec)(post
treatmenteffect)(MODERATECONFIDENCEINEFFECT)
13.10.1.4

Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

13.10.2

Recommendationsandlinktoevidence
103. Consideranklefootorthosesforpeoplewhohavedifficulty
withswingphasefootclearanceafterstroke(forexample,
trippingandfalling)and/orstancephasecontrol(for
example,kneeandanklecollapseorkneehyperextensions)
thataffectswalking.
104. Assesstheabilityofthepersonwithstroketoputonthe
anklefootorthosisorensuretheyhavethesupportneeded
todoso.
105. Assesstheeffectivenessoftheanklefootorthosisforthe
personwithstroke,intermsofcomfort,speedandeaseof
walking.

106. Assessmentforandtreatmentwithanklefootorthoses
shouldonlybecarriedoutaspartofastrokerehabilitation
programmeandperformedbyqualifiedprofessionals.

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StrokeRehabilitation
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107. Forguidanceonfunctionalelectricalstimulationforthe
lowerlimbseeFunctionalelectricalstimulationfordropfoot
ofcentralneurologicalorigin(NICEinterventionalprocedure
guidance278).

Relativevaluesofdifferent
outcomes

EffectiveAFOsshouldleadtoimprovementsinwalkingspeedand
endurance.Anumberoffactorsareimportantindeterminingthelong
termeffectivenessofanAFO,includingcomfortandtheabilitytoputon
theAFOeasily.SomeofthestudiesconsideredbytheGDGmaybe
regardedasefficacytrials(Tyson,2001266)inthattheyexamined
immediatebenefitsandnotlongtermoutcomes.Attentionneedstobe
paidtolongtermfunctionaloutcomeswithinthehomeandcommunity.

Tradeoffbetweenclinical
benefitsandharms

Noharmswerereportedinthestudiesreviewed.TheGDGagreedankle
footorthoses(AFOs)shouldhaveabiomechanicalrationale(toimprove
function),shouldbecomfortableandwellfittedtopreventpainand
pressuresores.

Economicconsiderations

Nocosteffectivenessstudieswereidentifiedforthisquestion.The
typicalcostofAFOswasestimatedtobebetween30and51
dependingonthetype.CustommadeAFOSwouldcostmore.Inaddition
thereissomepersonneltimerequiredtomakeadjustmentsforthe
patient.TheGDGconsideredthatinselectedpatientstheadditionalcost
ofAFOs,bothpremadeandcustommade,hadthepotentialtobeoffset
bybenefitstothepatientintermsofimprovedfunction,andtherefore
improvedqualityoflife.TheGDGwereawarethatlimiteduseismadeof
manyprescribedorthoseswithsignificantcostimplications.

Qualityofevidence

ThreesmallstudiesdemonstratedthattheuseofanAFOresultedina
statisticallysignificanteffectonvelocityatposttreatment(deWitt,
2004,Erel,2011,Tyson,200177.57,266).ThestudybyErel(2011)
demonstratedaclinicallysignificantimprovementinwalkingspeedin
theanklefootorthosesgroup.
Confidenceintheeffectsshownforthisoutcomerangedfromverylow
tomoderateduetolimitationsinstudydesignandthemeandifference
notreachingtheminimalimportantdifferenceintwoofthestudies(de
Witt2004andTyson200157,266).ItwasnotedbytheGDGthatthe
effectsshownintheDeWitstudy57maybeunderestimatedbecausea
flexibleAFOwasused.InclinicalpracticearigidAFOwouldnormallybe
usedifthepatientwasveryimmobile.Themobilityofthepatients
withinthisstudywaspoorthereforeforthepatienttheresultsmaybe
consideredhighlyclinicallysignificant.
Inonestudy(byBeckerman199621)someparticipantshadalreadyused
anklefootorthoses(AFOs)whichmayhaveintroducedabiasbutitis
unclearwhatdirectionthebiaswouldeffect.Thepopulationwere
stableandwalkedindependentlyatamedianvelocityof.32.45m/s,
however,therewasalargerangeofwalkingspeedsineachgroupand
noothertreatmentinterventions.Therefore,thoughthestudyshowed
noeffect,itisunclearhowmuchdifferencewouldbeseenwithtraining.
TheGDGconsideredtheTyson2009study265tobeoneofftests,and
althoughitdemonstratedastatisticallysignificantdifferenceinfavourof
AFOitisunclearhowthesewilltranslateintohomeandcommunity
settings.TheGDGconcludedthatfurtherresearchneedstobe
undertakentoevaluatetheuseofAFOsinthecommunitysetting.

Otherconsiderations

TheGDGconsideredthatAFOsareusedtosupportswingphasefoot
clearancetopreventtrippingorfallingandstancephasecontrolto

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StrokeRehabilitation
Movement
preventtheankleofkneecollapsingandthereforeAFOsshouldbe
consideredforpatientswhohavethesedifficulties.Theviewofthe
groupwasthatAFOsimprovewalkingspeedinselectedpatientsandthe
studiesrevieweddemonstratethis.Thepersonwouldneedtobeableto
putontheAFOthemselvesorhaveafamilymember/carerabletodo
thisforthem.
TheGDGagreedthatallstrokeunitsshouldhaveaccesstoanorthotics
service.AFOsshouldonlybeprovidedafterassessment,fittingandtrial
byanappropriatelytrainedandskilledmultidisciplinaryteam.Patients
shouldbeofferedregularreviewandfollowuptoensurecomfort,the
appropriatenessoftheprescriptiontotheindividualsdaytoday
requirementsandtoensureregularuse.

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StrokeRehabilitation
Selfcare

14 Selfcare
14.1 Intensityofoccupationaltherapyforpersonalactivitiesofdaily
living
PersonalActivitiesofDailyLiving(PADLs)arethosetaskswhichallofusundertakeeverydayofour
lives in order to maintain our level of care (Hopson, 1981) for example, eating, washing, brushing
teeth,anddressing.
A core aspect of Occupational Therapy is the skilled analysis of performance and the impact of
physical, sensory, psychological and emotional domains on function. Specific therapeutic goals are
thenset,andtreatmentdeliveredwhichtargetsfunctionalperformanceforexample,dressinginthe
contextofthephysical,sensoryorcognitiveimpairments.Gradingofactivitiesisoftenafeatureof
the intervention so that activities increase in complexity as patients develop necessary skills. The
theoretical perspective of occupational therapy is twofold, using restorative and compensatory
approachestointervention.

14.1.1

14.1.1.1

Evidencereview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessof
intensiveoccupationaltherapyfocusedspecificallyonpersonalactivitiesofdailyliving
(dressing/others)versususualcare?
ClinicalMethodologicalIntroduction

Population:

Adultsandyoungpeople16orolderwhohavehadastroke

Intervention:

Intensiveoccupationaltherapy(OT)dressing,grooming,bathing,
feeding/eating,washing,toileting

Comparison:

Usualcare(OTonceaweek)/nocare

Outcomes:

NottinghamExtendedActivitiesofDailyLiving(NEADL)
ExtendedActivitiesofDailyLiving(EADL)
FunctionalIndependenceMeasure(FIM)
BarthelIndex
NottinghamStrokeDressingAssessment
NorthwickParkNursingDependencyScale
RivermeadMobilityIndex

Clinicalevidence
SearcheswereconductedforsystematicreviewsandRCTscomparingtheclinicalandcost
effectivenessofintensiveoccupationaltherapyfocusedonpersonalactivitiesofdailylivingwith
usualcareornocareinadultsoryoungpeopleof16yearsoldorolderafterstroke.Onlystudieswith
aminimumsamplesizeof20participants(10ineacharm)wereselected.Weincludedseven(7)
RCTs.
Table119summarisesthepopulation,intervention,comparisonandoutcomesforeachofthe
studies.
Table119:Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
STUDY
43

Chiu,2004

POPULATION

INTERVENTION

COMPARISON

OUTCOME

Patientswitha
strokewhoareable
tofollow

Anadditionalhome
basedtraining
programmeon

Predischargehome
visit(mean1.39
visits)butno

Functional
Independence
Measure(FIM)

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StrokeRehabilitation
Selfcare
STUDY

POPULATION
instructionsand
verbally
communicateand
whoarelivingat
homewithfamily
support.

INTERVENTION
COMPARISON
bathingdevices
treatmentpost
includingatleast2
discharge.(N=23)
visitsbutnotmore
than3(mean2.74)
1stvisit:
explanationof
deviceandsafety;
2ndvisit:
opportunityto
discussproblems
usingdevicesand
devicescheckedfor
fitandsafety;
3rdvisit:optional,
dependingon
patient'sproficiency
usingdevice.(N=30)

OUTCOME

Corr,199548

Firstandsecond
strokepatients.
(Mediannumberof
dayssincestroke=
50).

Teachingnewskills,
facilitating
independencein
activitiesofdaily
living,facilitating
returnoffunction,
enablingpatientsto
useequipment,
givinginformation
topatient/carer;
referringtoor
liaisingwithother
agencies.Home
visitsbyanOTafter
dischargeand
offeredfurther
rehabilitationand
reviewedat2,8,16
and24weeks.
(N=55)

Usualcare.(N=55)

BarthelIndex
Nottingham
Extended
ActivitiesofDaily
Living

Gilbertson,
200091

Patientswitha
clinicaldiagnosisof
stroke(excluding
subarachnoid
haemorrhage)
withoutsevere
cognitiveor
communication
problems.

Domiciliary
occupational
therapy(OT):6
weekprogramme
(around10sessions
lasting3045
minutes)tailoredto
recoverygoalsset
bypatient(for
exampleregaining
selfcareor
domesticorleisure
activities).
(N=67)

Inpatient
multidisciplinary
rehabilitation,pre
dischargehome
visitforselected
patients,support
servicesand
equipment,regular
reviewin
multidisciplinary
strokeclinicand
selectedpatients
referredtoday
hospital.(N=71)

BarthelIndex
Nottingham
Extended
ActivitiesDaily
Living

Logan,1997158

Firsttimestroke
patientsdischarged
fromhospitaland
referredto

Enhanced
occupational
therapy(OT):equal
accesstoaidsand

Usualcare;85mean Extended
minutespertherapy
ActivitiesofDaily
forameannumber
Living(EADL)
of2.5visits(N=58). BarthelIndex

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StrokeRehabilitation
Selfcare
STUDY

POPULATION
occupational
therapy
department.

INTERVENTION
COMPARISON
budgetsfor

adaptations.
Patientsseenand
treatedbyasingle
researchOT(sooner
thanpossiblewith
routineservice)for
adurationof240
meanminutesper
therapyfor
meannumberof6
visits.(N=53)

OUTCOME

Parker,2001199

Patientswithstroke
notmorethan6
monthswithout
severeillnessand
nodocumented
historyofdementia

Treatmentgoals:
Nocare(N=157).
improving
independencein
selfcaretaskssuch
aswashing,dressing
orbathing.Home
occupational
therapy(total10
sessions)lasting
notlessthan30
minuteseach
sessionforupto6
months(N=156).

Nottingham
ExtendedADL
BarthelIndex

Sackley,2006226 Participantsin
residentialhomes
withmoderateto
severestroke
relateddisability(BI
score4to15)were
included.

Aimedatimproving
independencein
personalactivities
ofdailyliving,such
asfeeding,dressing,
toileting,bathing,
transferringand
mobilizing.
Frequencyand
durationof
therapieswas
dependenton
residentand
therapistsagreed
goals(over3
months).Median
visitsperresident
permonth:2.7
(range125);time
spentwiththerapist
perresidentper
month4.5hours
(range110);most
sessionslasted
around30minutes.
(N=63)

Usualcare
(occupational
therapistnot
involved(N=55).

BarthelIndex
Rivermead
MobilityIndex

Walker,1999278 Patientswithstroke
lessthan1month;
notbeenadmitted
tothehospital;not

Aimedatimproving
independencein
personaland
instrumental

Nocare(N=91).

Extended
ActivitiesofDaily
Living(EADL)
BarthelIndex

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StrokeRehabilitation
Selfcare
STUDY

POPULATION
livinginanursingor
residentialhome.

INTERVENTION
COMPARISON
activitiesofdaily
living.Visitsfrom
theoccupational
therapistforupto5
months(frequency
ofvisitswasagreed
betweenthe
therapist,patient,
andcarer).Mean
numberofvisits:5.8
(SD3.3,range115).
Meanlengthof
eachvisitwas52
min(11.8,2490).
(N=94)

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OUTCOME

StrokeRehabilitation
Selfcare

14.1.1.2

Comparison:Intensiveoccupationaltherapyfocussedonpersonalactivitiesofdailylivingversususualcare/nocare.

Table120:Intensiveoccupationaltherapyversususualcare/nocareClinicalstudycharacteristicsandclinicalsummaryoffindings

Summaryoffindings
Qualityassessment

Authors

Design

Limitations

Inconsistency

Indirectness

Usual
care/no
care
Median
(IQR)/Mean
(SD)/
Frequency
(%)

Effect

Intensive
occupational
therapy
Median
(IQR)/Mean
(SD)/Frequency
(%)

Veryserious
imprecision
(b)

78.6(7.4)

73.5(10.9)

5.1(0.08to
10.28)

MD5.1
higher(0.08
lowerto
10.28
higher)

Serious
imprecision
(k
d)

1(02)

0(31)

1(0.42to
1.58)

MD1higher Low
(0.42to1.58
higher)

Noserious
imprecision

10.8(5.5)

8.2(5.2)

2.6(0.54to
4.66)

MD2.6
higher(0.54
to4.66
higher)

Moderate

Serious
imprecision

Gilbertson:17
(1519)

Gilbertson:
17(1318)

0.59(0.55,
1.73)

MD0.59
higher(0.55

Low

Imprecision

Relative
Risk/Mean
difference
(95%CI)

Absolute
effect/
Mean
Difference
(MD)(95%
CI)orP
value

Confidence
(ineffect)

FunctionalIndependenceMeasure(3monthsfollowup)(Betterindicatedbyhighervalues)
Chiu,
200443

RCTSingle
blinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Verylow

BarthelIndex(2monthsfollowup)(Betterindicatedbyhighervalues)
Gilbertson
,200091

RCTsingle
blinded

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

BarthelIndex(3monthsfollowup)(Betterindicatedbyhighervalues)
Sackley,
2006226

ClusterRCT
Singleblinded

Serious
limitations(e
)

Noserious
inconsistency

Noserious
indirectness

BarthelIndex(6monthsfollowup)(Betterindicatedbyhighervalues)
3
Gilbertson

RCTs3single
blinded,1

Serious
limitations(c

Noserious
inconsistency

Noserious
indirectness

NationalClinicalGuidelineCentre,2013.

534

StrokeRehabilitation
Selfcare

Summaryoffindings
Qualityassessment

Authors
,200091;
Walker,
1999278
Sackley,
2006226

Design
ClusterRCT

Limitations
)

Inconsistency

Indirectness

Usual
care/no
Intensive
care
occupational
therapy
Median
(IQR)/Mean
Median
(SD)/
(IQR)/Mean
(SD)/Frequency Frequency
(%)
(%)
Walker:20(18 Walker:18
20)
(1620)

Sackley
(changes):0.3 Sackley
(4.2)
(changes):
2.1(3.7)

Effect

Relative
Risk/Mean
difference
(95%CI)

Absolute
effect/
Mean
Difference
(MD)(95%
CI)orP
value
lowerto
1.73higher)

(f)

16(120)

16(220)

(g)

(g)

Moderate
(f)

(f)

18(1520)

17(1520)

(g)

(g)

Moderate
(f)

Veryserious
imprecision
(m)

22/55(40%)

22/55(40%)

1(0.63to
1.58)

0fewerper Verylow
1000(from
148fewerto
232more)

(f)

17(1419)

17(1420)

(g)

(g)

Imprecision
(d)

Confidence
(ineffect)

BarthelIndex(6monthsfollowup)(Betterindicatedbyhighervalues)
Logan,
1997158

RCTSingle
blinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

BarthelIndex(6monthsfollowup)(Betterindicatedbyhighervalues)
Parker,
2001199

RCTSingle
blinded

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

BarthelIndex(score<12)(1yearfollowup)(Betterindicatedbyhighervalues)
Corr,1995 RCTSingle
48

blinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

BarthelIndex(1yearfollowup)(Betterindicatedbyhighervalues)
Parker,
2001199

RCTSingle
blinded

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

NationalClinicalGuidelineCentre,2013.

535

Moderate
(f)

StrokeRehabilitation
Selfcare

Summaryoffindings
Qualityassessment

Authors

Design

Limitations

Inconsistency

Indirectness

Imprecision

Usual
care/no
Intensive
care
occupational
therapy
Median
(IQR)/Mean
Median
(SD)/
(IQR)/Mean
(SD)/Frequency Frequency
(%)
(%)

Effect

Relative
Risk/Mean
difference
(95%CI)

Absolute
effect/
Mean
Difference
(MD)(95%
CI)orP
value

Confidence
(ineffect)

NottinghamExtendedActivitiesofDailyLiving(total)(2monthsfollowup)(Betterindicatedbyhighervalues)
Gilbertson
,200091

RCT

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(i)

27(1943)

23(1135)

4(0.43to
8.43)

MD4higher
(0.44lower
to8.44
higher)

Low

Parker:21
(1438)
Gilbertson:
33.1(18.9)

3.41(0.00,
6.82)

MD7higher
(12.37
lowerto
26.37
higher)

Low

33.3(19.5)

0.8(4.32to
5.92)

MD0.8
higher(4.32
lowerto
5.92higher)

Low

0.58(0.3to
1.1)

145fewer
per1000
(from242
fewerto35
more)

Low

NottinghamExtendedActivitiesofDailyLiving(total)(6monthsfollowup)(Betterindicatedbyhighervalues)
2Parker,
2001199
Gilbertson
,200091

RCTsSingle
blinded

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(i)

Parker:28(15
38)
Gilbertson:34.7
(18.4)

NottinghamExtendedActivitiesofDailyLiving(total)(1yearfollowup)(Betterindicatedbyhighervalues)
Parker,
2001199

RCTSingle
blinded

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(i)

34.1(19.1)

NottinghamExtendedActivitiesofDailyLiving(notabletofeed)(1yearfollowup)(Betterindicatedbyhighervalues)
Corr,1995 RCTSingle
48

blinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(j)

11/55(20%)

19/55
(34.5%)

NottinghamExtendedActivitiesofDailyLiving(Notabletousethetelephone)(1yearfollowup)(Betterindicatedbyhighervalues)

NationalClinicalGuidelineCentre,2013.

536

StrokeRehabilitation
Selfcare

Summaryoffindings
Qualityassessment

Authors

Design

Corr,1995 RCTSingle
48

blinded

Limitations

Inconsistency

Indirectness

Imprecision

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

Serious
imprecision
(j)

Usual
care/no
Intensive
care
occupational
therapy
Median
(IQR)/Mean
Median
(SD)/
(IQR)/Mean
(SD)/Frequency Frequency
(%)
(%)

Effect

16/55(29.1%)

29/55
(52.7%)

0.55(0.34to 237fewer
Low
0.89)
per1000
(from58
fewerto348
fewer)

2(021)

(g)

(g)

Low
(f)

8(019)

3(018)

(g)

P<0.01(g)
(h)

Moderate
(f)

5.2(3.7)

3.5(3.1)

1.7(0.40to
3.00)

MD1.7
higher(0.4
to3higher)

Moderate

4.5(3.5)

3.4(2.7)

1.1(0.20to
2.4)

MD1.1
higher(0.2
lowerto2.4
higher)

Verylow

Relative
Risk/Mean
difference
(95%CI)

Absolute
effect/
Mean
Difference
(MD)(95%
CI)orP
value

Confidence
(ineffect)

NottinghamExtendedActivitiesofDailyLiving(total)(1yearfollowup)(Betterindicatedbyhighervalues)
Corr,1995 RCTSingle
48

blinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

(f)

3(020)

ExtendedActivitiesofDailyLiving(total)(3monthsfollowup)(Betterindicatedbyhighervalues)
Logan,
1997158

RCTSingle
blinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

(f)

RivermeadMobilityIndex(3monthsfollowup)(Betterindicatedbyhighervalues)
Sackley,
2006226

Cluster
Randomised
TrialSingle
blinded

Serious
limitations(e
)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

RivermeadMobilityIndex(6monthsfollowup)(Betterindicatedbyhighervalues)
Sackley,
2006226

Cluster
Randomised
TrialSingle
blinded

Serious
limitations(e
)

Noserious
inconsistency

Noserious
indirectness

Veryserious
imprecision
(l)

NationalClinicalGuidelineCentre,2013.

537

StrokeRehabilitation
Selfcare

Summaryoffindings
Qualityassessment

Authors

Design

Limitations

Inconsistency

Indirectness

Imprecision

Usual
care/no
Intensive
care
occupational
therapy
Median
(IQR)/Mean
Median
(SD)/
(IQR)/Mean
(SD)/Frequency Frequency
(%)
(%)

Effect

16(1118.75)

12(617)

3(0.78to
5.22)

MD3higher Moderate
(0.78to5.22
higher)

6(018)

(g)

(g)(k)

Relative
Risk/Mean
difference
(95%CI)

Absolute
effect/
Mean
Difference
(MD)(95%
CI)orP
value

Confidence
(ineffect)

ExtendedActivitiesofDailyliving(6monthsfollowup)(Betterindicatedbyhighervalues)
Walker,
1999278

RCTSingle
blinded

Serious
limitations(c
)

Noserious
inconsistency

Noserious
indirectness

Noserious
imprecision

ExtendedActivitiesofDailyLiving(total)(6monthsfollowup)(Betterindicatedbyhighervalues)
Logan,
1997158

RCTSingle
blinded

Serious
limitations(a
)

Noserious
inconsistency

Noserious
indirectness

(f)

8(021)

(a)

Unclearrandomisationandallocationconcealment.
MeandifferencedidnotreachtheagreedMIDof17points.
(c)

Unclearblinding
(d)
MeandifferencedidnotreachtheagreedMIDof1.85points.
(e)

Unclearallocationconcealment

(f)
Imprecisioncouldnotbeassessedbecauseonlymedianandinterquartilerangesofdatareported

(g)
Relative/Absoluteeffectcouldnotbeestimatedbecauseonlymedianandinterquartilerangesofdatareported
(h)

P valueasreportedbytheauthors.

(i)
ConfidenceintervalcrossesthelowerlimitofspecifiedMID(0.9)

(j)
ConfidenceintervalcrossesoneendofthedefaultMID(0.75).
(k)
Authorsreportednosignificantdifferencebetweentheintensiveoccupationaltherapygroupandusualcaregroup.
(l)

ConfidenceintervalcrossedbothendsofdefaultMID.

(m)
ConfidenceintervalcrossesbothendsofdefaultMID(0.75to1.25)
(b)

NationalClinicalGuidelineCentre,2013.

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Moderate
(f)

StrokeRehabilitation
Selfcare

14.1.1.3

Economicevidence
Literaturereview
Norelevanteconomicevaluationscomparingintensiveoccupationaltherapywithusualcarewere
identified.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
TheGDGnotedthatthemaindifferenceintermsofresourcesbetweenintensivetherapyandusual
carewasthetimeoccupationaltherapistswouldspendwithpatients.
Theestimatedcostperhourofclientcontacttforaband6occupationaltherapistis45(hospital
based)or48(communitybased).TheGDGalsonotedthattothesecostsitmaybenecessarytoadd
thecostofadditionalspecificaids(suchasbarsusedtofacilitatetheuseofbathrooms)thatcanbe
usedintheseinterventions.

14.1.1.4

Evidencestatements
Clinicalevidencestatements
Onestudy43comprising53participantsfoundnosignificantdifferenceinFunctionalIndependence
Measureat3monthsafterstrokebetweenthegroupthatreceivedintensiveoccupationaltherapy
andtheusualcaregroup(VERYLOWCONFIDENCEINEFFECT).
Onestudy91comprising138participantsfoundasignificantdifferenceintheBarthelIndexat2
monthsinfavourofthegroupthatreceivedintensiveoccupationaltherapycomparedtotheusual
caregroup,althoughthisdifferencewasnotofclinicalimportance(LOWCONFIDENCEINEFFECT).
Onestudy226comprising118participantsfoundasignificantdifferenceintheBarthelscoresat3
monthsafterstrokeinfavourofthegroupthatreceivedintensiveoccupationaltherapycomparedto
theusualcaregroup(MODERATECONFIDENCEINEFFECT).
Threestudies91,226,278comprising441participantsfoundnosignificantdifferenceintheBarthelIndex
at6monthsfollowupbythegroupreceivingintensiveoccupationaltherapycomparedtotheusual
caregroup(LOWCONFIDENCEINEFFECT).
Onestudy48comprising110participantsfoundnosignificantdifferenceintheproportionof
participantsachievinglessthan12inBarthelscoresat1yearafterstrokebetweenthegroupthat
receivedintensiveoccupationaltherapyandtheusualcaregroup(VERYLOWCONFIDENCEIN
EFFECT).
Onestudy91comprising138participantsfoundnosignificantdifferenceintheNottinghamExtended
ADLscoresat2monthsbetweenthegroupthatreceivedintensiveoccupationaltherapyandthe
usualcaregroup(LOWCONFIDENCEINEFFECT).

t EstimatedbasedondataandmethodsfromthePersonalSocialServicesResearchUnitUnitcostsofhealthandsocial
51
carereportandAgendaforChangesalaryband6 (typicalsalarybandidentifiedbyclinicalGDGmembers).

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StrokeRehabilitation
Selfcare
Twostudies91,199comprising451participantsfoundnosignificantdifferenceintheNottingham
ExtendedADLscoresat6monthsafterstrokebetweenthegroupthatreceivedintensive
occupationaltherapyandtheusualcaregroup(LOWCONFIDENCEINEFFECT).
Onestudy199comprising313participantsfoundnosignificantdifferenceintheNottinghamExtended
ADLscoresat12monthsafterstrokebetweenthegroupthatreceivedintensiveoccupational
therapyandtheusualcaregroup(LOWCONFIDENCEINEFFECT).
Onestudy48comprising110participantsfoundnosignificantdifferenceintheproportionof
participantsabletofeedthemselvesasmeasuredbytheNottinghamExtendedActivitiesofDaily
Livingscaleat1yearafterstrokeintheintensiveoccupationaltherapygroupcomparedtotheusual
caregroup(LOWCONFIDENCEINEFFECT).
Onestudy48comprising110participantsshowedthatasignificantlyhigherproportionofparticipants
intheintensiveoccupationaltherapygroupwereabletousethetelephoneasmeasuredbythe
NottinghamExtendedActivitiesofDailyLivingscaleat1yearafterstrokecomparedtotheusualcare
group(LOWCONFIDENCEINEFFECT).
Onestudy226comprising118participantsfoundasignificantdifferenceintheRivermeadmobility
scoresat3monthsfollowupinfavourofthegroupthatreceivedintensiveoccupationaltherapy
comparedtotheusualcaregroup(MODERATECONFIDENCEINEFFECT).
Onestudy226comprising118participantsfoundnosignificantdifferenceintheRivermeadmobility
scoresat6monthsfollowupbetweenthegroupthatreceivedintensiveoccupationaltherapyand
theusualcaregroup(VERYLOWCONFIDENCEINEFFECT).
Onestudy278comprising185participantsfoundasignificantdifferenceintheExtendedActivitiesof
DailyLivingscoresat6monthsfollowupinfavourofthegroupthatreceivedintensiveoccupational
therapycomparedtotheusualcaregroup(MODERATECONFIDENCEINEFFECT).
Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

14.1.2

RecommendationsandLinktoEvidence
108. Provideoccupationaltherapyforpeopleafterstrokewho
arelikelytobenefit,toaddressdifficultieswithpersonal
activitiesofdailyliving.Therapymayconsistofrestorativeor
compensatorystrategies.
Restorativestrategiesmayinclude:
- encouragingpeoplewithneglecttoattendtothe
neglectedside
- encouragingpeoplewitharmweaknesstoincorporate
botharms
- establishingadressingroutineforpeoplewithdifficulties
suchaspoorconcentration,neglectordyspraxiawhich
makedressingproblematic.

Compensatorystrategiesmayinclude:
- teachingpeopletodressonehanded
- teachingpeopletousedevicessuchasbathingand

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StrokeRehabilitation
Selfcare
dressingaids.
109. Peoplewhohavedifficultiesinactivitiesofdailylivingafter
strokeshouldhaveregularmonitoringandtreatmentby
occupationaltherapistswithcoreskillsandtraininginthe
analysisandmanagementofactivitiesofdailyliving.
Treatmentshouldcontinueuntilthepersonisstableorable
toprogressindependently.
110. Assesspeopleafterstrokefortheirequipmentneedsand
whethertheirfamilyorcarersneedtrainingtousethe
equipment.Thisassessmentshouldbecarriedoutbyan
appropriatelyqualifiedprofessional.Equipmentmayinclude
hoists,chairraisersandsmallaidssuchaslonghandled
sponges.
111. Ensurethatappropriateequipmentisprovidedand
availableforusebypeopleafterstrokewhentheyare
transferredfromhospital,whateverthesetting(including
carehomes).

Relativevaluesofdifferent
outcomes

Theoutcomesincludedinthereviewwere:FunctionalIndependence
Measure,BarthelIndex,NottinghamExtendedADLIndex,Extended
ActivitiesofDailyLivingScaleandRivermeadMobilityIndex,
TheGDGconsideredthestudiesthatreportedFIM(Motorsubscale)and
Bartheloutcomestobethemostusefulforassessingfunctional
outcomes.

Tradeoffbetweenclinical
benefitsandharms

Providedtheinterventionisdeliveredbyanappropriatelytrained
OccupationalTherapisttheGDGdidnotconsidertheretobeany
significantharmsassociatedwiththistypeofinterventionandthatthe
benefitsgainedbybeingabletoparticipateinactivitiesofdailyliving
weresignificantintermsofpatientsqualityoflife.
TheGDGagreedthattherapiesshouldincludebotharestorative
approach(aimingtoregainfunction)andacompensatory(useofaids
andequipment)approachtohelpanindividualcompensateforresidual
impairments.Appropriateequipmentneedstobeprovidedtostroke
patientsoncedischargedfromhospital,whateverthesettingtheyare
dischargedto,includingnursinghomes.Thisprovisionwouldideallybe
followingassessmentbyanOccupationalTherapistandmayinclude
practiceandtrainingwithequipment.

Economicconsiderations

Nocosteffectivenessstudieswerefoundforthisquestion.Occupational
therapyiscurrentlyroutinelyprovidedtostrokepatients.Delivering
moreintensiveinterventionwouldrequirehigherpersonnelinput,and
possiblymoreequipment,hencemoreresourceswouldbeneeded.
However,thesemaybeoffsetbyareductioninsocialandhealthfunded
carepackagesandimprovementsinpatientsqualityoflife.

Qualityofevidence

TheGDGrecognisedthatmostofthestudieswerecommunitybasedand
thereforehaveapplicabilitytoearlysupporteddischargeandtothelong
termmanagementofstroke.
ItwasnotedthatthepatientpopulationintheSackleystudy,2006was
differentfromtheotherstudiesastheywereolderandinresidential
nursinghomes(thesepatientswereseentomaintainperformancein
comparisonwithcontrolgroup,whodeteriorated).TheGDGalso

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StrokeRehabilitation
Selfcare
consideredthatmanagementofpatientshadchangedsincethe
publicationoftheWalkerstudy278asthesepatientshadnotbeen
admittedtohospital,howeveritwasusefulanditmayreflecta
populationwhowouldnowreceiveearlysupporteddischargeasthey
scoredhigherontheBarthelindexatbaseline.
TheGDGconsideredthestudiesincludedinthereviewtobefeasibility
studies.Confidenceintheeffectshowninmostoftheoutcomeswere
lowtomoderateduetolimitationsinstudydesign(unclear
randomisationandallocationconcealment)andimprecisionaroundthe
effectestimate.Althoughitwasfoundthattherewasaclinically
significanteffectofintensiveOTinBarthelIndexat3monthscompared
tousualcaregroup(Sackley2006226)andtheconfidenceonthiseffect
wasmoderate,thiseffectwasnotpreservedatsixmonthsfollowup.
TheParkerstudy199wastheonlylargemulticentred,RCT,howeverthis
producedequivocalresults.Theinclusionofthisdatainametaanalysis
151
(whichincludedstudieswithsmallernumbersthanincludedinthis
clinicalreview)hasshownthattherewassignificantbenefitshowninthe
intensivearmofoccupationaltherapy.
OveralltheGDGagreedstudiesshowedshorttermfunctionalgainat3
monthsbutnotoveralongerterm.Somelimitedevidenceshowedthat
functionalgainsaremaintainedat6monthsand1yearintheintensive
OTgroups(Gilbertson2000,Sackley2006,Walker199991,226,278)
TheGDGagreedthatfromtheevidenceavailableforthosepatientswith
strokewhoaremanagedwithinthecommunity,occupationaltherapy
providessomebenefit,butthereiscurrentlynoevidenceforthose
patientswithmoderatestrokewhoaremanagedintheacute(hospital)
settingandfurtherresearchisrequired.

TheGDGconsideredthatthepatientsincludedinthestudiestendedto
bethosewithmoderatestrokeandphysicallyfitter,thereforetreatment
withinthecommunityratherthaninhospitalwouldbeappropriatefor
thisparticularpopulation,butwouldnotbeapplicableforallstroke
patients.
Otherconsiderations

TheGDGrecognisedthatdefiningintensityischallengingandcan
bedefinedintermsoffrequencyoftreatment,totalamountof
treatment,durationoftreatment,ormodeofdelivery.
Theamountofoccupationaltherapymentionedinthereviewed
studiesvariedbutwastypicallylessthanthecurrent(5sessionx
45minutesperweek)recommendedinthecurrentNICEQuality
standards.Thestudiesidentifiedgavelittleindicationhowmuch
occupationaltherapyisneededbutdidindicatethatoccupational
therapyiseffective.
TheGDGnotedthatthedescriptionofoccupationaltherapy
interventionswaslimitedwithinthestudiesreviewed,butthey
didemployarangeofrestorativeandcompensatorystrategies.
Consensusrecommendationsweremadetoreflectthisand
examplesofthetypesofinterventionsdeliveredwereindicated.

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StrokeRehabilitation
Communityparticipationandlongtermrecovery

15 Communityparticipationandlongtermrecovery
Atsomepointaftertheonsetofstroke,nofurtherchangescanreasonablybeexpectedatthe
impairmentlevel,howeverchangescanstillbemadeintermsofreintegrationintoanindividuals
family,socialandcommunitylifeRehabilitationservicesshouldaimtowithdrawonlywhenpeople
withstrokehavetheknowledge,skillsandifnecessarythesupporttheyneedtomanagethis
process.Thischapterfocussesonselfmanagement,longtermhealthandsocialsupportandreturn
totheworkplace.
Asearchforsystematicreviewevidenceforthetopicoflongtermhealthandsocialsupportofthe
personafterstroke.Therewasnoevidenceidentifiedandthereforerecommendationswerebased
onmodifiedDelphiconsensusstatementsthatweredrawnupbasedonrecommendationsin
publishednationalandinternationalguidelinesseeAppendixFfordetails.

15.1 Returntowork
Workcontributestoadultidentity,confersfinancialbenefitsandstatus,andcanimprovequalityof
lifeandreducesillhealth.TheStrokeStrategy61highlightedtheneedforpeoplewhohavehada
strokeandtheircarerstobeenabledtoparticipateinpaid,supportedandvoluntaryemployment.
TheNationalServiceFrameworkforpeoplewithlongterm(neurological)conditions60identifiedthe
needindividualsmayhaveforvocationalrehabilitationofferedbylocalorspecialistrehabilitation
servicesto:entertrainingorworkopportunities;remaininorreturntotheirexistingjob;identify
andprepareforsuitablealternativeworkoptions;planwithdrawalfromworkatanappropriatetime
(conservingpensionandotherrights);andaccessappropriatealternativeoccupationaland
educationalopportunities.
Vocationalrehabilitationisoftendeliveredbyhealthprofessionals,linkedtocommunity
rehabilitationservicesandaimstoreviewandoptimisetheskillsrequiredtoengageinmeaningful
occupation,whichmightbepaidorvoluntaryandmayormaynotbetheroletheywereemployedin
priortotheirstroke.Ideallyspecialistvocationalrehabilitationservicesarebothmultidisciplinary
andmultiagency(withrehabilitationservicesworkingalongsideJobCentrePlus),butinpractice
mostvocationalrehabilitationisdeliveredbyoccupationaltherapistsandpsychologistsbasedin
communityrehabilitationteams.
Interventionsaremosteffectivewhentheyaretailoredtotheindividualsimpairmentsinthe
contextofthedemandsoftheworkplace.Theymayincludetheuseofmemorystrategies,
computeruse,confidencebuilding,planningandpacing,aswellasliaisingwithemployersregarding
educationonstrokespecificissues,reasonableaccommodationsandgradedreturntowork
activities.

15.1.1

EvidenceReview:Inpeopleafterstrokewhatistheclinicalandcosteffectivenessof
interventionstoaidreturntoworkversususualcare?
ClinicalMethodologicalIntroduction

Population:

Adultsandyoungpeople16orolderwhohavehada
stroke

Intervention:

Jobretention
Returntowork(tailoredtotheimpairmentofthe
patientrecognisingthedemandsofthejob)

Comparison:

Usualcare(nothing)

Outcomes:

Samejobsameemployer
Samejobdifferentemployer

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StrokeRehabilitation
Communityparticipationandlongtermrecovery
ClinicalMethodologicalIntroduction

15.1.2

Differentjobsameemployer
Differentjobdifferentemployer
Unemployment
Retiredduetoillhealth
Voluntarywork
Benefitclaims

Clinicalevidence
SearcheswereconductedforsystematicreviewsandRCTscomparinginterventionstoaidreturnto
workwithusualcareforadultsoryoungpeopleof16yearsoldafterstroke.Onlystudieswitha
minimumsamplesizeof20participants(10ineacharm)andincludingatleast50%ofparticipants
withstrokewereselected.OneRCTwasidentified.Thisstudywasconductedinamixedpopulation
ofparticipantswithacquiredbraininjury,ofwhom59.1%hadexperiencedstroke.
Table121:Summaryofstudiesincludedintheclinicalevidencereview.Forfulldetailsofthe
extractionpleaseseeAppendixH.
STUDY

POPULATION

INTERVENTION

COMPARISON

OUTCOMES

Trexler
2010262

Patientswith
acquiredbrain
injury(traumatic
braininjury
(31.8%),
intracranial
haemorrhage
(31.8%),stroke
(27.3%),other
(13.6%))aged
between1860
years.
Participantshad
beenemployed
and/orattended
schoolfor2
yearspriorto
theinjuryand
hadagoalto
returntoworkor
toschool.

Resourcefacilitation
interventiontoreturn
towork(duration6
months)including
assessmentof
patientscurrent
status,needsand
resources,planand
documentmutually
agreeduponneeds,
identificationof
communityresources
forservicesand
supports,facilitation
ofaccesstoresources
througheducationand
advocacy,proactively
monitoringofthe
statusoftheplan
throughtelephone,
internetandpersonal
contactswithpatient
orcaregiverata
minimumofevery2
weeksandprovisionof
education
(informationonthe
injury,personal
advocacyand
partnership
development)withthe
patientorcaregiver.
Formeremployerwas
involvedthrough
education,titrating

Usualcare:patients
receivedonly
recommended
servicesbytheir
healthcareproviders
(outpatient
rehabilitation
therapies,
neuropsychological
services,medical
followup).No
contactduringthe6
monthsfollowupby
aresourcefacilitator
wasmade.(N=11)

Fulltime
employment
Parttime
employment
Employment
Unemployment

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StrokeRehabilitation
Communityparticipationandlongtermrecovery
STUDY

POPULATION

INTERVENTION
COMPARISON
returntowork
schedulesand
facilitatingutilization
ofjobsupports.(N=12)

NationalClinicalGuidelineCentre,2013.
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OUTCOMES

StrokeRehabilitation
Communityparticipationandlongtermrecovery

Comparisonofresourcefacilitationinterventionforreturntoworkversususualcare
Table122:Resourcefacilitationinterventionforreturntoworkversususualcareclinicalstudycharacteristicsandclinicalsummaryoffindings
Summaryoffindings
Qualityassessment
Noof
studies

Design

Usualcare
Frequencies
(%)

Effect

Limitations

Inconsistency Indirectness

Imprecision

Resource
facilitation
Frequencies
(%)

Very
serious
limitations
(a)

Noserious
inconsistency

Serious
indirectness
(b)

Veryserious
imprecision
(c)

4/12(33.3%) 3/11(27.3%) 1.22

(0.35to
4.28)

60moreper
1000(from
177fewerto
895more)

Verylow

Very
serious
limitations
(a)

Noserious
inconsistency

Serious
indirectness
(b)

Veryserious
imprecision
(c)

3/12(25%)

159moreper
1000(from61
fewerto1972
more)

Verylow

Very
serious
limitations
(a)

Noserious
inconsistency

Serious
indirectness
(b)

Veryserious
imprecision
(c)

7/12(58.3%) 4/11(36.4%) 1.6(0.64

to4.01)

7218more
per1000
(from131
fewerto1095
more)

Verylow

Very
serious
limitations
(a)

Noserious
inconsistency

Serious
indirectness
(b)

Veryserious
imprecision
(c)

5/12(41.7%) 7/11(63.6%) 0.65

(0.29to
1.46)

223fewerper
1000(from
452fewerto
293more)

Verylow

Relative
Risk
(95%ci)

Absolute
effect(95%
CI)

Confidence
(ineffect)

Fulltimeemployment
1Trexler
2010262

RCT
unblinded

Parttimeemployment
1Trexler
2010262

RCT
unblinded

1/11(9.1%)

2.75
(0.33to
22.69)

Anyemployment
1Trexler
2010262

RCT
unblinded

Unemployment
1Trexler
2010262

RCT
unblinded

(a) Unblindedstudy.Nodetailsonrandomizationandunclearallocationconcealment.
(b) Patientshadexperiencedtraumaticbraininjury(TBI)withnomentiononthephaseoftheirillness.59.1%participantshadstroke.
(c) ConfidenceintervalcrossedbothendsofdefaultMID(0.75,1.25)

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StrokeRehabilitation
Communityparticipationandlongtermrecovery

Narrativesummary
ThefollowingstudyissummarisedasanarrativebecausetheresultswerenotpresentedinnumericaldatathatcouldbeincludedintheGRADEtable:

Theauthorsoftheonceincludedstudy262alsoreportedthatthedistributionofthethreecategories(fulltime,parttimeandunemployed)ofthe
employmentitemoftheMayoPortlandAdaptabilityInventory4ParticipationIndex(M2PI)weresignificantlydifferentbetweentheresourcefacilitation
interventiongroupandtheusualcare(P<0.0001).

NationalClinicalGuidelineCentre,2013.

547

15.1.2.1

Economicevidence
Literaturereview
Norelevanteconomicevaluationscomparingoccupationaltherapytoaidreturntoworkwithusual
carewereidentified.
Interventioncosts
Intheabsenceofcosteffectivenessanalysisforthisreviewquestion,theGDGconsideredthe
expecteddifferencesinresourceusebetweenthecomparatorsandrelevantUKNHSunitcosts.
Considerationofthisalongsidetheclinicalreviewofeffectivenessevidencewasusedtoinformtheir
qualitativejudgementaboutcosteffectiveness.
TheGDGconsideredthattypicallyaband7communityoccupationaltherapistwoulddeliverthis
service.Theestimatedcostperhourofclientcontactis59u.Typicalresourceuseperpatientwas
estimatedtobeintherangeof9to15hours.

15.1.2.2

Evidencestatements
Clinicalevidencestatements
Onestudy262comprisingof23participantsshowedthattherewasnosignificantdifferenceinthe
proportionofparticipantsreturningtofulltimeemploymentbetweenthosewhoreceivedresource
facilitatorinterventionandtheusualcaregroup(VERYLOWCONFIDENCEINEFFECT).
Onestudy262comprisingof23participantsshowedthattherewasnosignificantdifferenceinthe
proportionofparticipantsreturningtoparttimeemploymentbetweenthosewhoreceivedresource
facilitatorinterventionandtheusualcaregroup(VERYLOWCONFIDENCEINEFFECT).
Onestudy262comprisingof23participantsshowedthattherewasnosignificantdifferenceinthe
proportionofparticipantsreturningtoemploymentbetweenthosewhoreceivedresourcefacilitator
interventionandtheusualcaregroup(VERYLOWCONFIDENCEINEFFECT).
Onestudy262comprisingof23participantsshowedthattherewasnosignificantdifferenceinthe
proportionofunemployedparticipantsbetweenthosewhoreceivedresourcefacilitatorintervention
toaidtoreturnworkandtotheusualcaregroup(VERYLOWCONFIDENCEINEFFECT).
Economicevidencestatements
Nocosteffectivenessevidencewasidentified.

15.1.3

Recommendationsandlinktoevidence
112. Returntoworkissuesshouldbeidentifiedassoonaspossible
afterthepersonsstroke,reviewedregularlyandmanaged
actively.Activemanagementshouldinclude:

identifyingthephysical,cognitive,communicationand
psychologicaldemandsofthejob(forexample,multitasking
byansweringemailsandtelephonecallsinabusyoffice)

u EstimatedbasedondataandmethodsfromPersonalSocialServicesResearchUnitUnitcostsofhealthandsocialcare
reportandAgendaforChangesalaryband751(typicalsalarybandidentifiedbyclinicalGDGmembers).

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identifyinganyimpairmentsonworkperformance(for
example,physicallimitations,anxiety,fatiguepreventing
attendanceforafulldayatwork,cognitiveimpairments
preventingmultitasking,andcommunicationdeficits)
tailoringanintervention(forexample,teachingstrategiesto
supportmultitaskingormemorydifficulties,teachingtheuse
ofvoiceactivatedsoftwareforpeoplewithdifficultytyping,
anddeliveryofworksimulations)
educatingabouttheEqualityAct2010vandsupportavailable
(forexample,anaccesstoworkscheme)
workplacevisitsandliaisonwithemployerstoestablish
reasonableaccommodations,suchasprovisionofequipment
andgradedreturntowork.
113. Managereturntoworkorlongtermabsencefromworkfor
peopleafterstrokeinlinewithrecommendationsinManaging
longtermsicknessandincapacityforwork(NICEpublichealth
guidance19).

Relativevaluesofdifferent
outcomes

Returntoworkwastheonlyoutcomeconsideredinthisreview.TheGDG
notedtheNationalStrokeStrategywhichstatesthatpeopleshouldbe
encouragedintheirparticipationroles61andcommentedthatvocational
rehabilitationprogrammesmayenableanindividualtoimprovethestructure
totheirdayandengageinmeaningfuloccupationwhilenotreturningto
work.Thismaymakeadifferenceintermsofimprovingthequalityoflifefor
thepatientandtheircarers.However,ifpeopledonotreturntoworkthe
therapycanberegardedasafailuredespiteresultingingreaterparticipation
insocialroles.
TheGDGacknowledgedthatotherparticipationrolesareasimportantas
returntoworkandsuggestedthatfuturestudiesshouldrecordHrQoLand
participationoutcomes.TheGDGagreedthatworkisoneofarangeof
participationroleswhichneedstobeconsidered,inacomprehensive
rehabilitationprogramme.

Tradeoffbetweenclinical
benefitsandharms

Manyofthedisabilitiesthatpreventreturntoworkarenotobvioussuchas:
lowselfesteem,lowconfidence,cognitiveimpairments,fatigue,lowmood
anddepression,andtreatmentofthesedifficultiescanhaveasignificant
impactnotonlyontheabilitytoreturntoworkbutmoregenerallyonquality
oflife32,33.

Economicconsiderations

Nopublishedstudieswereidentifiedassessingcostorcosteffectiveness.
Theestimatedcostofoccupationaltherapytoaidreturntoworkwas
estimatedtobeintherangeof531to885perpatients.
TheGDGconsideredthattheadditionalcostoftheinterventionmaybe
offsetbythepotentialincreaseinpatientandcarerqualityoflife.

Qualityofevidence

ThiswasasmallunderpoweredRCTwithamixedpopulation(acutebrain
injury)with59.1%oftheparticipantshadhadastroke.Althoughthestudy
describedamixedpopulationofacutebraininjuryincludingischaemicstroke
andintracerebralhaemorrhage,theGDGagreedthatinprinciplethe

HM Government (2010) Equality Act [online]

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interventionmaybetransferableto astrokepopulationprovidedthe
impairmentsinthedifferentpathologicalgroupsweresimilar.However,the
rangeofimpairmentswasnotclearlydescribed.Thegroupalsonotedthat
fromthelimiteddescriptiongivenoftheinterventionitwouldbedifficultto
reproduceinotherstudies.Confidenceintheeffectforthereturntowork
outcomes(fulltime,parttimeemployment,anyemployment,
unemployment)wasverylow.TheGDGwasnotconfidentintheresults
presentedbecauseofthestudylimitations(unblindedwithunclear
randomizationandallocationconcealment).HowevertheGDGnotedthere
areseriousproblemsonplanning(includingagreedblinding),recruiting,
conductingandanalysingRCTsofthissort.
TheGDGagreedthatbecauseofthesedifficultiestherewouldbeveryfew
studieslookingatinterventionsforreturntowork.Incontrast,therearea
largenumberofpaperssynthesisingconsensusnarrativesofwhatneedsto
bedonebutlittleRCTorhealtheconomicevidencethatwouldpromotethe
commissioningofthistypeofintervention.Thegrouphadwishedto
ascertainwhetherRCToreconomicevidencewasavailableandthisreview
hasansweredthatquestion.
Otherconsiderations

TheconsensusviewheldbytheGDGwasthatreturningtoworkafterstroke
wasclearlythebestoutcomeforanindividualofworkingageandthisstudy
providesoneexampleofaninterventiontoaidreturntowork.TheGDG
consideredthatidentifyingneedsandanyobstaclestoreturningtowork
shouldbeexploredassoonaspossibleinordertoplanreintegrationback
intotheworkplace.Becauseofthelackofevidencethereisnosystematic
wayofassessingpeopleontheircapacityforwork,whichcomponentsofa
vocationalinterventionworkorwhatthedurationofaninterventionshould
be.Futurestudiesneedtobeconductedtoascertainwhatdoesanddoesnt
workinthisfield.
TheGDGrecognisedtheimportanceoftheEqualOpportunitiesActin
creatinganenvironmentinwhichpatientsaresupportedtoreturntowork.
TheGDGrecognisedthenationalconsensusthatexitsaroundthekey
elementsofvocationalrehabilitation,namelyanalysisoftheimpairment,the
demandsofthejob,educationofthepatient,tailoredinterventions,work
placevisitsandestablishingworkplaceaccommodations.Althoughidentified
asanimportantinterventionwithintheStrokeStrategyandtheNational
ServiceFrameworkforlongterm(neurological)conditions,theGDGagreed
thatthereislimitedresourcetodelivervocationalrehabilitation
interventionswithintheNHS.TheGDGformulatedconsensus
recommendationsbasedondiscussionofcurrentpracticeofinterventionsin
theirownrehabilitationservicesandknowledgeofothernationalguidancein
thisarea.Thegroupwereinagreementthatthiswasanareawhere
provisionneededtoimproveandthereforedirectiverecommendationswere
drafted.

TheGDGagreedthatservicesneedthecapacitytodelivervocational
rehabilitationtopeoplewithneurologicalimpairmentssuchastroke.The
grouprecognisedthatmanyworkingagepatientshavevocationalneeds
whichareunmet,oftenleadingtojobloss.Thegroupnotedthatitisthe
resilienceofthepatientandwillingnessoftheemployertosupportthe
individualwhichwilldeterminewhetherapersonreturnstoworkornot.
Thegroupagreedthatmoredataneedstobecollectedonthenumberof
peoplewhoreturntoworkafterstroke.
Randomisedcontrolledtrialsofthetrainingneedsofhealthprofessionals
deliveringvocationalrehabilitationwouldbeanareawherefurtherresearch
isneeded.TheGDGacknowledgedthathealthprofessionalsreceivevery
littletraininginthisarea.

NationalClinicalGuidelineCentre,2013.
550


ItwasnotedthatotherNICEguidanceavailableonreturntoworkis
available:Managinglongtermsicknessabsenceandincapacityforwork
(NICEpublichealthguidance19).
Researchneedstobeundertakentoestablishthestructuralprocessesthat
alloweffectiveinteragencywork.

15.2 Longtermhealthandsocialsupport
Therewasalackofdirectevidenceforthistopic.Thereforerecommendationsinthissectionwere
basedonthemodifiedDelphiconsensusstatementsthatweredraftedfromrecommendationsof
publishednationalandinternationalguidelines.Weprovidetablesofstatementsthatreached
consensusandstatementsthatdidnotreachconsensusandgiveasummaryofhowtheywereused
todrawuptherecommendations.Fordetailsontheprocessandmethodologyusedforthemodified
DelphisurveyseeAppendixF.

15.2.1

Whatongoinghealthandsocialsupportdothepersonafterstrokeandtheircarer(s)
requiretomaximisesocialparticipationandlongtermrecovery?
Population

Adultsandyoungpeople16orolderwhohavehadastroke

Components

Continuedmonitoringandreaccessintorehab
Longtermsupport/careathome
Socialparticipationactivities
Carer/familysupport&education

Outcomes

Patientandcarersatisfaction
Qualityoflife
optimisedstrategiestominimiseimpairmentandmaximiseactivity/participation

15.2.2

Delphistatementswhereconsensuswasachieved
Table123:Tableofconsensusstatements,resultsandcomments(percentageintheresultscolumn
indicatestheoverallrateofresponderswhostronglyagreedwithastatementand
amountofcommentsinthefinalcolumnreferstorateofresponderswhousedthe
openendedcommentsboxes,i.e.No.peoplecommented/No.peoplewhoresponded
tothestatement)

Number

Statement

Ifthereisanewidentifiedneedfor
furtherstrokerehabilitationservices,
thepersonwhohashadastroke
shouldbeabletoselfreferwiththe
supportofaGPorspecialist
communityservices.

Results
%
66.7

NationalClinicalGuidelineCentre,2013.
551

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes
Inround223/99(23%)panel
memberscommented;11/81(14%)
inround3:

Oneissuethatwashighlightedisthe
demandthismaycreate(Directself
referralcouldleadtodemand
outstrippingresourcesofthestroke
rehabilitationservice.Theredoes
needtobeanassessment.).

Results
%

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes

Otherpanelmembersthoughtthat
thephrasewiththesupportofwas
unclearsincethiswouldnotmean
selfreferralanymore.
weoperateselfreferralforanyone
previouslyknowntothestoke
service.

thisisunclear,howcanyouself
referwiththesupportofaGP,are
theystillbeinggatekeepersthen?

Number

Statement

Focusonlifeafterstrokemayinclude:
Informationanddiscussionabout
communityaccess
Participationincommunityactivities
Socialroles
Informationaboutdriving
Opportunitiestodiscussissuesaround
sexualfunction

75.2

72.9
70.2
76.4
68.2

Inround210/98(10%)panel
memberscommented;37/85(44%)
inround3(directpromptgivenin
round3):

Afewotherareasoffocuswere
suggested.
Returntowork/training
Relationships,childcareissues
Secondarypreventiondiet,
exercise
Psychological/emotionaladaptation
Strokegroupscommunication
supportactivities
Supportforcarers
Accesstowelfarebenefitsand
allowances,equipment

Whilethepersonwithstrokeisin
hospitallocalprocessesshouldensure
thatreferralismadetoadultsocial
careforanassessmentofneed(ifthe
personhasaneedforsocialcare).

67

Inround219/99(19%)panel
memberscommented;21/84(25%)
inround3:

Itwashighlightedthatasocial
workershouldbepartoftheMDT.
atanappropriatetimetoallowthe
socialworkertoworkalongsidethe
MDTtofullyappreciatethepatients
difficultiesandgettoknowthemand
theirfamily.Thisshouldntbe
startedrightattheendofthe
inpatientstay,butworkedup
duringtheinpatientstay.

Somepeoplecommentedthatthis
shouldbeajoinedupprocessand
happeninatimelymanner.
yes,priortodischargesothereis
notalonggapbetweenservices

NationalClinicalGuidelineCentre,2013.
552

Number

15.2.3

Statement

Results
%

Amount(No.panelmemberswho
commented/No.panelmembers
whoresponded)andcontentof
panelcommentsorthemes
endingandothersbeginning.

Acoupleofpeoplecommentedthat
thestatementwasnotveryclear(for
examplelocalprocesseswasnot
definedandalso,whowouldbe
makingtheassessmentisunclear)

Delphistatementwhereconsensuswasnotreached
Table124:Tableofnonconsensusstatementswithqualitativethemesofpanelcomments
Number

Statement

Results

Amountandcontentofpanel
commentsorthemes

1.

Reviewintervalsneedtobespecified
andagreedwiththepersonwhohas
hadastrokeinregardstotheirlong
termrehabilitationneeds.

65.0

Inround213/100(13%)panel
memberscommented;9/80(11%)in
round3:

Opinionsweredivided.Some
memberssuggestedthatthisshould
beneedsbasedandflexiblewhereas
otherssaidthatthe6and12month
followupwassufficient.

2.

Areviewofhealthandsocialcare
needsofthepersonwhohashada
strokethatisformallyreportedand/
orcoordinatedorconductedwiththe
GPservicesshouldtakeplaceatleast
(options:6months,12months,
unspecified)

44.6

Inround240/98(41%)panel
memberscommented;20/83(24%)
inround3:

Themajorityofcommentsstated,6
weeks,6monthsandthenannually.
(inaccordancewiththeNational
StrokeStrategy@6/52,6/12then
annually).

Thereweresomecomments
recommendinganeedbasedsystem
thatwouldallowmorefrequent
intervalsifnecessary.

Itwasalsocommentedthatthis
woulddependonthetimepost
discharge.

Therewasaconcernthatifitwere
tobeaneedsbasedapproach
peoplewouldnotbegivenan
opportunityforameetingunless
theyhaveaneed

Iflefttoindividualneedsittendsto
resultincrisesmanagement

NationalClinicalGuidelineCentre,2013.
553

Number

Statement

Results

Amountandcontentofpanel
commentsorthemes
meetings.Thereshouldbesomesort
ofstructureandprocesstoensure
thatreviewsarefrequentenoughto
monitorthepatientlongerterm
safelyandreasonablybutnottoo
frequenttobeunnecessaryand
possiblydevaluingthemerit

3.

Wherethepersonswhohavehada
strokearestillmakingprogresslikely
toleadtofunctionalchange,they
shouldbeofferedagoalfocused
enablingcarepackage.

56.9

Inround321/84(25%)panel
memberscommented;15/72(21%)
inround4:

Somepeoplecommentedthatthis
statementwasnotveryclearand
thatthetermenablingcarepackage
wasnotuniversallyunderstood.

Extract:
Isuspecttherewillbesomeissues
astohowyoumeasurefunctional
changeandthewordlikelyshould
therebeatimescaleputonthisas
thiscaveatwouldsuggestthatmost
patients/clientswouldfallintothis
categoryandserviceswillfindthis
verydifficulttodeliver

Somecommentsweremadeabout
thetermfunctionalchangeand
thatthestatementwasunclear
aboutwhatitmaybereferringto.

4.

Whenapersonwithstrokeleaves
56.9
hospital,thereshouldbeareviewof
thedischargeprocesswiththeperson
whohashadastroketogetherwith
theirfamilyandcarersbyamemberof
thecommunitystrokerehabilitation
team.Theaimofthisreviewisto
ensurethatthedischargeplanwas
followedandcarriedout,thattheir
currentstatusandgoalsarereviewed,
andacontinuingrehabilitationplanis
devised.

Inround222/99(22%)panel
memberscommented;16/85(19%)
inround3and11/72(15%)inround
4:

Thereweresomecommentsabout
theamountofreviewsthatwere
suggested.

Thisshouldbedoneaccordingto
needsincesomepeoplemaybe
dischargedanddonotwishorneed
apostdischargemeeting.

Willthisapplytoeverystroke
patientoronlythosedischargedwith
adisabilityIagreeitshouldbe
everystrokepatientbutthatwould
createahugeworkloadforthe
communitystroketeamIfeelthat
thisshouldbereconsideredand
reflectthevariedpoststrokeneeds
ofpatientsandtheircarers.

NationalClinicalGuidelineCentre,2013.
554

Number
5.

15.2.4

Statement

Results

Selfmanagementandtrainingneeds
formpartoflongtermhealth
educationforthepersonafterstroke.

61.1

Amountandcontentofpanel
commentsorthemes
Inround212/98(12%)panel
memberscommented;13/84(11%)
inround3and9/72(15%)inround
4:

Itwasstatedthattherewas
insufficientevidencetoconclude
thatthisworks.

Thereisalsotheissuethatit
dependsonthelevelofpoststroke
ability.
inordertosupportsecondary
preventionandmoreindependence,
educationisimportant.

selfmanagementisntjustabout
education,apersonmayneedother
interventionstofacilitatebehaviour
change.

RecommendationsandlinkstoDelphiconsensussurvey
Statements

34.Ifthereisanewidentifiedneedforfurtherstrokerehabilitation
services,thepersonwhohashadastrokeshouldbeabletoselfrefer
withthesupportofaGPorspecialistcommunityservices.
35.Focusonlifeafterstrokemayinclude:
Informationanddiscussionaboutcommunityaccess
Participationincommunityactivities
Socialroles
Informationaboutdriving
Opportunitiestodiscussissuesaroundsexualfunction
36.Whilethepersonwithstrokeisinhospitallocalprocessesshould
ensurethatreferralismadetoadultsocialcareforanassessmentof
need(ifthepersonhasaneedforsocialcare).
Forhealthandsocialcareinterfacerecommendationssee5.3.2.
114. Informpeopleafterstrokethattheycanselfrefer,usuallywiththe
supportofaGPornamedcontact,iftheyneedfurtherstroke
rehabilitationservices.
115. Provideinformationsothatpeopleafterstrokeareableto
recognisethedevelopmentofcomplicationsofstroke,including
frequentfalls,spasticity,shoulderpainandincontinence.
116. Encouragepeopletofocusonlifeafterstrokeandhelpthemto
achievetheirgoals.Thismayinclude:
facilitatingtheirparticipationincommunityactivities,suchas

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shopping,civicengagement,sportsandleisurepursuits,visiting
theirplaceofworshipandstrokesupportgroups
supportingtheirsocialroles,forexample,work,education,
volunteering,leisure,familyandsexualrelationships
providinginformationabouttransportanddriving(including
DVLArequirements;seewww.dft.gov.uk/dvla/medical/aag).
117. Manageincontinenceafterstrokeinlinewithrecommendationsin
Urinaryincontinenceinneurologicaldisease(NICEclinicalguideline
148)andFaecalincontinence(NICEclinicalguideline49).
118. Reviewthehealthandsocialcareneedsofpeopleafterstrokeand
theneedsoftheircarersat6monthsandannuallythereafter.These
reviewsshouldcoverparticipationandcommunityrolestoensure
thatpeoplesgoalsareaddressed.
119. Forguidanceonsecondarypreventionofstroke,follow
recommendationsinLipidmodification(NICEclinicalguideline67),
Hypertension(NICEclinicalguideline127),Type2diabetes(NICE
clinicalguideline87)andAtrialfibrillation(NICEclinicalguideline
36).
120. Provideadviceonprescribedmedicationsinlinewith
recommendationsinMedicinesadherence(NICEclinicalguideline
76).

Economic
considerations

Otherconsiderations

Therearesomecostsassociatedwiththereferralandwiththereviewof
healthandsocialcareneedsintermsofstafftime;howeverthese
interventionswillalsoimprovethequalityoflifeofthepersonwith
stroke;anannualfrequencyofreview(afterthefirstreviewat6
months)wasconsideredbalancedintermsofcostsandeffectiveness.
TheGDGnotedthedifferentviewsexpressedintheDelphisurveywith
regardsbeingabletoreaccessrehabilitationservicesatalatertime
point.Somepeoplehadcommentedthatthiswouldcreatetoogreata
demandwhichcouldnotbemet,whileothersthoughtthestatement
unclearasitimpliedaGPwasrequiredtomakearecommendationfor
furtherservices,andthereforethiswasnotselfreferral.Itwasthought
thatreferralbackintorehabilitationwouldoftenbeafteraconversation
withaGPornamedcontactbuttheGDGagreedthatitshouldbe
possibleforapersontoselfreferthemselves.Informationandsupportto
enablethepersonandtheirfamiliestoreadjustafterwhatisoftenalife
changingexperiencewasrecognisedasextremelyimportant.TheGDG
agreedwiththecommentssuggestingadditionalareassuchas
informationaboutvoluntaryorganisationsandpatientgroups,
recognisingtheneedsofcarersetc.Thevarietyofotherexamplesgiven
withinthecommentshighlightedtotheGDGthatitwasnotpossibleto
capturethevastrangeofdifferentinformationneedsinthewordingof
recommendations.Itwasagreedinformationandsupportisindividual
andprovidingalistofareastoinclude(ortheprofessionalwhowouldbe
responsibletodothis)wasnothelpful.Thestatementonreferralto

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socialcarewasfelttobeunclear,andfollowingconsultationtheGDG
agreedtoremovethisasitwasfelttobecoveredwithinthesocialcare
interfaceandtransferofcaresectionsoftheguideline.
TheGDGdiscussedthestatementaboutregularlyreviewinghealthand
socialcareneedswhichdidnotachieveconsensus.Itwasfeltthatthere
wasdisagreementaboutthefrequencyofthereviewratherthanabout
whetherareviewshouldtakeplace.TheGDGagreedthatopinion
seemeddividedonadoptinganeedsbasedapproachorhavinga
structuredprocessdeterminingwhenareviewshouldbeundertaken.
Thegroupfeltitwasextremelyimportanttoemphasisethatreviews
needtobedone,inordertopickupanyproblemsordifficultiesandto
highlighttobothpatientsandtheircarersthatthisiswhattheyshould
expecttohappen.TheGDGnotedthattheNationalStrokeStrategy
recommendedareviewat6monthsandthenannually,andthatmanyof
thecommentshadstatedthesameapproachshouldbeadopted.

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16 Acronymsandabbreviations
AAT

AachenerAphasiaTest

ABMT

AbbreviatedMentalTestScore

ADL

ActivitiesofDailyLiving

AFO

AnkleFootOrthosis

AGREEII

AdvancingGuidelineDevelopment,ReportingandEvaluationinHealthCare

ANELTA

AmsterdamNijmeganEverydayLanguageTest,scaleA

ANELTA

AmsterdamNijmeganEverydayLanguageTest

APT

AttentionProcessTraining

ARAT

ActionResearchArmTest

ASCOT

AngloScandinavianCardiacOutcomesTrial

ASHAFACS

FunctionalAssessmentofCommunicationSkillsforAdults

BADL

BasicActivitiesofDailyLiving

BBS

BergBalanceScale

BIT

BehaviouralInattentionTest

BNT

BostonNamingTest

CBSWRAT

CriterionTestofBasicSkillsWideRangeAchievementTest

CESD

CenterforEpidemiologicStudiesDepressionScale

CETI

CommunicationEffectivenessIndex

CETI

CommunicationEffectivenessIndex

CFQ

CognitiveFailuresQuestionnaire

CIMT

ConstraintInducedMovementTherapy

CMSA

ChedokeMcMasterStrokeAssessment

CMSMR

ChedokeMcMasterStagesofMotorRecovery

CNS

CentralNervousSystem

COAST

CommunicationOutcomesAfterStrokescale

CPT

ContinuousPerformanceTest

CRPS

ComplexRegionalPainSyndromes

DAFO

DynamicAnkleFootOrthosis

DWP

DepartmentofWorkandPensions

EMG

Electromyography

EQVAS

EuroQolVisualAnalogueScale

ESD

EarlySupportedDischarge

ESUS

ExtendedStrokeUnitService

FAI

FrenchayActivityIndex

FAST

FrenchayAphasiaScreeningTest

FCP

FunctionalCommunicationProgramme

FCTP

FunctionalCommunicationTherapyPlanner

FCTP

FunctionalCommunicationTherapyPlanner

FES

FunctionalElectricalStimulation

FIM

FunctionalIndependenceMeasure

FPA

FunctionalCommunicationProfile

GDS

GeriatricDepressionScale

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GHQ

GeneralHealthQuestionnaire

GMW

GeneralMedicalWard

GRAFO

GroundReactionAnkleFootOrthosis

HADS

HospitalAnxietyandDepressionScale

IADL

InstrumentalActivitiesofDailyLiving

ICF

InternationalClassificationofFunctioning,DisabilityandHealth

ICF

InternationalClassificationofFunctioning,DisabilityandHealth

LLFMA

LowerlimbsectionoftheFuglMeyerAssessment

MAS

MotorassessmentScale

MID

MinimalImportantDifference

MMSE

MiniMentalStateExamination

MOCA

MontrealCognitiveAssessment

MPCA

MeasureofParticipationinConversationforAdultswithAphasia

MRC

MedicalResearchCouncil

MRW

MixedRehabilitationWard

MSCA

MeasureofSkillinProvidingSupportedConversationforAdultswithAphasia

MUST

MalnutritionUniversalScreeningTool

NAO

NationalAuditOffice

NIHSS

NationalInstitutesofHealthStrokeScale

OKN

OptokineticNystagmus

OSUS

OrdinaryStrokeUnitService

PASAT

PacedAuditorySerialAdditionTest

PEG

PercutaneousEndoscopicGastrostomy

PHQ

PatientHealthQuestionnaire

PICA

PorchIndexofCommunicativeAbility

PROM

PassiveRangeofMobility

PRT

ProgressiveResistanceTraining

PSSRU

PersonalSocialServicesResearchUnit

PTH

PlaceboThermocoagulation

RPAB

RivermeadPerceptualAssessmentBattery

SADQ

StrokeAphasicDepressionQuestionnaire

SIAS

StrokeImpairmentAssessmentSet

SSS

ScandinavianStrokeScale

TOM

TherapyOutcomeMeasure

UEFT

UpperExtremityFunctionTest

USN

UnilateralSpatialNeglect

WAB

WesternAphasiaBattery

WABAQ

WesternAphasiaBatteryAphasiaQuotient

WHO

WorldHealthOrganisation

WMFT

WolfMotorFunctionTest

YSQ

YaleSingleQuestion

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17 Glossary
AachenerAphasieTest
(AAT)

CommonlyusedmajorcomprehensivelanguagetestinGermanspeaking
countries.

Abbreviatedmentaltest
score(ABMT)

Testtoassessforconfusionandothercognitiveimpairments.

Abstract

Summaryofastudy,whichmaybepublishedaloneorasanintroductiontoa
fullscientificpaper.

ActionResearchArmTest
(ARAT)

Observationaltestusedtodetermineupperlimbfunction.

ActivitiesofDailyLiving
(ADL)

Termusedinhealthcaretorefertodailyselfcareactivitieswithinan
individual'splaceofresidence,outdoorenvironments,orboth.

AddenbrooksCognitive
Examination

Examwhichincorporatesfivesubdomainscoresforcognition:
orientation/attention,memory,verbalfluency,languageandvisuospatial.

Adjustedanalysis

Usuallyreferstoattemptstocontrol(adjust)forbaselineimbalances
betweengroupsinimportantpatientcharacteristics.Sometimesusedto
refertoadjustmentsofPvaluetotakeaccountofmultipletesting.

Allocationconcealment

Theprocessusedtopreventadvanceknowledgeofgroupassignmentina
RCT.Theallocationprocessshouldbeimpervioustoanyinfluencebythe
individualmakingtheallocation,bybeingadministeredbysomeonewhois
notresponsibleforrecruitingparticipants.

Anosognosia

Alackofawarenessofimpairment,notknowingthatadeficitorillness
exists,inmemoryorotherfunction

Aphasia

Lossorimpairmentoftheabilitytouseandcomprehendlanguageusually
resultingfrombraindamage

Applicability

Thedegreetowhichtheresultsofanobservation,studyorreviewarelikely
toholdtrueinaparticularclinicalpracticesetting.

Apraxia(ofspeech)

Difficultyininitiatingandexecutingthevoluntarymovementneededto
producespeechwhenthereisnoweaknessofspeechmuscles.Itmaycause
difficultyproducingthecorrectspeechorchangesintherhythmorrateof
speaking.

Arm(ofaclinicalstudy)

Subsectionofindividualswithinastudywhoreceiveoneparticular
intervention,forexampleplaceboarm

Assessment

Adetailedprocesswhichaimstodefinethenatureandimpactofan
impairment,anddeviseatreatmentplan.

Association

Statisticalrelationshipbetweentwoormoreevents,characteristicsorother
variables.Therelationshipmayormaynotbecausal.

BarthelIndex

TheBarthelIndexconsistsof10itemsthatmeasureaperson'sdaily
functioning,specificallytheactivitiesofdailylivingandmobility.Theitems
includefeeding,movingfromwheelchairtobedandreturn,grooming,
transferringtoandfromatoilet,bathing,walkingonlevelsurface,goingup
anddownstairs,dressing,continenceofbowelsandbladder.
Theinitialsetofmeasurementsatthebeginningofastudy(afterrunin
periodwhereapplicable),withwhichsubsequentresultsarecompared.

Baseline
BasicactivitiesofDaily
Living(BADL)

Listofbasicactivitiesthatneedtobeperformedindependentlyinorderfor
anindividualtotakecareofhimself/herself.

BeckDepressionInventory

Amultiplechoiceselfreportinventory,usedformeasuringtheseverityof
depression.

Beforeandafterstudy

Astudythatinvestigatestheeffectsofaninterventionbymeasuring
particularcharacteristicsofapopulationbothbeforeandaftertakingthe
intervention,andassessinganychangethatoccurs.

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Bergbalancescale

Awidelyusedclinicaltestofaperson'sfunctionalbalance.

Bias

Systematic(asopposedtorandom)deviationoftheresultsofastudyfrom
thetrueresultsthatiscausedbythewaythestudyisdesignedor
conducted.

Blinding

Keepingsomeorallstudyparticipants,caregivers,researchersoroutcome
assessorsunawareabouttheinterventionstowhichtheparticipantshave
beenallocatedinastudy.Seesingle,doubleandtripleblindingand
allocationconcealment.

BostonDiagnosticAphasia
Examination

Testusedtoevaluateadultssuspectedofhavingaphasia

BostonNamingTest(BNT)

Aconfrontationnamingtestusedtomeasurewordretrievalperformancein
aphasicpatients

BoxandBlocktest

Testusedtoevaluatethegrossmanualdexterityofindividualswitha
physicalimpairment.

Brunnstromapproach

Physicaltherapythatemphasisesthesynergicpatternofmovementwhich
developsduringrecoveryfromhemiplegia.Thisapproachencourages
developmentofflexorandextensorsynergiesduringearlyrecovery,withthe
intentionthatsynergicactivationofmuscleswill,withtraining,transitioninto
voluntaryactivationofmovements.

C&Ecancellation

Testusedtodetectthepresenceofunilateralspatialneglectinthenear
extrapersonalspaceinpatientswithstroke.

Caregiverburdenscale

Questionnaireusedtomeasurethesubjectiveburdenofcaregiversinfive
domains:generalstrain,isolation,disappointment,emotionalinvolvement,
andenvironment.

Carer(caregiver)

Someoneotherthanahealthprofessionalwhoisinvolvedincaringfora
personwithamedicalcondition.

Carersstrainindexrankin

Isabrief,easilyadministeredinstrumentwhichcanidentifystrainininformal
careproviders.Itisdividedintofivecategories.Itisa13questiontoolthat
measuresstrainrelatedtocareprovision.

Cerebrovasculardisease

Diseaseofthebloodvesselssupplyingthebrain,whichmayresultinbrain
dysfunctionincludingStroke.

ChedokeMcMasterstages
ofMotionRecovery

Testusedtoassessthefunctionalstateoftheaffectedupperextremity.

Clinicaleffectiveness

Theextenttowhichaninterventionproducesanoverallhealthbenefitin
routineclinicalpractice.

Clustertrial

Atypeofrandomizedcontrolledtrial(RCT),inwhichgroupsorclustersof
individualsratherthanindividualsthemselvesarerandomized.

CochraneReview

TheCochraneLibraryconsistsofaregularlyupdatedcollectionofevidence
basedmedicinedatabasesincludingtheCochraneDatabaseofSystematic
Reviews(reviewsofrandomisedcontrolledtrialspreparedbytheCochrane
Collaboration).

Cohortstudy

Aretrospectiveorprospectivefollowupstudy.Groupsofindividualstobe
followeduparedefinedonthebasisofpresenceorabsenceofexposuretoa
suspectedriskfactororintervention.Acohortstudycanbecomparative,in
whichcasetwoormoregroupsareselectedonthebasisofdifferencesin
theirexposuretotheinterventionofinterest.

Comorbidity

Coexistenceofmorethanonediseaseoranadditionaldisease(otherthan
thatbeingstudiedortreated)inanindividual.

Comparability

Similarityofthegroupsincharacteristicslikelytoaffectthestudyresults
(suchashealthstatusorage).

Confidenceinterval(CI)

Arangeofplausiblevaluesforthepopulationmean(oranotherpopulation
parametersuchasanestimationofriskincrease/decrease),calculatedfrom

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data.Aconfidenceintervalwith(conventionally)a95%confidencelevelhas
a95%chanceofcapturingthepopulationmean.Thismeansthat,ifthe
experimentwererepeatedmanytimes,95%oftheconfidenceintervals
wouldcontainthetruepopulationmean.
Confounding

Inastudy,confoundingoccurswhentheeffectofaninterventiononan
outcomeisdistortedasaresultofanassociationbetweenthepopulationor
interventionoroutcomeandanotherfactor(theconfoundingvariable)that
caninfluencetheoutcomeindependentlyoftheinterventionunderstudy.

Consensusmethods

Techniquesthataimtoreachanagreementonaparticularissue.Consensus
methodsmaybeusedwhenthereisalackofstrongevidenceonaparticular
topic.

Continuousdata

Datawithapotentiallyinfinitenumberofpossiblevaluesalongacontinuum.
Height,weightandbloodpressureareexamplesofcontinuousvariables.

Contralateral

Onorrelatingtotheoppositesideofthebody.

Contralesional

Describingthehalfofapatient'sbrainorbodyawayfromthesiteofalesion.

Controlgroup

Agroupofpatientsrecruitedintoastudythatreceivesnotreatment,a
treatmentofknowneffect,oraplacebo(dummytreatment)inorderto
provideacomparisonforagroupreceivinganexperimentaltreatment,such
asanewdrug.

Costbenefitanalysis

Atypeofeconomicevaluationwherebothcostsandbenefitsofhealthcare
treatmentaremeasuredinthesamemonetaryunits.Ifbenefitsexceed
costs,theevaluationwouldrecommendprovidingthetreatment.

Costconsequencesanalysis
(CCA)

Atypeofeconomicevaluationwherevarioushealthoutcomesarereported
inadditiontocostforeachintervention,butthereisnooverallmeasureof
healthgain.

Costeffectivenessanalysis
(CEA)

Aneconomicstudydesigninwhichconsequencesofdifferentinterventions
aremeasuredusingasingleoutcome,usuallyinnaturalunits(Forexample,
lifeyearsgained,deathsavoided,heartattacksavoided,casesdetected).
Alternativeinterventionsarethencomparedintermsofcostperunitof
effectiveness.

Costeffectivenessmodel

Anexplicitmathematicalframework,whichisusedtorepresentclinical
decisionproblemsandincorporateevidencefromavarietyofsourcesin
ordertoestimatethecostsandhealthoutcomes.

Costutilityanalysis(CUA)

Aformofcosteffectivenessanalysisinwhichtheunitsofeffectivenessare
qualityadjustedlifeyears(QALYs).

CredibleInterval

TheBayesianequivalentofaconfidenceinterval.

Crossovertrial

Atypeofclinicaltrialcomparingtwoormoreinterventionsinwhichthe
participants,uponcompletionofthecourseofonetreatmentareswitched
toanother.Forexample,foracomparisonoftreatmentsAandB,halfthe
participantsarerandomlyallocatedtoreceivethemintheorder,A,Band
halftoreceivethemintheorderB,A.Aproblemwiththisdesignisthatthe
effectsofthefirsttreatmentmaycarryoverintotheperiodwhenthesecond
isgiven.

DerSimonianandLaird

Amethodofrandomeffectsmetaanalysis(seebelow).

Diplopia

Doublevision.

Discounting

Costsandperhapsbenefitsincurredtodayhaveahighervaluethancostsand
benefitsoccurringinthefuture.Discountinghealthbenefitsreflects
individualpreferenceforbenefitstobeexperiencedinthepresentrather
thanthefuture.Discountingcostsreflectsindividualpreferenceforcoststo
beexperiencedinthefutureratherthanthepresent.

Dominance

Aninterventionissaidtobedominatedifthereisanalternativeintervention
thatisbothlesscostlyandmoreeffective.

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EuroQolVisualAnalogue
Scale(EQVAS)

Qualityoflifemeasure.

Dorsiflexion

Movementwhichdecreasestheanglebetweenthedorsum(superior
surface)ofthefootandtheleg,sothatthetoesarebroughtclosertothe
shin.

Doubleblind

Also,Doublemasked.Neithertheparticipantsinatrialnortheinvestigators
(outcomeassessors)areawareofwhichinterventiontheparticipantsare
given.Thepurposeofblindingtheparticipants(recipientsandprovidersof
care)istopreventperformancebias.Thepurposeofblindingthe
investigators(outcomeassessors,whomightalsobethecareproviders)isto
protectagainstdetectionbias.Seealsoblinding,singleblind,tripleblind,
andallocationconcealment.

Dropout

Aparticipantwhowithdrawsfromatrialbeforetheend.

Dysarthria

Difficultyinarticulatingwords.

Dysarthrophonia

Anacquiredneurologicalspeechimpairmentthataffectsrespiration,
productionofspeechsounds,articulationandintonationofspeech.

Dysphagia

Difficultyinswallowing.

Dyspraxia

Difficultyinplanningandexecutingmovement

Earlysupporteddischarge

Aserviceforpeopleafterstrokewhichallowstransferofcarefroman
inpatientenvironmenttoaprimarycaresettingtocontinuerehabilitation,at
thesamelevelofintensityandexpertisethattheywouldhavereceivedin
theinpatientsetting.

Economicevaluation

Comparativeanalysisofalternativehealthstrategies(interventionsor
programmes)intermsofboththeircostsandconsequences.

EdmansActivitiesofDaily
LivingIndex

Agradedtestwhichassessesfunctionalabilitiesinstrokepatients,including
theactivitiesnecessarytoenableapersontoliveindependentlyathome.

Effectsize

1.Agenerictermfortheestimateofeffectforastudy.
2.Adimensionlessmeasureofeffectthatistypicallyusedforcontinuous
datawhendifferentscales(forexampleformeasuringpain)areusedto
measureanoutcomeandisusuallydefinedasthedifferenceinmeans
betweentheinterventionandcontrolgroupsdividedbythestandard
deviationofthecontrolorbothgroups.Seestandardisedmeandifference.)

Effectiveness

SeeClinicaleffectiveness.

Efficacy

SeeClinicalefficacy.

EQ5D(EuroQol5D)

Astandardisedinstrumentusedtomeasureahealthoutcome.Itprovidesa
singleindexvalueforhealthstatus.

Equinovarus

Adevelopmentaldisorderofthefootinwhichwalkingisdoneonthetoes
andoutersideofthesole

Errorlesslearning

Procedurewhichallowsdiscriminationlearningtooccurwithfeworno
responsestothenegativestimulus.

Evidence

Informationonwhichadecisionorguidanceisbased.Evidenceisobtained
fromarangeofsourcesincludingrandomisedcontrolledtrials,observational
studies,expertopinion(ofclinicalprofessionalsand/orpatients).

Exclusioncriteria(clinical
study)

Criteriathatdefinewhoisnoteligibletoparticipateinaclinicalstudy.

Exclusioncriteria(literature
review)

Explicitstandardsusedtodecidewhichstudiesshouldbeexcludedfrom
considerationaspotentialsourcesofevidence.

Extendeddominance

IfOptionAisbothmoreclinicallyeffectivethanOptionBandhasalower
costperunitofeffect,whenbotharecomparedwithadonothing
alternativethenOptionAissaidtohaveextendeddominanceoverOptionB.

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OptionAisthereforemoreefficientandshouldbepreferred,otherthings
remainingequal.
Extrapolation

Indataanalysis,predictingthevalueofaparameteroutsidetherangeof
observedvalues.

Followup

Fixedeffectsmetaanalysis

Theascertainmentofoutcomesofaninterventionatoneormorestated
timesaftertheinterventionhasended.
Afixedeffectmodelofmetaanalysisisbasedonamathematicalassumption
thateverystudyisevaluatingacommontreatmenteffect.Thatmeansthe
effectoftreatment,allowingfortheplayofchance,wasthesameinall
studies.

FrenchayActivitiesIndex
(FAI)

Measureofinstrumentalactivitiesofdailylivingforusewithpatients
recoveringfromstroke.Thisindexcoversabroadrangeofactivities
associatedwitheverydaylife.

FrenchayArmTest

Testusedtoassessproximalcontrolanddexterity.

FuglMeyerAssessment

Strokespecific,performancebased,impairmentindex;designedtoassess
motorfunctioning,balance,sensationandjointfunctioninginhemiplegic,
poststrokepatients.

Functionalambulation
category

Afunctionalwalkingtestthatevaluatesambulationability.This6pointscale
assessesambulationstatusbydetermininghowmuchhumansupportthe
patientrequireswhenwalking,regardlessofwhetherornottheyusea
personalassistivedevice

Functionalambulation
classification

Assessesfunctionalmobilityandgaitinpatientsundergoingphysicaltherapy.

FunctionalAssessmentof
CommunicationSkillsfor
Adults(ASHAFACS),

Thisassessmentassistswithmeasuringandrecordingthefunctional
communicationofadultswithspeech,language,andcognitive
communicationdisorders.Itassessesfunctionalcommunicationinfour
areas:socialcommunication;communicationofbasicneeds;reading,
writing,andnumberconcepts;anddailyplanning.

FunctionalIndependence
Measure(FIM)

Scaleusedtomeasurethefunctionalabilitiesofpatientsundergoing
rehabilitation.

Generalisability

Theextenttowhichtheresultsofastudybasedonmeasurementina
particularpatientpopulationand/oraspecificcontextholdtrueforanother
populationand/orinadifferentcontext.Inthisinstance,thisisthedegreeto
whichtheguidelinerecommendationisapplicableacrossbothgeographical
andcontextualsettings.Forinstance,guidelinesthatsuggestsubstituting
oneformoflabourforanothershouldacknowledgethatthesecostsmight
varyacrossthecountry.

Geriatricdepressionscale

Thisissuitableasascreeningtestfordepressivesymptomsintheelderly;
idealforevaluatingtheclinicalseverityofdepression.

GlobalNottinghamHealth
Profile1&2

Patientcompletedtwopartquestionnairedesignedtodetermineand
quantifyperceivedhealthproblems.Partonecovers6areas(sleep,mobility,
energy,pain,emotionalreactions,socialisolation);andparttwocovers
specificaspectsofdailylife(employment,householdchores,sociallife,
relationships,sexlife,hobbies,holidays).

GRADE/GRADEprofile

AsystemdevelopedbytheGRADEWorkingGrouptoaddressthe
shortcomingsofpresentgradingsystemsinhealthcare.TheGRADEsystem
usesacommon,sensibleandtransparentapproachtogradingthequalityof
evidence.TheresultsofapplyingtheGRADEsystemtoclinicaltrialdataare
displayedinatableknownasaGRADEprofile.

HabitualGaitVelocity

Alsoknownascomfortablegaitspeed,itisdefinedasapersonsusualor
comfortable,selfselectedpace.

Handgripforce

Thestrengthappliedbythehandtopullonorsuspendfromobjectsandisa
specificpartofhandstrength.

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Harms

Adverseeffectsofanintervention.

Healtheconomics

Thestudyoftheallocationofscarceresourcesamongalternativehealthcare
treatments.Healtheconomistsareconcernedwithbothincreasingthe
averagelevelofhealthinthepopulationandimprovingthedistributionof
health.

Healthrelatedqualityoflife
(HRQoL)

Acombinationofanindividualsphysical,mentalandsocialwellbeing;not
merelytheabsenceofdisease.

Hemiagnosia

Inabilityofapersontoprocessandperceivestimuliononesideofthebody
orenvironmentthatisnotduetoalackofsensationadeficitinattention
toandawarenessofonesideofspaceisobserved.

Hemianopia

Blindnessinonehalfofthevisualfieldofoneorbotheyes.

Hemineglect

SeeHemiagnosia

Hemiparesis

Weaknessononesideofthebody.

Hemiparetic

Pertainingtohemiparesisorapatientaffectedwithhemiparesis.

hemiplegia

Totalparalysisofthearm,leg,andtrunkononesideofthebody.

Hemispatialneglect

SeeHemiagnosia

Heterogeneity Orlackof
homogeneity.

Thetermisusedinmetaanalysesandsystematicreviewswhentheresults
orestimatesofeffectsoftreatmentfromseparatestudiesseemtobevery
differentintermsofthesizeoftreatmenteffectsoreventotheextentthat
someindicatebeneficialandotherssuggestadversetreatmenteffects.Such
resultsmayoccurasaresultofdifferencesbetweenstudiesintermsofthe
patientpopulations,outcomemeasures,definitionofvariablesordurationof
followup.

Imprecision

Resultsareimprecisewhenstudiesincluderelativelyfewpatientsandfew
eventsandthushavewideconfidenceintervalsaroundtheestimateof
effect.

Inclusioncriteria(literature
review)

Explicitcriteriausedtodecidewhichstudiesshouldbeconsideredas
potentialsourcesofevidence.

Incrementalanalysis

Theanalysisofadditionalcostsandadditionalclinicaloutcomeswith
differentinterventions.

Incrementalcost

Themeancostperpatientassociatedwithaninterventionminusthemean
costperpatientassociatedwithacomparatorintervention.

Incrementalcost
effectivenessratio(ICER)

Thedifferenceinthemeancostsinthepopulationofinterestdividedbythe
differencesinthemeanoutcomesinthepopulationofinterestforone
treatmentcomparedwithanother.

Indirectness

Theavailableevidenceisdifferenttothereviewquestionbeingaddressed,in
termsofPICO(population,intervention,comparisonandoutcome).

InstrumentalActivitiesof
DailyLiving(IADL)

Listofactivitieswhichallowsanindividualtoliveindependentlyina
community:housework,mealpreparation,takingmedications,managing
money,shoppingforgroceriesorclothing,telephoneuseandifapplicable,
theuseoftechnology.

Intentiontotreatanalysis
(ITT)

Anintentiontotreatanalysisisoneinwhichalltheparticipantsinatrialare
analysedaccordingtotheinterventiontowhichtheywereallocated,
whethertheyreceiveditornot.Intentiontotreatanalysesarefavouredin
assessmentsofeffectivenessastheymirrorthenoncomplianceand
treatmentchangesthatarelikelytooccurwhentheinterventionisusedin
practiceandbecauseoftheriskofattritionbiaswhenparticipantsare
excludedfromtheanalysis.

IntermediateOutcome

Ameasureofresultsthatindicatesprogresstowarddesiredendresultsbutis
notitselfafinaloutcome.

Interphalangeal

Betweenthephalanges.

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Intervention

Healthcareactionintendedtobenefitthepatient,forexample,drug
treatment,surgicalprocedure,psychologicaltherapy.

Inversevariance

Amethodofaggregatingtwoormorerandomvariablestominimizethe
varianceofthesum.Eachrandomvariableinthesumisweightedininverse
proportiontoitsvariance.Wecouldassumethatvarianceisinversely
proportionaltoimportance,i.e.thelessvarianceinthestudy,themore
weightitshouldcontribute.TheInverseVariancemethodinRevMan(see
below),calculatesstudyweightsdirectlybasedonthisassumption.

Ipsilateral

Onorrelatingtothesameside(ofthebody)

Isometricelbowextension
force

Theforceusedwhenattemptingtoextendtheelbowagainstresistance.
Isometricimpliesnoactualmovementismade.

Isometricelbowflexion
force

Theforceusedwhenattemptingtobendthearmattheelbowagainst
resistance.Isometricimpliesnoactualmovementismade.

IVAContinuous
PerformanceTestFull
ScaleAttentionQuotient

Testusedtomeasureauditoryandvisualreactiontimeandstability,
simultaneously,notseparately.

JebsenTaylorHandfunction Testdesignedtoprovideashort,objectivetestofhandfunctionscommonly
test
usedinactivitiesofdailyliving(ADLs).Thetargetpatientpopulationincludes
adultswithneurologicalconditionsinvolvinghanddisabilities.Thetestwas
developedtobeusedbyhealthprofessionalsworkinginrestorationofhand
function.
Kneeextensionpeaktorque

Measurementofthepersonsabilitytoflexthequadricepsmuscleswhich
straightentheleg.

Kneeflexionpeaktorque

Sitandreachtestusedtotestflexibility.

Lengthofstay

Thetotalnumberofdaysaparticipantstaysinhospital.

Lifeyearsgained

Meanaverageyearsoflifegainedperpersonasaresultoftheintervention
comparedwithanalternativeintervention.

Likelihoodratio

Thelikelihoodratiocombinesinformationaboutthesensitivityand
specificity.Ittellsyouhowmuchapositiveornegativeresultchangesthe
likelihoodthatapatientwouldhavethedisease.Thelikelihoodratioofa
positivetestresult(LR+)issensitivitydividedby1specificity.

LineBisection

Quickmeasuretodetectthepresenceofunilateralspatialneglect.

Linebisectiontask

Standardassessmentofunilateralvisualneglect.

LocusofControlScale

Referstotheextenttowhichindividualsbelievethattheycancontrolevents
thataffectsthem.

Longtermcare

Residentialcareinahomethatmayincludeskillednursingcareandhelp
witheverydayactivities.Thisincludesnursinghomesandresidentialhomes.

Losstofollowup

Lossofcontactwithsomeparticipants,sothatresearcherscannotcomplete
datacollectionasplanned.Losstofollowupisacommoncauseofmissing
data,especiallyinlongtermstudiesandcancausebiaswhensubjectslost
fromacohorthavedifferenthealthresponsedistributionsfromsubjectswho
remaininfollowup

MantelHaenszelapproach

Markovmodel

Amethodtoanalyseoddsratiosthathasbeenextendedtoanalyserisk
ratiosandriskdifferences.Itassumesafixedeffectandcombinesstudies
usingamethodsimilartoinversevarianceapproachestodeterminethe
weightgiventoeachstudy.
Amethodforestimatinglongtermcostsandeffectsforrecurrentorchronic
conditions,basedonhealthstatesandtheprobabilityoftransitionbetween
themwithinagiventimeperiod(cycle).

MaximalGaitVelocity

Alsoknownasfastgaitspeed,itisdefinedasthespeedapersonsfastas
safelypossible,selfselectedpace.

McKennaGradedNaming

Testusedtoassessobjectnamingability,butisinadditiongradedin

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Test

difficultytoallowforindividualdifferences.Thismeansthatitmaybeableto
detectanywordfindingdifficultyeveninthosewithanextensivenaming
vocabulary.

Measurement

theuseofpsychometricallyrobusttoolstorecordtheextentofaproblem,
whetheritisimpairment,activityorparticipationbasedandcanbegeneric
ordiseasespecific.

Mean

Theaveragevalue,calculatedbyaddingalltheobservationsanddividingby
thenumberofobservations.

Median

Thenumericalvalueseparatingthehigherhalfofasample,apopulation,ora
probabilitydistribution,fromthelowerhalf.Themedianofafinitelistof
numberscanbefoundbyarrangingalltheobservationsfromlowestvalueto
highestvalueandpickingthemiddleone.Ifthereisanevennumberof
observations,thenthereisnosinglemiddlevalue;themedianisthenusually
definedtobethemeanofthetwomiddlevalues.

MedicalResearchcouncil
Scale(MRCScale)for
Musclestrength

Scaleforassessingmuscleweakness/strength.

MesulamVerbal
CancellationTest

TestusedtoevaluatehemispatialdominanceinStrokePatients.

Metaanalysis

Astatisticaltechniqueforcombining(pooling)theresultsofanumberof
studiesthataddressthesamequestionandreportonthesameoutcomesto
produceasummaryresult.Theaimistoderivemorepreciseandclear
informationfromalargedatapool.Itisgenerallymorereliablylikelyto
confirmorrefuteahypothesisthantheindividualtrials.

MinimalImportant
Differences(MID)

Forcontinuousoutcomes,theMIDisdefinedasthesmallestdifferencein
scoreintheoutcomeofinterestthatinformedpatientsorinformedproxies
perceiveasimportant,eitherbeneficialorharmful,andthatwouldleadthe
patientorcliniciantoconsiderachangeinthemanagement(refs).Aneffect
estimatelargerthantheMIDisconsideredtobeclinicallyimportant.For
dichotomousoutcomestheMIDisthesmallestdecreaseorincreaseisthe
incidenceofanoutcomethatwouldbeconsideredtoshowaclear
appreciablebenefitorharmfromaninterventionthiscanbeconsideredin
relativeterms(usingtheriskratio)butpreferablyshouldbebasedon
absoluteriskdifferences.

Mnemonicstrategies

Systematicstrategiesforstrengtheninglongtermretentionandretrievalof
information.

ModifiedAshworthScale

Thisscalemeasuresresistanceduringpassivesofttissuestretching.

Modifiedrankin

Acommonlyusedscaleformeasuringthedegreeofdisabilityordependence
inthedailyactivitiesofpeoplewhohavesufferedastroke.

MotricityIndex

Staffcompletedindexoflimbmovementaimingtomeasuregeneralmotor
impairment.Threemovementsforeachlimbareassessedbasedonthe
MedicalResearchCouncilstrengthgradesandweighted,zeroforno
movement,nineforpalpablemovement,fourteenformovementseen,
nineteenforfullrangeagainstgravity,twentyfiveformovementagainst
resistanceandtwentytwofornormalpower.

Neglect

Inabilitytoorienttowardsandattendtostimuli,includingbodyparts,onthe
sideofthebodyaffectedbythestroke.

Neuroplasticity

Structuralandfunctionalchangestothebrainandnervoussystemasaresult
ofinputfromtheenvironment.

Neuropsychological

Relatedtothestructureandfunctionofthebrainspecifictopsychological
processesandbehaviours.

Nonparetic

Usuallyreferstotheunaffectedlimb

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NottinghamExtended
ActivitiesofDailyLiving

Selfreportscaledesignedprimarilyforuseinthestrokepopulationfor
functionalassessment.

Observationalstudy

Retrospectiveorprospectivestudyinwhichtheinvestigatorobservesthe
naturalcourseofeventswithorwithoutcontrolgroups;forexample,cohort
studiesandcasecontrolstudies.

Opportunitycost

Thelossofotherhealthcareprogrammesdisplacedbyinvestmentinor
introductionofanotherintervention.Thismaybebestmeasuredbythe
healthbenefitsthatcouldhavebeenachievedhadthemoneybeenspenton
thenextbestalternativehealthcareintervention.

Orthosis

Adevicethatsupportsorcorrectsthefunctionofalimborthetorso.

Orthotics

Specialtywithinthemedicalfieldconcernedwiththedesign,manufacture
andapplicationoforthoses.Anorthosis(plural:orthoses)isanorthopaedic
devicethatsupportsorcorrectsthefunctionofalimborthetorso.

Outcome

Measureofthepossibleresultsthatmaystemfromexposuretoapreventive
ortherapeuticintervention.Outcomemeasuresmaybeintermediate
endpointsortheycanbefinalendpoints.SeeIntermediateoutcome.

Palmargriptorque

Palmargriptorqueisameasurementoftheabilitytoholdlargerandheavier
objectssuchascansandbottlesbetweenthepalmofthehandandthefour
fingers.

Perimetry

Awaytosystematicallytest,usedtomapandquantifythevisualfield,
especiallyattheextremeperipheryofthevisualfield.Thenamecomesfrom
themethodoftestingtheperimeterofthevisualfield.

Pinchgripforce

Thestrengthappliedbythehandtopinchanobjectsothatthefingersareon
onesideoftheobject,andthethumbisontheother.Typically,anobject
liftedinapinchgripdoesnottouchthepalm.

Placebo

Aninactiveandphysicallyidenticalmedicationorprocedureusedasa
comparatorincontrolledclinicaltrials.

Power(statistical)

Theabilitytodemonstrateanassociationwhenoneexists.Powerisrelated
tosamplesize;thelargerthesamplesize,thegreaterthepowerandthe
lowertheriskthatapossibleassociationcouldbemissed.

Pretestprobability

Fordiagnostictests.Theproportionofpeoplewiththetargetdisorderinthe
populationatriskataspecifictimepointortimeinterval.Prevalencemay
dependonhowadisorderisdiagnosed.

Primarycare

Healthcaredeliveredtopatientsoutsidehospitals.Primarycarecoversa
rangeofservicesprovidedbygeneralpractitioners,nurses,dentists,
pharmacists,opticiansandotherhealthcareprofessionals.

Primaryoutcome

Theoutcomeofgreatestimportance,usuallytheoneinastudythatthe
powercalculationisbasedon.

Prismglasses

Medicaldeviceusedincorrectingeyeabnormalities.

Prognosis

Aprobablecourseoroutcomeofadisease.Prognosticfactorsarepatientor
diseasecharacteristicsthatinfluencethecourse.Goodprognosisis
associatedwithlowrateofundesirableoutcomes;poorprognosisis
associatedwithahighrateofundesirableoutcomes.

Proprioceptive

Individualssenseoftherelativepositionofneighbouringpartsofthebody.

Prospectivestudy

Astudyinwhichpeopleareenteredintotheresearchandthenfollowedup
overaperiodoftimewithfutureeventsrecordedastheyhappen.This
contrastswithstudiesthatareretrospective.

Psychometric

Relatedtothetheoryandtechniqueofeducationalmeasurementand
psychologicalmeasurement,whichincludesthemeasurementofknowledge,
abilities,attitudes,andpersonalitytraits.

Publicationbias

Alsoknownasreportingbias.Abiascausedbyonlyasubsetofallthe
relevantdatabeingavailable.Thepublicationofresearchcandependonthe

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natureanddirectionofthestudyresults.Studiesinwhichaninterventionis
notfoundtobeeffectivearesometimesnotpublished.Becauseofthis,
systematicreviewsthatfailtoincludeunpublishedstudiesmayoverestimate
thetrueeffectofanintervention.Inaddition,apublishedreportmight
presentabiasedsetofresults(forexampleonlyoutcomesorsubgroups
whereastatisticallysignificantdifferencewasfound.
Pvalue

Theprobabilitythatanobserveddifferencecouldhaveoccurredbychance,
assumingthatthereisinfactnounderlyingdifferencebetweenthemeansof
theobservations.Iftheprobabilityislessthan1in20,thePvalueislessthan
0.05;aresultwithaPvalueoflessthan0.05isconventionallyconsideredto
bestatisticallysignificant.

Quadrantanopia

Referstolossofvisionaffectingaquarterofthefieldofvision.Itcanbe
associatedwithalesionofanopticradiation.

Qualityoflife

SeeHealthrelatedqualityoflife.

Qualityadjustedlifeyear
(QALY)

Anindexofsurvivalthatisadjustedtoaccountforthepatientsqualityoflife
duringthistime.QALYshavetheadvantageofincorporatingchangesinboth
quantity(longevity/mortality)andquality(morbidity,psychological,
functional,socialandotherfactors)oflife.Usedtomeasurebenefitsincost
utilityanalysis.TheQALYsgainedarethemeanQALYsassociatedwithone
treatmentminusthemeanQALYsassociatedwithanalternativetreatment.

Quasirandomisedtrial

Atrialusingaquasirandommethodofallocatingparticipantstodifferent
formsofcare.Thereisagreaterriskofselectionbiasinquasirandomtrials
whereallocationisnotadequatelyconcealedcomparedwithrandomised
controlledtrialswithadequateallocationconcealment.

QuickReferenceGuide

Randomeffectsmeta
analysis

AnabridgedversionofNICEguidance,whichpresentsthekeyprioritiesfor
implementationandsummarisestherecommendationsforthecoreclinical
audience.
Therandomeffectsmodelassumesthatthetruetreatmenteffectsinthe
individualstudiesmaybedifferentfromeachother.Thatmeansthereisno
singlenumbertoestimateinthemetaanalysis,butadistributionof
numbers.Themostcommonrandomeffectsmodelalsoassumesthatthese
differenttrueeffectsarenormallydistributed.Themetaanalysistherefore
estimatesthemeanandstandarddeviationofthedifferenteffects.

Randomisation

Allocationofparticipantsinaresearchstudytotwoormorealternative
groupsusingachanceprocedure,suchascomputergeneratedrandom
numbers.Thisapproachisusedinanattempttoensurethereisaneven
distributionofparticipantswithdifferentcharacteristicsbetweengroupsand
thusreducesourcesofbias.

Randomisedcontrolledtrial
(RCT)

Acomparativestudyinwhichparticipantsarerandomlyallocatedto
interventionandcontrolgroupsandfolloweduptoexaminedifferencesin
outcomesbetweenthegroups.

RCT

SeeRandomisedcontrolledtrial.

Relativerisk(RR)

Thenumberoftimesmorelikelyorlesslikelyaneventistohappeninone
groupcomparedwithanother(calculatedastheriskoftheeventingroup
A/theriskoftheeventingroupB).

Reportingbias

Seepublicationbias.

Resourceimplication

Thelikelyimpactintermsoffinance,workforceorotherNHSresources.

Retrospectivestudy

Aretrospectivestudydealswiththepresent/pastanddoesnotinvolve
studyingfutureevents.Thiscontrastswithstudiesthatareprospective.

Reviewquestion

Inguidelinedevelopment,thistermreferstothequestionsabouttreatment
andcarethatareformulatedtoguidethedevelopmentofevidencebased
recommendations.

ReyOsterreithTest

Neuropsychologicalassessmentinwhichexamineesareaskedtoreproducea

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complicatedlinedrawing,firstbycopyingandthenfrommemory.
RivermeadADL

Scaledevelopedtoassessactivitiesofdailylivinginstrokepatients.

RivermeadMobilityIndex

Measureofdisabilityrelatedtobodilymobility.Itdemonstratesthepatient's
abilitytomoveherorhisownbody.

RivermeadPerceptual
AssessmentBattery(RPAB)

Preliminaryassessmentofone'slevelofvisualperceptualabilitypriorto
therapy.Theresultsmaybeusedtoplananappropriatetherapyprogramme.

Screening

Aprocessofidentifyingpeoplewithparticularimpairments.Peoplecanthen
beofferedinformation,furtherassessmentandappropriatetreatment.
Screeningmaybeperformedasaprecursortomoredetailedassessment.

Searchstrategy

Themethodsusedtoidentifystudiesincludinghandsearchingrelevant
journals,searchingelectronicdatabases,contactingdrugcompanies,other
formsofpersonalcontactandcheckingreferencelists.

Secondaryoutcome

Anoutcomeusedtoevaluateadditionaleffectsoftheinterventiondeemeda
prioriasbeinglessimportantthantheprimaryoutcomes.

Selectionbias

Asystematicbiasinselectingparticipantsforstudygroups,sothatthe
groupshavedifferencesinprognosisand/ortherapeuticsensitivitiesat
baseline.Randomisation(withconcealedallocation)ofpatientsprotects
againstthisbias.

ShortForm36(SF36)

Multipurpose,shortformhealthsurveywiththirtysixquestions.Ityieldsan
eightscaleprofileoffunctionalhealthandwellbeingscoresaswellas
psychometricallybasedphysicalandmentalhealthsummarymeasuresanda
preferencebasedhealthutilityindex.

Significance(clinical)

Inmedicineandpsychology,thisreferstoeitheroftworelatedbutslightly
dissimilarconceptswherebycertainfindingsordifferences,evenif
measurableorstatisticallyconfirmed,eithermayormaynothaveadditional
significance,eitherby(1)beingofamagnitudethatconveyspractical
relevance(ausagethatconflatespracticalandclinicalsignificance
interchangeably),or(2)moretechnicallyandrestrictively,addresseswhether
aninterventionortreatmentmayormaynotfullycorrectthefinding.

Significance(statistical)

Aresultisdeemedstatisticallysignificantiftheprobabilityoftheresult
occurringbychanceislessthan1in20(p<0.05).

Singleblind

Also,singlemasked.Theinvestigatorisawareofthetreatment/intervention
theparticipantisgetting,buttheparticipantisunaware.Seealsoblinding,
doubleblind,tripleblind.

Spasticity

Muscularhypertonicitywithincreasedtendonreflexes

Spatialneglect

SeeHemiagnosia

Stakeholder

Thosewithaninterestintheuseoftheguideline.Stakeholdersinclude
manufacturers,sponsors,healthcareprofessionals,andpatientandcarer
groups.

Standardisedmean
difference

Thedifferencebetweentwomeansdividedbyanestimateofthewithin
groupstandarddeviation.Whenanoutcome(suchaspain)ismeasuredina
varietyofwaysacrossstudies(usingdifferentscales)itmaynotbepossible
directlytocompareorcombinestudyresultsinasystematicreview.By
expressingtheeffectsasastandardisedvaluetheresultscanbecombined
sincetheyhavenounits.Standardisedmeandifferencesaresometimes
referredtoasadindex.

Statisticalpower

Theprobabilitythatthenullhypothesiswillberejectedifitisindeedfalse.In
studiesoftheeffectivenessofhealthcareinterventions,powerisameasure
ofthecertaintyofavoidingafalsenegativeconclusionthataninterventionis
noteffectivewhenintruthitiseffective.Thepowerofastudyisdetermined
byhowlargeitis(thenumberofparticipants),thenumberofevents(for
examplestrokes)orthedegreeofvariationinacontinuousoutcome(suchas
weight),howsmallaneffectonebelievesisimportant(i.e.thesmallest

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differenceinoutcomesbetweentheinterventionandthecontrolgroupsthat
isconsideredtobeimportant),andhowcertainonewantstobeofavoiding
afalsepositiveconclusion(i.e.thecutoffthatisusedforstatistical
significance).
Strengthandfinger
extension

Measurementofthestrengthusedtoopenthehand,stretchingallthe
fingers.

StrokeSelfEfficacy
Questionnaire

Questionnaireusedtomeasureselfefficacyjudgementsinspecificdomains
offunctioningrelevanttoindividualsfollowingstroke.

Strokeimpactscale

Strokespecific,selfreport,healthstatusmeasure,designedtoassess
multidimensionalstrokeoutcomes,includingstrength,handfunction,
activitiesofdailyliving/instrumentalactivitiesofdailyliving,mobility,
communication,emotion,memoryandthinking,andparticipation.
Anenvironmentinwhichmultidisciplinarystroketeamsdeliverstrokecarein
StrokeUnit
adedicatedwardwhichhasabedarea,diningarea,gym,andaccessto
assessmentkitchens.
StrokeRehabilitationService Astrokeservicedesignedtodeliverstrokerehabilitationeitherinhospitalor
inthecommunity.
Aservicedesignedtodeliverarangeofactivitiesincludingassessmentin
StrokeService
casualty,deliveryofacutecare,followupofoutpatientreview,community
services.
Strokeunit
Anenvironmentinwhichmultidisciplinarystroketeamsdeliverstrokecarein
adedicatedwardwhichhasabedarea,diningarea,gym,andaccessto
assessmentkitchens.
Stylusmazetest

Spatialmemorytaskthoughttobesensitivetofrontalandparietaldamage.

Systematicreview

Researchthatsummarisestheevidenceonaclearlyformulatedquestion
accordingtoapredefinedprotocolusingsystematicandexplicitmethodsto
identify,selectandappraiserelevantstudies,andtoextract,collateand
reporttheirfindings.Itmayormaynotusestatisticalmetaanalysis.

TangentScreenExamination Visualfieldtestusedtoanalyseapatient'svisualfield.
ThePacedAuditorySerial
AdditionTest(PASAT)

Measureofcognitivefunctionthatspecificallyassessesauditoryinformation
processingspeedandflexibility,aswellascalculationability.

Timehorizon

Thetimespanoverwhichcostsandhealthoutcomesareconsideredina
decisionanalysisoreconomicevaluation.

TranscranialMagnetic
Stimulation(TMS)

Noninvasivemethodthatuseselectromagneticinductiontoinduceweak
electriccurrentsusingarapidlychangingmagneticfieldallowingthe
functioningandinterconnectionsofthebraintobestudied.

Treatmentallocation

Assigningaparticipanttoaparticulararmofthetrial.

Unilateralneglect

SeeHemiagnosia

Univariate

Analysiswhichseparatelyexploreseachvariableinadataset.

Utility

Ameasureofthestrengthofanindividualspreferenceforaspecifichealth
stateinrelationtoalternativehealthstates.Theutilityscaleassigns
numericalvaluesonascalefrom0(death)to1(optimalorperfecthealth).
Healthstatescanbeconsideredworsethandeathandthushaveanegative
value.

VisualAnalogueMoodScale

Scaleusedtomeasuretheinternalmoodstateinneurologicallyimpaired
patients.

WechslerAdultIntelligence
ScaleRevisedDigitSpan

Primaryclinicalinstrumentusedtomeasureadultandadolescent
intelligence;itconsistsofsixverbalandfiveperformancesubtests.The
verbaltestsare:Information,Comprehension,Arithmetic,DigitSpan,
Similarities,andVocabulary.ThePerformancesubtestswere:Picture
Arrangement,PictureCompletion,BlockDesign,ObjectAssembly,andDigit
Symbol.Verbal,performanceandfullscaleIntelligenceQuotientscoreswere
alsoobtained.

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Wechslermemoryscale

Testdesignedtomeasuredifferentmemoryfunctionsinaperson.

WesternAphasiaBattery
(WAB)

Instrumentusedtoassessthelanguagefunctionofadults,abletodiscernthe
presence,degree,andtypeofaphasia.

Wiener
Determinationsgerat

Computerassistedreactiontraining,whichmeasuresalertness.

WolfMotorFunctionTest
(WMFT)

Testusedtoquantifyupperextremitymotorabilitythroughtimedand
functionaltasks.

WunndtJastrowIssusion
andreading

Testusedtoassessneglect.

YaleSingleQuestion(YSQ)

AssessmentusedfordepressionthatentailsaskingpatientstheYaleSingle
Question:Doyoufrequentlyfeelsadordepressed?

ZahlenVerbindungsTest

Germanlanguagefreeintelligencetest,thatusesnumberconnectionteststo
assessparticipants.

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572

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