Improving walking after stroke

Group-based circuit class therapy can help people to walk again after a stroke

Research findings: Improving walking after stroke

Why was this study needed?

There are more than 100,000 strokes in the UK each year. In England alone, stroke is estimated to cost the economy around £7 billion per year, including costs to the NHS, social care, disability and loss of productivity.

Stroke survivors are often left with long-term impairment, caused by loss of blood supply to part of the brain. Most report upper or lower limb weakness, which can affect daily activities and lead to difficulty walking and balancing.

Circuit class therapy (CCT) is a group physical therapy where participants have the chance to repeatedly practise everyday functional tasks and activities at workstations within sight of each other, encouraging people to see how things are done. These group-based sessions are also used for other conditions such as chronic obstructive pulmonary disease in pulmonary rehabilitation centres. Most studies to date have focused on the effects of CCT for improving mobility. Therefore, this updated Cochrane review focused on the question of whether mobility-tailored CCT can improve the ability to walk and balance.

What did this study do?

This review identified 17 randomised controlled trials assessing CCT in 1,297 adults with any severity of stroke or stage of rehabilitation. Time since stroke varied considerably between trials.

CCT had to involve a sequence of functional tasks aimed at improving mobility and impairment, rather than just strength or fitness. Sessions had to be group-based, with a staff-to-client ratio of no more than 1:3, and given a minimum of once a week for at least four weeks. Conventional therapy included individual physiotherapy and education as well as other physical therapy methods, or no intervention.

The main outcome was distance walked during the Six Minute Walk Test. Other outcomes included the ability to walk independently and have confidence in their balance.

Two studies came from the UK. Four were conducted in inpatient settings, the rest in the community. Selective reporting of outcomes was the most likely source of bias.

What did it find?

  • People who received mobility-related CCT walked further than the comparison group on the Six Minute Walk Test (mean difference [MD] 60.86 m, 95 per cent confidence interval [CI] 44.55 to 77.17m; 10 moderate quality studies, 835 people). This was a clinically meaningful difference (threshold MD 34.4m).
  • The CCT group had faster-walking speed over a short distance (MD 0.15 m/s, 95 per cent CI 0.10 to 0.19; eight moderate quality studies, 744 people). This was also considered clinically meaningful.
  • Five low-quality studies looked at balance and mobility as measured by time to stand up, walk and return to sitting, finding the CCT group quicker than the comparison group (MD -3.62 seconds, 95 per cent CI -6.09 to -1.16; 488 people).
  • Three moderate quality studies also found that people receiving CCT were more likely to be able to walk independently without assistance ability (odds ratio 1.91, 95 per cent CI 1.01 to 3.62; 469 people).
  • Low-quality evidence from eight studies (815 people) found no significant difference between groups in the reported number of falls (roughly 13 per 100 in the CCT group vs nine per 100 with controls).

What does current guidance say?

NICE guidelines on stroke rehabilitation (2013) recommend that, post-hospital discharge, people receive rehabilitation from a specialist stroke team in the community. This should be multidisciplinary, including physiotherapists and occupational therapists. NICE recommends at least 45 minutes of each relevant rehabilitation therapy on at least five days a week for as long as necessary.

Repetitive task training for both the upper limbs (eg, manipulating objects) and lower limbs (eg, sit-to-stand transfers and using stairs) is specifically recommended. Treadmill training may be considered for people who can walk with or without assistance. NICE does not make any recommendations about the form in which it is delivered, for instance, whether rehabilitation should be individual or group-based.

What are the implications?

Group CCT focusing on mobility seems to provide meaningful improvements in walking ability, speed and independence, although the reasons for the success – such as peer support – may need further exploration. Cost-effectiveness was not assessed, but group-based rehabilitation in the community or hospital centres potentially needs fewer staff than individual sessions, especially in their own homes.

The time since stroke varied, so the most effective timing of CCT is unclear. There may also be practical considerations; some might find travelling to a group session difficult. 

Citation and Funding

English C, Hillier SL, Lynch EA. Circuit class therapy for improving mobility after stroke. Cochrane Database Syst Rev. 2017;6:CD007513. This research was funded by Cochrane UK and the Cochrane Stroke Group.

The full NIHR Signal and additional expert commentary was published on 12 September 2017 and can be found here.


Nicola Hancock says CCT looks promising

We know that physical rehabilitation after stroke improves motor function and independence. The National Clinical Guidelines for Stroke recommend that 45 minutes of relevant rehabilitation therapy be provided on at least five days per week, for as long as necessary. Sufficient intensity of provision can be challenging in the context of increasing demands on services and financial constraints; some creative thinking around delivery is required. 

One way of providing intense rehabilitation is via CCT. Participants carry out repetitive practice of functional, everyday activities in groups, with no more than one staff member per three participants. Activities might include practice of sitting-to-standing tasks and walking. Recovery of walking is particularly important to people after stroke; CCT is an intervention that can help people to walk further, faster, and more independently, so it could enhance community mobility. Encouragingly, people who are more than one year after stroke can benefit. 

Further consideration needs to be given to the cost-effectiveness of CCT, and to how severity of stroke might influence participation in, and outcomes from, such programmes. Nevertheless, these findings suggest that CCT is one promising way in which stroke teams might deliver intense, functional rehabilitation after stroke.

  • Nicola Hancock, PhD, MCSP, FACPIN is a lecturer in physiotherapy and researcher with ABIRA, the Acquired Brain Injury Rehabilitation Alliance, at the University of East Anglia

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