Group task-specific circuit training for patients discharged home after stroke may be as effective as individualized physiotherapy in improving mobility
Blikk på forskning i Fysioterapeuten 1/2013.
Blikk på forskning utarbeides i samarbeid med Journal of Physiotherapy (Australia), som trykker forskningspresentasjonene under betegnelsen Critically appraised Papers, CAPs.
Summary of: van de Port IGL et al (2012) Effects of circuit training as alternative to usual physiotherapy after stroke: randomised controlled trial.BMJ344: e2672 doi: 10.1136/bmj.e2672. [Prepared by Nicholas Taylor, CAP Co-ordinator.]
Question: Does task oriented circuit training improve mobility in patients with stroke compared with individualised physiotherapy?
Design: Randomised, controlled trial with concealed allocation and blinded outcome assessment. Setting: Nine outpatient rehabilitation centres in the Netherlands.
Participants: Patients with a stroke who had been discharged home and who could walk 10 m without assistance were included. Cognitive deficits and inability to communicate were key exclusion criteria. Randomisation of 250 participants allocated 126 to task oriented circuit training and 124 to individualized physiotherapy.
Interventions: The task oriented circuit training group trained for 90 min twice-weekly for 12 weeks supervised by physiotherapists and sports trainers as they completed 8 mobility-related stations in groups of 2 to 8 participants. Individualised outpatient physiotherapy was designed to improve balance, physical conditioning, and walking.
Outcome measures: The primary outcome was the mobility domain of the stroke impact scale measured at 12 weeks and 24 weeks. The domain includes 9 questions about a patient’s perceived mobility competence and is scored from 0 to 100 with higher scores indicating better mobility. Secondary outcome measures included other domains of the stroke impact scale, the Nottingham extended ADL scale, the falls efficacy scale, the hospital anxiety and depression scale, comfortable walking speed, 6-minute walk distance, and a stairs test.
Results: 242 participants completed the study. There were no differences in the mobility domain of the stroke impact scale between the groups at 12 weeks (mean difference (MD) –0.05 units, 95% CI –1.4 to 1.3 units) or 24 weeks (MD –0.6, 95% CI –1.8 to 0.5). Comfortable walking speed (MD 0.09 m/s, 95% CI 0.04 to 0.13), 6-minute walk distance (MD 20 m, 95% CI 35.3 to 34.7), and stairs test (MD –1.6 s, 95% CI –2.9 to –0.3) improved a little more in the circuit training group than the control group at 12 weeks. The memory and thinking domain of the stroke impact scale (MD –1.6 units, 95% CI –3.0 to –0.2), and the leisure domain of the Nottingham extended ADL scale (MD –0.74, 95% CI –1.47 to –0.01) improved a little more in the control group than the circuit training group at 12 weeks. The groups did not differ significantly on the remaining secondary outcomes at 12 weeks or 24 weeks.
Conclusion: In patients with mild to moderate stroke who have been discharged home, task oriented circuit training completed in small groups was as effective as individual physiotherapy in improving mobility and may be a more efficient way of delivering therapy.
[95% CIs calculated by the CAP Co-ordinator]
Evidence that task-specific circuit training may improve walking after stroke has been growing since the first pilot study published in 2000 (Dean et al 2000). From research into motor learning and several meta-analyses of rehabilitation we know that increasing the amount of practice will improve outcome. However repeated behavioural observation studies have shown low levels of physical activity during rehabilitation after stroke. Circuit class training was proposed as a means of increasing the amount of activity undertaken by having a higher patientto-staff ratio. This high quality, large multi-centre trial by Van de Port and colleagues (2012) is the latest contribution to the body of evidence. The study confirms that taskoriented circuit class training in small groups is as effective as individual intervention in improving mobility in people who require outpatient rehabilitation within the first six months after stroke. More important, the efficiency in terms of staff resources of small groups suggests that where possible circuit class intervention should be used. Specifically, for the same healthcare costs, classes could afford more therapy for the individual either through increases in amount delivered in one day or by increasing the time over which services can be delivered. The differences between the groups in terms of walking speed and 6 minute walk distance were modest but in favour of the circuit class intervention. Without more detail of the interventions delivered to both groups it is hard to discuss the reasons for this result. For example there is evidence that treadmill training improves walking in both ambulatory (Ada et al, in press) and non-ambulatory (Dean et al 2010, Ada et al 2010) people after stroke. Similarly the use of biofeedback has been found to improve outcome (Stanton et al 2010). The trial also had a large number of secondary outcomes measures some of which were redundant. Omitting some redundant measures and including a measure of free-living physical activity would have been useful to see if benefits had carried over into everyday life. Alzahrani and colleagues (2009) have shown stair ability predicts free living physical activity after stroke. Inclusion of a free-living activity measure could have allowed subsequent analysis of this relationship in a Dutch sample.
Department of Health Professions, Macquarie University, Australia
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Dean CM et al (2010)J Physiother56: 97–103.
Stanton R et al (2011)J Physiother57: 145–155.
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