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Three Part Question

In [adult stroke patients] does [participation in an upper limb circuit class] improve [upper limb motor function in the hemiplegic arm]

Clinical Scenario

Evidence for the effectiveness of circuit class therapy (CCT) in patients post stroke has concentrated on lower limb parameters, walking tasks and balance. There is some research emerging on the effects of participation in CCT on upper limb recovery post stroke. This BET will help to inform class structure and content.

Search Strategy

AMED, CINAHL and MEDLINE 1992 to present via OVID interface using the following strategy.
KEY WORDS ((stroke OR hemiplegi* OR hemipare* OR cerebrovascular accident) AND (exercise OR class OR circuit training OR physiotherap* OR physical therap*) AND (arm OR shoulder OR hand)).ti,ab [Limit to:publication year 1991- current and (Languages English)
Evidence spanning the last 20 years was checked as this has been a time when upper limb treatment interventions post strike have developed and been exposed to research trials. Both the title and abstract were searched for key terms and duplicates removed.
The Cochrane database was searched via the NHS Evidence website and a search of PEDro was also undertaken. The cited reference research facility on ISI Web of Knowledge was used to identify any further relevant studiesas well as reviewing the reference lists of eligible studies

Search Outcome

103 studies were retrieved and abstracts were studied further to establish suitability for inclusion in a review. Studies were included for review if they specifically descibed an exercise class or circuit class type intervention for the recovery of motor function of the upper limb post stroke. As a result 4 papers were identified for review.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Jannette Blennerhassett and Wanyne Dite 2004 Australia	30 inpatients with a primary diagnosis of stroke. Inclusion criteria were being able to walk 10 metres with close supervision and able to give consent. Patients were excluded if they had a deteriorating medical condition or were independant community ambulators .	This was a prospective, randomised, single blind clinical trial. Subjects were randomly assigned to either an upper limb or mobility training group. Intervention was in the form of a circuit class in addition to their usual therapy. Measures of mobility (six minute walk test, timed up and go test and step test) and upper limb function (Motor assessment scale- upper extremity and Jebsen Taylor hand function test) were performed on three occaisons, pre commencement in the trial, at four weeks and at 6 months.	Only the upper limb group made significant improvements over time on the motor assessment scale (p<0.001)		Subjects were relatively young with only four in each group over the age of 65. Also they were relatively mobile with all study participants able to walk at least 10 metres with close supervision. The sample was one of convenience. As subjects were not blinded therapists providing the usual therapy may have been aware of their intervention group which may have affected the content of usual therapy. Care needs to be taken when generalising the results.
			At four weeks post stroke there was a moderate between group effect in favour of additional practice of upper limb tasks	Jebsen Taylor hand function test (d=0.36 95% CI -0.42 to 1.19)
Coralie K English, Susan L Hillier, Kathy R Stiller, Andrea Warden-Flood 2007 Australia	Sixty eight inpatients receiving rehabilitation following a primary diagnosis of stroke.Inclusion criteria included being able to sit unsupported, stand with one person supporting, able to follow a three part command and able to give informed consent. Patients were excluded if they had a cerebellar lesion or history of any other neurological condition, regularly used a walking aid other than a single point stick or required help with ADL prior to their stroke.	A non randomized, single blind controlled study. The study had two objectives, the first was to test the hypothesis that circuit class therapy would result in greater improvements in mobility and balance than individual physiotherapy sessions. The second objective was to investigate between group differences for a number of parameters including upper limb function. Subjects were allocated to aphysiotherapy group, either usual therapy or circuit class therapy comprising sit to stand exercises, lower limb strengthening exercises, gait training, postural control exercises in standing, reach and grasp exercises and hand/finger dexterity exercises using everyday objects. The upper limb outcome measure used was the Motor Assessment scale-upper extremity. This hierarchical scale has 3 upper limb items added together to create a single score. Measures were taken at admission, week four of rehabilitation, on discharege and at 6 months post stroke. Patients received all other usual interdisciplinary treatment	No statistically significant differences between one to one physiotherapy and circuit class therapy on arm motor function post stroke		No statistical analysis of upper limb outcomes for the two groups other than descriptive statistics. Subjects in the circuit class therapy received a mean of 129.1+/-22.6 minutes therapy time compared to a mean of 36.6 +/-9.4 minutes therapy time for subjects receiving individual physiotherapy.it is possible that the high intensity of input rather than content is responsible for the outcome. Non-random allocation of subjects which can introduce bias, the circuit class group were on average seven years younger. The authors did however use age as a co-variant for analysis and the results were not altered.

References

1. Janette Blennerhassett and Wayne Dite Additional task-related practice improves mobility and upper limb function early after stroke: A randomised controlled trial Ausralian Journal of Physiotherapy Vol 50 pp219-224
2. Coralie K English, Susan L Hillier, Kathy R Stiller, Andrea Warden-Flood Circuit class therapy versus individual Physiotherapy sessions during inpatient stroke rehabilitation: A controlled trial Archives of Physical,and Medical Rehabilitation 2007 Vol 88:pp955-63
3. Marco Y Pang, Jocelyn E Harris, Janice J Eng A community-based upper extremity group exercise program improves motor function and performance of functional activities in chronic stroke: A randomized controlled trial. 2006, Vol 87pp1-9
4. Coralie English, Susan Hillier, Kathy Stiller Incidence and severity of shoulder pain does not increase with the use of circuit class therapy during inpatient stroke rehabilitation: a controlled trial