![](media/image1.png){width="5.96875in" height="0.41944444444444445in"}

Top of Form

## Complete Summary

#### GUIDELINE TITLE

Clinical practice guidelines for therapeutic exercises.

#### BIBLIOGRAPHIC SOURCE(S)

Brosseau L, Wells GA, Finestone HM, Egan M, Dubouloz CJ, Graham I,
Casimiro L, Robinson VA, Bilodeau M, McGowan J. Clinical practice
guidelines for therapeutic exercises. Top Stroke Rehabil 2006
Spring;13(2):10-21.

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Hemiplegia or hemiparesis following a single clinically identifiable
ischemic or hemorrhagic cerebrovascular accident (CVA)

#### GUIDELINE CATEGORY

Management\
Rehabilitation

#### CLINICAL SPECIALTY

Neurology\
Physical Medicine and Rehabilitation

#### INTENDED USERS

Occupational Therapists\
Patients\
Physical Therapists\
Physicians\
Students

#### GUIDELINE OBJECTIVE(S)

To promote the appropriate use of various rehabilitation interventions
in the management of stroke survivors

#### TARGET POPULATION

Adult patients (\>18 years of age) presenting with hemiplegia or
hemiparesis following a single clinically identifiable ischemic or
hemorrhagic cerebrovascular accident (CVA)

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Aerobic training

2.  Resistance training

3.  Passive range of motion exercises

4.  Proprioceptive neuromuscular facilitation

5.  Bobath technique

6.  Kinetron

7.  Use of the overhead pulley

**Note**: See the \"Major Recommendations\" field and the original
guideline document for specific recommendations for individual
interventions.

#### MAJOR OUTCOMES CONSIDERED

-   Body function: pain reduction, muscle strength, motor function/motor
    recovery, range of motion (ROM), postural status, balance status,
    gait status, cadence, stride length, sensory status,
    spasticity/muscle tone, global physician assessment, global patient
    assessment, and cardiopulmonary function.

-   Activities and participation: walking speed, walking distance,
    endurance, functional status, patient adherence, patient
    satisfaction, length of stay, discharge disposition, quality of
    life, and return to work.

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

**Literature Search**

The library scientist developed a structured literature search based on
the sensitive search strategy recommended by The Cochrane Collaboration
and modifications to that strategy proposed by Haynes et al\*. The
Cochrane Collaboration method minimizes bias through a quantitative
systematic Weighted Mean Difference approach to the literature search,
study selection, and data extraction and synthesis. The search was
organized around the condition and interventions rather than the
outcomes because it was an a priori search. Thus, the guideline
developers had no control over the outcomes that the authors of the
primary studies decided to measure (See Appendix 1 in the original
guideline document for literature search results).

The library scientist expanded the search strategy to identify case
control, cohort, and non-randomized studies and conducted the search in
the electronic databases of MEDLINE, EMBASE, Current Contents, the
Cumulative Index to Nursing and Allied Health (CINAHL), and the Cochrane
Controlled Trials Register up to December 2004. She also searched the
registries of the Cochrane Field of Rehabilitation and Related
Therapies, the Cochrane Musculoskeletal Group, the Physiotherapy
Evidence Database (PEDro), and the University of Ottawa EBCPGs Web site.
Finally, she searched the reference lists of all of the included trials
for relevant studies and contacted content experts for additional
studies.

In the first round of study inclusion or exclusion, two trained
independent reviewers appraised the titles and abstracts of the
literature search, using a checklist with the a priori defined selection
criteria (Table 1 in the original guideline document). For each pair of
reviewers, individuals independently read the title and abstract of each
article and created a list of all of the articles in the database along
with a reason for either including or excluding each article. If the
reviewers were uncertain about a particular article after having read
the abstract, they ordered the article and read it in full before making
a determination. Before deciding whether to include or exclude the
article, a comparison of their individual lists was performed. A senior
reviewer, a methodologist and a clinical expert, checked the two
independent lists of articles and the reasons for inclusion or exclusion
to determine potential inconsistencies. Seven percent of the abstracts
needed the consultation of the senior reviewer and an additional review
of the problematic article. For the second round of the inclusion and
exclusion process, the pairs of reviewers retrieved articles selected
for inclusion from the first round and independently assessed the full
articles for inclusion or exclusion in the study. Using predetermined
extraction forms, the pairs of reviewers independently extracted from
included articles data on the population characteristics, details of the
interventions, trial design, allocation concealment, and outcomes. The
pairs of reviewers assessed the methodological quality of the studies
using the Jadad Scale a 5-point scale with reported reliability and
validity that assigns 2 points each for randomization and double
blinding and 1 point for description of withdrawals. The reviewers
resolved differences in data extraction and quality assessment through
consensus with the senior reviewer. This consensus served to support the
reliability of data obtained with the article selection process.

**Study Inclusion/Exclusion Criteria**

The inclusion/exclusion criteria were based upon previous criteria used
by the Philadelphia Panel. This list of criteria, which had been created
for multiple diagnoses, was adapted and approved by the Ottawa Methods
Group (OMG) for use with patients post stroke (Table 1 in the original
guideline document).

All original comparative controlled studies that evaluated relevant
physical rehabilitation interventions in stroke patients were included:
randomized controlled trials (RCTs), controlled clinical trials
(CCTs),\*\* cohort studies, and case-control studies. Crossover studies
were included, but to avoid potential confounding carry-over effects the
data from only the first part of the study (before crossing) was
analyzed. Studies where patients served as their own controls were
excluded. No limitations based on methodological quality were imposed a
priori with regard to the selection of comparative controlled studies;
however, the quality of the studies was considered when grading the
recommendations resulting from our analysis.

Uncontrolled cohort studies (studies with no comparison group) and case
series were excluded, as were eligible studies with greater than a 20%
drop-out rate or a sample size of fewer than 5 patients per group.
Trials published in languages other than French and English were not
analyzed, because of the additional time and resources required for
translation. Abstracts were excluded if they contained insufficient data
for analysis and additional information could not be obtained from the
authors. For further exclusion criteria, see Table 1 in the original
guideline document.

\*Haynes R, Wilczynski N, McKibbon KA, Walker CJ. Developing optimal
search strategies for detecting clinically sound studies in MEDLINE. *J
Am Med Inform Assoc*. 1994;1:447-458.

\*\*Controlled clinical trials (CCTs) are considered the same as
randomized control trials (RCTs). However, according to the Jadad Scale,
CCTs are either not randomized or have not been appropriately
randomized.

#### NUMBER OF SOURCE DOCUMENTS

29 trials met the inclusion criteria and were then included.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)\
Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Level I**: Randomized controlled trials

**Level II**: Nonrandomized studies

#### METHODS USED TO ANALYZE THE EVIDENCE

Meta-Analysis of Randomized Controlled Trials\
Review of Published Meta-Analyses

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

The data were analyzed using Review Manager Software. Continuous data,
\"data with a potentially infinite number of possible values along a
continuum,\" were analyzed using the weighted mean differences (WMDs)
between the intervention and control groups at the end of the study,
where the weight is the inverse of the variance. A WMD is \"a method of
meta-analysis used to combine measures on continuous scales (such as
weight), where the mean, standard deviation and sample size in each
group are known.\" Dichotomous data or data with only two
classifications were analyzed using relative risks. According to
Cochrane, the relative risk is \"the ratio of risk in the intervention
group to the risk in the control group. The risk (proportion,
probability, or rate) is the ratio of people with an event in a group to
the total in the group.\"

See the original guideline document for more information.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The research staff reviewed articles and created draft evidence tables,
which the nine clinical experts received in preparation for their
consensus meeting with the Ottawa Methods Group (OMG). These tables were
used as the basis for making the Ottawa Panel recommendations.

A methods group developed the draft guidelines and they were adopted by
expert consensus.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grade A**: Evidence from one or more randomized controlled trials
(RCTs) of a statistically significant, clinically important benefit
(\>15%)

**Grade B**: Statistically significant, clinically important benefit
(\>15%), if the evidence was from observational studies or controlled
clinical trials (CCTs)

**Grade C+**: Evidence of clinical importance (\>15%) but not
statistical significance

**Grade C**: Interventions where an appropriate outcome was measured in
a study that met the inclusion criteria, but no clinically important
difference and no statistical significance were shown

**Grade D**: Evidence from one or more randomized controlled trials of a
statistically significant benefit favoring the control group (\<0%:
favors controls)

**Grade D+**: Evidence of clinical importance ([\<]{.underline}-15% for
controls) without statistical significance

**Grade D-**: Evidence from one or more randomized controlled trials of
a clinically important benefit ([\<]{.underline}-15% for controls) that
was statistically significant, where the number of participants in the
study is equal to or higher than 100

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guidelines were sent to the external experts for review. To judge
the clinical usefulness of the guidelines, the positive recommendations
were also sent to practitioners for feedback. Practitioners were asked
four questions for each guideline: whether the recommendation was clear,
whether the practitioners agreed with the recommendation, whether they
felt that the literature search on the different intervention of
rehabilitation was relevant and complete, and whether the results of the
trials in the guidelines were interpreted according to the
practitioners\' understanding of the data. Their questions and comments
were carefully addressed to improve the clarity of the final guidelines.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The recommendations are graded by their level (I, II) and strength (A,
B, C+, C, D, D+, D-) of evidence. Definitions for the level and strength
of the recommendations are presented at the end of the \"Major
Recommendations\" field.

**Clinical Practice Guidelines for Therapeutic Exercises**

**Aerobic training versus control**, level I (randomized controlled
trial \[RCT\]): **Grade A** for cardiopulmonary function (expiration per
minute \[VE\]), muscle power, and functional status (walking) at end of
treatment, 10 weeks (clinically important benefit demonstrated); **grade
C+** for gait speed at end of treatment, 10 weeks (clinically important
benefit demonstrated without statistical significance); **grade C** for
cardiopulmonary function (maximal heart rate, maximal oxygen uptake
\[VO~2~ max\], maximal carbon dioxide production \[VCO~2~ max\]) and
motor function at end of treatment, 10 weeks, and for functional status
(Frenchay Activities Index \[FAI\]: global, social outings, walking
outside) at end of treatment, 6 months (no benefit demonstrated);
**grade D** for functional status (FAI: light housework activities) at
end of treatment, 6 months (no benefit demonstrated but favoring
control). Patients with subacute and chronic stroke.

**Aerobic individualized program training versus control**, level I
(RCT): **Grade A** for physical fitness (highest test stage completed of
the stress test and maximal workload) and mobility (stair climbing) at
end of treatment, 8 weeks (clinically important benefit demonstrated);
**grade C+** for mobility (walking distance) at end of treatment, 8
weeks (clinically important benefit demonstrated without statistical
significance); **grade C** for cardiovascular function (maximal heart
rate, decrease of resting heart rate and decrease of resting systolic
and diastolic blood pressure), gait speed, and functional status at end
of treatment, 8 weeks (no benefit demonstrated). Patients with subacute
stroke.

**Proprioceptive neuromuscular facilitation (PNF) for upper extremity
versus standard customary muscle training**, level I (RCT): **Grade C**
for functional status and upper extremity muscle strength at end of
treatment, 6 weeks (no benefit demonstrated); **grade D** for mobility
at end of treatment, 2, 4, and 6 weeks, range of motion (ROM) of the
wrist at end of treatment, 6 weeks (no benefit demonstrated but favoring
control); **grade D+** for ROM of the ankle at end of treatment, 6 weeks
(clinically important benefit favoring control demonstrated without
statistical significance). Patients with postacute stroke.

**Proprioceptive neuromuscular facilitation versus Bobath approach
training**, level I (RCT): **Grade C** for mobility at end of treatment,
2, 4, and 6 weeks, ROM of the wrist and ankle at end of treatment, 6
weeks (no benefit demonstrated). Patients with subacute stroke.

**Bobath approach versus standard customary muscle training**, level I
(RCT): **Grade C+** motor function (Sodring Motor Evaluation Scale
\[SMES\]: upper extremity) at follow-up, 4 years, quality of life
(Nottingham Health Profile \[NHP\]--global) at follow-up, 1 year and 4
years, and quality of life (NHP--loss of energy) at end of treatment, 3
months (clinically important benefit demonstrated without statistical
significance); **grade C** for mobility at end of treatment, 2, 4, and 6
weeks, motor function (SMES: lower extremity and trunk, balance, and
gait, and Motor Assessment Scale) at end of treatment, 3 months, and
follow-up, 1 year and 4 years, motor function (SMES: upper extremity) at
end of treatment, 3 months, and follow-up, 1 year, functional status
(Barthel Index) at follow-up, 4 years (no benefit demonstrated); **grade
D** for ROM of the wrist and ankle at end of treatment, 6 weeks,
functional status (Barthel Index) at end of treatment, 3 months, and
follow-up, 1 year, (no benefit demonstrated but favoring control);
**grade D+** for pain relief (NHP--pain) at end of treatment, 3 months
(clinically important benefit favoring control demonstrated without
statistical significance). Patients with acute and subacute stroke.

**Bobath approach training versus control**, level I (RCT): **Grade C+**
for balance standing at follow-up, 2 and 12 weeks (clinically important
benefit demonstrated without statistical significance); **grade C** for
balance sitting at end of treatment, 4 weeks (no benefit demonstrated);
**grade D** for balance sitting at follow-up, 2 weeks, and balance
standing at end of treatment, 4 weeks (no benefit demonstrated but
favoring control); **grade D+** for balance sitting at follow-up, 12
weeks (clinically important benefit favoring control demonstrated
without statistical significance). Patients with subacute stroke.

**Progressive resistance training versus active training for the lower
extremity**, level I (RCT): **Grade A** for functional status at end of
treatment, 1 month (clinically important benefit demonstrated). Patients
with post-acute stroke.

**Active training for the lower extremity versus control (no
exercise)**, level I (RCT): **Grade D** for functional status at end of
treatment, 1 month (no benefit demonstrated but favoring control).
Patients with post-acute stroke.

**Progressive resistance training for the lower extremity versus
control**, level I (RCT): **Grade C+** for functional status at end of
treatment, 1 month (clinically important benefit demonstrated without
statistical significance). Patients with postacute stroke.

**Progressive resistance versus no resistance training**, level I (RCT):
**Grade C** for motor recovery at end of treatment, 4 weeks and 8 weeks,
and follow-up, 6 months (no benefit demonstrated); **grade D** for gait
endurance at end of treatment, 4 weeks and 8 weeks, and follow-up, 6
months (no benefit demonstrated but favoring control). Patients with
subacute stroke.

**Functional task training for upper extremity versus strength
training**, level I (RCT): **Grade C+** favoring functional task
training for functional status (functional independence measure \[FIM\]
self-care and FIM mobility), isometric torque, grip strength, and palmar
pinch at follow-up, 6.5 to 8 months, and lateral pinch at end of
treatment, 4 weeks, and follow-up, 6.5 to 8 months, and **grade C+**
favoring strength training for grip strength and palmar pinch at end of
treatment, 4 weeks (clinically important benefit demonstrated without
statistical significance); **grade C** functional status (FIM self-care
and FIM mobility) at end of treatment, 4 weeks, ROM upper extremity,
pain relief, sensory function upper extremity, motor function upper
extremity, functional status (Functional Test of the Hemiparetic Upper
Extremity \[FTHUE\]) at end of treatment, 4 weeks, and follow-up, 6.5 to
8 months, isometric torque at end of treatment, 4 weeks (no benefit
demonstrated). Patients with subacute stroke.

**Strength training versus control**, level I (RCT): **Grade A** for
upper extremity isometric torque at end of treatment, 4 weeks
(clinically important benefit demonstrated); **grade C+** for motor
function upper extremity and functional status (FTHUE) at end of
treatment, 4 weeks, palmar pinch at end of treatment, 4 weeks, and
follow-up, 6.5 to 8 months, grip strength and lateral pinch at
follow-up, 6.5 to 8 months (clinically important benefit demonstrated
without statistical significance); **grade C** for sensory function
upper extremity at end of treatment, 4 weeks, and follow-up, 6.5 to 8
months, functional status (FIM mobility), pain relief, and grip strength
at end of treatment, 4 weeks (no benefit demonstrated); **grade D+** for
lateral pinch at end of treatment, 4 weeks, functional status (FIM
self-care and FIM mobility), upper extremity isometric torque at
follow-up, 6.5 to 8 months (clinically important benefit favoring
control demonstrated without statistical significance); **grade D** for
ROM upper extremity at end of treatment, 4 weeks, and follow-up, 6.5 to
8 months, functional status (FIM self-care) at end of treatment, 4
weeks, pain relief, motor function upper extremity, functional status
(FTHUE) at follow-up, 6.5 to 8 months (no benefit demonstrated but
favoring control). Patients with subacute stroke.

**Aerobic and strength versus aerobic training**, level I (RCT): **Grade
A** for cardiopulmonary function and peak torque for shoulder flexors at
end of treatment, 16 weeks (clinically important benefit demonstrated);
**grade C+** for peak torque for knee flexors at end of treatment, 16
weeks (clinically important benefit demonstrated without statistical
significance); **grade C** for peak torque for shoulder extensors and
peak torque for knee extensors at end of treatment, 16 weeks (no benefit
demonstrated). Patients with chronic stroke.

**Kinetron training for lower extremity versus control** (no Kinetron),
level I (RCT): **Grade D** for mobility at end of treatment, 5 weeks (no
benefit demonstrated but favoring control). Patients with post-acute
stroke.

**Home-based exercise training versus control**, level I (RCT): **Grade
A** for change in gait speed, gait endurance, torque (change in knee
isometric extensors), endurance, and cardiopulmonary function at end of
treatment, 12 weeks; **grade C+** for motor function (change in
Fugl-Meyer lower extremity), change in gait speed, gait endurance, and
functional status (physical function index), strength (change in grip
strength) at end of treatment, 12 weeks (clinically important benefit
demonstrated without statistical significance); **grade C** for motor
function (change in Fugl-Meyer upper extremity and lower extremity),
balance (Berg balance and change in Berg balance), functional status
(Instrumental Activity of Daily Living (ADL) and Barthel ADL Index), at
end of treatment, 12 weeks (no benefit demonstrated); **grade D+** for
balance (functional reach) at end of treatment, 12 weeks (clinically
important benefit favoring control demonstrated without statistical
significance); **grade D** for torque (change in ankle isometric
dorsiflexors) (no benefit demonstrated but favoring control). Patients
with post-acute stroke.

**Skateboard versus overhead pulley training for the shoulder**, level I
(RCT): **Grade C+** for pain relief at end of treatment, 8 to 10 weeks
(clinically important benefit demonstrated without statistical
significance). Patients with subacute stroke.

**Overhead pulley versus control** (passive ROM training for shoulder),
level I (RCT): **Grade D** for pain relief at end of treatment, 8 to 10
weeks (no benefit demonstrated but favoring control). Patients with
subacute stroke.

**Passive ROM training for shoulder versus skateboard**, level I (RCT):
**Grade C** for pain relief at end of treatment, 8 to 10 weeks (no
benefit demonstrated). Patients with subacute stroke.

**Resisted extension versus ballistic extension training for the hand**,
level I (RCT): **Grade C+** for ROM at end of treatment, 2 weeks
(clinically important benefit demonstrated without statistical
significance); **grade C** motor function at end of treatment, 2 weeks
(no benefit demonstrated). Patients with subacute and post-acute stroke.

**Resisted extension versus resisted grasp training for the hand**,
level I (RCT): **Grade A** for motor function (change in tapping) at end
of treatment, 2 weeks (clinically important benefit demonstrated);
**grade C+** for ROM at end of treatment, 2 weeks (clinically important
benefit demonstrated without statistical significance); **grade C** for
motor function (change in grasp/release) at end of treatment, 2 weeks
(no benefit demonstrated). Patients with subacute and post-acute stroke.

**Resisted extension training for the hand versus control**, level I
(RCT): **Grade A** for motor function (change in tapping) and ROM at end
of treatment, 2 weeks (clinically important benefit demonstrated);
**grade D** for motor function (change in grasp/release) at end of
treatment, 2 weeks (no benefit demonstrated but favoring control).
Patients with subacute and post-acute stroke.

**Ballistic extension versus resisted grasp training for the hand**,
level I (RCT): **Grade A** for motor function (change in tapping) at end
of treatment, 2 weeks (clinically important benefit demonstrated);
**grade C+** for ROM at end of treatment, 2 weeks (clinically important
benefit demonstrated without statistical significance); **grade C** for
motor function (change in grasp/release) and ROM at end of treatment, 2
weeks (no benefit demonstrated). Patients with subacute and postacute
stroke.

**Ballistic extension training for the hand versus control**, level I
(RCT): **Grade C+** for motor function (change in tapping) at end of
treatment, 2 weeks (clinically important benefit without statistical
significance); **grade C** for ROM at end of treatment, 2 weeks (no
benefit demonstrated); **grade D** for motor function (change in
grasp/release) at end of treatment, 2 weeks (no benefit demonstrated but
favoring control). Patients with subacute and post-acute stroke.

**Resisted grasp training for the hand versus control**, level I (RCT),
**Grade C+** for ROM at end of treatment, 2 weeks (clinically important
benefit demonstrated); **grade C** for motor function (change in
tapping) at end of treatment, 2 weeks (no benefit demonstrated); **grade
D** for motor function (change in grasp/release) at end of treatment, 2
weeks (no benefit demonstrated but favoring control). Patients with
subacute and post-acute stroke.

**Robot-aided training versus no robot-aided training**, level I (RCT)
and level II (controlled clinical trials \[CCT\]): **Grade A** for motor
power for shoulder and elbow at end of treatment, 5 weeks, change in
motor power upper extremity at end of treatment, 6 weeks, motor function
(Fugl-Meyer for shoulder, elbow, and coordination and Motor Status Score
\[MSS\] for shoulder and elbow) at end of treatment, 5 weeks, motor
function (MSS for wrist and hand) at end of treatment, 5 weeks, and
motor function (change in MSS for shoulder and elbow) at end of
treatment, 6 weeks, and follow-up, 3 years, motor function (MSS for
wrist and hand) at end of treatment, 5 weeks (clinically important
benefit demonstrated); **grade B** for motor function (MSS for upper
extremity) at end of treatment, 6 weeks (clinically important benefit
demonstrated); **grade C+** for change in motor power for shoulder and
elbow at follow-up, 3 years, motor function (Fugl-Meyer scale for upper
extremity), motor power for upper extremity at end of treatment, 6 weeks
(clinically important benefit demonstrated without statistical
significance); **grade C** for motor function (change in Fugl-Meyer for
shoulder, elbow, and coordination) at end of treatment, 6 weeks,
functional status (FIM for upper extremity) at end of treatment, 5 weeks
and 6 weeks, motor function (change in Fugl-Meyer for wrist and hand and
change in MSS for wrist and hand) at end of treatment, 6 weeks, and
follow-up, 3 years (no benefit demonstrated); **grade D** for motor
function (change in Fugl-Meyer for shoulder, elbow, and coordination) at
follow-up, 3 years (no benefit demonstrated but favoring control).
Patients with subacute-chronic stroke.

**Robot-assisted versus neurodevelopmental (NDT) training**, level I
(RCT): **Grade A** for strength (change in elbow extensors, shoulder
internal rotators, abductors, adductors, and flexors strength \[%\]) and
functional reach (change in forward medial, forward, forward lateral,
and lateral reach extent) at end of treatment, 2 months; **grade C+**
for strength (change in shoulder external rotators and extensors
strength \[%\]) at end of treatment, 2 months (clinically important
benefit demonstrated); **grade C** for functional status (change in
Barthel Index and change in FIM) at follow-up, 6 months, motor function
(change in Fugl-Meyer shoulder and elbow) at end of treatment, 1 month,
2 months, and follow-up, 6 months, motor function (change in Fugl-Meyer
hand and wrist) at end of treatment, 1 month, 2 months, and follow-up, 6
months, (no benefit demonstrated). Patients with chronic stroke.

**Robot-aided progressive resistance training versus robot-aided
active-assisted training**, level I (RCT): **Grade C** for decrease of
spasticity, motor function, and strength at end of treatment, 6 weeks
(no benefit demonstrated). Patients with chronic stroke.

**Progressive-resistive robotic training versus sensorimotor training**,
level I (RCT): **Grade C+** for decrease of spasticity at end of
treatment, 6 weeks (clinically important benefit demonstrated without
statistical significance); **grade C** for motor function (Fugl-Meyer
upper extremity and MSS for shoulder and elbow and wrist and hand), and
motor power for shoulder and elbow at end of treatment, 6 weeks (no
benefit demonstrated). Patients with chronic stroke.

**Music-making training versus control**, level I (RCT): **Grade C+**
for ROM (elbow extension) at end of treatment, 10 weeks (clinically
important benefit demonstrated without statistical significance);
**grade C** for ROM (shoulder flexion) at end of treatment, 10 weeks (no
benefit demonstrated). Patients with post-acute stroke.

**Water-based training versus control**, level I (RCT): **Grade A** for
hip and knee extensors strength (affected side) at end of treatment, 8
weeks (clinically important benefit demonstrated); **grade C+** for
cardiopulmonary function (VO~2~ max) at end of treatment, 8 weeks,
muscle power at end of treatment, 8 weeks, and gait speed at end of
treatment, 8 weeks (clinically important benefit demonstrated without
statistical significance); **grade C** for hip and knee extensors
strength (unaffected side) at end of treatment, 8 weeks (no benefit
demonstrated); **grade D** for balance at end of treatment, 8 weeks (no
benefit demonstrated but favoring control). Patients with chronic
stroke.

**Agility exercise versus stretching/weightshifting exercise**, level I
(RCT): **Grade C+** for step reaction time at follow-up, 1 month
(clinically important benefit demonstrated without statistical
significance); **grade C** for balance, mobility, balance confidence,
and quality of life at end of treatment, 10 weeks, and follow-up, 1
month, step reaction time at end of treatment, 10 weeks (no benefit
demonstrated). Patients with chronic stroke.

**Maximal isokinetic strengthening versus control**, level I (RCT):
**Grade C+** for change in strength at end of treatment, 6 weeks
(clinically important benefit demonstrated without statistical
significance); **grade C** for quality of life and at end of treatment,
6 weeks (no benefit demonstrated); **grade D** for level-walking and
stair-walking (no benefit demonstrated but favoring control). Patients
with chronic stroke.

**Mental imagery versus standard functional training**, level I (RCT):
**Grade A** for level of independence in performing tasks at end of
treatment, 1 week, 2 weeks, and 3 weeks (clinically important benefit
demonstrated). Patients with acute stroke.

**[Definitions]{.underline}**:

**Level of Evidence**

**Level I**: Randomized controlled trials

**Level II**: Nonrandomized studies

**Grade of Recommendation**

**Grade A**: Evidence from one or more randomized controlled trials
(RCTs) of a statistically significant, clinically important benefit
(\>15%)

**Grade B**: Statistically significant, clinically important benefit
(\>15%), if the evidence was from observational studies or controlled
clinical trials (CCTs)

**Grade C+**: Evidence of clinical importance (\>15%) but not
statistical significance

**Grade C**: Interventions where an appropriate outcome was measured in
a study that met the inclusion criteria, but no clinically important
difference and no statistical significance were shown

**Grade D**: Evidence from one or more randomized controlled trials of a
statistically significant benefit favoring the control group (\<0%:
favors controls)

**Grade D+**: Evidence of clinical importance ([\<]{.underline}-15% for
controls) without statistical significance

**Grade D-**: Evidence from one or more randomized controlled trials of
a clinically important benefit ([\<]{.underline}-15% for controls) that
was statistically significant, where the number of participants in the
study is equal to or higher than 100

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Post-stroke physical rehabilitation interventions have been used to
reduce pain and spasticity, as well as to increase range of motion
(ROM), muscle force, mobility, walking ability, functional status,
physical fitness, and quality of life. Post-stroke physical
rehabilitation interventions are mostly noninvasive interventions that
present very few adverse side effects and contraindications as compared
with a large number of pharmacologic interventions.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This publication is designed to provide accurate and authoritative
information in regard to the Subject Matter covered. It is sold with the
understanding that the publisher is not engaged in rendering legal,
accounting, or other professional service. If legal advice or other
expert assistance is required, the services of a competent professional
person should be sought. (From a Declaration of Principles jointly
adopted by a Committee of the American Bar Association and a Committee
of Publishers and Associations.)

Drug and dosage selection: The authors have exerted every effort to
ensure that drug selection and dosage set forth in this text are in
accord with recommendations and practice current at the time of
publication. However, we suggest that appropriate information sources be
consulted when dealing with new and unfamiliar drugs. It remains the
responsibility of every practitioner to evaluate the appropriateness of
a particular opinion in the context of the actual clinical situation and
with due consideration to any new developments in the field.

**Limitations**

It is important to point out that the Ottawa Panel Evidence-Based
Clinical Practice Guidelines (EBCPGs) are not without limitations. First
of all, the strength of clinical practice guidelines depends upon the
quality of the primary studies found in the literature. The clinical
studies that met the Ottawa Panel\'s selection criteria rarely exceeded
3 out of 5 on the Jadad scale, and the sample sizes were generally
small. These methodological issues limit the reliability of the reported
outcomes and the overall quality of the evidence. For example, it is
often difficult to achieve adequate blinding with physical treatments
that produce cutaneous sensation. However, all guidelines developers
face these same issues with regard to methodological considerations. Of
additional note, heterogeneity with respect to interventions, treatment
schedules, study populations, outcome measures, and comparators was
frequently encountered, which reduced the comparability of individual
trials. As a result, quantitative pooling of data through meta-analysis
was not appropriate in most cases. Equally, the findings were sometimes
inconsistent from one study or outcome measure to the next. Weighing the
evidence in such situations inevitably involves value judgments and is
subject to interpretation. Due to the absence of a clear consensus with
regard to the relative importance of specific, validated outcome
measures, individual study findings were not weighted according to the
type of outcome assessed or measurement scale used.

The Ottawa Panel also faced other limitations with regard to the
development of these guidelines. Articles in the scientific literature
were only considered if they were written in English or French due to
the additional time and resources required for translation. Moreover,
the categorization of studies according to the type of intervention
examined was not always straightforward, because in some cases a
particular study could be applied to several categories. A decision was
made as to which category of intervention a particular study best
belonged in order to avoid duplication. This decision was inherently
subjective and could contribute to potential variation in the Ottawa
Panel\'s recommendations with other published clinical practice
guidelines.

With regard to the calculation of treatment benefit, the Ottawa Panel
considered a 15% improvement relative to control as clinically
important. However, this criterion remains somewhat arbitrary and may
not be applicable to all rehabilitation interventions or outcome
measures. Interventions that showed clinically important benefits
without statistical significance for validated outcomes (grade C+) were
interpreted as worthy of consideration in the rehabilitation of stroke
patients and were given positive recommendations. Most of the existing
EBCPGs on stroke rehabilitation did not consider clinical significance
in synthesizing the evidence, which may further account for any
differences in recommendations made by other guideline development
groups. In the calculations of clinical relevance, difficulties also
arose when the variance of data was not directly provided in the
published articles. As a result, the Ottawa Methods Group, working
closely with a senior biostatistician, developed a standardized
methodology to estimate the variance of data (Appendix 2 in the original
guideline document). This was the best conservative approximation that
could be used to produce the Ottawa Panel recommendations.

Finally, the Ottawa Panel did not formally assess the cost-effectiveness
of the various interventions studied. It is recognized, however, that
cost and resource availability are important factors in the individual
clinician\'s decision-making process.

The recommendations of the Ottawa Panel cannot replace clinical
judgment, which is critical for applying the available evidence
appropriately to the care of individual patients under specific
circumstances.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Brosseau L, Wells GA, Finestone HM, Egan M, Dubouloz CJ, Graham I,
Casimiro L, Robinson VA, Bilodeau M, McGowan J. Clinical practice
guidelines for therapeutic exercises. Top Stroke Rehabil 2006
Spring;13(2):10-21.

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006

#### GUIDELINE DEVELOPER(S)

Ottawa Panel - Independent Expert Panel

#### SOURCE(S) OF FUNDING

Ottawa Panel

#### GUIDELINE COMMITTEE

Ottawa Panel Evidence-Based Clinical Practice Guidelines Development
Group

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Group Members*: Lucie Brosseau, PhD, School of Rehabilitation Sciences,
Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario,
Canada; George A. Wells, PhD, Department of Epidemiology and Community
Medicine, University of Ottawa, Ottawa, Ontario, Canada, Centre for
Global Health, Institute of Population Health, Ottawa, Ontario, Canada;
Hillel M. Finestone, MD, Sisters of Charity of Ottawa Health Service,
Ottawa, Ontario, Canada; Mary Egan, PhD, School of Rehabilitation
Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa,
Ontario, Canada; Claire-Jehanne Dubouloz, PhD, School of Rehabilitation
Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa,
Ontario, Canada; Ian Graham, PhD, School of Nursing Sciences, Faculty of
Health Sciences, University of Ottawa, Ottawa, Ontario, Canada; Lynn
Casimiro, MA; Vivian A. Robinson, MSc, Centre for Global Health,
Institute of Population Health, Ottawa, Ontario, Canada; Martin
Bilodeau, PhD, School of Rehabilitation Sciences, Faculty of Health
Sciences, University of Ottawa, Ottawa, Ontario, Canada; Jessie McGowan,
MLIS, Centre for Global Health, Institute of Population Health, Ottawa,
Ontario, Canada

*External Panel Members*: Robert Teasell, MD, University of Western
Ontario, London, Ontario, Canada; Johanne Desrosiers, PhD, Research
Centre on Aging and Sherbrooke University, Sherbrooke, Québec, Canada;
Susan Barreca, MSc, Hamilton Health Sciences, Hamilton, Ontario, Canada;
Lucie Laferrière, MHA, Regional Stroke Centre, Ottawa Hospital, Ottawa
(Ontario), Canada; Joyce Fung, PhD, Department of Physical Therapy,
McGill University, Montreal, Québec, Canada; Hélène Corriveau, PhD, MHA,
Research Centre on Aging and Sherbrooke University, Sherbrooke, Québec,
Canada; Gordon Gubitz, MD, Division of Neurology, Dalhousie University,
Halifax (Nova Scotia), Canada; Michael Sharma, MD, Regional Stroke
Centre, Ottawa Hospital, Ottawa (Ontario), Canada; Mr. S. U., Patient
who had a stroke.

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available for purchase from the [Thomas Land
Publishers, Inc. Web site](http://www.thomasland.com/strokeguide.html).

Print copies: Available from Thomas Land Publishers, Inc., Subscription
Office, P.O. Box 361, Birmingham, AL 35201-0361; Email:
<TLPsubs@ebsco.com>

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on December 11, 2006. The
information was verified by the guideline developer on January 19, 2007.

#### COPYRIGHT STATEMENT

This guideline is copyrighted by Thomas Land Publishers, Inc. and may
not be reproduced without specific permission from the Publisher.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

Bottom of Form

© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008