Evidence reviews for circuit training for walking

Evidence reviews for circuit training for walking

Stroke rehabilitation in adults (update)

Evidence review L

NICE Guideline, No. 236

London: National Institute for Health and Care Excellence (NICE); 2023 Oct.

ISBN-13: 978-1-4731-5461-2

1. Circuit training for walking

1.1. Review question

In people after stroke, what is the clinical and cost effectiveness of group training to improve walking?

1.1.1. Introduction

Physical activity after stroke is known to improve functional recovery and is also a factor in prevention of recurrent stroke. Group based training with focus on mobility provides increased opportunity to be more physically active, may lead to improvements in walking ability and has possible added benefits of providing peer support and increased motivation to engage in walking activities. Group based training has potential to reduce staffing resource needed to deliver programmes to support people to improve their walking depending on the setting in which it is delivered.

Group based activities are currently delivered in acute, inpatient and community settings, both within NHS and voluntary organisations but provision is variable depending on location and service availability. There is not currently any guidance regarding the method of delivering rehabilitation for walking or the setting that group training might be delivered. Recent studies suggest that group training may be effective to improve walking after stroke and further review is required to demonstrate both effectiveness and cost effectiveness of delivering group training to improve walking.

1.1.2. Summary of the protocol

Table 1

PICO characteristics of review question.

For full details see the review protocol in Appendix A.

1.1.3. Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in Appendix A and the methods document.

Declarations of interest were recorded according to NICE’s conflicts of interest policy.

1.1.4. Effectiveness evidence

1.1.4.1. Included studies

One systematic review¹⁰ and in total twenty seven randomised controlled trial studies (thirty four papers) were included in the review^{2–13, 15–24, 26–37} these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary (section 1.1.6 Summary of the effectiveness evidence).

This review updated a published Cochrane review, English 2017¹⁰. This review included seventeen randomised controlled trials with a search conducted up to January 2017. In this evidence review, an additional eleven randomised controlled trial studies were identified and added to the review^{2, 4, 8, 15, 16, 18, 21, 22, 29, 30, 34}. This included one cross-over trial²⁰. The protocol for this review originally specified that cross-over trials would be excluded. However, this study was ultimately included to maintain consistency with the Cochrane review, which stated that the first phase of cross-over trials could be considered for inclusion.

The evidence from the randomised controlled trial studies investigated the follow comparisons:

Circuit class training compared to:

Any other intervention (19 studies)
Other types of circuit class training (2 studies)
No treatment (1 study)

Circuit class training with education compared to:

Any other intervention (2 studies)
Circuit class training (without education) (1 study)

Circuit class training interventions generally focused on repetitive (within session) practice of functional tasks arranged in a circuit, with the aim of improving mobility. Studies of interventions that included exercises solely aimed at improving impairment (such as strengthening, range of motion or cardiovascular fitness) were excluded as per the Cochrane review protocol. The comparator interventions varied between the studies and included a mix of the following: the same exercise as the circuit class but delivered individually rather than in a group; group classes but for upper limb training or stretching only; education only; Bobath therapy; usual care only or waiting list control.

Circuit class training was generally offered alongside usual care and in some cases in conjunction with a home-based programme that was given as homework. In the majority of studies the intervention and control group treatments were matched for treatment time. However, in some studies the control group were only provided with usual care or were not provided with matched treatment time^{9, 11, 13, 15, 17, 24, 32, 34}.

In general circuit class training was delivered for approximately 30 minute – 3 hours per day and sessions ranged from once per fortnight to 7 days per week. The duration of the interventions ranged from 2 weeks to 40 weeks. Most commonly, circuit classes took place 3 times per week for six weeks and were approximately 60 minute sessions. The staff participant ratio varied between studies and ranged from 1:3 – 1:6. In the majority of studies the intervention was delivered by a physiotherapist.

Four studies^{4, 11, 13, 34} reported circuit class training with education. These involved approximately 20 minutes to 1 hour of education usually prior to the circuit class training and included the following topics: falls risk, health education, interactive self-management education, discussions around physical activity and goal setting.

The majority of studies included people in the chronic phase post stroke and most commonly interventions were delivered in an outpatient setting. The baseline stroke severity and premorbid Modified Rankin status of the participants was not reported in most studies.

Indirectness

14 outcomes were downgraded for indirectness due to intervention or outcome indirectness. In most cases this was due to the studies not stating the staff: participant ratio for the circuit classes. The protocol, adapted from the included Cochrane review¹⁰, only included studies with a staff participant ratio of 1:3. Any studies which did not explicitly state the ratio or had a greater staff ratio were downgraded for intervention indirectness. One study ³⁴ reported withdrawal due to adverse events rather than all adverse events and so outcomes including this data were downgraded for outcome indirectness. One study was downgraded as it compared circuit class training with education to the same circuit class training with mental imagery instead⁴.

Inconsistency

Several outcomes showed heterogeneity and was not resolved by sensitivity or subgroup analyses. Therefore, the outcomes were downgraded for inconsistency and analysed using a random effects model.

See also the study selection flow chart in Appendix C, study evidence tables in Appendix D, forest plots in Appendix E. and GRADE tables in Appendix F.

1.1.4.2. Excluded studies

See the excluded studies list in Appendix J.

1.1.5. Summary of studies included in the effectiveness evidence

Table 2

Summary of studies included in the evidence review.

See Appendix D for full evidence tables.

1.1.6. Summary of the effectiveness evidence

Table 3

Clinical evidence summary: Circuit class therapy compared to any other intervention.

Table 4

Clinical evidence summary: Circuit class training compared to other types of circuit training.

Table 5

Clinical evidence summary: Circuit class training compared to no treatment.

Table 6

Clinical evidence summary: Circuit class training with education compared to any other intervention.

Table 7

Clinical evidence summary: Circuit class training with education compared to circuit class training (without education).

See Appendix F for full GRADE tables.

1.1.7. Economic evidence

1.1.7.1. Included studies

Two health economic studies were included in this review.^{8, 11} The first study compared circuit class training to any other intervention⁸ while the second compared circuit class training with education to any other intervention.¹¹ Note that the second study was also included as part of the community participation review for this guideline.

These studies are summarised in the health economic evidence profiles below (Table 8 and Table 9) and the health economic evidence tables in Appendix H.

1.1.7.2. Excluded studies

No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.

See also the health economic study selection flow chart in Appendix G.

1.1.8. Summary of included economic evidence

Table 8

Health economic evidence profile: Circuit training interventions to improve walking compared to standard care.

Table 9

Circuit class training with education compared to any other intervention.

1.1.9. Economic model

This area was not prioritised for new cost-effectiveness analysis.

1.1.10. Unit costs

Group training interventions require additional resource use compared to not providing such interventions. As described in Section 1.1.5 Summary of studies included in the effectiveness evidence, in studies included in the clinical review, circuit classes were most commonly delivered by a physiotherapist in an outpatient setting with a staff to participant ratio between 1:3 and 1:6 and took place 3 times per week for six weeks and were approximately 60-minute sessions. This would equate to costs of £150 to £372 using the physiotherapist costs shown in Table 10.

However, studies included in the clinical review reported varied resource use. Key differences in resource use were due to:

Variation in method of delivery of therapy sessions: studies reported a staff to participant ratio ranging from 1:2–6. The lower the ratio, the more staff are required to assist with the group training, increasing costs.
The frequency and duration of the group training delivered, with sessions ranging from 30–60 minutes, occurring 2–5 days per week. In the included clinical studies, the interventions were delivered for between 2 weeks and 3 months.
Staff who delivered the intervention varied as studies reported that treatment was delivered by either physiotherapists, occupational therapists, or trained instructors. The health economic study (Harrington 2010¹¹) used rehabilitation therapists, trained instructors and trained volunteers to deliver the intervention.
Study setting: interventions were conducted in hospitals, community and leisure centres, church halls and physiotherapy outpatient rehabilitation centres. Non-clinical settings will incur lower or no costs compared to clinical settings.
Additional resource use required to deliver the intervention, such as staff-training costs and information or instructional materials. Several studies included an education component to the intervention. One study (Dean 2018⁸) also mentioned that instructors were specifically trained by the Action for Rehabilitation following Neurological Injury (ARNI) Trust, with courses fees set at £649.¹

Relevant unit costs are provided below to aid consideration of cost effectiveness.

Table 10

Unit costs of health care professionals who may be involved in delivering group training interventions.

1.1.11. Evidence statements

Effectiveness/Qualitative

Economic

One cost-utility analysis found that for people following stroke, circuit-based training was dominated (higher costs and lower quality of life) by usual care. This analysis was assessed as partially applicable with potentially serious limitations.

One cost-consequence analysis found that for people following stroke, a community exercise and education scheme was dominated by usual care, incurring higher costs (£746 more per participant) after 12 months, while the clinical evidence reported that the intervention performed worse on a functional mobility measure after 9 weeks (mean score of 17.4 seconds (SD 7.5)) (16.4 seconds (SD 7.5)). This analysis was assessed as partially applicable with potentially serious limitations.

1.1.12. The committee’s discussion and interpretation of the evidence

1.1.12.1. The outcomes that matter most

The committee included the following outcomes: person/participant generic health-related quality of life, carer generic health-related quality of life, 6-minute walk test, walking speed, functional mobility measures, measures of standing balance, measures of motor impairment activities of daily living, stroke-specific Patient-Reported Outcome Measures, length of hospital stay and adverse events. All outcomes were considered equally important for decision making and therefore have all been rated as critical.

This review updated a published Cochrane review, English, 2018 ¹⁰. Therefore, the outcomes used in this review are the same as those reported in the Cochrane review, with the inclusion of carer generic health-related quality of life to maintain consistency with other reviews in this guideline. Stroke specific Patient Reported Outcome Measures were included in the Cochrane review but combined with health-related quality of life outcomes. These outcomes have been reported separately in this review, for consistency with previous reviews and to provide greater insight into how the interventions affect the persons functional abilities or quality of life more specific to their condition.

The committee chose to investigate these outcomes at post-intervention and follow-up time points as they considered that there could be a difference in the short term and long-term effects of the intervention. The longest follow-up time point available in each study was used for the follow up category.

The committee agreed that there was generally a sufficient amount of evidence available for the majority of the outcomes at both follow up time points with the exception of length of hospital stay which was only reported by one study. Evidence was also more limited for measures of motor impairment and activities of daily living, but it was agreed that there was sufficient evidence available for the committee to make a recommendation.

1.1.12.2. The quality of the evidence

One systematic review and in total 27 randomised controlled trial studies were included in the review. The evidence varied from high to very low quality, with the majority being of low quality. Outcomes were commonly downgraded for risk of bias, inconsistency and imprecision due to uncertainty around the effect estimate. Risk of bias was rated as a concern in the majority of the studies. This was generally due to bias arising from the randomisation process, deviations from the intended interventions, missing outcome data and in the measurement of the reported result.

Inconsistency was present in many of the outcomes which was possibly due to the heterogenous nature of the included evidence which reported differences in the following: types of circuit class exercises, time periods post stroke and intensity of the intervention. Heterogeneity was investigated with sensitivity analyses and the pre-specified subgroup analyses. None of the analyses resolved the heterogeneity so these outcomes were downgraded for inconsistency and a random effects model was used in the analysis. Imprecision was seen in a number of outcomes due to small sample sizes and uncertainty around the effect estimate.

Fourteen outcomes were downgraded for indirectness due to either intervention or outcome indirectness. In most cases this was due to the studies not stating the staff:participant ratio for the circuit classes. The protocol, adapted from the included Cochrane review¹⁰, only included studies with a staff:participant ratio of 1:3. Any studies which did not explicitly state the ratio or had a greater staff ratio were downgraded for intervention indirectness. One study³⁴ reported withdrawal due to adverse events rather than all adverse events and so outcomes including this data were downgraded for outcome indirectness. One study was considered to have two sources of intervention indirectness as it did not state the staff participant ratio and it compared circuit class training with education to the same circuit class training with mental imagery instead. This did not fit exactly into any of the comparisons included in the protocol, however, it has been classified as circuit class training with education versus circuit class training without education. This study only included one relevant outcome measure so did not greatly influence the results presented in this review.

The committee concluded that the evidence was of a sufficient quality to make recommendations. They acknowledged the very low quality rating of the evidence but this was balanced by the large number of studies reporting many of the outcomes. They noted that a number of studies took place in a wide range of countries which in some cases may limit their applicability to the NHS. However, seven studies took place in the UK and are applicable to an NHS setting. Most of these papers compared circuit class training to any other intervention while one study compared circuit class training with education to any other intervention.

1.1.12.3. Benefits and harms

1.1.12.3.1. Key uncertainties

The committee acknowledged that the evidence was not straightforward. It was difficult to interpret the effect of the intervention due to the variety in how much therapy was provided; whether circuit class training was provided in addition to usual care or as therapy time that would be used by usual care; the differences in levels of supervision and who provided the therapy and the variation in education programmes. Furthermore, the committee noted that limited reporting of participant characteristics, including the severity of stroke symptoms before entering the trial, made it difficult to draw conclusions on which people would respond well to circuit class training.

The committee noted that qualitative benefits may be present with circuit class training that will not be captured in this review. The effects of being in a group and interactions with other people who have had a stroke are likely to have an important effect to help people to know what to expect in their rehabilitation, to come up with solutions for the future and to engage more with the therapy that they are doing. The committee noted that these wider benefits may be present for group therapies beyond circuit training to support people to improve walking (for example: circuit training to improve upper limb function). They supported that group training may be useful for a range of different aims and would suggest that this be considered as an option for other types of therapies as this was considered as a helpful option by the lay members on the committee.

1.1.12.3.2. Circuit class training without education compared to any other intervention, other types of circuit class training and no treatment

The results showed that when circuit class training without education was compared to any other intervention, other types of circuit class training and no treatment, there were clinically important benefits reported in the six minute walk test at post intervention and follow up and length of hospital stay at post intervention. Unclear effects were reported for measures of walking speed, measures of motor impairment and activities of daily living with some outcomes reporting clinically important benefits and others showing no clinically important differences. The majority of these smaller studies reported a benefit. No clinically important difference at both the post-intervention and follow up were seen in functional mobility measures, measures of standing balance, stroke-specific Patient-Reported Outcome Measures and adverse events.

Two clinically important benefits for the other interventions (where the outcome was worse in the circuit class group) were reported for person/participant health-related quality of life measured using the SF-12 physical component at post intervention and EQ-5D at follow up. The committee acknowledged that in the case of the SF-12 physical component outcome there were large differences between the groups at baseline and so the control group almost caught up with the intervention group rather than exceeding it, and if this outcome was reported as a final value it was represent a benefit of the intervention group. Similarly for the EQ-5D there were differences in baseline values between the groups but in this case the control group started with a greater EQ-5D value. Therefore, this result could merely be explained by poorly matched groups at baseline the effect of small sample sizes. A committee member also theorised that lower quality of life scores in the intervention groups could be down to the patients finding the intervention too challenging or potential increase in falls/fear of falling. However, this was not borne out in the data for adverse events.

The committee discussed the benefit reported in length of hospital stay for the intervention group. While this outcome was only based on one small study comparing mobility circuit class training with upper limb circuit training only it reported 24 days fewer spent in hospital. One committee member argued that this finding would have a massive impact on resource use for the NHS and theorised it could be due to people achieving the levels of independence required to be discharged sooner and the criteria for this being strongly linked to walking ability. However, the committee acknowledged that it was only reported by one study which was based in Sweden so may not be so applicable to an NHS setting. The study authors themselves highlighted that this result should be interpreted with caution as it was a secondary outcome and may be influenced by external factors.

The committee concluded that while these outcomes were reported in small studies, which were generally of high or very high risk of bias that the evidence was strong enough to suggest an overall benefit of circuit class training in improving six-minute walk test scores, along with a reduction in hospital stay without any increases in adverse events and falls. The committee agreed that even if these benefits did not translate to consistent overall gains in quality of life or activities of daily living, the fact that mobility has been improved without increases in adverse events would probably lead to a reduction in resource use to the NHS.

Taking into account all of this information, weighing up the benefits and harms identified in the evidence and the expert opinion of the committee, the committee agreed that circuit class training should be considered for people after stroke.

1.1.12.3.3. Circuit class training with education compared to any other intervention and circuit class training without education

The results showed that, when circuit class training with education was compared to any other intervention and circuit class training without education, there were clinically important benefits reported for the 6-minute walk test at post intervention, walking speed at post intervention and follow up and measures of standing balance at follow up. Unclear effects were reported for person/participant health-related quality of life with some outcomes reporting clinically important benefits and others showing clinically important harms or no clinically important differences. No clinically important difference was reported for functional mobility measures at both the post intervention and follow up periods.

A clinically important harm was reported at both the post intervention and follow up for adverse events. However, the committee noted that these were due to medical conditions and acute disease and therefore unlikely to be related to the intervention. Moreover, fall related self-efficacy was separately reported by the study and indicated a higher self-efficacy in the intervention group.

There was also a clinically important harm (where the outcome was worse in the circuit class group) in the 6-minute walk test at follow up, however, at post intervention there was a benefit of circuit class training. It was noted that follow up took place 15 months after the intervention which suggests that any gains in mobility may be lost if participants do not continue training. The study authors also suggested that the benefit in the control group could be explained by baseline differences in mobility between the two treatment groups. The control group had a higher 6-minute walk test at baseline and therefore may find it easier to maintain their mobility levels and to continue improving.

The committee acknowledged the additional benefits that education programs may provide. Lay members on the committee noted that this allowed for more interaction with other people who have had a stroke and the chance to learn from each other during these sessions. This was agreed to be important to be a great source of support during rehabilitation.

1.1.12.4. Cost effectiveness and resource use

The review identified two UK-based health economic analyses. The first study was a within-trial cost-utility analysis of a pilot feasibility RCT. The control group received treatment as usual, which ranged from zero treatment to engagement with any health service(s). All participants were asked to not participate in additional physical rehabilitation (either NHS or private) but received an advice booklet about exercise. The circuit-based training group received twice-weekly 2-hour sessions over 3 months followed by 3 (one per month) drop-in sessions. The results found that the circuit-based training program was dominated (higher costs and lower quality of life) by usual care, reporting a mean cost per participant of £777 for a QALY loss of -0.045. The clinical results also showed that the control group performed better on a functional mobility measure (timed up and go, lower values are better) with a mean difference of 4.81 seconds compared to the intervention group, however this is in contrast to the wider evidence base which reported clinical benefits and no harms compared to usual care. The results suggest that circuit class training is not cost-effective, however, the study was assessed as partially applicable for this review as EQ-5D-5L scores were used to calculate QALYs when the NICE reference case currently prefers EQ-5D-3L. It was also not stated that an NHS and PSS perspective is taken however, the costs included are all considered relevant if the intervention is funded by the NHS. Potentially serious limitations were also identified, as the analysis was based on a pilot feasibility RCT (n=45) that was not powered to test the effectiveness of the intervention or differences in healthcare resource use. The aim was to inform a future study where effectiveness and cost-effectiveness could be assessed. The within-trial analysis also meant that results only reflect the health outcomes and costs from a single trial and the 9-month follow-up period may not capture full health effects of the intervention if these persist. Furthermore, cost sources were not reported, making it difficult to assess how the intervention compared to current practice: only the total intervention cost per participant was reported and it was unclear whether this included the training course fees (set at £649¹) that instructors were required to complete before delivering the program, while other healthcare resource use was collected but not included. Sensitivity analysis was not performed on areas of uncertainty.

The second study analysed compared standard care to a community exercise and education scheme, in which participants carried out a circuit of various exercises adapted to their own capabilities. This was a within-trial cost consequence analysis of an RCT which was included in the clinical review. This study was also included as part of the community participation review for this guideline. The circuit class training intervention was held twice weekly for eight weeks, facilitated by volunteers and qualified exercise instructors (supported by a physiotherapist), each with 9 participants plus carers or family members. Sessions were held in leisure and community centres and consisted of 1 hour of exercise followed by a short break, and 1 hour of interactive education. Committee members agreed that the educational component described in the study reflects similar schemes available in current practice. NHS costs (primary care consultations, secondary care, community care and prescribed medication), and social care costs (home care, meals on wheels, use of a day centre and social worker time) were included.

The main results found that costs associated with the intervention were £746 (95%CI: –£432 to £1,924) higher per participant compared to standard care. The wide confidence interval reported was highlighted to the committee as this creates uncertainty regarding the costs incorporated into the analysis. The cost breakdown provided in the analysis showed that the increase in the intervention costs accounted for only a small proportion of overall additional costs (£99), with the rest of difference coming from other resource use required by the intervention group, such as inpatient and social care. This was potentially due to the intervention being partly staffed by volunteer, suggesting that costs could potentially be higher if the NHS were to fund similar interventions. The clinical results also showed that the standard care group performed better on the timed up and go test, with a mean score of 16.4 seconds (SD 7.5), compared to 17.4 seconds (SD 7.5) observed in the intervention group, however this is in contrast to the wider evidence base which reported clinical benefits and no harms compared to usual care. These results suggest that the circuit class training intervention may not be cost-effective considering the additional costs and lack of clinical benefit. The study was assessed as partially applicable as EQ-5D and QALYs were not reported, and the use of 2005 resource use and unit costs may not reflect current UK NHS context. Potentially serious limitations were noted for this study, largely due to the within-trial analysis when considering the heterogenous nature of the included evidence. Furthermore, it was unclear if time if the 12-month time horizon was sufficient to assess the full costs and benefits. Sensitivity analyses were also not performed.

In addition to these studies, relevant unit costs were presented to the committee to inform consideration of cost-effectiveness. Additional resource use associated with circuit class training will largely relate to staff time, with the majority of studies in the clinical review reporting that a physiotherapist had delivered the intervention in an outpatient setting. Circuit classes most commonly took place three times per week for 6 weeks, with sessions typically lasting 60 minutes. The staff participant ratio varied between studies and ranged from 1:3 – 1:6, with higher proportions of participants incurring lower staff costs. Based on this description it was estimated that the cost of circuit class training would be between £150-£372, based on either a band 6 or 7 physiotherapist delivered the intervention. However, during the committee discussion it was noted that a band 4 or 5 physiotherapist could also deliver the intervention, as well as physiotherapist assistant, which would further reduce staff costs. Additional resource use would also be incurred for interventions containing an educational component or staff training costs. It was not possible to assess the potential for downstream cost-savings based on the clinical evidence reported.

The clinical evidence based was large and suggested an overall benefit of circuit class training (both with and without an educational component) in improving 6-minute walk test scores. Some of the evidence suggested these programmes allowed people to walk faster, improved their balance and ability to complete daily tasks compared to usual care. Committee members acknowledged the additional benefits of emotional support during rehabilitation, as well as the potential for greater interaction between participants resulting from the addition of educational programs. However, the presence of heterogeneity across the clinical studies, the mixed effects reported for several outcomes and a lack of sufficient economic analysis made it challenging to ascertain the clinical and cost effectiveness of circuit class training. Furthermore, variation in the availability of circuit class training interventions across current practice suggests that there would be a resource impact if a recommendation was made. For these reasons, the committee agreed on a ‘consider’ recommendation for circuit class training as an option for post-stroke adults (rather than something to be offered to everyone), which could include education programmes.

1.1.12.5. Other factors the committee took into account

The committee acknowledged that circuit class training may be used as a method to increase intensity of rehabilitation. The committee agreed that this may be appropriate but only if the intense therapy is delivered for the same amount of time with sufficient healthcare professional input, rather than using a group-based setting as a substitute for individual therapy time. The committee acknowledged that the majority of the evidence was in an outpatient setting but agreed that circuit training could be used in stroke rehabilitation units/wards.

The committee acknowledged several additional benefits to this treatment. Group based circuit classes allowed for people who have had a stroke to interact with each other, which can help them to talk to others who can understand what they are experiencing, to learn from each other and to find emotional support. The lay members on the committee highlighted how crucial this was and how this provided more opportunities to do this. This was noted to be important regardless of the person’s walking ability at the start of the program. They acknowledged that group programmes may be associated with challenges, such as seeing other people progressing at different rates which may make it ‘a bit depressing’, but the overall benefits from interacting with other people were very important.

1.1.13. Recommendations supported by this evidence review

This evidence review supports recommendation 1.13.23.

1.1.14. References

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22.: Martins JC, Nadeau S, Aguiar LT, Scianni AA, Teixeira-Salmela LF, De Morais Faria CDC. Efficacy of task-specific circuit training on physical activity levels and mobility of stroke patients: A randomized controlled trial. NeuroRehabilitation. 2020; 47(4):451–462 [PubMed: 33136078]

23.: Moore SA, Hallsworth K, Jakovljevic DG, Blamire AM, He J, Ford GA et al Effects of Community Exercise Therapy on Metabolic, Brain, Physical, and Cognitive Function Following Stroke: A Randomized Controlled Pilot Trial. Neurorehabilitation and Neural Repair. 2015; 29(7):623–635 [PubMed: 25538152]

24.: Mudge S, Barber PA, Stott NS. Circuit-based rehabilitation improves gait endurance but not usual walking activity in chronic stroke: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2009; 90(12):1989–1996 [PubMed: 19969159]

25.: National Institute for Health and Care Excellence. Developing NICE guidelines: the manual [updated January 2022]. London. National Institute for Health and Care Excellence, 2014. Available from: https://www.nice.org.uk/process/pmg20

26.: Outermans JC, van Peppen RP, Wittink H, Takken T, Kwakkel G. Effects of a high-intensity task-oriented training on gait performance early after stroke: a pilot study. Clinical Rehabilitation. 2010; 24(11):979–987 [PubMed: 20719820]

27.: Pang MY, Eng JJ, Dawson AS, McKay HA, Harris JE. A community-based fitness and mobility exercise program for older adults with chronic stroke: a randomized, controlled trial. Journal of the American Geriatrics Society. 2005; 53(10):1667–1674 [PMC free article: PMC3226792] [PubMed: 16181164]

28.: Pang MY, Harris JE, Eng JJ. A community-based upper-extremity group exercise program improves motor function and performance of functional activities in chronic stroke: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2006; 87(1):1–9 [PMC free article: PMC3123334] [PubMed: 16401430]

29.: Qurat ul A, Malik AN, Amjad I. Effect of circuit gait training vs traditional gait training on mobility performance in stroke. JPMA - Journal of the Pakistan Medical Association. 2018; 68(3):455–458 [PubMed: 29540885]

30.: Qurat ul A, Malik AN, Haq U, Ali S. Effect of task specific circuit training on gait parameters and mobility in stroke survivors. Pakistan Journal of Medical Sciences. 2018; 34(5):1300–1303 [PMC free article: PMC6191776] [PubMed: 30344596]

31.: Song HS, Kim JY, Park SD. The effect of class-based task-oriented circuit training on the self-satisfaction of patients with chronic stroke. Journal of Physical Therapy Science. 2015; 27(1):127–129 [PMC free article: PMC4305542] [PubMed: 25642055]

32.: Song HS, Kim JY, Park SD. Effect of the class and individual applications of task-oriented circuit training on gait ability in patients with chronic stroke. Journal of Physical Therapy Science. 2015; 27(1):187–189 [PMC free article: PMC4305558] [PubMed: 25642070]

33.: Tang A, Eng JJ, Krassioukov AV, Madden KM, Mohammadi A, Tsang MY et al Exercise-induced changes in cardiovascular function after stroke: a randomized controlled trial. International Journal of Stroke. 2014; 9(7):883–889 [PMC free article: PMC4486377] [PubMed: 24148695]

34.: Vahlberg B, Cederholm T, Lindmark B, Zetterberg L, Hellstrom K. Short-term and long-term effects of a progressive resistance and balance exercise program in individuals with chronic stroke: a randomized controlled trial. Disability and Rehabilitation. 2017; 39(16):1615–1622 [PubMed: 27415645]

35.: van de Port IG, Wevers L, Roelse H, van Kats L, Lindeman E, Kwakkel G. Cost-effectiveness of a structured progressive task-oriented circuit class training programme to enhance walking competency after stroke: the protocol of the FIT-Stroke trial. BMC Neurology. 2009; 9:43 [PMC free article: PMC2736157] [PubMed: 19674485]

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37.: Verma R, Arya KN, Garg RK, Singh T. Task-oriented circuit class training program with motor imagery for gait rehabilitation in poststroke patients: a randomized controlled trial. Topics in Stroke Rehabilitation. 2011; 18suppl1:620–632 [PubMed: 22120031]

Appendices

Appendix A. Review protocols

Review protocol for the clinical and cost effectiveness of group training to improve walking (PDF, 277K)

Appendix B. Literature search strategies

B.1. Clinical search literature search strategy

Searches were constructed using a PICO framework where population (P) terms were combined with Intervention (I) and in some cases Comparison (C) terms. Outcomes (O) are rarely used in search strategies as these concepts may not be indexed or described in the title or abstract and are therefore difficult to retrieve. Search filters were applied to the search where appropriate.

Download PDF (251K)

B.2. Health Economics literature search strategy

Health economic evidence was identified by conducting searches using terms for a broad Stroke Rehabilitation population. The following databases were searched: NHS Economic Evaluation Database (NHS EED - this ceased to be updated after 31^st March 2015), Health Technology Assessment database (HTA - this ceased to be updated from 31^st March 2018) and The International Network of Agencies for Health Technology Assessment (INAHTA). Searches for recent evidence were run on Medline and Embase from 2014 onwards for health economics, and all years for quality-of-life studies. Additional searches were run in CINAHL and PsycInfo looking for health economic evidence.

Download PDF (193K)

Appendix C. Effectiveness evidence study selection

Download PDF (218K)

Appendix D. Effectiveness evidence

Ali, 2020 (PDF, 192K)

Blennerhassett, 2004 (PDF, 225K)

Bovonsunthonchai, 2020 (PDF, 213K)

Dean, 2000 (PDF, 228K)

Dean, 2009 (PDF, 152K)

Dean, 2012 (PDF, 284K)

Dean, 2018 (PDF, 251K)

English, 2015 (PDF, 225K)

Harrington, 2010 (PDF, 206K)

Hillier, 2011 (PDF, 117K)

Holmgren, 2010 (PDF, 251K)

Kang, 2021 (PDF, 226K)

Kim, 2017 (PDF, 224K)

Kim, 2016 (PDF, 222K)

Knox, 2018 (PDF, 246K)

Marigold, 2005 (PDF, 213K)

Marsden, 2010 (PDF, 272K)

Martins, 2017 (PDF, 159K)

Martins, 2020 (PDF, 222K)

Moore, 2015 (PDF, 219K)

Mudge, 2009 (PDF, 218K)

Outermans, 2010 (PDF, 219K)

Pang, 2005 (PDF, 214K)

Pang, 2006 (PDF, 188K)

Qurat ul, 2018 (PDF, 202K)

Qurat ul, 2018 (PDF, 217K)

Song, 2015 (PDF, 182K)

Song, 2015 (PDF, 195K)

Tang, 2014 (PDF, 207K)

Vahlberg, 2017 (PDF, 296K)

van de Port, 2012 (PDF, 224K)

van de Port, 2009 (PDF, 189K)

Verma, 2011 (PDF, 198K)

Appendix E. Forest plots

E.5. Circuit class training with education compared to circuit class training (without education)

Download PDF (91K)

Appendix F. GRADE tables

Download PDF (384K)

Appendix G. Economic evidence study selection

Download PDF (180K)

Appendix H. Economic evidence tables

H.1. Circuit class training compared to any other intervention

Download PDF (220K)

H.2. Circuit class training with education compared to any other intervention

Download PDF (218K)

Appendix I. Health economic model

Modelling was not prioritised for this question.

Appendix J. Excluded studies

Clinical studies

Table 19

Studies excluded from the clinical review.

Health Economic studies

Published health economic studies that met the inclusion criteria (relevant population, comparators, economic study design, published 2006 or later and not from non-OECD country or USA) but that were excluded following appraisal of applicability and methodological quality are listed below. See the health economic protocol for more details.

Table 20

Studies excluded from the health economic review.

Final version

Evidence reviews underpinning recommendation 1.13.23 in the NICE guideline

These evidence reviews were developed by NICE

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Bookshelf ID: NBK601174PMID: 38442215

Table 1PICO characteristics of review question

Population	Inclusion: Adults (age ≥16 years) who have had a first or recurrent stroke (including people after subarachnoid haemorrhage). Exclusion: Children (age <16 years) People who had a transient ischaemic attack
Intervention	Circuit class training Definition: An intervention that involves participants receiving physical rehabilitation involving repetitive (within session) practice of functional tasks arranged in a circuit with the aim of improving mobility. This is completed in a group environment, with a staff-to-client ratio of no greater than 1:3 (that is, no more than one staff member per three clients). Providing a minimum of once weekly sessions for a minimum of four weeks Circuit class therapy with education
Comparison	Other types of circuit class training Any other intervention, including: Active interventions aiming at improving mobility/usual care (including individual therapy) No treatment
Outcomes	All outcomes are considered equally important for decision making and therefore have all been rated as critical: At time period: Post-intervention Follow-up (wherever available, for example: 3–6 months post-intervention) Person/participant generic health-related quality of life (continuous outcomes will be prioritised [validated measures]) Carer generic health-related quality of life (continuous outcomes will be prioritised [validated measures]) 6-minute walk test (continuous outcomes will be prioritised) Walking speed (continuous outcomes will be prioritised) Functional mobility measures Timed Up and Go (continuous outcomes will be prioritised) Rivermead Mobility Index (continuous outcomes will be prioritised) Measures of standing balance Measures of motor impairment Lower limb strength (continuous outcomes will be prioritised) Range of motion (continuous outcomes will be prioritised) Activities of daily living (continuous outcomes will be prioritised) Stroke-specific Patient-Reported Outcome Measures (continuous outcomes will be prioritised) Length of hospital stay (continuous outcomes will be prioritised) Adverse events (dichotomous outcome)
Study design	Systematic reviews of RCTs Parallel RCTs If insufficient RCT evidence is available, non-randomised studies will be considered, including: Prospective and retrospective cohort studies Case control studies (if no other evidence identified)

Table 2Summary of studies included in the evidence review

Study

Intervention and comparison

Population

Outcomes

Comments

Ali 2020²

Circuit class training

(n=11)

Circuit training program comprised of five stations including Sit to Stand training, Step up forward, backwards and sideways, trunk control and rotation, reaching out in various directions collecting an object and passing on other side. Five minutes per station. Treatment was 3 sessions of 50 minutes each for six weeks.

Any other intervention

(n=11)

The same program but completed as an individual with 1:1 supervision.

Concomitant therapy: Not reported.

People after a first or recurrent stroke

Mean age: 60.81 years

N = 22

Mean time after stroke: Subacute (7 days - 6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Not stated/unclear

Walking speed at post-intervention

Measures of standing balance at post-intervention

Setting: Outpatient follow up in Pakistan.

Sources of funding: Not reported.

Blennerhassett 2004³

Circuit class training

(n=15)

Mobility-related CCT, 10 5-minute workstations consisting of functional tasks including sit to stand, step ups, obstacle course walking, standing balance, stretching and strengthening exercises); 1 h/day, 5 days/week for 4 weeks.

Staff:participant

ratio: 1:4.

Any other intervention

(n=15)

Upper limb-related CCT, 10 5-minute workstations consisting of functional tasks to improve reach to grasp, hand eye co-ordination, stretching and strengthening exercises; 1 h/day, 5 days/week for 4 weeks.

Staff:participant

ratio: 1:4.

Concomitant therapy: Both groups received additional CCT therapy in addition to usual care

People after a first or recurrent stroke

Mean age (SD): 55.1 (15.9) years

N = 30

Mean time after stroke: Subacute (7 days - 6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Not stated/unclear

Six minute walk test at post-intervention and follow up

Functional mobility measures at post-intervention and follow up

Length of hospital stay at post-intervention and follow up

*This study was included in the original Cochrane review that was updated in this review. For further details see English 2017¹⁰

Bovonsunthonchai 2020⁴

Circuit class training with education

(n=20)

25 minutes of health education preceded by 65 minutes of structured program circuit class training. The circuit training program involved 7 different workstations and took place 3 times a week for 4 weeks.

Other type of circuit class training with mental imagery

(n=20)

25 minutes of mental imagery preceded by 65 minutes of structured program circuit class training. Groups practiced 3 times a week for 4 weeks. The same circuit class training was provided, with mental imagery being practiced in four phases.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 52.7 (11.5) years

N = 40

Mean time after stroke: Subacute (7 days - 6 months)

Ethnicity: Not stated/unclear

Severity: Mild (or NIHSS 1–5)

Premorbid Modified Rankin Scale: Not stated/unclear

Walking speed at post-intervention

Setting: Outpatient follow up in three centres: the Physical Medicine and Rehabilitation Department, North Okkalapa General Hospital, East General Hospital and National Rehabilitation Hospital, Yangon, Myanmar in Thailand.

Sources of funding: This study was funded by the Norway Scholarship (Mahidol-Norway Capacity Building Initiative for ASEAN) and Faculty of Physical Therapy, Mahidol University.

Dean 2000⁵

Circuit class training

(n=6)

Mobility-related CCT, 10 workstations functional tasks including seated reaching beyond arms’ reach, sit to stand, stepping activities, heel lifts, standing balance, strengthening exercises, walking activities; 1 h, 3 times/week for 4 weeks.

Staff:participant

ratio: 1:6

Any other intervention

(n=6)

Upper limb-related CCT, workstations consisting of upper limb tasks; 1 h, 3 times/week for 4 weeks.

Staff:participant

ratio: 1:6.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 64.3 (7.4) years

N = 12

Mean time after stroke: Chronic (>6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Not stated/unclear

Six minute walk test at post-intervention and follow up

Walking speed at post-intervention and follow up

Functional mobility measures at post-intervention and follow up

Measures of standing balance at post-intervention and follow up

*This study was included in the original Cochrane review that was updated in this review. For further details see English 2017¹⁰

Dean 2012⁷

Subsidiary study: Dean 2009⁶

Circuit class training

(n=76)

Mobility-related CCT, task-related training with progressive balance, strengthening, standing, walking and stair climbing exercises, home programme and advice to increase walking. Delivered weekly 40 weeks.

Staff:participant

ratio: not reported

Any other intervention

(n=75)

Upper-limb related CCT, task-related strength and co-ordination training, cognitive training, home programme and advice to increase use of upper limb and engage in more cognitive tasks.

Staff:participant

ratio: not reported

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 67.1 (12.4) years

N = 151

Mean time after stroke: Chronic (>6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Not stated/unclear

Person/participant generic health-related quality of life at post-intervention

Six minute walk test at post-intervention

Walking speed at post-intervention

Functional mobility measures at post-intervention

Measures of standing balance at post-intervention

Measures of motor impairment at post-intervention

Adverse events at post-intervention

*This study was included in the original Cochrane review that was updated in this review. For further details see English 2017¹⁰

Dean 2018⁸

Circuit class training

(n=23)

Circuit class training delivered in a community setting (one gym, two church halls and one community centre) with twice-weekly 2-hour sessions over 3 months, comprising: an introductory one-to-one session (home visit); 10 twice-weekly group classes with up to 2 trainers and 8 clients (training venue); a closing one-to-one session (home visit); followed by 3 (one per month) drop-in sessions. Participants completed home-based training throughout.

Staff:participant

ratio: 1:4

Any other intervention

(n=22)

Treatment as usual. This ranged from zero treatment to engagement with any health service(s). All participants were asked to not participate in additional physical rehabilitation (either NHS or private). All people received an advice booklet about exercise.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 70.5 (11.1) years

N = 45

Mean time after stroke: Subacute (7 days - 6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Mixed (majority 3)

Person/participant generic health-related quality of life at post-intervention and follow up

Functional mobility measures at post-intervention and follow up

Stroke-specific Patient-Reported Outcome

Measures at post-intervention and follow up

Adverse events at post-intervention and follow up

Setting: Community based in the United Kingdom.

Sources of funding: Funded by the Stroke Association and the Peninsula Patient Involvement Group with the ReTrain Stroke Service User Group. The NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula at the Royal Devon and Exeter NHS Foundation Trust also supported this work.

English 2015⁹

Subsidiary study: Hillier 2011¹²

Circuit class training

(n=93)

Circuit class therapy for up to 3 hours per day, usually in two 90 minute sessions morning and afternoon 5 days a week for 4 weeks. Therapists were encouraged to prescribe exercises and activities that were task-specific, included part- as well as whole-practice of tasks, with an emphasis on repetition and feedback

Staff:participant

ratio: between 1:3 and 1:6.

Any other intervention

(n=190)

A combination of two groups. One (n=96) received usual care provided 7 days a week on both Saturday and Sunday for the duration of their inpatient stay, in addition to their usual 5 days therapy. The other (n=94) received usual care dependent on the site provided for 5 days a week. This was done with daily individual therapy and augmented for some people by group physiotherapy 1–4 times a week.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 70.1 (l2.9) years

N = 283

Mean time after stroke: Subacute (7 days - 6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Not stated/unclear

Person/participant generic health-related quality of life at post-intervention

Six minute walk test at post-intervention

Walking speed at post-intervention

Activities of daily living at post-intervention

Stroke-specific patient-report outcome measures post-intervention

Length of hospital stay at post-intervention

Adverse events at post-intervention

*This study was included in the original Cochrane review that was updated in this review. For further details see English 2017¹⁰

Harrington 2010¹¹

Circuit class training with education

(n=119)

CCT with exercises adapted to ability aimed at improving balance, strength and endurance, plus home exercise programme, plus interactive self-management education sessions; 1 h exercise and 1 h of education twice a week for 8 weeks. Duration and frequency: not reported.

Staff:participant

ratio: 2:9

Any other intervention

(n=124)

Standard care and information sheet with list of local exercise classes.

Duration and frequency: not reported.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 70.5 (10.4) years

N = 243

Mean time after stroke: Chronic (>6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Not stated/unclear

Functional mobility measures at post-intervention

*This study was included in the original Cochrane review that was updated in this review. For further details see English 2017¹⁰

Holmgren 2010¹³

Circuit class training with education

(n=15)

Mobility-related circuit-class therapy, focus on physical activity and functional performance and education about falls risk. Circuit class therapy duration not specified, 7 sessions a week for 5 weeks; education 1 h/week for 5 weeks.

Staff:participant

ratio: not reported.

Any other intervention (education only)

(n=19)

Education about coping with hidden dysfunctions after stroke 1 h/week for 5 weeks.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 78.5 (7.6) years

N = 34

Mean time after stroke: Subacute (7 days - 6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: >2

Person/participant generic health-related quality of life at post-intervention and follow up

*This study was included in the original Cochrane review that was updated in this review. For further details see English 2017¹⁰

Kang 2021¹⁵

Circuit class training

(n=30)

A multicomponent exercise program performed for 60 minutes per session, three times a week for 8 weeks. Two groups high speed (n =15) and low speed (n=15) velocity strength training were combined in a circuit. Aerobic and resistance exercises were performed.

Staff:participant

ratio: not reported.

Any other intervention

(n=15)

Whole-body static stretching performed for 1 hour per class, twice a week for 8 weeks.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 54.8 (3.4) years

N = 45

Mean time after stroke: Chronic (>6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Not stated/unclear

Functional mobility measures at post-intervention

Measures of standing balance at post-intervention Measures of motor impairment at post-intervention

Setting: People admitted to the sports center of N Hospital in Seoul, Republic of Korea.

Sources of funding: This research was funded by a grant (#15-C-01) from the Korea National Rehabilitation Research Institute, Seoul, Republic of Korea.

Kim 2016¹⁷

Circuit class training

(n=10)

Mobility-related CCT, including trunk exercises, active sitting practice, sit-to-stand practice, standing and walking practice, aerobic exercise and strength training; 90 min/per day, 5 days/ week for 4 weeks

Staff:participant

ratio: at least 2 participants to 1 therapist

Any other intervention

(n=10)

Usual care physiotherapy provided in 2 × 30min sessions, 5 × per week for 4 weeks. Content based on neurodevelopmental approach and provided in one-to-one therapy sessions

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 65.6 (6.2) years

N = 20

Mean time after stroke: Subacute (7 days - 6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Not stated/unclear

Six minute walk test at post-intervention

Measure of standing balance at post-intervention

Functional mobility measures at post-intervention

Activities of daily living at post-intervention

Adverse events at post-intervention

*This study was included in the original Cochrane review that was updated in this review. For further details see English 2017¹⁰

Kim 2017¹⁶

Circuit class training

(n=15)

Task-oriented circuit training at the rehabilitation centre, for a total of 50 minutes, five times a week, for 4 weeks for a total of 20 sessions. It consisted of task-oriented activities for improving balance, walking competence, and respiration ability.

Staff:participant

ratio: 2:3

Any other intervention

(n=15)

Exercise focused on task-oriented exercise, such as strengthening exercise (resistance exercise), standing balance (using varying methods) and functional activities for gait improvement.

Concomitant therapy: Both groups received neuro-development treatment (postural control exercise, resistance exercise and functional activity exercise) for approximately 1 hour per day. In addition, they received some other therapies, including occupational and speech therapy, as needed.

People after a first or recurrent stroke

Mean age (SD): 55.7 (12.2) years

N = 30

Mean time after stroke: Subacute 7 days - 6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Not stated/unclear

Six minute walk test at post-intervention

Function mobility measures post-intervention

Measures of standing balance at post-intervention

Setting: Inpatients in the rehabilitation centres from South Korea.

Sources of funding: No additional information.

Knox 2018¹⁸

Circuit class training

(n=51)

Task orientated gait training. The participants attended six 1-hour sessions over this 12-week period with their caregiver. It consisted of a series of six exercises and focused on improving strength, balance, and task performance while standing and walking, and included an endurance walking station.

Staff:participant

ratio: 1:4–6

Any other intervention

(n=93)

Two groups combined for the review. Strength intervention (n=45) delivered by a physiotherapist, and included 10 exercises targeting the major muscles in the lower extremities. Each exercise consisted of 3 × 10 repetitions and progressed as per the participants’ performance. Participants in the Control group (n=48) attended a 90-minute educational session on stroke management that included 20 minutes of exercises

People after a first or recurrent stroke

Mean age (SD): 50.0 (13.9) years

N = 144

Mean time after stroke: Subacute 7 days - 6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Not stated/unclear

Six minute walk test at post-intervention and follow up

Walking speed at post-intervention and follow up

Functional mobility measures at post-intervention and follow up

Measures of standing balance at post-intervention and follow up

Setting: Outpatients physiotherapy department in South Africa.

Sources of funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial support was obtained from the Medical Research Council of South Africa and the Fonds de recherche du Québec-Santé (FRQS).

Martins 2020²²

Subsidiary study: Martins 2017²¹

Circuit class training

(n=18)

Task-specific circuit training divided into 30 minutes of tasks for the upper limb and 30 minutes for the lower limb. The tasks were organised in a circuit with 11-stations. The participants performed five minutes of exercises in each station, except for the gait training with auditory cue, which lasted 10 minutes.

Staff:participant

ratio: 1:2–6

Any other intervention (n=18)

Stretching and memory exercise and health education, 3 times a week, 60 minute sessions over 12 weeks. The control group intervention consisted of 40 minutes of static global stretching and 20 minutes of memory exercises, and/or health education sessions. Health education sessions included information on risk factors for stroke, the importance of correct consumption of medications and fluid intake, frequency of medical consultations, and quality of sleep.

Concomitant therapy: All participants received 60 minute interventions, in groups of two to six, three times a week for 12 weeks, totalling 36 sessions.

People after a first or recurrent stroke

Mean age (SD): 55.5 (15.1) years

N = 36

Mean time after stroke: Chronic (>6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Not stated/unclear

Six minute walk test at post-intervention and follow up

Walking speed at post-intervention and follow up

Stroke-specific Patient-Reported Outcome Measures at post-intervention and follow up

Adverse events at post-intervention and follow up

Setting: Outpatient follow up in Canada.

Sources of funding: This study was funded by the following research funding agencies: Coordenacao de Aperfeicoamento de Pessoal Ensino Superior (CAPES - Financial Code 001), Conselho Nacional de Desenvolvimento Cientifico e Tecnologico, Fundacao de Amparo a Pesquisa de Minas Gerias (FAPEMIG), and Pro-reitoria de Pesquisa da Universidade Federal de Minas Gerais (PRPq/UFMG).

Moore 2015²³

Circuit class training

(n=20)

Mobility CCT based on FAME programme including warm-up, stretching, functional strengthening, balance, agility & fitness, cool down; 45–60 minutes, 3 times/week for 19 weeks.

Any other intervention

(n=20)

Home stretching programme of matched duration; 45 to 60 minutes. 3 times/week for 19 weeks.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 69 (9.7) years

N = 40

Mean time after stroke: Chronic (>6 months)

Ethnicity: Not stated/unclear

Severity: Mild (NIHSS 1–5)

Premorbid Modified Rankin Scale: Not stated/unclear

Six minute walk test at post-intervention

Walking speed at post-intervention

Measures of standing balance at post-intervention

Adverse events at post-intervention and follow up

*This study was included in the original Cochrane review that was updated in this review. For further details see English 2017¹⁰

Mudge 2009²⁴

Circuit class training

(n=31)

Mobility circuit class training. 15 × 2-minute workstations including walking, standing balance and strengthening. 50–60 minutes for 3 times/week for 4 weeks.

Any other intervention (social and education classes only)

(n=27) 4 social and 4 educational sessions; duration not specified, twice a week for 4 weeks.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Median age (range):

Intervention: 76.0 (39.0–89.0)

Control: 71.0 (44.0–86.0) years

N = 58

Mean time after stroke: Chronic (>6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Not stated/unclear

Six minute walk test at post-intervention and follow up

Walking speed at post-intervention and follow up

Measures of standing balance at post-intervention and follow up

*This study was included in the original Cochrane review that was updated in this review. For further details see English 2017¹⁰

Outermans 2010²⁶

Circuit class training (high intensity)

(n=22)

High-intensity mobility CCT, workstations based on Dean 2000 with progressive target heart rate; 45–60 minutes, 3 times/week for 4 weeks in addition to 30 min/day usual care physiotherapy.

Staff:participant

ratio: not reported

Other circuit class training (low intensity)

(n=21)

Low-intensity mobility CCT, based on motor control and balance, no progression of heart rate; 45–60 minutes, 3 times/week for 4 weeks in addition to 30 min/day usual care physiotherapy.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 56.6 (8.6) years

N = 43

Mean time after stroke: Subacute (7 days - 6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Not stated/unclear

Six minute walk test at post-intervention

Walking speed at post-intervention

Measures of standing balance at post-intervention

Adverse events at post-intervention

*This study was included in the original Cochrane review that was updated in this review. For further details see English 2017¹⁰

Pang 2005²⁷

Subsidiary study: Pang 2006²⁸

Circuit class training

(n=32)

Mobility-related circuit class training based on FAME programme including warm-up, stretching, functional strengthening, balance, agility & fitness, cool down including target heart rate; 1-h session, 3 times/week for 19 weeks

Staff:participant

ratio: 3:9–12

Any other intervention

(n=31)

Upper-limb-related exercise training including strengthening, range of motion, functional reach and manipulation tasks; 1-h session, 3 times/week for 19 weeks.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 65.3 (8.8) years

N = 63

Mean time after stroke: Chronic (>6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Not stated/unclear

Six minute walk test at post-intervention

Measures of standing balance at post-intervention

Measures of motor impairment at post-intervention

Adverse events at post-intervention

*This study was included in the original Cochrane review that was updated in this review. For further details see English 2017¹⁰

Qurat 2018²⁹

Subsidiary study: Qurat 2018³⁰

Circuit class training (task specific circuit gait training)

(n=18)

Eight work stations of different activities related to balance and gait were defined at each work stations. Patient practiced each task on station for 4–5 minutes. Total time for the session was 40–50 minutes and continued four days a week over a period of six weeks. All work stations were supervised by therapist.

Staff:participant

ratio: not reported

Any other intervention

(n=18)

Traditional gait training exercises were given to the control group for four days a week with session duration 40–50 minutes. This treatment was continued for a period of six weeks.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 54.1 (10.1) years

N = 36

Mean time after stroke: Subacute (7 days - 6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: >2

Functional mobility measures at post-intervention

Measures of standing balance at post-intervention

Setting: Outpatient follow up in Pakistan.

Sources of funding: No funding.

Song 2015³²

Subsidiary study: Song 2015³¹

Circuit class training

(n=11)

Mobility CCT, provided in circuit. 30 min/day, 3 times/week for 4 weeks. Inpatient rehabilitation.

Staff:participant

ratio: not reported

Any other intervention

(n=19)

1 group (n=10) receiving mobility exercises, provided one-to-one. 1 group (n=9) receiving conventional therapy (not described).

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 62.2 (8.6) years

N = 30

Mean time after stroke: Chronic (>6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Not stated/unclear

Walking speed at post-intervention

*This study was included in the original Cochrane review that was updated in this review. For further details see English 2017¹⁰

Tang 2014³³

Circuit class training

(n=25)

Mobility circuit class training. Aerobic training with target progressive heart rate using brisk walking, cycling, step ups, sit to stands. 60-min sessions 3 times/week for 6 months.

Staff:participant

ratio: 3:12.

Any other intervention

(n=19)

Balance and flexibility non-aerobic, including balance exercise progressed to be challenging. 60-min sessions 3 times/week for 6 months.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 66.3 (7.1) years

N = 50

Mean time after stroke: Chronic (>6 months)

Ethnicity: Not stated/unclear

Severity: Mild (NIHSS 1–5)

Premorbid Modified Rankin Scale: Not stated/unclear

Six minute walk test at post-intervention

Adverse events at post-intervention

*This study was included in the original Cochrane review that was updated in this review. For further details see English 2017¹⁰

Vahlberg 2017³⁴

Circuit class training with education

(n=34)

Circuit class training conducted twice weekly over a 3 month period.

Included: a warm-up (10 minutes), a circuit class (approximately 45 minutes) and a motivational session that included discussions about issues and personal goals that are related to physical activity (20 minutes).

Any other intervention

(n=33)

Continue with regular activities. Were not restricted from participating in ordinary physical activities and rehabilitation programs.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 73.1 (5.4) years

N = 67

Mean time after stroke: Chronic (>6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Not stated/unclear

Person/participant generic health-related quality of life at post-intervention and follow up

Six minute walk test at post-intervention and follow up

Walking speed at post-intervention and follow up

Functional mobility measures at post-intervention and follow up

Measures of standing balance at post-intervention and follow up

Adverse events at post-intervention and follow up

Setting: Outpatient follow up in Sweden.

Sources of funding: Supported by grants from the Medical Faculty at Uppsala University STROKE-Riksfőrbundet and the Uppsala County Council and municipality in Sweden.

Van de Port 2012³⁶

Subsidiary study: Van de Port 2009³⁵

Circuit class training

(n=126)

Mobility circuit class training. Aerobic training with target progressive heart rate using brisk walking, cycling, step ups, sit to stands. 60-min sessions 3 times/week for 6 months.

Staff:participant

ratio: 3:12.

Any other intervention

(n=124)

Balance and flexibility non-aerobic, including balance exercise progressed to be challenging. 60-min sessions 3 times/week for 6 months.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 57.0 (10.1) years

N = 250

Mean time after stroke: Subacute (7 days - 6 months)

Ethnicity: Not stated/unclear

Severity: Not stated/unclear

Premorbid Modified Rankin Scale: Not stated/unclear

Six minute walk test at post-intervention and follow up

Walking speed at post-intervention and follow up

Functional mobility measures at post-intervention and follow up

Measures of standing balance at post-intervention and follow up

*This study was included in the original Cochrane review that was updated in this review. For further details see English 2017¹⁰

Verma 2011³⁷

Circuit class training

(n=15)

Workstations including balance, stair walking, turning, transfers, and speed walking plus mental imagery. 40-min sessions, 7 days/week for 2 weeks.

Staff:participant

ratio: 1:4

Any other intervention

(n=15)

Conventional lower limb therapy based on Bobath techniques. 40-min sessions, 7 days/week for 2 weeks.

Concomitant therapy: No additional information.

People after a first or recurrent stroke

Mean age (SD): 54.2 (7.8) years

N = 30

Mean time after stroke: Subacute (7 days - 6 months)

Ethnicity: Not stated/unclear

Severity: Mild (NIHSS 1–5)

Premorbid Modified Rankin Scale: Not stated/unclear

Six minute walk test at post-intervention and follow up

Walking speed at post-intervention and follow up

Functional mobility measures at post-intervention and follow up

Activities of daily living balance at post-intervention and follow up

Adverse events at post-intervention and follow up

*This study was included in the original Cochrane review that was updated in this review. For further details see English 2017¹⁰

Table 3Clinical evidence summary: Circuit class therapy compared to any other intervention

Outcomes	№ of participants (studies) Follow-up	Certainty of the evidence (GRADE)	Relative effect (95% CI)	Anticipated absolute effects		Comments
Outcomes	№ of participants (studies) Follow-up	Certainty of the evidence (GRADE)	Relative effect (95% CI)	Risk with any other intervention	Risk difference with circuit class training	Comments
Person/participant health related quality of life (SF-12 PCS, 0–100, higher values are better, change score) at end of intervention	133 (1 RCT) follow-up: mean 12 months	⨁◯◯◯ Very low_^a^,^b^,^c	-	The mean person/participant generic health-related quality of life at post-intervention was 2	MD 2 lower (5.06 lower to 1.06 higher)	MID = 2 (SF-12 established MID)
Person/participant generic health-related quality of life (SF-12 MCS, 0–100, higher values are better, change score) at post-intervention	133 (1 RCT) follow-up: mean 12 months	⨁◯◯◯ Very low_^a^,^b^,^c	-	The mean person/participant generic health-related quality of life at post-intervention was 0	MD 0 (3.91 lower to 3.91 higher)	MID = 3 (SF-12 established MID)
Person/participant generic health-related quality of life (AQOL, unclear range, higher values are better, final value) at post-intervention	283 (1 RCT) follow-up: mean 4 weeks	⨁⨁⨁⨁ High	-	The mean person/participant generic health-related quality of life at post-intervention was 0.22	MD 0 (0.1 lower to 0.1 higher)	MID = 0.22 (0.5 × median control group SD)
Person/participant generic health-related quality of life (EQ5D-5L, −0.11–1, higher values are better, final values) at follow up	41 (1 RCT) follow-up: mean 9 months	⨁◯◯◯ Very low_^c^,^d	-	The mean person/participant generic health-related quality of life at follow up was 0.62	MD 0.1 lower (0.25 lower to 0.05 higher)	MID = 0.03 (EQ5D established MID)
Six minute walk test ([meters] higher values are better, change scores and final values) at post-intervention	1154 (14 RCTs) follow-up: mean 15.6 weeks	⨁◯◯◯ Very low_^c^,^e^,^f	-	The mean six minute walk test at post-intervention was 214.5	MD 42.08 meters higher (24.21 higher to 59.96 higher)	MID = 28 meters (established MID)
Six minute walk test ([meters], higher values are better, change scores and final values) at follow up	517 (7 RCTs) follow-up: mean 16.4 weeks	⨁◯◯◯ Very low_^c^,^f^,^g	-	The mean six minute walk test at follow up was 216.8	MD 47.93 meters higher (22.37 higher to 73.48 higher)	MID = 28 meters (established MID)
Walking speed (10 meter walk test, comfortable walk test [m/s], higher values are better, change scores) at post-intervention	169 (2 RCTs) follow-up: mean 34 weeks	⨁◯◯◯ Very low_^a^,^b^,^f	-	The mean walking speed at post-intervention was 0.008	MD 0.03 m/s higher (0.05 lower to 0.12 higher)	MID = 0.2 m/s (established MID for chronic stroke)
Walking speed (10 meter walk test, gait speed, comfortable walk test [m/s], higher values are better, final values) at post-intervention	825 (8 RCTs) follow-up: mean 7.4 weeks	⨁⨁◯◯ Low_^c^,^h	-	The mean walking speed at post-intervention was 0.71	MD 0.16 m/s higher (0.12 higher to 0.21 higher)	MID = 0.2 m/s (established MID for chronic stroke)
Walking speed (10 meter walk test, unclear units, higher values are better, final values) at post-intervention	22 (1 RCT) follow-up: mean 6 weeks	⨁◯◯◯ Very low_^c^,ⁱ	-	The mean walking speed at post-intervention was 35.27	MD 0.91 higher (5.08 lower to 6.9 higher)	MID = 2.80 (0.5 × baseline SDs)
Walking speed (comfortable walking speed [m/s], higher values are better, change scores) at follow up	36 (1 RCT) follow-up: 16 weeks	⨁⨁⨁◯ Moderate_^g	-	The mean walking speed at follow up was 0.03	MD 0 m/s (0.09 lower to 0.09 higher)	MID = 0.2 m/s (established MID for chronic stroke)
Walking speed (comfortable walk test, gait speed [m/s], higher values are better, final values) at follow up	451 (5 RCTs) follow-up: mean 14.8 weeks	⨁◯◯◯ Very low_^c^,ⁱ	-	The mean walking speed at follow up was 0.71	MD 0.14 m/s higher (0.09 higher to 0.2 higher)	MID = 0.2 m/s (established MID for chronic stroke)
Functional mobility measures (timed up and go [seconds], lower values are better, change scores and final values) at post-intervention	728 (10 RCTs) follow-up: mean 11.4 weeks	⨁⨁⨁◯ Moderate_^e	-	The mean functional mobility measures at post-intervention was 14.9	MD 2.63 seconds fewer (4.44 fewer to 0.82 fewer)	MID = 10 seconds (established MID)
Functional mobility measures (Functional Ambulation Classification, FMA-LL [different scale ranges], higher values are better, final values) at post-intervention	50 (2 RCTs) follow-up: mean 3 weeks	⨁⨁⨁◯ Moderate_^c	-	-	SMD 0.28 SD higher (0.28 lower to 0.84 higher)	MID = 0.5 (SMD)
Functional mobility measures (timed up and go [seconds], lower values are better, final values) at follow up	484 (6 RCTs) follow-up: mean 17.6 weeks	⨁⨁◯◯ Low_^j	-	The mean functional mobility measures at follow up was 19.77	MD 2.93 seconds lower (5.21 lower to 0.65 lower)	MID = 10 seconds (established MID)
Measures of standing balance (Berg balance scale, balance confidence scale, timed balance test [different scales ranges], higher values are better, final values) at post-intervention	685 (10 RCTs) follow-up: mean 11 weeks	⨁⨁⨁◯ Moderate_^e	-	-	SMD 0.3 SD higher (0.15 higher to 0.45 higher)	MID = 0.5 (SMD)
Measures of standing balance (step test [number of steps], higher values are better, change score and final value) at post-intervention	142 (2 RCTs) follow-up: mean 28 weeks	⨁◯◯◯ Very low_^a^,^b^,^c	-	The mean measures of standing balance at post-intervention was 3	MD 1.11 steps higher (0.68 lower to 1.33 higher)	MID = 1.88 (0.5 × median control group SD)
Measures of standing balance (Berg balance scale, 0–56, higher values are better, change score) at post-intervention	30 (1 RCT) follow-up: 4 weeks	⨁◯◯◯ Very low_^b^,^c^,^k	-	The mean measures of standing balance at post-intervention was 5.27	MD 1.33 higher (2.93 lower to 5.59 higher)	MID = 5.1 (0.5 × median baseline SDs)
Measures of standing balance (Berg balance scale, balance confidence scale, timed balance test [different scales ranges], higher values are better, final values) at follow up	454 (4 RCTs) follow-up: mean 18.5 weeks	⨁⨁◯◯ Low_^j	-	-	SMD 0.25 SD higher (0.06 higher to 0.44 higher)	MID = 0.5 (SMD)
Measures of motor impairment (affected knee strength [kg], higher values are better, change score) at post-intervention	130 (1 RCT) follow-up: 12 months	⨁⨁◯◯ Low_^a^,^b	-	The mean measures of motor impairment at post-intervention was −0.1	MD 0.3 kg higher (2.22 lower to 2.82 higher)	MID = 4.73 (0.5 × median baseline SD)
Measures of motor impairment (paretic leg muscle strength [newtons], higher values are better, final value) at post-intervention	63 (1 RCT) follow-up: 19 weeks	⨁⨁⨁◯ Moderate_^c	-	The mean measures of motor impairment at post-intervention was 205.3	MD 17.9 Newtons higher (26.59 lower to 62.39 higher)	MID = 35.7 (0.5 × median baseline SD)
Measures of motor impairment (K-trunk impairment scale, 0–23, higher values are better, final values) at post-intervention	29 (1 RCT) follow-up: mean 8 weeks	⨁◯◯◯ Very low_^b^,^c^,^e	-	The mean measures of motor impairment at post-intervention was 14.82	MD 2.35 higher (0.21 higher to 4.49 higher)	MID = 1.48 (0.5 × median baseline SD)
Activities of daily living (Barthel index, FIM [different scale ranges], higher are better, final values) at post-intervention	303 (2 RCTs) follow-up: mean 4 weeks	⨁⨁⨁⨁ High	-	-	SMD 0.12 SD lower (0.36 lower to 0.12 higher)	MID = 0.5 (SMD)
Activities of daily living (Barthel index, 0–100, higher are better, final value) at follow up	30 (1 RCT) follow-up: 6 weeks	⨁⨁⨁⨁ High	-	The mean activities of daily living at follow up was 74.67	MD 16 higher (7.59 higher to 24.41 higher)	MID = 1.85 (established MID 1.85)
Stroke-specific Patient-Reported Outcome Measures (SSQOL, 0–245, higher values are better, change score) at post-intervention	36 (1 RCT) follow-up: 12 weeks	⨁◯◯◯ Very low_^c^,^g	-	The mean stroke-specific Patient-Reported Outcome Measures at post-intervention was −3	MD 12 higher (2.52 higher to 21.48 higher)	MID = 17 (0.5 × median baseline SD)
Stroke-specific Patient-Reported Outcome Measures (Stroke impact scale - physical domain, different scale ranges, higher values are better, final values) at post-intervention	323 (2 RCTs) follow-up: mean 11.5 weeks	⨁⨁⨁◯ Moderate_^c	-	-	SMD 0.13 SD lower (0.36 lower to 0.1 higher)	MID = 0.5 (SMD)
Stroke-specific Patient-Reported Outcome Measures (Stroke impact scale - recovery score, 0–100, higher values are better, final value) at post-intervention	283 (1 RCT) follow-up: 4 weeks	⨁⨁⨁⨁ High	-	The mean stroke-specific Patient-Reported Outcome Measures at post-intervention was 50	MD 0 (8.34 lower to 8.34 higher)	MID = 20 (0.5 × median control group SD)
Stroke-specific Patient-Reported Outcome Measures (SSQOL, 0–245, higher values are better, final value) at follow up	36 (1 RCT) follow-up: 16 weeks	⨁◯◯◯ Very low_^c^,^g	-	The mean stroke-specific Patient-Reported Outcome Measures at follow up was −9	MD 16 higher (2.51 higher to 29.49 higher)	MID = 17 (0.5 × median baseline SD)
Stroke-specific Patient-Reported Outcome Measures (SSQOL, unclear scale range, higher values are better, final value) at follow up	41 (1 RCT) follow-up: 9 months	⨁◯◯◯ Very low_^c^,^d	-	The mean stroke-specific Patient-Reported Outcome Measures at follow up was 3.63	MD 0.25 lower (0.72 lower to 0.22 higher)	MID = 0.34 (0.5 × median baseline SD 0.34)
Length of hospital stay ([days], lower values are better, final value) at post-intervention	30 (1 RCT) follow-up: 4 weeks	⨁⨁⨁◯ Moderate_^b	-	The mean length of hospital stay at post-intervention was 67.5	MD 26.8 days fewer (52.84 fewer to 0.76 fewer)	MID = 21.5 (0.5 × median control group SD)
Adverse events at post-intervention	673 (8 RCTs) follow-up: mean 14.5 weeks	⨁◯◯◯ Very low_^e^,^m^,ⁿ	RD 0.02 (−0.03 to 0.08)	99 per 1,000	20 more per 1,000 (30 fewer to 80 more)_^l	Precision calculated through Optimal Information Size (OIS) due to zero events in some studies. OIS determined power for the sample size = 0.33 (0.8–0.9 = serious, <0.8 = very serious).
Adverse events at follow up	107 (3 RCTs) follow-up: mean 19 weeks	⨁◯◯◯ Very low_^h^,^m^,ⁿ	RD 0.02 (−0.10 to 0.06)	358 per 1,000	20 more per 1,000 (10 fewer to 60 more)_^l	Precision calculated through Optimal Information Size (OIS) due to zero events in some studies. OIS determined power for the sample size = 0.03 (0.8–0.9 = serious, <0.8 = very serious).

a: Downgraded by 1 increment as the majority of the evidence was of high risk of bias (due to bias arising from the randomisation process)

b: Downgraded by 1 increment due to intervention indirectness (the participant : staff ratio was not stated by the study)

c: Downgraded by 1 increment if the confidence interval crossed one MID or by 2 increments if the confidence interval crossed both MIDs

d: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process and bias due to deviation from the intended intervention)

e: Downgraded by 1 increment as the majority of the evidence was of high risk of bias (due to a mixture of bias arising from the randomisation process, bias due to deviation from the intended intervention, bias due to missing outcome data and bias in measurement of the outcome)

f: Downgraded by 1 increment because heterogeneity, unexplained by subgroup analysis

g: Downgraded by 1 increment as the majority of the evidence was of high risk of bias (due to bias arising from the randomisation process and bias due to missing outcome data)

h: Downgraded by 1 increment as the majority of the evidence was of high risk of bias (due to a mixture of bias arising from the randomisation process, bias due to deviation from the intended intervention and bias due to missing outcome data)

i: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process, bias due to deviation from the intended intervention, bias due to missing outcome data and bias in measurement of the outcome)

j: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process and bias due to missing outcome data)

k: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process and bias in measurement of the outcome)

l: Absolute effect calculated by risk difference due to zero events in at least one arm of one study

m: Downgraded for heterogeneity due to conflicting number of events in different studies (zero events in one or more studies)

n: Downgraded by 2 increments for imprecision due to zero events and small sample size

Table 4Clinical evidence summary: Circuit class training compared to other types of circuit training

Outcomes	№ of participants (studies) Follow-up	Certainty of the evidence (GRADE)	Relative effect (95% CI)	Anticipated absolute effects		Comments
Outcomes	№ of participants (studies) Follow-up	Certainty of the evidence (GRADE)	Relative effect (95% CI)	Risk with other types of circuit training	Risk difference with circuit class training	Comments
Six minute walk test ([meters], higher values are better, final values) at post-intervention	90 (2 RCTs) follow-up: 14 weeks	⨁◯◯◯ Very low_^a^,^b^,^c	-	The mean six minute walk test at post-intervention was 376.95	MD 30.25 meters higher (96.83 lower to 157.34 higher)	MID = 28 meters (established MID)
Walking speed (10m walk test [m/s], higher values are better, final values) at post-intervention	43 (1 RCT) follow-up: 4 weeks	⨁◯◯◯ Very low_^a^,^b^,^c	-	The mean walking speed at post-intervention was 1.4	MD 0.3 m/s higher (0.03 higher to 0.57 higher)	MID = 0.2 m/s (established MID for chronic stroke)
Measures of standing balance (Berg balance scale, 0–56, higher values are better, final value) at post-intervention	43 (1 RCT) follow-up: 4 weeks	⨁◯◯◯ Very low_^a^,^c	-	The mean measures of standing balance at post-intervention was 54.1	MD 0 (1.45 lower to 1.45 higher)	MID = 2.8 (0.5 × baseline median SD)
Adverse events at post-intervention	93 (3 RCT) follow-up: 14 weeks	⨁◯◯◯ Very low_^a^,^e	RD 0.00 (−0.09 to 0.09)	0 per 1,000	0 fewer per 1,000 (90 fewer to 90 more)_^f	Precision calculated through Optimal Information Size (OIS) due to zero events in some studies. OIS determined power for the sample size = 0.07 (0.8–0.9 = serious, <0.8 = very serious).

a: Downgraded by 1 increment as the majority of the evidence was of high risk of bias (due to a mixture of bias due to deviation from the intended intervention and bias in measurement of the outcome)

b: Downgraded by 1 increment if the confidence interval crossed one MID or by 2 increments if the confidence interval crossed both MIDs

c: Downgraded by 1 increment if the confidence interval crossed one MID or by 2 increments if the confidence interval crossed both MIDs

d: Downgraded by 1 increment due to intervention indirectness (does not state staff: participant ratio)

e: Downgraded by 2 increments for imprecision due to zero events and small sample size

f: Absolute effect calculated by risk difference due to zero events in at least one arm of one study

Table 5Clinical evidence summary: Circuit class training compared to no treatment

Outcomes	№ of participants (studies) Follow-up	Certainty of the evidence (GRADE)	Relative effect (95% CI)	Anticipated absolute effects		Comments
Outcomes	№ of participants (studies) Follow-up	Certainty of the evidence (GRADE)	Relative effect (95% CI)	Risk with no treatment	Risk difference with circuit class training	Comments
Six minute walk test ([meters], higher values are better, change score) at post-intervention	25 (1 RCT) follow-up: 9 weeks	⨁◯◯◯ Very low_^a^,^b	-	The mean six minute walk test at post-intervention was 5.3	MD 18.3 meters higher (13.02 lower to 49.62 higher)	MID = 28 meters (established MID)
Functional mobility measures (timed up and go [seconds], lower values are better, change score) at post-intervention	25 (1 RCT) follow-up: 9 weeks	⨁⨁⨁◯ Moderate_^a	-	The mean functional mobility measures at post-intervention was 0.3	MD 0.1 seconds higher (1.76 lower to 1.96 higher)	MID = 10 seconds (established MID)
Stroke-specific Patient-Reported Outcome Measures (Stroke impact scale - communication, 0–100, higher values are better, change score) at post-intervention	24 (1 RCT) follow-up: 9 weeks	⨁◯◯◯ Very low_^a^,^b	-	The mean stroke-specific Patient-Reported Outcome Measures at post-intervention was −3.3	MD 24.4 higher (9.75 higher to 39.05 higher)	MID = 10.95 (0.5 × median baseline SD)
Stroke-specific Patient-Reported Outcome Measures (Stroke impact scale - emotion, 0–100, higher values are better, change score) at post-intervention	25 (1 RCT) follow-up: 9 weeks	⨁◯◯◯ Very low_^a^,^b	-	The mean stroke-specific Patient-Reported Outcome Measures at post-intervention was 2.6	MD 7.1 higher (2.4 lower to 16.6 higher)	MID = 6.87 (0.5 × median baseline SD)
Stroke-specific Patient-Reported Outcome Measures (Stroke impact scale - ADL, 0–100, higher values are better, change score) at post-intervention	25 (1 RCT) follow-up: 9 weeks	⨁⨁◯◯ Low_^a	-	The mean stroke-specific Patient-Reported Outcome Measures at post-intervention was −0.2	MD 3.1 higher (3.53 lower to 9.73 higher)	MID = 10.8 (0.5 × median baseline SD)
Stroke-specific Patient-Reported Outcome Measures (Stroke impact scale - hand, 0–100, higher values are better, change score) at post-intervention	25 (1 RCT) follow-up: 9 months	⨁⨁◯◯ Low_^a	-	The mean stroke-specific Patient-Reported Outcome Measures at post-intervention was −1.2	MD 7.9 higher (1.53 lower to 17.33 higher)	MID = 18.42 (0.5 × median baseline SD)
Stroke-specific Patient-Reported Outcome Measures (Stroke impact scale - memory, 0–100, higher values are better, change score) at post-intervention	25 (1 RCT) follow-up: 9 weeks	⨁◯◯◯ Very low_^a^,^b	-	The mean stroke-specific Patient-Reported Outcome Measures at post-intervention was 6	MD 8.7 lower (19.44 lower to 2.04 higher)	MID = 12.28 (0.5 × median baseline SD)
Stroke-specific Patient-Reported Outcome Measures (Stroke impact scale - mobility, 0–100, higher values are better, change score) at post-intervention	25 (1 RCT) follow-up: 9 weeks	⨁◯◯◯ Very low_^a^,^b	-	The mean stroke-specific Patient-Reported Outcome Measures at post-intervention was 5.3	MD 2.8 lower (10.5 lower to 4.9 higher)	MID = 9.87 (0.5 × median baseline SD)
Stroke-specific Patient-Reported Outcome Measures (Stroke impact scale - participation, 0–100, higher values are better, change score) at post-intervention	25 (1 RCT) follow-up: 9 weeks	⨁◯◯◯ Very low_^a^,^b	-	The mean stroke-specific Patient-Reported Outcome Measures at post-intervention was 3.4	MD 0.2 higher (13.63 lower to 14.03 higher)	MID = 11.5 (0.5 × median baseline SD)
Stroke-specific Patient-Reported Outcome Measures (Stroke impact scale - strength, 0–100, higher values are better, change score) at post-intervention	25 (1 RCT) follow-up: 9 weeks	⨁◯◯◯ Very low_^a^,^b	-	The mean stroke-specific Patient-Reported Outcome Measures at post-intervention was −3.8	MD 6.9 higher (6.45 lower to 20.25 higher)	MID = 13.3 (0.5 × median baseline SD)

a: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process and bias due to deviation from the intended intervention)

b: Downgraded by 1 increment if the confidence interval crossed one MID or by 2 increments if the confidence interval crossed both MIDs

Table 6Clinical evidence summary: Circuit class training with education compared to any other intervention

Outcomes	№ of participants (studies) Follow-up	Certainty of the evidence (GRADE)	Relative effect (95% CI)	Anticipated absolute effects		Comments
Outcomes	№ of participants (studies) Follow-up	Certainty of the evidence (GRADE)	Relative effect (95% CI)	Risk with any other intervention	Risk difference with circuit class training with education	Comments
Person/participant generic health-related quality of life (EQ5D, −0.11–1, higher values are better, change score) at post-intervention	67 (1 RCT) follow-up: 3 months	⨁◯◯◯ Very low_^a^,^b	-	The mean person/participant generic health-related quality of life at post-intervention was 0.001	MD 0.07 higher (0.06 lower to 0.2 higher)	MID = 0.03 (EQ5D established MID)
Person/participant generic health-related quality of life (SF-36 PCS, 0–100, higher values are better, final value) at post-intervention	33 (1 RCT) follow-up: 5 weeks	⨁◯◯◯ Very low_^b^,^c^,^d	-	The mean person/participant generic health-related quality of life at post-intervention was 33.2	MD 1 lower (8.74 lower to 6.74 higher)	MID = 2 (SF36 established MID)
Person/participant generic health-related quality of life (SF-36 MCS, 0–100, higher values are better, final value) at post-intervention	33 (1 RCT) follow-up: 5 weeks	⨁◯◯◯ Very low_^b^,^c^,^d	-	The mean person/participant generic health-related quality of life at post-intervention was 54.8	MD 0.4 lower (7.42 lower to 6.62 higher)	MID = 3 (SF36 established MID)
Person/participant generic health-related quality of life (EQ5D, −0.11–1, higher values are better, change score) at follow up	67 (1 RCT) follow-up: 15 months	⨁◯◯◯ Very low_^a^,^b	-	The mean person/participant generic health-related quality of life at follow up was 0.04	MD 0.01 lower (0.15 lower to 0.13 higher)	MID = 0.03 (EQ5D established MID)
Person/participant generic health-related quality of life (SF-36 - PCS, 0–100, higher values are better, final value) at follow up	31 (1 RCT) follow-up: 6 months	⨁◯◯◯ Very low_^b^,^c^,^d	-	The mean person/participant generic health-related quality of life at follow up was 35.4	MD 0.1 lower (9.47 lower to 9.27 higher)	MID = 2 (SF36 established MID)
Person/participant generic health-related quality of life (SF-36 - MCS, 0–100, higher values are better, final value) at follow up	31 (1 RCT) follow-up: 6 months	⨁◯◯◯ Very low_^b^,^c^,^d	-	The mean person/participant generic health-related quality of life at follow up was 55.4	MD 5 lower (14.22 lower to 4.22 higher)	MID = 3 (SF-36 established MID)
Six minute walk test ([meters], higher values are better, change score) at post-intervention	67 (1 RCT) follow-up: 3 months	⨁◯◯◯ Very low_^a^,^b	-	The mean six minute walk test at post-intervention was 5.3	MD 28.2 meters higher (3.83 lower to 60.23 higher)	MID 28 meters (established MID)
Six minute walk test ([meters], higher values are better, change score) at follow up	67 (1 RCT) follow-up: 15 months	⨁◯◯◯ Very low_^a^,^b	-	The mean six minute walk test at follow up was −0.5	MD 28.5 meters lower (76.8 lower to 19.8 higher)	MID = 28 meters (established MID)
Walking speed (10m walk test [m/s], higher values are better, change score) at post-intervention	67 (1 RCT) follow-up: 3 months	⨁◯◯◯ Very low_^a^,^b	-	The mean walking speed at post-intervention was −0.02	MD 0.12 m/s higher (0.03 higher to 0.21 higher)	MID = 0.2 m/s (established MID for chronic stroke)
Walking speed (10m walk test [m/s], higher values are better, change score) at follow up	67 (1 RCT) follow-up: 15 months	⨁◯◯◯ Very low_^a^,^b	-	The mean walking speed at follow up was 0.15	MD 0.85 m/s higher (0.16 lower to 1.86 higher)	MID = 0.2 m/s (established MID for chronic stroke)
Functional mobility measures (short physical performance test, 0–12, higher values are better, change score) at post-intervention	67 (1 RCT) follow-up: 3 months	⨁◯◯◯ Very low_^a^,^b	-	The mean functional mobility measures at post-intervention was 0.15	MD 0.85 higher (0.16 lower to 1.86 higher)	MID = 1.38 (0.5 × median baseline SD)
Functional mobility measures (timed up and go [seconds], lower values are better, final value) at post-intervention	243 (1 RCT) follow-up: 9 weeks	⨁⨁⨁⨁ High	-	The mean functional mobility measures at post-intervention was 16.4	MD 1 seconds higher (0.89 lower to 2.89 higher)	MID = 10 seconds (established MID)
Functional mobility measures (short physical performance test, 0–12, higher values are better, change score) at follow up	67 (1 RCT) follow-up: 15 months	⨁◯◯◯ Very low_^a^,^b	-	The mean functional mobility measures at follow up was 0.7	MD 0.6 higher (0.55 lower to 1.75 higher)	MID = 1.38 (0.5 × median baseline SD)
Measures of standing balance (Berg balance scale, 0–56, higher values are better, change score) at post-intervention	67 (1 RCT) follow-up: 3 months	⨁◯◯◯ Very low_^a^,^b	-	The mean measures of standing balance at post-intervention was −0.06	MD 4.16 higher (0.96 higher to 7.36 higher)	MID = 4.82 (0.5 × median baseline SD)
Measures of standing balance (Berg balance scale, 0–56, higher values are better, change score) at follow up	67 (1 RCT) follow-up: 15 months	⨁⨁◯◯ Low_^a	-	The mean measures of standing balance at follow up was −0.6	MD 1.9 higher (0.25 lower to 4.05 higher)	MID = 4.82 (0.5 × median baseline SD)
Adverse events (withdrawal due to adverse events) at postintervention	67 (1 RCT) follow-up: 3 months	⨁◯◯◯ Very low_^a^,^e^,^f	RD 0.06 (−0.04 to 0.15)	0 per 1,000	60 more per 1,000 (40 fewer to 150 more)_^g	Sample size used to determine precision: 75–150 = serious imprecision , <75 = very serious imprecision
Adverse events (withdrawal due to adverse events) at follow up	67 (1 RCT) follow-up: 15 months	⨁◯◯◯ Very low_^a^,^e^,^f	RD 0.09 (−0.02 to 0.20)	0 per 1,000	90 more per 1,000 (20 fewer to 200 more)_^g	Sample size used to determine precision: 75–150 = serious imprecision, <75 = very serious imprecision.

a: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias due to deviation from the intended intervention, bias due to missing outcome data and bias in measurement of the outcome)

b: Downgraded by 1 increment if the confidence interval crossed one MID or by 2 increments if the confidence interval crossed both MIDs

c: Downgraded by 2 increments as the majority of the evidence was of very high risk of bias (due to bias arising from the randomisation process, bias due to deviation from the intended intervention, and bias in selection of reported result)

d: Downgraded by 1 increment due to intervention indirectness (the participant : staff ratio was not stated by the study)

e: Downgraded by 1 increment due to outcome indirectness (reports withdrawal due to adverse events rather than all adverse events)

f: Downgraded by 1 increment for imprecision due to zero events and small sample size

g: Absolute effect calculated by risk difference due to zero events in at least one arm of one study

Table 7Clinical evidence summary: Circuit class training with education compared to circuit class training (without education)

Outcomes

№ of participants (studies) Follow-up

Certainty of the evidence (GRADE)

Relative effect (95% CI)

Anticipated absolute effects

Comments

Risk with circuit class training (without education)

Risk difference with circuit class training with education

Walking speed (gait speed [m/s], higher values are better, final value) at post-intervention

40 (1 RCT) follow-up: 4 weeks

⨁⨁◯◯

Low_^a^,^b

The mean walking speed (gait speed [m/s], higher values are better, final value) at post-intervention was 0.58

MD 0.2 m/s higher (0.05 higher to 0.35 higher)

MID 0.2 m/s (established MID for chronic stroke)

a: Downgraded by 1 increment due to intervention indirectness (The staff ratio is not mentioned and the comparison group includes mental imagery as an extra treatment that is not available in both study arms.)

b: Downgraded by 1 increment if the confidence interval crossed one MID or by 2 increments if the confidence interval crossed both MIDs

Table 8Health economic evidence profile: Circuit training interventions to improve walking compared to standard care

Study

Applicability

Limitations

Other comments

Incremental cost

Incremental effects

Cost effectiveness

Uncertainty

Dean 2018⁸

Partially applicable^(a)

Potentially serious limitations^(b)

Within-RCT analysis (Dean 2018⁸).
Cost-utility analysis (health outcome: QALYs)
Population: Adults with stroke living in the community for at least 1 month since discharge, with self-reported difficulty with stairs, slopes or uneven surfaces.
Comparators:
1. Treatment as usual (n=22) This ranged from zero treatment to engagement with any health service(s). All participants were asked to not participate in additional physical rehabilitation (either NHS or private). All people received an advice booklet about exercise.
2. Circuit based training (ReTrain program) (n=23). Circuit class training delivered in a community setting (one gym, two church halls and one community centre) with twice-weekly 2-hour sessions over 3 months, comprising: an introductory one-to-one session (home visit); 10 twice-weekly group classes with up to 2 trainers and 8 clients (training venue); a closing one-to-one session (home visit); followed by 3 (one per month) drop-in sessions. Participants completed home-based training throughout.
Follow-up: 9 months

£777^(c)

−0.045 QALYs^(d)

From clinical review (2-1) – same paper: ^(e)

EQ-5D-5L scores (higher values are better, final value) at 9-months post-randomisation: −0.10

Functional mobility measures (timed up and go [seconds], lower values are better, final values) at follow up: 4.81

Other outcomes were reported and can be seen in clinical evidence table.

Results suggested that the ReTrain intervention dominates usual care (lower costs and higher QALYs).

Cost CI: not reported EQ-5D-5L 95% CI at 9-month follow-up: −0.25 to 0.05 (p=NR)

No sensitivity analyses undertaken.

: Abbreviations: 95% CI= 95% confidence interval; EQ-5D-5L= Euroqol 5 dimensions - 5 level version (scale: 0.0 [death] to 1.0 [full health], negative values mean worse than death); n/a= not applicable; NR= not reported; RCT= randomised controlled trial; QALYs= quality-adjusted life years

(a): Mean EQ-5D-5L scores (UK tariff) at 9 months were used to calculate the cost per QALY gained for this review: the NICE reference case currently prefers EQ-5D-3L. It is not stated that an NHS and PSS perspective is taken however, the costs included are all considered relevant if the intervention is funded by the NHS.

(b): Pilot feasibility RCT (n=45) that was not powered to test the effectiveness of the intervention or differences in healthcare resource use; the aim was to inform a future study where effectiveness and cost-effectiveness could be assessed. Within-trial analysis only reflects health outcomes and costs from a single trial. The 9-month follow-up period may not capture full health effects of the intervention if these persist. Furthermore, cost sources were not reported, making it difficult to assess how the intervention compared to current practice: only the total intervention cost per participant was reported and it was unclear whether this included the training course fees (set at £649¹) that instructors were required to complete before delivering the program, while other healthcare resource use was collected but not included. Sensitivity analysis was not performed on areas of uncertainty.

(c): 2016 UK pounds (£). Cost components incorporated: Staff time (trainers, administrator, and facilitators), venue hire, training equipment (annualised over time), course materials, consumables and travel costs (participants, trainers and facilitators).

(d): QALYs not reported but were estimated using 9-month EQ-5D-5L scores collected within the study and assuming no difference in mortality.

(e): Mean difference taken from Appendix E.1 (Circuit class training compared to any other intervention– Forest plots). Rounded to one decimal place from −0.06 reported in the study.

Table 9Circuit class training with education compared to any other intervention

Study

Applicability

Limitations

Other comments

Incremental cost

Incremental effects

Cost effectiveness

Uncertainty

Harrington 2010¹¹ (UK)

Partially applicable^(a)

Potentially serious limitations^(b)

Within-RCT analysis (Harrington 2010¹¹)
Cost consequence analysis (various health outcomes)
Population: Adults with stroke living in the community for at least three months
Comparators:
1. Standard care plus an information sheet detailing local groups and contact numbers (n=124). In all areas stroke survivors were invited to a six-month review.
2. Community exercise and education scheme in addition to standard care (n=119) held twice weekly for eight weeks. Circuit class training was facilitated by volunteers and qualified exercise instructors (supported by a physiotherapist), each with nine participants plus carers or family members. Sessions were held in leisure and community centres and consisted of 1 hour of exercise followed by a short break, and 1 hour of interactive education.
Follow-up: 12 months

£746^(c)

From clinical review (2- 1);¹¹

Functional mobility measures^(d) (timed up and go [seconds], lower values are better, final value) at post-intervention: 1.00

n/a

No sensitivity analyses undertaken.

: Abbreviations: n/a= not applicable; RCT= randomised controlled trial

(a): QALYs not used. 2005 resource use and unit costs may not reflect current UK NHS context.

(b): Within-trial analysis and so only reflects this study and not the wider evidence base identified in the clinical review. Unclear if follow up (12 months) was sufficient to assess the full costs and benefits. Sensitivity analyses not performed.

(c): 2005 UK pounds. Cost components included: NHS costs (primary care consultations, secondary care, community care and prescribed medication), and social care costs (home care, meals on wheels, use of a day centre and social worker time). See Table 18 in Appendix H for cost breakdown between intervention groups.

(d): Mean difference taken from Appendix E.4 (Circuit class training with education compared to any other intervention) of guideline clinical review. The study reports outcomes relevant to the review as median and interquartile range values, that could not be used in the analysis of the clinical evidence and so were not extracted in the clinical review. In the circuit class training review, unpublished data was obtained from a Cochrane review for the outcome of the timed up and go test for this study that included mean and standard deviation values. This outcome was not relevant to the community participation review.

Table 10Unit costs of health care professionals who may be involved in delivering group training interventions

Resource	Cost per working hour (hospital / community) ^(a)	Source
Band 4 PT/OT	£37	PSRRU 2021¹⁴
Band 5 PT/OT	£41 / £42
Band 6 PT/OT	£53 / £55
Band 7 PT/OT	£64 / £66
Rehabilitation assistant	£33 / £32	PSRRU 2021¹⁴, estimated based on agenda for change band 3 salary^(b)

: Abbreviations: OT= occupational therapist; PT= physiotherapist; PSSRU= personal social services research unit.

(a): Note: Costs per working hour include salary, salary oncosts, overheads (management and other non-care staff costs including administration and estates staff), capital overheads and qualification costs.

(b): Band 3 PT/OT not in PSSRU 2021 so salary was assumed to equal Band 3 Mean annual basic pay per FTE for administration and estates staff, NHS England (PSSRU2021 p.149).

Table 19Studies excluded from the clinical review

Study	Code [Reason]
(2018) The Effects of Task-Oriented Exercise Program on Balance Ability in Patients with Acute Stroke. J korean phys ther 30(4): 112–116	- Study not reported in English
Abbud G. and Pearce A. (2019) Implementing cardiovascular exercise training and education in a community setting to maximize long-term functional changes in subacute stroke-A feasibility study. International journal of stroke conferencecanadianstrokecongress2019canada14(3supplement): 29	- Conference abstract
Priti Agni, Nisheet Vivek (2017) EFFECT OF STRENGTH TRAINING, FUNCTIONAL TASK RELATED TRAINING AND COMBINED STRENGTH AND FUNCTIONAL TASK RELATED TRAINING ON UPPER EXTREMITY IN POST STROKE PATIENTS. 4(3): 184–190	- Study does not contain an intervention relevant to this review protocol
Aguiar L. T., Nadeau S., Martins J. C. et al (2020) Efficacy of interventions aimed at improving physical activity in individuals with stroke: a systematic review. Disability & Rehabilitation 42(7): 902–917 [PubMed: 30451539]	- Study does not contain an intervention relevant to this review protocol Does not specifically look at circuit based exercises. References checked.
Ahmed U., Karimi H., Amir S. et al (2021) Effects of intensive multiplanar trunk training coupled with dual-task exercises on balance, mobility, and fall risk in patients with stroke: a randomized controlled trial. Journal of international medical research 49(11): 3000605211059413 [PMC free article: PMC8647262] [PubMed: 34812070]	- Study does not contain an intervention relevant to this review protocol Dual task training compared to standardised trunk care regime - does not appear to be circuit based exercises
Amoros-Aguilar L., Rodriguez-Quiroga E., Sanchez-Santolaya S. et al (2021) Effects of Combined Interventions with Aerobic Physical Exercise and Cognitive Training on Cognitive Function in Stroke Patients: A Systematic Review. Brain Sciences 11(4): 08 [PMC free article: PMC8068294] [PubMed: 33917909]	- Systematic review used as source of primary studies
Anandan D., Tamil Nidhi P. K., Arun B. et al (2020) Effect of task specific training with proprioceptive neuromuscular facilitation on stroke survivors. Biomedicine (India) 40(3): 363–366	- Study does not contain an intervention relevant to this review protocol Does not mention circuit based training - does not appear to be group based, does not mention staffing ratio
Arabzadeh S., Goljaryan S., Salahzadeh Z. et al (2018) Effects of a task-oriented exercise program on balance in patients with hemiplegia following stroke. Iranian Red Crescent Medical Journal 20(1)	- Study does not contain an intervention relevant to this review protocol Task-oriented exercise but not clearly group based with no indication of the staff-to-client ratio being no more than one staff member per three clients.
Best J. R., Eng J. J., Davis J. C. et al (2018) Study protocol for Vitality: a proof-of-concept randomised controlled trial of exercise training or complex mental and social activities to promote cognition in adults with chronic stroke. BMJ Open 8(3): e021490 [PMC free article: PMC5875626] [PubMed: 29550783]	- Protocol only
Bo W., Lei M., Tao S. et al (2019) Effects of combined intervention of physical exercise and cognitive training on cognitive function in stroke survivors with vascular cognitive impairment: a randomized controlled trial. Clinical Rehabilitation 33(1): 54–63 [PubMed: 30064268]	- Study does not contain an intervention relevant to this review protocol Task-oriented exercise but not clearly group based with no indication of the staff-to-client ratio being no more than one staff member per three clients.
Bonini-Rocha A. C., de Andrade A. L. S., Moraes A. M. et al (2018) Effectiveness of Circuit-Based Exercises on Gait Speed, Balance, and Functional Mobility in People Affected by Stroke: A Meta-Analysis. Pm & R 10(4): 398–409 [PubMed: 29111465]	- Study does not contain an intervention relevant to this review protocol Different definition of circuit based exercise to that used in the English 2017 review and different from that used in our protocol. References checked.
Callister R., Dunn A., Marsden D. et al (2017) Improvements in fitness at 12-months follow up of an individualised home and community based exercise program after stroke. Journal of Science & Medicine in Sport 20: e22–e23	- Conference abstract
Cha H. G. and Kim M. K. (2017) Effects of strengthening exercise integrated repetitive transcranial magnetic stimulation on motor function recovery in subacute stroke patients: A randomized controlled trial. Technology & Health Care 25(3): 521–529 [PubMed: 28106573]	- Study does not contain an intervention relevant to this review protocol Not circuit based training - not group based, no information about staffing ratio
Church G., Parker J., Powell L. et al (2019) The effectiveness of group exercise for improving activity and participation in adult stroke survivors: a systematic review. Physiotherapy 105(4): 399–411 [PubMed: 31003848]	- Systematic review used as source of primary studies
de Sousa D. G., Harvey L. A., Dorsch S. et al (2018) Interventions involving repetitive practice improve strength after stroke: a systematic review. Journal of Physiotherapy 64(4): 210–221 [PubMed: 30245180]	- Systematic review used as source of primary studies
Deshpande Shruti; Mohapatra Sidhiparada; Girish N. (2020) Influence of task-oriented circuit training on upper limb function among rural community-dwelling survivors of stroke. International Journal of Therapy & Rehabilitation 27(8): 1–8	- Study design not relevant to this review protocol Single arm non-randomised study
Diermayr G., Schomberg M., Greisberger A. et al (2020) Task-Oriented Circuit Training for Mobility in Outpatient Stroke Rehabilitation in Germany and Austria: A Contextual Transferability Analysis. Physical Therapy 100(8): 1307–1322 [PubMed: 32266383]	- Study design not relevant to this review protocol Contextual transferability analysis
Dunn Ashlee, Marsden Dianne L., Barker Daniel et al (2017) Cardiorespiratory fitness and walking endurance improvements after 12 months of an individualised home and community-based exercise programme for people after stroke. Brain Injury 31(12): 1617–1624 [PubMed: 28872360]	- Study design not relevant to this review protocol Single arm non-randomised study
Barbosa Dutra, Diogo RuffTrojahn, Mirele GulartePorto, Veber Daniela et al (2018) Strength training protocols in hemiparetic individuals post stroke: a systematic review. Fisioterapia em Movimento 31(1): 1–11	- Study does not contain an intervention relevant to this review protocol Does not specifically look at circuit based training
Ghous M., Malik A. N., Amjad M. I. et al (2017) Effects of activity repetition training with Salat (prayer) versus task oriented training on functional outcomes of stroke. JPMA - Journal of the Pakistan Medical Association 67(7): 1091–1093 [PubMed: 28770893]	- Study does not contain an intervention relevant to this review protocol Not obviously circuit based - no mention of group based activity or staffing ratio
Iqbal M., Arsh A., Hammad S. M. et al (2020) Comparison of dual task specific training and conventional physical therapy in ambulation of hemiplegic stroke patients: A randomized controlled trial. JPMA - Journal of the Pakistan Medical Association 70(1): 7–10 [PubMed: 31954014]	- Study does not contain an intervention relevant to this review protocol Not obviously circuit based - no mention of group based activity or staffing ratio
Johar M. N.; Mohd Nordin N. A.; Abdul Aziz A. F. (2022) The effect of game-based in comparison to conventional circuit exercise on functions, motivation level, self-efficacy and quality of life among stroke survivors. Medicine 101(2): e28580 [PMC free article: PMC8758024] [PubMed: 35029235]	- Protocol only
Kelly L. P., Devasahayam A. J., Chaves A. R. et al (2021) Task-Oriented Circuit Training as an Alternative to Ergometer-Type Aerobic Exercise Training after Stroke. Journal of Clinical Medicine 10(11): 30 [PMC free article: PMC8198652] [PubMed: 34070731]	- No relevant outcomes Outcomes were related to oxygen consumption, heart rate or biochemical measures
Khallaf M. E. (2020) Effect of Task-Specific Training on Trunk Control and Balance in Patients with Subacute Stroke. Neurology Research International 2020 [PMC free article: PMC7688364] [PubMed: 33294224]	- Study does not contain an intervention relevant to this review protocol
Kim K. H. and Jang S. H. (2021) Effects of Task-Specific Training after Cognitive Sensorimotor Exercise on Proprioception, Spasticity, and Gait Speed in Stroke Patients: A Randomized Controlled Study. Medicina 57(10): 13 [PMC free article: PMC8541560] [PubMed: 34684135]	- Study does not contain an intervention relevant to this review protocol
Lim C. (2019) Multi-Sensorimotor Training Improves Proprioception and Balance in Subacute Stroke Patients: A Randomized Controlled Pilot Trial. Frontiers in neurology [electronic resource]. 10: 157 [PMC free article: PMC6407432] [PubMed: 30881333]	- Study does not contain an intervention relevant to this review protocol
Liu T. W.; Ng G. Y. F.; Ng S. S. M. (2018) Effectiveness of a combination of cognitive behavioral therapy and task-oriented balance training in reducing the fear of falling in patients with chronic stroke: study protocol for a randomized controlled trial. Trials [Electronic Resource] 19(1): 168 [PMC free article: PMC5842580] [PubMed: 29514677]	- Protocol only Protocol for Lim 2019
Moon J. H., Park K. Y., Kim H. J. et al (2018) The effects of task-oriented circuit training using rehabilitation tools on the upper-extremity functions and daily activities of patients with acute stroke: A randomized controlled pilot trial. Osong Public Health and Research Perspectives 9(5): 225–230 [PMC free article: PMC6202022] [PubMed: 30402377]	- Population not relevant to this review protocol People with upper limb weakness rather than lower limb problems (intervention is focused on upper limb problems only)
Nordin N. A. M., Aziz N. A., Sulong S. et al (2019) Effectiveness of home-based carer-assisted in comparison to hospital-based therapist-delivered therapy for people with stroke: A randomised controlled trial. NeuroRehabilitation 45(1): 87–97 [PubMed: 31450518]	- Data not reported in an extractable format or a format that can be analysed Outcomes reported as median (interquartile range)
Oh S. J.; Lee J. H.; Kim D. H. (2019) The effects of functional action-observation training on gait function in patients with poststroke hemiparesis: A randomized controlled trial. Technology & Health Care 27(2): 159–165 [PubMed: 30664512]	- Study does not contain an intervention relevant to this review protocol Not circuit based exercise, not group based
Pang M. Y. C., Yang L., Ouyang H. et al (2018) Dual-task exercise reduces cognitive-motor interference in walking and falls after stroke: A randomized controlled study. Stroke 49(12): 2990–2998 [PubMed: 30571419]	- Duplicate reference
Pang M. Y. C., Yang L., Ouyang H. et al (2018) Dual-Task Exercise Reduces Cognitive-Motor Interference in Walking and Falls After Stroke. Stroke 49(12): 2990–2998 [PubMed: 30571419]	- Study does not contain an intervention relevant to this review protocol Does not appear to be circuit class training. Insufficient participant:staff ratio.
Pogrebnoy D. and Dennett A. (2020) Exercise Programs Delivered According to Guidelines Improve Mobility in People With Stroke: A Systematic Review and Meta-analysis. Archives of Physical Medicine & Rehabilitation 101(1): 154–165 [PubMed: 31400308]	- Study does not contain an intervention relevant to this review protocol Does not specifically investigate circuit based training
Regan Elizabeth W., Handlery Reed, Liuzzo Derek M. et al (2019) The Neurological Exercise Training (NExT) program: A pilot study of a community exercise program for survivors of stroke. Disability and Health Journal 12(3): 528–532 [PMC free article: PMC6581575] [PubMed: 30967342]	- Study design not relevant to this review protocol Single arm non-randomised study
Reynolds H., Steinfort S., Tillyard J. et al (2021) Feasibility and adherence to moderate intensity cardiovascular fitness training following stroke: a pilot randomized controlled trial. BMC Neurology 21(1): 132 [PMC free article: PMC7983371] [PubMed: 33745454]	- Study does not contain an intervention relevant to this review protocol Intervention does not appear to be circuit based (could be individual or group based)
Rosenfeldt A. B., Linder S. M., Davidson S. et al (2019) Combined Aerobic Exercise and Task Practice Improve Health-Related Quality of Life Poststroke: a Preliminary Analysis. Archives of physical medicine and rehabilitation 100(5): 923–930 [PMC free article: PMC6487221] [PubMed: 30543801]	- Study does not contain an intervention relevant to this review protocol Does not appear to be circuit based training (intervention appears to be individual and supervised by a physiotherapist)
Salbach N. (2017) Does participation in a group, task-oriented community-based exercise program improve the ability to do everyday activities among people with stroke?.	- Trial registry data only
SchrÖDer Jonas, Truijen Steven, Van Criekinge Tamaya et al (2019) FEASIBILITY AND EFFECTIVENESS OF REPETITIVE GAIT TRAINING EARLY AFTER STROKE: A SYSTEMATIC REVIEW AND META-ANALYSIS. Journal of Rehabilitation Medicine (Stiftelsen Rehabiliteringsinformation) 51(2): 78–88 [PubMed: 30516821]	- Study does not contain an intervention relevant to this review protocol Does not appear to specifically investigate circuit based training
Shen Cuiling, Liu Fang, Yao Liqun et al (2018) Effects of MOTOmed movement therapy on the mobility and activities of daily living of stroke patients with hemiplegia: a systematic review and meta-analysis. Clinical Rehabilitation 32(12): 1569–1580 [PubMed: 30088421]	- Study does not contain an intervention relevant to this review protocol Not circuit based exercise
Suchetha P. S.; Supriya B.; Krishna KovelaRakesh (2018) Effects of Modified Sit to Stand Training with Mental Practice on Balance and Gait in Post Stroke Patients. Indian Journal of Physiotherapy & Occupational Therapy 12(4): 16–21	- Study does not contain an intervention relevant to this review protocol Not obviously circuit based - no mention of group based activity or staffing ratio
Sun Ruifeng, Li Xiaoling, Zhu Ziman et al (2021) Effects of Combined Cognitive and Exercise Interventions on Poststroke Cognitive Function: A Systematic Review and Meta-Analysis. BioMed Research International: 1–11 [PMC free article: PMC8612794] [PubMed: 34840972]	- Study does not contain an intervention relevant to this review protocol Does not specifically investigate circuit based training
Sung-Jun Moon and Tae-Ho Kim (2017) Effect of three-dimensional spine stabilization exercise on trunk muscle strength and gait ability in chronic stroke patients: A randomized controlled trial. NeuroRehabilitation 41(1): 151–159 [PubMed: 28505994]	- Study does not contain an intervention relevant to this review protocol Not circuit based therapy, not group based
Tetik Aydogdu Y.; Aydogdu O.; Inal H. S. (2018) The Effects of Dual-Task Training on Patient Outcomes of Institutionalized Elderly Having Chronic Stroke. Dementia and geriatric cognitive disorders extra: 328–332 [PMC free article: PMC6206953] [PubMed: 30386369]	- Study does not contain an intervention relevant to this review protocol Does not appear to be circuit based training (no statement if completed in a group)
Tramontano M., Bergamini E., Iosa M. et al (2018) Vestibular rehabilitation training in patients with subacute stroke: A preliminary randomized controlled trial. Neurorehabilitation 43(2): 247–254 [PubMed: 30040765]	- Study does not contain an intervention relevant to this review protocol Does not appear to be circuit based training (no statement if completed in a group)
Tramontano M., Dell'Uomo D., Cinnera A. M. et al (2019) Visual-spatial training in patients with sub-acute stroke without neglect: A randomized, single-blind controlled trial. Functional Neurology 34(1): 7–13 [PubMed: 31172934]	- Study does not contain an intervention relevant to this review protocol Does not appear to be circuit based training (no statement if completed in a group)
Traxler K., Schinabeck F., Baum E. et al (2021) Feasibility of a specific task-oriented training versus its combination with manual therapy on balance and mobility in people post stroke at the chronic stage: study protocol for a pilot randomised controlled trial. Pilot & Feasibility Studies 7(1): 146 [PMC free article: PMC8313417] [PubMed: 34311772]	- Study does not contain an intervention relevant to this review protocol Does not appear to be circuit based training (no statement if completed in a group)
Tshiswaka DaudetIlunga; Bennett Crystal; Franklin Cheyanne (2018) Effects of walking trainings on walking function among stroke survivors: a systematic review. International Journal of Rehabilitation Research 41(1): 1–13 [PubMed: 28857950]	- Study does not contain an intervention relevant to this review protocol Systematic review that does not specifically investigate circuit based training
Van Criekinge Tamaya, Truijen Steven, Schröder Jonas et al (2019) The effectiveness of trunk training on trunk control, sitting and standing balance and mobility post-stroke: a systematic review and meta-analysis. Clinical Rehabilitation 33(6): 992–1002 [PubMed: 30791703]	- Study does not contain an intervention relevant to this review protocol Does not specifically investigate circuit based training
Van Wissen K. and Blanchard D. (2019) Circuit class therapy for improving mobility after stroke: A Cochrane review summary. International Journal of Nursing Studies 97: 130–131 [PubMed: 30360974]	- Study design not relevant to this review protocol Summary of English 2017, the Cochrane review that this review is based on
Varas Diaz Gonzalo (2022) Effect of cognitive, impairment-oriented and task-specific interventions on balance and locomotion control. Dissertation Abstracts International: Section B: The Sciences and Engineering 83(2b): no pagination specified	- Thesis only
Wu C. Y. (2017) Effects and mechanism of the sequential combination of exercise and cognitive training in stroke patients.	- Trial registry data only
Wu C. Y., Yeh T. T., Hu Y. T. et al (2018) The beneficial effects of sequential combination of cognitive training and aerobic exercise in stroke patients with cognitive decline. Stroke 49(suppl1)	- Conference abstract
Ziyal Leyla (2018) Me before/me after: A group rehabilitation programme for brain injury survivors.	- Book only

Table 20Studies excluded from the health economic review

Reference	Reason for exclusion
None.

Evidence reviews for circuit training for walking

1. Circuit training for walking

1.1. Review question

1.1.1. Introduction

1.1.2. Summary of the protocol

1.1.3. Methods and process

1.1.4. Effectiveness evidence

1.1.4.1. Included studies

Indirectness

Inconsistency

1.1.4.2. Excluded studies

1.1.5. Summary of studies included in the effectiveness evidence

1.1.6. Summary of the effectiveness evidence

1.1.7. Economic evidence

1.1.7.1. Included studies

1.1.7.2. Excluded studies

1.1.8. Summary of included economic evidence

1.1.9. Economic model

1.1.10. Unit costs

1.1.11. Evidence statements

Effectiveness/Qualitative

Economic

1.1.12. The committee’s discussion and interpretation of the evidence

1.1.12.1. The outcomes that matter most

1.1.12.2. The quality of the evidence

1.1.12.3. Benefits and harms

1.1.12.3.1. Key uncertainties

1.1.12.3.2. Circuit class training without education compared to any other intervention, other types of circuit class training and no treatment

1.1.12.3.3. Circuit class training with education compared to any other intervention and circuit class training without education

1.1.12.4. Cost effectiveness and resource use

1.1.12.5. Other factors the committee took into account

1.1.13. Recommendations supported by this evidence review

1.1.14. References

Appendices

Appendix A. Review protocols

Appendix B. Literature search strategies

B.1. Clinical search literature search strategy

B.2. Health Economics literature search strategy

Appendix C. Effectiveness evidence study selection

Appendix D. Effectiveness evidence

Appendix E. Forest plots

E.1. Circuit class training compared to any other intervention

E.2. Circuit class training compared to other circuit class training

E.3. Circuit class training compared to no treatment

E.4. Circuit class training with education compared to any other intervention

E.5. Circuit class training with education compared to circuit class training (without education)

Appendix F. GRADE tables

Appendix G. Economic evidence study selection

Appendix H. Economic evidence tables

H.1. Circuit class training compared to any other intervention

H.2. Circuit class training with education compared to any other intervention

Appendix I. Health economic model

Appendix J. Excluded studies

Clinical studies

Health Economic studies

Table 1PICO characteristics of review question

Table 2Summary of studies included in the evidence review

Table 3Clinical evidence summary: Circuit class therapy compared to any other intervention

Table 4Clinical evidence summary: Circuit class training compared to other types of circuit training

Table 5Clinical evidence summary: Circuit class training compared to no treatment

Table 6Clinical evidence summary: Circuit class training with education compared to any other intervention

Table 7Clinical evidence summary: Circuit class training with education compared to circuit class training (without education)

Table 8Health economic evidence profile: Circuit training interventions to improve walking compared to standard care

Table 9Circuit class training with education compared to any other intervention

Table 10Unit costs of health care professionals who may be involved in delivering group training interventions

Table 19Studies excluded from the clinical review

Table 20Studies excluded from the health economic review