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Meta-Analysis
. 2016 Dec 21;12(12):CD011058.
doi: 10.1002/14651858.CD011058.pub2.

Caregiver-mediated exercises for improving outcomes after stroke

Judith Dm Vloothuis  1 , Marijn Mulder  2 , Janne M Veerbeek  2   3 , Manin Konijnenbelt  1 , Johanna Ma Visser-Meily  4 , Johannes Cf Ket  5 , Gert Kwakkel  6 , Erwin Eh van Wegen  7
Affiliations
Meta-Analysis

Caregiver-mediated exercises for improving outcomes after stroke

Judith Dm Vloothuis et al. Cochrane Database Syst Rev. .

Abstract

Background: Stroke is a major cause of long-term disability in adults. Several systematic reviews have shown that a higher intensity of training can lead to better functional outcomes after stroke. Currently, the resources in inpatient settings are not always sufficient and innovative methods are necessary to meet these recommendations without increasing healthcare costs. A resource efficient method to augment intensity of training could be to involve caregivers in exercise training. A caregiver-mediated exercise programme has the potential to improve outcomes in terms of body function, activities, and participation in people with stroke. In addition, caregivers are more actively involved in the rehabilitation process, which may increase feelings of empowerment with reduced levels of caregiver burden and could facilitate the transition from rehabilitation facility (in hospital, rehabilitation centre, or nursing home) to home setting. As a consequence, length of stay might be reduced and early supported discharge could be enhanced.

Objectives: To determine if caregiver-mediated exercises (CME) improve functional ability and health-related quality of life in people with stroke, and to determine the effect on caregiver burden.

Search methods: We searched the Cochrane Stroke Group Trials Register (October 2015), CENTRAL (the Cochrane Library, 2015, Issue 10), MEDLINE (1946 to October 2015), Embase (1980 to December 2015), CINAHL (1982 to December 2015), SPORTDiscus (1985 to December 2015), three additional databases (two in October 2015, one in December 2015), and six additional trial registers (October 2015). We also screened reference lists of relevant publications and contacted authors in the field.

Selection criteria: Randomised controlled trials comparing CME to usual care, no intervention, or another intervention as long as it was not caregiver-mediated, aimed at improving motor function in people who have had a stroke.

Data collection and analysis: Two review authors independently selected trials. One review author extracted data, and assessed quality and risk of bias, and a second review author cross-checked these data and assessed quality. We determined the quality of the evidence using GRADE. The small number of included studies limited the pre-planned analyses.

Main results: We included nine trials about CME, of which six trials with 333 patient-caregiver couples were included in the meta-analysis. The small number of studies, participants, and a variety of outcome measures rendered summarising and combining of data in meta-analysis difficult. In addition, in some studies, CME was the only intervention (CME-core), whereas in other studies, caregivers provided another, existing intervention, such as constraint-induced movement therapy. For trials in the latter category, it was difficult to separate the effects of CME from the effects of the other intervention.We found no significant effect of CME on basic ADL when pooling all trial data post intervention (4 studies; standardised mean difference (SMD) 0.21, 95% confidence interval (CI) -0.02 to 0.44; P = 0.07; moderate-quality evidence) or at follow-up (2 studies; mean difference (MD) 2.69, 95% CI -8.18 to 13.55; P = 0.63; low-quality evidence). In addition, we found no significant effects of CME on extended ADL at post intervention (two studies; SMD 0.07, 95% CI -0.21 to 0.35; P = 0.64; low-quality evidence) or at follow-up (2 studies; SMD 0.11, 95% CI -0.17 to 0.39; P = 0.45; low-quality evidence).Caregiver burden did not increase at the end of the intervention (2 studies; SMD -0.04, 95% CI -0.45 to 0.37; P = 0.86; moderate-quality evidence) or at follow-up (1 study; MD 0.60, 95% CI -0.71 to 1.91; P = 0.37; very low-quality evidence).At the end of intervention, CME significantly improved the secondary outcomes of standing balance (3 studies; SMD 0.53, 95% CI 0.19 to 0.87; P = 0.002; low-quality evidence) and quality of life (1 study; physical functioning: MD 12.40, 95% CI 1.67 to 23.13; P = 0.02; mobility: MD 18.20, 95% CI 7.54 to 28.86; P = 0.0008; general recovery: MD 15.10, 95% CI 8.44 to 21.76; P < 0.00001; very low-quality evidence). At follow-up, we found a significant effect in favour of CME for Six-Minute Walking Test distance (1 study; MD 109.50 m, 95% CI 17.12 to 201.88; P = 0.02; very low-quality evidence). We also found a significant effect in favour of the control group at the end of intervention, regarding performance time on the Wolf Motor Function test (2 studies; MD -1.72, 95% CI -2.23 to -1.21; P < 0.00001; low-quality evidence). We found no significant effects for the other secondary outcomes (i.e.

Patient: motor impairment, upper limb function, mood, fatigue, length of stay and adverse events; caregiver: mood and quality of life).In contrast to the primary analysis, sensitivity analysis of CME-core showed a significant effect of CME on basic ADL post intervention (2 studies; MD 9.45, 95% CI 2.11 to 16.78; P = 0.01; moderate-quality evidence).The methodological quality of the included trials and variability in interventions (e.g. content, timing, and duration), affected the validity and generalisability of these observed results.

Authors' conclusions: There is very low- to moderate-quality evidence that CME may be a valuable intervention to augment the pallet of therapeutic options for stroke rehabilitation. Included studies were small, heterogeneous, and some trials had an unclear or high risk of bias. Future high-quality research should determine whether CME interventions are (cost-)effective.

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Conflict of interest statement

Judith DM Vloothuis: none known. Marijn Mulder: none known. Janne M Veerbeek: none known. Manin Konijnenbelt: none known. Johanna MA Visser‐Meily: none known. Johannes CF Ket: none known. Gert Kwakkel: none known. Erwin EH van Wegen: none known.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 1 Patient: activities of daily living (ADL) measures: combined.
1.2
1.2. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 2 Patient: ADL measures: extended ADL: combined.
1.3
1.3. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 3 Caregiver: burden: combined.
1.4
1.4. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 4 Measures of motor impairment: Fugl‐Meyer Assessment lower extremity.
1.5
1.5. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 5 Measures of motor impairment: Fugl‐Meyer Assessment upper extremity.
1.6
1.6. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 6 Gait and gait‐related measures: balance: combined.
1.7
1.7. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 7 Gait and gait‐related measures: Six‐Minute Walk Test.
1.8
1.8. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 8 Gait and gait‐related measures: walking speed.
1.9
1.9. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 9 Measures of upper limb activities or function: Wolf Motor Function test ‐ functional ability.
1.10
1.10. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 10 Measures of upper limb activities or function: Wolf Motor Function Test ‐ performance time.
1.11
1.11. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 11 Measures of upper limb activities or function: Motor Activity Log (MAL) ‐ amount of use.
1.12
1.12. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 12 Measures of upper limb activities or function: MAL ‐ quality of movement.
1.13
1.13. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 13 Measures of upper limb activities or function: Nine Hole Peg test.
1.14
1.14. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 14 Measures of mood and quality of life (QoL) of the patient: Stroke Impact Scale (SIS) ‐ composite physical.
1.15
1.15. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 15 Measures of mood and QoL of the patient: SIS ‐ strength.
1.16
1.16. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 16 Measures of mood and QoL of the patient: SIS ‐ ADL/IADL.
1.17
1.17. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 17 Measures of mood and QoL of the patient: SIS ‐ mobility.
1.18
1.18. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 18 Measures of mood and QoL of the patient: SIS ‐ hand function.
1.19
1.19. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 19 Measures of mood and QoL of the patient: SIS ‐ memory.
1.20
1.20. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 20 Measures of mood and QoL of the patient: SIS ‐ communication.
1.21
1.21. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 21 Measures of mood and QoL of the patient: SIS ‐ emotion.
1.22
1.22. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 22 Measures of mood and QoL of the patient: SIS ‐ social participation.
1.23
1.23. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 23 Measures of mood and QoL of the patient: SIS ‐ general recovery.
1.24
1.24. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 24 Length of stay ‐ hospital.
1.25
1.25. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 25 Length of stay ‐ rehabilitation unit.
1.26
1.26. Analysis
Comparison 1 Caregiver‐mediated exercises versus control ‐ end of intervention, Outcome 26 Adverse outcomes: falls.
2.1
2.1. Analysis
Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 1 Patient: activities of daily living (ADL) measures: ADL.
2.2
2.2. Analysis
Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 2 Patient: ADL measures: extended ADL: combined.
2.3
2.3. Analysis
Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 3 Caregiver: burden.
2.4
2.4. Analysis
Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 4 Measures of motor impairment: Fugl‐Meyer Assessment lower extremity.
2.5
2.5. Analysis
Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 5 Measures of motor impairment: Fugl‐Meyer Assessment upper extremity.
2.6
2.6. Analysis
Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 6 Gait and gait‐related measures: balance.
2.7
2.7. Analysis
Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 7 Gait and gait‐related measures: Six‐Minute Walking Test.
2.8
2.8. Analysis
Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 8 Gait and gait‐related measures: walking speed.
2.9
2.9. Analysis
Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 9 Measures of upper limb activities or function: Wolf Motor Function test ‐ functional ability.
2.10
2.10. Analysis
Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 10 Measures of upper limb activities or function: Wolf Motor Function test ‐ performance time.
2.11
2.11. Analysis
Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 11 Measures of upper limb activities or function: Motor Activity Log ‐ amount of use.
2.12
2.12. Analysis
Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 12 Measures of upper limb activities or function: Motor Activity Log ‐ quality of movement.
2.13
2.13. Analysis
Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 13 Measures of upper limb activities or function: Nine Hole Peg test.
2.14
2.14. Analysis
Comparison 2 Caregiver‐mediated exercises versus control ‐ end of follow‐up, Outcome 14 Measures of mood and quality of life of the patient: Stroke Impact Scale (SIS) ‐ hand function.
3.1
3.1. Analysis
Comparison 3 Timing post stroke ‐ end of intervention, Outcome 1 Patient: activities of daily living measures: combined.
4.1
4.1. Analysis
Comparison 4 Mean change from post intervention ‐ end of follow‐up, Outcome 1 Patient: activities of daily living (ADL) measures: Barthel Index.
4.2
4.2. Analysis
Comparison 4 Mean change from post intervention ‐ end of follow‐up, Outcome 2 Patient: ADL measures: extended ADL ‐ Nottingham Extended Activities of Daily Living Index.
4.3
4.3. Analysis
Comparison 4 Mean change from post intervention ‐ end of follow‐up, Outcome 3 Patient: ADL measures: extended ADL ‐ reintegration to normal living index.
4.4
4.4. Analysis
Comparison 4 Mean change from post intervention ‐ end of follow‐up, Outcome 4 Caregiver: Caregiver Strain Index.
4.5
4.5. Analysis
Comparison 4 Mean change from post intervention ‐ end of follow‐up, Outcome 5 Measures of motor impairment: Fugl‐Meyer Assessment lower extremity.
4.6
4.6. Analysis
Comparison 4 Mean change from post intervention ‐ end of follow‐up, Outcome 6 Gait and gait‐related measures: balance: Berg Balance Scale.
4.7
4.7. Analysis
Comparison 4 Mean change from post intervention ‐ end of follow‐up, Outcome 7 Gait and gait‐related measures: Six‐Minute Walking Test.
4.8
4.8. Analysis
Comparison 4 Mean change from post intervention ‐ end of follow‐up, Outcome 8 Other outcomes: Motor Assessment Scale.
5.1
5.1. Analysis
Comparison 5 Sensitivity analysis ‐ caregiver‐mediated exercise (CME)‐core ‐ end of intervention, Outcome 1 Patient: activities of daily living (ADL) measures: Barthel Index.
5.2
5.2. Analysis
Comparison 5 Sensitivity analysis ‐ caregiver‐mediated exercise (CME)‐core ‐ end of intervention, Outcome 2 Patient: ADL measures: extended ADL ‐ Nottingham Extended Activities of Daily Living Index.
5.3
5.3. Analysis
Comparison 5 Sensitivity analysis ‐ caregiver‐mediated exercise (CME)‐core ‐ end of intervention, Outcome 3 Gait and gait‐related measures: balance: Berg Balance Scale.
6.1
6.1. Analysis
Comparison 6 Sensitivity analysis ‐ caregiver‐mediated exercise (CME)‐core ‐ end of follow‐up, Outcome 1 Patient: activities of daily living (ADL) measures: Barthel Index.
6.2
6.2. Analysis
Comparison 6 Sensitivity analysis ‐ caregiver‐mediated exercise (CME)‐core ‐ end of follow‐up, Outcome 2 Patient: ADL measures: extended ADL ‐ Nottingham Extended Activities of Daily Living Index.
7.1
7.1. Analysis
Comparison 7 Walking speed, different possibilities study of Wall, Outcome 1 Walking speed ‐ caregiver‐mediated exercises (CME) vs physiotherapy ‐ end of intervention.
7.2
7.2. Analysis
Comparison 7 Walking speed, different possibilities study of Wall, Outcome 2 Walking speed ‐ CME vs physiotherapy ‐ end of follow‐up.
7.3
7.3. Analysis
Comparison 7 Walking speed, different possibilities study of Wall, Outcome 3 Walking speed ‐ CME vs no intervention ‐ end of intervention.
7.4
7.4. Analysis
Comparison 7 Walking speed, different possibilities study of Wall, Outcome 4 Walking speed ‐ CME vs no intervention ‐ end of follow‐up.
7.5
7.5. Analysis
Comparison 7 Walking speed, different possibilities study of Wall, Outcome 5 Walking speed ‐ CME and physiotherapy vs physiotherapy ‐ end of intervention.
7.6
7.6. Analysis
Comparison 7 Walking speed, different possibilities study of Wall, Outcome 6 Walking speed ‐ CME and physiotherapy vs physiotherapy ‐ end of follow‐up.
7.7
7.7. Analysis
Comparison 7 Walking speed, different possibilities study of Wall, Outcome 7 Walking speed ‐ CME and physiotherapy vs no intervention ‐ end of intervention.
7.8
7.8. Analysis
Comparison 7 Walking speed, different possibilities study of Wall, Outcome 8 Walking speed ‐ CME and physiotherapy vs no intervention ‐ end of follow‐up.
8.1
8.1. Analysis
Comparison 8 Extended activities of daily living (ADL) ‐ analyses with Reintegration to Normal Living Index (RNLI), Outcome 1 Patient: ADL measures: extended ADL ‐ combined ‐ end of intervention.
8.2
8.2. Analysis
Comparison 8 Extended activities of daily living (ADL) ‐ analyses with Reintegration to Normal Living Index (RNLI), Outcome 2 Patient: ADL measures: extended ADL ‐ combined ‐ end of follow‐up.
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Update of

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References to ongoing studies

ATTEND trial 2013 {published data only}
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Care4Stroke trial 2014 {published data only}
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