The recommendations are graded by their level (I, II) and strength (A, B, C+, C, D, D+, D-) of evidence. Definitions for the level and strength of the recommendations are presented at the end of the "Major Recommendations" field.
Clinical Practice Guidelines for Therapeutic Exercises
Aerobic training versus control, level I (randomized controlled trial [RCT]): Grade A for cardiopulmonary function (expiration per minute [VE]), muscle power, and functional status (walking) at end of treatment, 10 weeks (clinically important benefit demonstrated); grade C+ for gait speed at end of treatment, 10 weeks (clinically important benefit demonstrated without statistical significance); grade C for cardiopulmonary function (maximal heart rate, maximal oxygen uptake [VO2 max], maximal carbon dioxide production [VCO2 max]) and motor function at end of treatment, 10 weeks, and for functional status (Frenchay Activities Index [FAI]: global, social outings, walking outside) at end of treatment, 6 months (no benefit demonstrated); grade D for functional status (FAI: light housework activities) at end of treatment, 6 months (no benefit demonstrated but favoring control). Patients with subacute and chronic stroke.
Aerobic individualized program training versus control, level I (RCT): Grade A for physical fitness (highest test stage completed of the stress test and maximal workload) and mobility (stair climbing) at end of treatment, 8 weeks (clinically important benefit demonstrated); grade C+ for mobility (walking distance) at end of treatment, 8 weeks (clinically important benefit demonstrated without statistical significance); grade C for cardiovascular function (maximal heart rate, decrease of resting heart rate and decrease of resting systolic and diastolic blood pressure), gait speed, and functional status at end of treatment, 8 weeks (no benefit demonstrated). Patients with subacute stroke.
Proprioceptive neuromuscular facilitation (PNF) for upper extremity versus standard customary muscle training, level I (RCT): Grade C for functional status and upper extremity muscle strength at end of treatment, 6 weeks (no benefit demonstrated); grade D for mobility at end of treatment, 2, 4, and 6 weeks, range of motion (ROM) of the wrist at end of treatment, 6 weeks (no benefit demonstrated but favoring control); grade D+ for ROM of the ankle at end of treatment, 6 weeks (clinically important benefit favoring control demonstrated without statistical significance). Patients with postacute stroke.
Proprioceptive neuromuscular facilitation versus Bobath approach training, level I (RCT): Grade C for mobility at end of treatment, 2, 4, and 6 weeks, ROM of the wrist and ankle at end of treatment, 6 weeks (no benefit demonstrated). Patients with subacute stroke.
Bobath approach versus standard customary muscle training, level I (RCT): Grade C+ motor function (Sodring Motor Evaluation Scale [SMES]: upper extremity) at follow-up, 4 years, quality of life (Nottingham Health Profile [NHP]–global) at follow-up, 1 year and 4 years, and quality of life (NHP–loss of energy) at end of treatment, 3 months (clinically important benefit demonstrated without statistical significance); grade C for mobility at end of treatment, 2, 4, and 6 weeks, motor function (SMES: lower extremity and trunk, balance, and gait, and Motor Assessment Scale) at end of treatment, 3 months, and follow-up, 1 year and 4 years, motor function (SMES: upper extremity) at end of treatment, 3 months, and follow-up, 1 year, functional status (Barthel Index) at follow-up, 4 years (no benefit demonstrated); grade D for ROM of the wrist and ankle at end of treatment, 6 weeks, functional status (Barthel Index) at end of treatment, 3 months, and follow-up, 1 year, (no benefit demonstrated but favoring control); grade D+ for pain relief (NHP–pain) at end of treatment, 3 months (clinically important benefit favoring control demonstrated without statistical significance). Patients with acute and subacute stroke.
Bobath approach training versus control, level I (RCT): Grade C+ for balance standing at follow-up, 2 and 12 weeks (clinically important benefit demonstrated without statistical significance); grade C for balance sitting at end of treatment, 4 weeks (no benefit demonstrated); grade D for balance sitting at follow-up, 2 weeks, and balance standing at end of treatment, 4 weeks (no benefit demonstrated but favoring control); grade D+ for balance sitting at follow-up, 12 weeks (clinically important benefit favoring control demonstrated without statistical significance). Patients with subacute stroke.
Progressive resistance training versus active training for the lower extremity, level I (RCT): Grade A for functional status at end of treatment, 1 month (clinically important benefit demonstrated). Patients with post-acute stroke.
Active training for the lower extremity versus control (no exercise), level I (RCT): Grade D for functional status at end of treatment, 1 month (no benefit demonstrated but favoring control). Patients with post-acute stroke.
Progressive resistance training for the lower extremity versus control, level I (RCT): Grade C+ for functional status at end of treatment, 1 month (clinically important benefit demonstrated without statistical significance). Patients with postacute stroke.
Progressive resistance versus no resistance training, level I (RCT): Grade C for motor recovery at end of treatment, 4 weeks and 8 weeks, and follow-up, 6 months (no benefit demonstrated); grade D for gait endurance at end of treatment, 4 weeks and 8 weeks, and follow-up, 6 months (no benefit demonstrated but favoring control). Patients with subacute stroke.
Functional task training for upper extremity versus strength training, level I (RCT): Grade C+ favoring functional task training for functional status (functional independence measure [FIM] self-care and FIM mobility), isometric torque, grip strength, and palmar pinch at follow-up, 6.5 to 8 months, and lateral pinch at end of treatment, 4 weeks, and follow-up, 6.5 to 8 months, and grade C+ favoring strength training for grip strength and palmar pinch at end of treatment, 4 weeks (clinically important benefit demonstrated without statistical significance); grade C functional status (FIM self-care and FIM mobility) at end of treatment, 4 weeks, ROM upper extremity, pain relief, sensory function upper extremity, motor function upper extremity, functional status (Functional Test of the Hemiparetic Upper Extremity [FTHUE]) at end of treatment, 4 weeks, and follow-up, 6.5 to 8 months, isometric torque at end of treatment, 4 weeks (no benefit demonstrated). Patients with subacute stroke.
Strength training versus control, level I (RCT): Grade A for upper extremity isometric torque at end of treatment, 4 weeks (clinically important benefit demonstrated); grade C+ for motor function upper extremity and functional status (FTHUE) at end of treatment, 4 weeks, palmar pinch at end of treatment, 4 weeks, and follow-up, 6.5 to 8 months, grip strength and lateral pinch at follow-up, 6.5 to 8 months (clinically important benefit demonstrated without statistical significance); grade C for sensory function upper extremity at end of treatment, 4 weeks, and follow-up, 6.5 to 8 months, functional status (FIM mobility), pain relief, and grip strength at end of treatment, 4 weeks (no benefit demonstrated); grade D+ for lateral pinch at end of treatment, 4 weeks, functional status (FIM self-care and FIM mobility), upper extremity isometric torque at follow-up, 6.5 to 8 months (clinically important benefit favoring control demonstrated without statistical significance);
grade D for ROM upper extremity at end of treatment, 4 weeks, and follow-up, 6.5 to 8 months, functional status (FIM self-care) at end of treatment, 4 weeks, pain relief, motor function upper extremity, functional status (FTHUE) at follow-up, 6.5 to 8 months (no benefit demonstrated but favoring control). Patients with subacute stroke.
Aerobic and strength versus aerobic training, level I (RCT): Grade A for cardiopulmonary function and peak torque for shoulder flexors at end of treatment, 16 weeks (clinically important benefit demonstrated); grade C+ for peak torque for knee flexors at end of treatment, 16 weeks (clinically important benefit demonstrated without statistical significance); grade C for peak torque for shoulder extensors and peak torque for knee extensors at end of treatment, 16 weeks (no benefit demonstrated). Patients with chronic stroke.
Kinetron training for lower extremity versus control (no Kinetron), level I (RCT): Grade D for mobility at end of treatment, 5 weeks (no benefit demonstrated but favoring control). Patients with post-acute stroke.
Home-based exercise training versus control, level I (RCT): Grade A for change in gait speed, gait endurance, torque (change in knee isometric extensors), endurance, and cardiopulmonary function at end of treatment, 12 weeks; grade C+ for motor function (change in Fugl-Meyer lower extremity), change in gait speed, gait endurance, and functional status (physical function index), strength (change in grip strength) at end of treatment, 12 weeks (clinically important benefit demonstrated without statistical significance); grade C for motor function (change in Fugl-Meyer upper extremity and lower extremity), balance (Berg balance and change in Berg balance), functional status (Instrumental Activity of Daily Living (ADL) and Barthel ADL Index), at end of treatment, 12 weeks (no benefit demonstrated); grade D+ for balance (functional reach) at end of treatment, 12 weeks (clinically important benefit favoring control demonstrated without statistical significance); grade D for torque (change in ankle isometric dorsiflexors) (no benefit demonstrated but favoring control). Patients with post-acute stroke.
Skateboard versus overhead pulley training for the shoulder, level I (RCT): Grade C+ for pain relief at end of treatment, 8 to 10 weeks (clinically important benefit demonstrated without statistical significance). Patients with subacute stroke.
Overhead pulley versus control (passive ROM training for shoulder), level I (RCT): Grade D for pain relief at end of treatment, 8 to 10 weeks (no benefit demonstrated but favoring control). Patients with subacute stroke.
Passive ROM training for shoulder versus skateboard, level I (RCT): Grade C for pain relief at end of treatment, 8 to 10 weeks (no benefit demonstrated). Patients with subacute stroke.
Resisted extension versus ballistic extension training for the hand, level I (RCT): Grade C+ for ROM at end of treatment, 2 weeks (clinically important benefit demonstrated without statistical significance); grade C motor function at end of treatment, 2 weeks (no benefit demonstrated). Patients with subacute and post-acute stroke.
Resisted extension versus resisted grasp training for the hand, level I (RCT): Grade A for motor function (change in tapping) at end of treatment, 2 weeks (clinically important benefit demonstrated); grade C+ for ROM at end of treatment, 2 weeks (clinically important benefit demonstrated without statistical significance); grade C for motor function (change in grasp/release) at end of treatment, 2 weeks (no benefit demonstrated). Patients with subacute and post-acute stroke.
Resisted extension training for the hand versus control, level I (RCT): Grade A for motor function (change in tapping) and ROM at end of treatment, 2 weeks (clinically important benefit demonstrated); grade D for motor function (change in grasp/release) at end of treatment, 2 weeks (no benefit demonstrated but favoring control). Patients with subacute and post-acute stroke.
Ballistic extension versus resisted grasp training for the hand, level I (RCT): Grade A for motor function (change in tapping) at end of treatment, 2 weeks (clinically important benefit demonstrated); grade C+ for ROM at end of treatment, 2 weeks (clinically important benefit demonstrated without statistical significance); grade C for motor function (change in grasp/release) and ROM at end of treatment, 2 weeks (no benefit demonstrated). Patients with subacute and postacute stroke.
Ballistic extension training for the hand versus control, level I (RCT): Grade C+ for motor function (change in tapping) at end of treatment, 2 weeks (clinically important benefit without statistical significance); grade C for ROM at end of treatment, 2 weeks (no benefit demonstrated); grade D for motor function (change in grasp/release) at end of treatment, 2 weeks (no benefit demonstrated but favoring control). Patients with subacute and post-acute stroke.
Resisted grasp training for the hand versus control, level I (RCT), Grade C+ for ROM at end of treatment, 2 weeks (clinically important benefit demonstrated); grade C for motor function (change in tapping) at end of treatment, 2 weeks (no benefit demonstrated); grade D for motor function (change in grasp/release) at end of treatment, 2 weeks (no benefit demonstrated but favoring control). Patients with subacute and post-acute stroke.
Robot-aided training versus no robot-aided training, level I (RCT) and level II (controlled clinical trials [CCT]): Grade A for motor power for shoulder and elbow at end of treatment, 5 weeks, change in motor power upper extremity at end of treatment, 6 weeks, motor function (Fugl-Meyer for shoulder, elbow, and coordination and Motor Status Score [MSS] for shoulder and elbow) at end of treatment, 5 weeks, motor function (MSS for wrist and hand) at end of treatment, 5 weeks, and motor function (change in MSS for shoulder and elbow) at end of treatment, 6 weeks, and follow-up, 3 years, motor function (MSS for wrist and hand) at end of treatment, 5 weeks (clinically important benefit demonstrated); grade B for motor function (MSS for upper extremity) at end of treatment, 6 weeks (clinically important benefit demonstrated); grade C+ for change in motor power for shoulder and elbow at follow-up, 3 years, motor function (Fugl-Meyer scale for upper extremity), motor power for upper extremity at end of treatment, 6 weeks (clinically important benefit demonstrated without statistical significance); grade C for motor function (change in Fugl-Meyer for shoulder, elbow, and coordination) at end of treatment, 6 weeks, functional status (FIM for upper extremity) at end of treatment, 5 weeks and 6 weeks, motor function (change in Fugl-Meyer for wrist and hand and change in MSS for wrist and hand) at end of treatment, 6 weeks, and follow-up, 3 years (no benefit demonstrated); grade D for motor function (change in Fugl-Meyer for shoulder, elbow, and coordination) at follow-up, 3 years (no benefit demonstrated but favoring control). Patients with subacute-chronic stroke.
Robot-assisted versus neurodevelopmental (NDT) training, level I (RCT): Grade A for strength (change in elbow extensors, shoulder internal rotators, abductors, adductors, and flexors strength [%]) and functional reach (change in forward medial, forward, forward lateral, and lateral reach extent) at end of treatment, 2 months; grade C+ for strength (change in shoulder external rotators and extensors strength [%]) at end of treatment, 2 months (clinically important benefit demonstrated); grade C for functional status (change in Barthel Index and change in FIM) at follow-up, 6 months, motor function (change in Fugl-Meyer shoulder and elbow) at end of treatment, 1 month, 2 months, and follow-up, 6 months, motor function (change in Fugl-Meyer hand and wrist) at end of treatment, 1 month, 2 months, and follow-up, 6 months, (no benefit demonstrated). Patients with chronic stroke.
Robot-aided progressive resistance training versus robot-aided active-assisted training, level I (RCT): Grade C for decrease of spasticity, motor function, and strength at end of treatment, 6 weeks (no benefit demonstrated). Patients with chronic stroke.
Progressive-resistive robotic training versus sensorimotor training, level I (RCT): Grade C+ for decrease of spasticity at end of treatment, 6 weeks (clinically important benefit demonstrated without statistical significance); grade C for motor function (Fugl-Meyer upper extremity and MSS for shoulder and elbow and wrist and hand), and motor power for shoulder and elbow at end of treatment, 6 weeks (no benefit demonstrated). Patients with chronic stroke.
Music-making training versus control, level I (RCT): Grade C+ for ROM (elbow extension) at end of treatment, 10 weeks (clinically important benefit demonstrated without statistical significance); grade C for ROM (shoulder flexion) at end of treatment, 10 weeks (no benefit demonstrated). Patients with post-acute stroke.
Water-based training versus control, level I (RCT): Grade A for hip and knee extensors strength (affected side) at end of treatment, 8 weeks (clinically important benefit demonstrated); grade C+ for cardiopulmonary function (VO2 max) at end of treatment, 8 weeks, muscle power at end of treatment, 8 weeks, and gait speed at end of treatment, 8 weeks (clinically important benefit demonstrated without statistical significance); grade C for hip and knee extensors strength (unaffected side) at end of treatment, 8 weeks (no benefit demonstrated); grade D for balance at end of treatment, 8 weeks (no benefit demonstrated but favoring control). Patients with chronic stroke.
Agility exercise versus stretching/weightshifting exercise, level I (RCT): Grade C+ for step reaction time at follow-up, 1 month (clinically important benefit demonstrated without statistical significance); grade C for balance, mobility, balance confidence, and quality of life at end of treatment, 10 weeks, and follow-up, 1 month, step reaction time at end of treatment, 10 weeks (no benefit demonstrated). Patients with chronic stroke.
Maximal isokinetic strengthening versus control, level I (RCT): Grade C+ for change in strength at end of treatment, 6 weeks (clinically important benefit demonstrated without statistical significance); grade C for quality of life and at end of treatment, 6 weeks (no benefit demonstrated); grade D for level-walking and stair-walking (no benefit demonstrated but favoring control). Patients with chronic stroke.
Mental imagery versus standard functional training, level I (RCT): Grade A for level of independence in performing tasks at end of treatment, 1 week, 2 weeks, and 3 weeks (clinically important benefit demonstrated). Patients with acute stroke.
Definitions:
Level of Evidence
Level I: Randomized controlled trials
Level II: Nonrandomized studies
Grade of Recommendation
Grade A: Evidence from one or more randomized controlled trials (RCTs) of a statistically significant, clinically important benefit (>15%)
Grade B: Statistically significant, clinically important benefit (>15%), if the evidence was from observational studies or controlled clinical trials (CCTs)
Grade C+: Evidence of clinical importance (>15%) but not statistical significance
Grade C: Interventions where an appropriate outcome was measured in a study that met the inclusion criteria, but no clinically important difference and no statistical significance were shown
Grade D: Evidence from one or more randomized controlled trials of a statistically significant benefit favoring the control group (<0%: favors controls)
Grade D+: Evidence of clinical importance (<-15% for controls) without statistical significance
Grade D-: Evidence from one or more randomized controlled trials of a clinically important benefit (<-15% for controls) that was statistically significant, where the number of participants in the study is equal to or higher than 100
