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 Task-Oriented Training
Seated reaching task training versus control, level I (randomized controlled trial [RCT]): Grade A for hand movement time (ipsilateral and across), peak vertical ground reaction force (forward and across) at end of treatment, 2 weeks (clinically important benefit demonstrated); grade C+ for hand movement time (forward) at end of treatment, 2 weeks (clinically important benefit demonstrated without statistical significance); grade C for reaching distance and peak vertical reaction force (ipsilateral) at end of treatment, 2 weeks (no benefit demonstrated). Patients with chronic stroke.
Adapted game training versus control, level I (RCT): Grade A for ROM in forearm supination at end of treatment, 1 day (clinically important benefit demonstrated). Patients with post-acute stroke.
Repetitive elbow joint movement training versus control, level II (controlled clinical trial [CCT]): Grade C for joint velocity (maximal extension velocity to target and to mouth), motor function (Fugl-Meyer) at end of treatment, 3 weeks (no benefit demonstrated); grade D for functional status, motor function (Frenchay Arm Test), and joint velocity (maximal flexion velocity to target and to mouth) at end of treatment, 3 weeks (no benefits demonstrated but favoring control). Patients with subacute stroke.
Functional upper extremity training versus control, level I (RCT): Grade A for quality of life (Nottingham Health Profile [NHP]) at end of treatment, 12 weeks (clinically important benefit demonstrated); grade C+ for comfortable gait speed at end of treatment, 12 and 20 weeks, and follow-up, 6 weeks, maximum gait speed at end of treatment, 12 and 20 weeks, and follow-up, 6 and 32 weeks, and quality of life (NHP) at follow-up, 6 and 32 weeks (clinically important benefit demonstrated without statistical significance); grade C for quality of life (NHP) at follow-up, 18 weeks, comfortable gait speed at follow-up, 18 and 32 weeks, maximum gait speed at follow-up, 18 weeks, quality of life (Sickness Impact Profile) at end of treatment, 12 weeks, and follow-up, 6, 18, and 32 weeks, functional status (Frenchay Activities Index) at follow-up, 6 and 32 weeks, and mobility at end of treatment, 12 weeks, and follow-up, 6, 18, and 32 weeks (no benefit demonstrated); grade D for mobility at end of treatment, 20 weeks (no benefit demonstrated but favoring control). Patients with subacute stroke.
Functional task training for upper extremity versus control, level I (RCT): Grade C+ for motor function upper extremity, functional status (Functional Test of the Hemiparetic Upper Extremity [FTHUE]), and isometric torque at end of treatment, 4 weeks, grip strength and lateral pinch at follow-up, 8 months, palmar pinch at end of treatment, 4 weeks, and follow-up, 8 months (clinically important benefit demonstrated without statistical significance); grade C for functional status (functional independence measure [FIM] mobility) at end of treatment, 4 weeks, functional status (FIM self-care and Functional Test of the Hemiparetic Upper Extremity) and isometric torque at follow-up, 8 months, pain relief and upper extremity sensory function at end of treatment, 4 weeks, and follow-up, 8 months (no benefit demonstrated); grade D for functional status (FIM self-care) and lateral pinch at end of treatment, 4 weeks, functional status (FIM mobility) and motor function upper extremity at follow-up, 8 months, upper extremity range of motion (ROM) at end of treatment, 4 weeks, and follow-up, 8 months (no benefit demonstrated but favoring control); grade D+ for grip strength at end of treatment, 4 weeks (clinically important benefit favoring control demonstrated without statistical significance). Patients with acute and subacute stroke.
Task-specific reach training versus Bobath approach training, level I (RCT): Grade C+ for balance sitting at follow-up, 12 weeks; grade C+ favoring Bobath approach training for balance sitting at end of treatment, 4 weeks (clinically important benefit demonstrated without statistical significance); grade C for balance sitting at follow-up, 2 weeks, and balance standing at end of treatment, 4 weeks, and follow-up, 2 and 12 weeks (no benefit demonstrated). Patients with subacute stroke.
Task-specific reach training versus standard rehabilitation, level I (RCT): Grade C+ for balance sitting at follow-up, 12 weeks, and balance standing at follow-up, 2 and 12 weeks (clinically important benefit demonstrated without statistical significance); grade C for balance standing at end of treatment, 4 weeks (no benefit demonstrated); grade D+ for balance sitting at end of treatment, 4 weeks, and follow-up, 2 weeks (clinically important benefit favoring control demonstrated without statistical significance). Patients with subacute stroke.
Trunk control training versus control, level I (RCT): Grade C+ for postural status, mobility, and unilateral neglect at end of treatment, 1 month, and follow-up, 2 months (clinically important benefit demonstrated without statistical significance); grade C for functional status at end of treatment, 1 month, and follow-up, 2 months (no benefit demonstrated). Patients with subacute stroke.
Trunk rotation feedback training versus control, level I (RCT): Grade A for functional status and unilateral neglect at end of treatment, 1 month, and follow-up, 1 month (clinically important benefit demonstrated). Patients with subacute stroke.
Traditional functional retraining (TFR) approach versus neurodevelopmental (NDT) training, level I (RCT): Grade A (favoring TFR) for gross manual dexterity at follow-up, 6 months and 1 year (clinically important benefit demonstrated); grade C+ (favoring TFR) for gait speed at end of treatment, 1 month, and follow-up, 6 months and 1 year, stride length at follow-up, 6 months and 1 year, and functional status (time for independence: prone-to-supine, supine-to-prone, supine-to-sit, unsupported standing, grooming, bathing, dressing, ambulation without device, and feeding) at end of treatment, 1 month (clinically important benefit demonstrated without statistical significance); grade C for functional status (time for independence: unsupported sitting) and stride length at end of treatment, 1 month, functional status (FIM), fine motor coordination, and finger dexterity at end of treatment, 1 month, and follow-up, 6 months and 1 year (no benefit demonstrated). Patients with subacute stroke.
Functional training (dressing practice) versus control, level I (RCT): Grade C for functional status (Nottingham stroke dressing) at end of treatment, 3 months (no benefit demonstrated); grade D for functional status (Rivermead activities of daily living [ADL] selfcare) at end of treatment, 3 months (no benefit demonstrated but favoring control). Patients with chronic stroke.
Leisure task versus functional task (ADL selfcare) training, level I (RCT): Grade C for leisure activities and functional status at follow-up, 6 months and 1 year (no benefit demonstrated). Patients with acute, subacute, and post-acute stroke.
Leisure task training versus control, level I (RCT): Grade C for leisure activities at follow-up, 6 months and 1 year, and functional status at follow-up, 6 months (no benefit demonstrated); grade D for functional status at follow-up, 1 year (no benefit demonstrated but favoring control). Patients with acute, subacute, and post-acute stroke.
Functional task (ADL self-care) training versus control, level I (RCT): Grade C for functional status (Nottingham Extended Activities of Daily Living [EADL]) at follow-up, 6 months and 1 year (no benefit demonstrated); grade D for functional status (London Handicap Scale) and leisure activities at follow-up, 6 months and 1 year (no benefit demonstrated but favoring control). Patients with acute, subacute, and post-acute stroke.
Functional (ADL) training versus leisure activities, level I (RCT): Grade C for functional status (number patients improved on Barthel Index [dressing and bathing] and number patients improved on EADL Scale [cleaning, cooking, and mobility outside]) and leisure activities (number of patients improved on Nottingham Leisure Questionnaire Scale [shopping, gardening, and hobbies]) at 6-months follow-up (no benefit demonstrated); grade D for functional status (number patients improved on Barthel Index [bed to chair transfers] and number of patients improved on EADL Scale [mobility on uneven ground]) and leisure activities (number of patients improved on Nottingham Leisure Questionnaire Scale [cooking, entertainment, games and sports]) at 6-months follow-up (no benefit demonstrated but favoring control). Patients with acute, subacute, and postacute stroke.
Weight garments training versus control, level I (RCT): Grade C+ for single support time symmetry and support base width symmetry at end of treatment, 6 weeks (clinically important benefit demonstrated without statistical significance); grade C for gait speed and cadence at end of treatment, 6 weeks (no benefit demonstrated); grade D+ for step length symmetry and double support time symmetry at end of treatment, 6 weeks (clinically important benefit favoring control demonstrated without statistical significance); grade D for balance at end of treatment, 6 weeks (no benefit demonstrated but favoring control). Patients with chronic stroke.
Functional approach versus transfer approach training, level I (RCT): Grade A favoring functional approach for functional status (Edmans ADL index) and gross motor function at end of treatment, 6 weeks (clinically important benefit demonstrated); grade C for resource cost perception and functional status (Barthel Index) at end of treatment, 6 weeks (no benefit demonstrated). Patients with post-acute stroke.
Bilateral arm training versus neurodevelopmental approach, level I (RCT): Grade C+ for change in shoulder strength, Wolf Motor Arm Test (time), and self reported use of paretic arm at end of treatment, 6 weeks (clinically important benefit demonstrated without statistical significance); grade C for change in Fugl-Meyer at end of treatment, 6 weeks (no benefit demonstrated); grade D+ for change in Wolf Motor Arm Test (weight) and elbow strength at end of treatment, 6 weeks (clinically important benefit favoring control demonstrated without statistical significance). Patients with chronic stroke.
Task-specific training versus control, level I (RCT): Grade C+ for motor function (Fugl-Meyer subscale: upper extremity and lower extremity control]) and balance (Berg Scale) at end of treatment, 6 weeks (clinically important benefit demonstrated without statistical significance); grade C for balance (Fugl-Meyer subscale: balance) and gait speed at end of treatment, 6 weeks (no benefit demonstrated); grade D for functional status (Barthel Index) at end of treatment, 6 weeks (clinical benefits favoring control). Patients with subacute 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
