ORIGINAL ARTICLE

Circuit Class Therapy Versus Individual Physiotherapy

Sessions During Inpatient Stroke Rehabilitation:
A Controlled Trial
Coralie K. English, PhD, Susan L. Hillier, PhD, Kathy R. Stiller, PhD, Andrea Warden-Flood, PhD

ABSTRACT. English CK, Hillier SL, Stiller KR, Warden-

Flood A. Circuit class therapy versus individual physiotherapy
sessions during inpatient stroke rehabilitation: a controlled
trial. Arch Phys Med Rehabil 2007;88:955-63.
Objective: To compare the effectiveness of circuit class
therapy and individual physiotherapy (PT) sessions in improv-
ing walking ability and functional balance for people recover-
ing from stroke.
Design: Nonrandomized, single-blind controlled trial.
Setting: Medical rehabilitation ward of a rehabilitation
hospital.
Participants: Sixty-eight persons receiving inpatient reha-
bilitation after a stroke.
Interventions: Subjects received group circuit class therapy
or individual treatment sessions as the sole method of PT
service delivery for the duration of their inpatient stay.
Main Outcome Measures: Five-meter walk test (5MWT),
two-minute walk test (2MWT), and the Berg Balance Scale
(BBS) measured 4 weeks after admission. Secondary outcome
measures included the Iowa Level of Assistance Scale,
Motor Assessment Scale upper-limb items, and patient sat-
isfaction. Measures were taken on admission and 4 weeks
later.
Results: Subjects in both groups showed signicant im-
provements between admission and week 4 in all primary
outcome measures. There were no signicant between group
differences in the primary outcome measures at week 4
(5MWT mean difference, .07m/s; 2MWT mean difference,
1.8m; BBS mean difference, 3.9 points). A signicantly
higher proportion of subjects in the circuit class therapy
group were able to walk independently at discharge (P.01)
and were satised with the amount of therapy received
(P.007).
Conclusions: Circuit class therapy appeared as effective as
individual PT sessions for this sample of subjects receiving
inpatient rehabilitation poststroke. Favorable results for circuit
classes in terms of increased walking independence and patient
satisfaction suggest this model of service delivery warrants
further investigation.
Key Words: Cerebrovascular accident; Physical therapy
modalities; Rehabilitation.
2007 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
I
T IS WELL ESTABLISHED that positive cortical reorga-
nization poststroke in both the animal
1-3
and human
4,5
cortex
is driven by activity and repetitive practice of new tasks.
Furthermore, 2 recent meta-analyses
6,7
have concluded that
recovery of motor function in persons with stroke is best
facilitated by providing intensive, task-specic therapy. How-
ever, observational studies have repeatedly shown that persons
receiving inpatient rehabilitation poststroke spend large parts
of the day inactive
8-11
and appear to require the presence of a
therapist to practice new skills.
12
Providing task-specic ther-
apy to groups of people with stroke in circuit classes has been
proposed as a method of increasing the amount of time people
spend actively engaged in task practice.
12,13
Other benets of
group therapy include peer support and social interaction
14
as
well as potential cost-savings to the health care system by
reducing staff to patient ratios.
Circuit class therapy can be dened as therapy: provided to
more than 2 participants; involving a tailored intervention
program, with a focus on practice of functional tasks received
within a group setting; provided to participants with similar or
different degrees of functional ability; and involving a staff to
patient ratio no greater than 1:3.
Practically, this can involve participants physically moving
between work stations set up in specic locations within each
class, or participants performing a set of core activities adapted
to suit individual needs within a group setting, but without the
need to physically move between work stations. Optimally, the
intervention is targeted at multiple levels, such as strength and
balance and walking practice and range of movement. Partic-
ipants progress is continuously monitored and activities are
adapted as required. This denition is consistent with previous
descriptions of circuit class therapy.
6,13-15
This denition is
also distinct from the concept of group therapy, which is
dened as therapy involving more than 2 patients, usually with
a similar degree of functional ability, undertaking the same
exercises or activities at the same time under the direction of 1
therapist with little or no individual tailoring or progression of
activities and usually targeting only 1 impairment (eg, balance
or strength or aerobic tness).
Circuit class therapy (consistent with the denition outlined
above) has been shown to be effective for improving the
mobility of people greater than 6 months poststroke
14,16
and for
improving mobility and upper-limb function for people receiv-
ing rehabilitation poststroke, when provided in addition to
individual physiotherapy (PT) sessions.
15
However, the effec-
tiveness of circuit class therapy as an alternative sole method of
PT service delivery for persons receiving inpatient rehabilita-
tion poststroke has not been investigated to date. Therefore our
primary objective was to test the hypothesis that circuit class
therapy would result in greater improvements in mobility and
From the School of Health Sciences, University of South Australia, Adelaide,
South Australia (English, Hillier, Warden-Flood); and the Physiotherapy Department,
Royal Adelaide Hospital, Adelaide, South Australia (English, Stiller).

Deceased.
Supported by the Australian Physiotherapy Association Physiotherapy Research
Foundation and the Royal Adelaide Hospital Allied Health Group.
No commercial party having a direct nancial interest in the results of the research
supporting this article has or will confer a benet upon the author(s) or upon any
organization with which the author(s) is/are associated.
Correspondence to Coralie K. English, PhD, School of Health Sciences, University
of South Australia, North Terrace, Adelaide, SA 5000, Australia, e-mail:
Coralie.English@unisa.edu.au. Reprints are not available from the author.
0003-9993/07/8808-11498$32.00/0
doi:10.1016/j.apmr.2007.04.010
955
Arch Phys Med Rehabil Vol 88, August 2007
balance than individual PT sessions. Our secondary objective
was to investigate between-group differences in level of walk-
ing independence achieved, upper-limb function, length of stay
(LOS) in rehabilitation, and patient satisfaction with therapy.
METHODS
Study Design
We conducted a single-blind, nonrandomized controlled
trial. We obtained ethics approval from the University of South
Australia and Royal Adelaide Hospital Research Ethics Com-
mittees.
Participants
Persons received inpatient rehabilitation poststroke. Specic
inclusion and exclusion criteria were as follows.
Inclusion criteria. Subjects who were diagnosed with a
cerebrovascular accident resulting in unilateral motor decits;
had sufcient ability to participate in circuit class therapy (ie,
ability to follow 3-part commands, sit unsupported and stand
with 1 person assisting); and were able to give informed
consent.
Exclusion criteria. Persons who had suffered a cerebellar
lesion; had a history of any neurologic disorder (excluding
previous stroke); or regularly used a walking aid (excluding
single-point cane) or required assistance for activities of daily
living prior to their stroke.
Withdrawal criterion. Subjects were withdrawn from the
trial if they suffered any signicant medical complication
and/or were readmitted to an acute hospital for more than
1 week.
Recruitment
We approached all persons admitted to Hampstead Rehabil-
itation Centre, Adelaide, South Australia, for rehabilitation
poststroke between March 2002 and October 2003 who met the
inclusion and exclusion criteria within the rst 2 days after
admission and invited them to participate in the study.
Group Allocation
Within 3 days of admission to rehabilitation, we assigned
consenting subjects to their treatment group. To ensure a suf-
cient number of circuit class participants at any one time for
circuit class therapy sessions, it was not feasible to randomly
allocate individual subjects to treatment groups. Instead, we
allocated subjects in blocks according to the date of admission
to rehabilitation. Subject recruitment occurred between March
2002 and October 2003 in 4 alternating blocks of time. Because
of this, we were not able to conceal assignment to groups from
the allocator, or blind the subjects or treating therapists to
group allocation.
Evaluations
We assessed subjects on all outcome measures at admission,
week 4 of rehabilitation, discharge from rehabilitation, and 6
months poststroke. An examiner who was unaware of the
design and aim of the study and was blinded to subjects group
allocation completed all subject assessments. The examiner
remained blinded to the study design and aims, and subjects
group allocation, until after data collection ceased. We consid-
ered the 4-week assessment as the primary end point of inter-
est, as it was the average LOS for stroke rehabilitation at
Hampstead Rehabilitation Centre at the time of the trial.
Measurements
Our primary outcome measures were gait speed measured by
the ve-meter walk test (5MWT),
17
functional walking capac-
ity as measured by the two-minute walk test (2MWT),
18
and
functional balance as measured by the Berg Balance Scale
(BBS).
19
For the 5MWT the assessor asked subjects to walk at
a comfortable pace along a corridor which was marked at 3, 8,
and 10m from the start position, without verbal encouragement.
The assessor used a stopwatch to record the time taken to walk
the middle 5m of the walkway. The 2MWT was conducted
along the same walkway with large orange cones placed 1 and
9m from the start position. The assessor asked subjects to walk
up and down the walkway, walking around the cones at each
end, continuously for 2 minutes, at a comfortable pace, taking
rests if required. The assessor counted the number of com-
pleted laps and at the end of the 2 minutes (measured on a stop
watch) the subject was asked to stop and stand still. The
walkway was marked at 0.5-m intervals and the assessor re-
corded the distance walked to the nearest 0.5m. In both the
5MWT and 2MWT, the assessor walked behind the subject at
all times to avoid inuencing the speed at which they walked.
The BBS was assessed according to the standard protocol
20
using the same equipment (stool, chairs, plinth) for each as-
sessment.
Our secondary outcome measures were upper-limb function
as measured by the upper-limb subscale of the Motor Assess-
ment Scale (MAS) for stroke,
21
which consists of the 3 upper-
limb items added together to create 1 summary score, the
degree of physical assistance required to walk as measured by
the Iowa Level of Assistance Scale (ILAS),
22
LOS in rehabil-
itation, and patient satisfaction as measured by a stroke-specic
satisfaction questionnaire (adapted from Pound et al
23
). We
measured LOS as the number of days between admission and
discharge from Hampstead Rehabilitation Centre.
All of the outcome measures have been shown to have accept-
able interrater reliability and construct validity
17,18,22,24-33
and
were applied using standardized protocols.
17-22
Intrarater reli-
ability of the primary outcome measures was measured by the
assessor re-scoring videotaped performances of the rst 10
assessments 4 weeks later.
In addition, we obtained information regarding sociodemo-
graphic and stroke characteristics from the subjects medical
records, with the level of stroke severity measured at admission
to rehabilitation using the FIM instrument,
34
administered by
the treating multidisciplinary team.
Interventions
Subjects received the allocated type of PT for the duration of
their inpatient stay and non-PT components of multidisci-
plinary rehabilitation were provided to both groups per usual
practice. The broad aim of both individual and circuit class
treatment sessions was to improve subjects mobility and
upper-limb function to allow safe discharge to either their own
home or appropriate supportive accommodation. The treating
therapist recorded details regarding the content and duration of
each therapy session. Subjects received their allocated PT
intervention for the duration of their inpatient stay. Indepen-
dent practice outside of individual therapy times was not usual
practice at Hampstead Rehabilitation Centre at the time and
therefore was not encouraged for either group during the trial.
We provided circuit class therapy to groups of up to 6
patients at any one time with a maximum of 1 physiotherapist
and 1 PT assistant providing supervision in each class. If there
were less than 5 participants in the class, only 1 physiotherapist
provided supervision. The same physiotherapist (with 5 years
956 CIRCUIT CLASS THERAPY FOR STROKE REHABILITATION, English
Arch Phys Med Rehabil Vol 88, August 2007
of experience in stroke rehabilitation) supervised all circuit
classes, although several different PT assistants were involved.
Circuit class participants attended two 90-minute treatment
sessions a day, 5 days a week, and performed a set of core
activities that addressed their key impairments and functional
limitations. These core activities were: sit-to-stand practice;
strengthening lower-limb extensor muscles in weight-bearing
positions; postural control in standing; walking practice includ-
ing negotiating obstacles, steps, ramps, stairs, and outdoor
surfaces; reach and grasp; and ne manipulation of everyday
household items in both unilateral and bilateral tasks. These
core activities were individually adapted for each subject by the
treating therapist and progressed as required, such that the level
of difculty, complexity, and dosage (number of repetitions)
matched each individuals ability. For example, practice of
sit-to-stand ranged from starting with the subject perched on
the edge of a high plinth with 1 therapist assisting, to indepen-
dent practice using a low chair with no assistance while holding
a glass of water. Appendix 1 includes a comprehensive list of
exercises included in the class. We incorporated walking on a
treadmill (without body-weight support) into the class for each
subject as soon as they were able to walk overground with
minimal assistance. We progressed treadmill training by in-
creasing time (up to a maximum of 20min per session) and
speed. Group activities such as relay races were incorporated
into the majority of classes. Although treating therapists pro-
vided some verbal feedback during circuit class therapy, the
majority of feedback was provided by setting up each task such
that it provided a concrete goal and intrinsic feedback regard-
ing its correct completion.
Individual therapy sessions occurred under the direct and
constant supervision of a physiotherapist or PT assistant, on a
1 therapist to 1 subject ratio, for up to 60 minutes a day, 5 days
a week. Several different physiotherapists with a range of
experience in stroke rehabilitation were involved in providing
individual therapy. Individual therapy sessions were not based
on any particular treatment philosophy and were tailored to the
individual based on the physiotherapists assessment. Thera-
pists often used manual guidance and verbal feedback for
correct completion of tasks.
Sample Size
Prospective power calculations based on the ability to detect
a between-group difference of 0.2m/s in walking speed with
80% power (.05) indicated that a sample size of 37 subjects
per group was required. We considered 0.2m/s to be the min-
imum clinically important difference in walking speed, based
on previous ndings of an inherent measurement error of
approximately .17m/s with repeated measurements of walking
speed.
35
We used an estimated standard deviation (SD) of
0.3m/s in the calculation, based on data from previous studies
involving similar patient groups.
28,36
Data Analysis
We analyzed differences between treatment groups at base-
line using the independent t test, or Mann-Whitney U test if
data were not normally distributed or were ordinal in nature.
When all data were available, analysis was by intention-to-
treat. However, ongoing collection of data was not possible for
the majority of subjects withdrawn from the trial because they
were either readmitted to an acute hospital or refused assess-
ment.
We analyzed differences between groups over time on con-
tinuous outcome measures (ie, 5MWT, 2MWT, BBS) using a
linear mixed-model analysis (with time and group as xed
effects and subjects as a random effect). We chose this method
over the general multivariate model analysis of variance due to
the considerable amount of missing data within the nal data
set. The linear mixed-model analysis allows all available data
to be included by constructing estimated mean scores where
data are missing, thereby minimizing bias resulting from an
analysis restricted to complete cases.
37
When signicant group
by time interactions were found, we performed a post hoc
pairwise comparison of mean scores to examine when these
differences occurred. The post hoc tests used the same data set
as that used for the linear mixed-model analysesthat is, it
involved imputed values for missing data. We calculated 95%
condence intervals (CIs) for mean differences to further ex-
amine both signicant and nonsignicant ndings. Although
the BBS is strictly an ordinal scale, we treated the data as
continuous, because the range in scores was large and the
distribution of scores closely approached normality. We used
independent t tests to analyze between-group differences for
hospital LOS, duration of therapy, and content of therapy. We
used the Mann-Whitney U test to analyze between-group dif-
ferences in MAS upper-limb subscale scores, and the chi-
square statistic to analyze between-group differences in ILAS
scores and responses to the patient satisfaction questionnaire.
Analyses of the MAS upper-limb subscale scores, ILAS, and
patient satisfaction questionnaire were based on cross-sectional
data, not change scores.
We used the SPSS
a
for all analyses, with a signicance level
of equal to .05.
RESULTS
We conducted the trial between March 2002 and December
2003. Seventy-eight subjects consented to participate and were
allocated to groups. Figure 1 depicts the progression of subjects
through the trial and the reasons for exclusion and withdrawal.
Ten subjects withdrew before the week-4 assessment and a
further 4 subjects withdrew between week 4 and discharge.
Table 1 presents reasons for the 14 subjects who were with-
drawn from the study. One subject withdrew from the circuit
class therapy group after week 4 due to safety concerns. Al-
though this subject received individual therapy for the remain-
der of her inpatient stay, we included her discharge and
follow-up data in the circuit class therapy group for all analyses
according to intention to treat principles. Only 43 (63.2%)
subjects attended the follow-up assessment. Those subjects
who did attend had a faster walking speed at discharge from
rehabilitation than those who did not attend (attendees,
.81.43m/s; nonattendees, .59.38m/s; P.04; t2.08,
95% CI, .01.46). There were no signicant differences in
discharge 2MWT scores and BBS data between those subjects
who did and did not attend the follow-up assessment.
Intrarater reliability for the primary outcome measures was
high, with intraclass correlation coefcient scores of 1.00, 1.00,
and 0.96 for the 5MWT, 2MWT, and BBS scores, respectively.
Table 2 presents baseline characteristics of subjects included
in data analyses. Data from the 5MWT and 2MWT were highly
skewed at admission due to 21 (30.9%) subjects being unable
to walk. There were no signicant differences between treat-
ment groups at baseline for any of the primary outcome mea-
sures or the admission FIM score. However, circuit class ther-
apy subjects were signicantly younger (individual therapy,
68.912.3y; circuit class therapy, 61.611.8y; P.02).
Table 3 presents summary data for all outcome measures.
The linear mixed-model analyses demonstrated a signicant
group by time interaction effect for each of the 3 primary
outcome measures (5MWT: F2.88, P.04; 2MWT: F6.82,
P.001; BBS scores: F2.79, P.04) suggesting that the
957 CIRCUIT CLASS THERAPY FOR STROKE REHABILITATION, English
Arch Phys Med Rehabil Vol 88, August 2007
treatment groups behaved differently over time. Post hoc pair-
wise comparisons of mean scores demonstrated that both
groups showed signicant improvement between admission
and week 4 on the 5MWT (mean improvement: individual
therapy, .16m/s; circuit class therapy, .17m/s), the 2MWT
(mean improvement: individual therapy, 21.3m; circuit class
therapy, 16.5m), and the BBS (mean improvement: individual
therapy, 8.9 points; circuit class therapy, 8.5 points). Both
groups continued to show signicant improvement in all 3
measures between week 4 and discharge; however, only sub-
jects receiving individual therapy showed signicant improve-
ment in the 5MWT and 2MWT between discharge and follow-
up. There were no signicant between-group differences at any
time point, with the exception of the follow-up assessment at
which subjects in the individual therapy group scored signi-
cantly higher on the 2MWT. Analyses were repeated with age
as a covariate, which did not alter results.
There were no signicant differences between groups on the
MAS upper-limb subscale at any time point. There was a low
frequency of scores on the ILAS for the majority of categories;
therefore, data were collapsed into 2 categories (independent,
assistance required/unsafe to attempt assessment) prior to anal-
ysis. At discharge a signicantly higher proportion of subjects
in the circuit class therapy group (n26 [92.9%]) were able to
walk independently compared with the individual therapy
group (n23 [67.6%],
2
test5.89, P.01). There were no
signicant differences between groups in the responses to the
patient satisfaction questionnaire at discharge or follow-up
Fig 1. Flow chart of trial par-
ticipants. *These subjects
were not withdrawn, but did
not complete either the
week-4 or discharge assess-
ment.

Includes 1 subject in
each treatment group with
LOS of less than 4 weeks,
therefore did not complete a
week-4 assessment.

One sub-
ject refused a discharge as-
sessment, but completed a
follow-up assessment.
958 CIRCUIT CLASS THERAPY FOR STROKE REHABILITATION, English
Arch Phys Med Rehabil Vol 88, August 2007
with 1 exception. At follow-up, signicantly more subjects in
the circuit class therapy group agreed or strongly agreed (n21
[95.5%]) that they had received enough PT during their
inpatient rehabilitation stay compared with the individual
therapy group (n11 [55.0%],
2
test12.27, P.003) (see
table 3).
We calculated LOS for all 64 subjects who completed the
trial, including 2 subjects who refused to complete the dis-
charge assessment. Discharge was delayed (due to waiting
either for a bed in a residential care facility or for essential
home modications to be completed) for 8 subjects (5 in the
individual therapy group, 3 in the circuit class therapy group).
LOS for these subjects was calculated as the number of days
between admission to rehabilitation and the date of the dis-
charge assessment (this assessment occurred within 1 week of
the multidisciplinary team deciding that the patient was ready
for discharge). Although subjects in the circuit class therapy
group had a shorter mean LOS (mean difference, 15.2d), this
did not reach statistical signicance (95% CI, 4.5 to 34.7d).
Subjects in the circuit class therapy group received signi-
cantly more therapy time per day (mean, 129.122.6min) than
subjects in the individual therapy group (mean, 36.69.4min)
(P.001, t22.68; 95% CI, 101.1 to 83.7). Subjects in
the individual therapy group received an average of 49.0 ther-
apy sessions with a mean of 0.94 sessions per day. Subjects in
the circuit class therapy group received an average of 60.0
therapy sessions with a mean of 1.6 sessions per day. On
average there were 4 subjects in the circuit class at any one
time. Both types of therapy were well tolerated with an atten-
dance rate of 92.1% in the individual therapy group and 83.3%
in the circuit class therapy group. Two subjects fell during
individual therapy sessions and 4 subjects fell during circuit
class therapy sessions. None of these falls caused injury.
We analyzed data from the rst 20 treatment sessions for
each subject in order to accurately describe the content of
individual therapy and circuit class therapy, and to determine
key differences in therapy content between the groups (table 4).
More than 75% of circuit class sessions included walking and
sit-to-stand practice and approximately a third of all circuit
class sessions included treadmill training. By contrast, only a
third of individual sessions included walking practice and
treadmill training was never included. However, almost half of
all individual treatment sessions included activities directed at
improving the quality of a subjects gait (eg, part-practice of
the swing phase of gait with a focus on reducing compensatory
hip circumduction or part-practice of the stance phase of gait
with a focus on increasing weight shift to the paretic side),
whereas gait quality was not specically addressed in any
circuit class therapy sessions. Practice of upper-limb functional
activitiessuch as lifting a cup to the mouthwas included in
a quarter of both circuit class therapy and individual therapy
sessions. In terms of the key statistical differences in therapy
content between groups, signicantly more circuit class ther-
apy sessions included practice of sit-to-stand (P.001,
t6.32; 95% CI, 12.3 to 6.4), walking (including negoti-
ating obstacles and stairs, P.001, t7.01; 95% CI, 11.5
to 6.4) and treadmill training (P.001, t5.78; 95% CI,
7.7 to 4.0). Signicantly more individual therapy sessions
included practice of transfers (including bed-to-chair, bed-to-
toilet, and car transfers, but not including sit-to-stand practice,
P.001, t4.37; 95% CI, 1.75.2) and exercises aimed at
improving gait quality (P.001, t7.68; 95% CI, 6.311.1).
DISCUSSION
We found no clinically important or statistically signicant
differences between circuit class therapy and individual PT
sessions for recovery of walking ability, functional balance,
and upper-limb function among a sample of persons receiving
inpatient rehabilitation poststroke. However, a signicantly
greater number of subjects in the circuit class therapy group
were able to walk independently at discharge from rehabilita-
tion and were satised with the amount of therapy received
compared with subjects who received individual therapy. The
sample included in our study can be considered representative
of a larger population of persons receiving inpatient rehabili-
tation after stroke because it included a broad range of func-
tional disability at baseline.
Despite the fact that subjects in the circuit class therapy
group did not receive individual treatment sessions, there were
few signicant differences between the groups in terms of
walking ability, functional balance, and upper-limb function,
with subjects in both groups showing signicant improvement
over time. In addition, circuit class therapy was more effective
than individual therapy in promoting independence in walking
at discharge from rehabilitation in this sample of subjects. This
may have been due to circuit class therapy subjects spending a
signicantly greater amount of time engaged in walking prac-
tice. Additionally, the structure of circuit class therapy was
such that it encouraged greater participant autonomy, thereby
encouraging problem solving and independence. Thus, it is
possible that not only the increased amount of walking prac-
tice, but also the environment in which this practice occurred,
had an impact on the increased level of walking independence
Table 2: Baseline Characteristics of the Study Sample
Characteristics
Individual
Therapy
(n37)
Circuit Class
Therapy
(n31)
Mean age SD (y) 68.912.3 61.611.8*
Mean FIM score SD (range, 18126) 78.717.6 83.116.5
Sex (male/female) 25/12 16/15
Side of stroke lesion (left/right) 15/22 11/20
Stroke type (infarct/hemorrhage) 34/3 24/7
Mean time between stroke and
admission to rehabilitation SD (d) 24.412.4 29.715.5
*Statistically signicant difference at P.05.
Table 1: Reasons for Subject Attrition
Reason for Attrition
Individual
Therapy
Circuit Class
Therapy
Suspected lower-limb fracture after
fall on ward 1 2
Suspected extension of stroke 0 2
Withdrawal of informed consent 0 1
Lower-limb vascular surgery required 0 1
Acute illness requiring readmission
to an acute hospital (decreased
respiratory function, severe urinary
tract infection, acute bowel
obstruction) 1 2
Discharged within 2 weeks 0 2
Acute psychiatric illness requiring
readmission to an acute hospital 2 0
Total number of subjects lost 4 10
NOTE. Values are counts. Ten subjects withdrew before the week-4
assessment and a further 4 subjects withdrew between week 4 and
discharge.
959 CIRCUIT CLASS THERAPY FOR STROKE REHABILITATION, English
Arch Phys Med Rehabil Vol 88, August 2007
within the circuit class therapy group. All known previous
studies of circuit class therapy involved subjects who were
already able to walk independently at baseline.
14,16,38-40
There-
fore, this study is the rst to show that circuit class therapy is
effective in promoting independent walking ability poststroke.
The reasons for the signicant improvement in gait speed and
functional walking capacity between discharge and follow-up
for the individual therapy group but not the circuit class therapy
Table 3: Summary of Main Outcome Variables
Outcome Variables Individual Therapy Circuit Class Therapy
Mean Difference
Between Groups (95% CI)
5MWT (m/s)
Mean SD (n)
Admission 0.370.40 (37) 0.410.43 (31) 0.04 (0.25 to 0.17)
Week 4 0.530.43 (36) 0.580.46 (30) 0.07 (0.28 to 0.14)
Discharge 0.720.43 (34) 0.760.41 (28) 0.02 (0.20 to 0.23)
Follow-up 0.950.45 (20) 0.850.48 (22) 0.13 (0.09 to 0.35)
2MWT (m)
Mean SD (n)
Admission 36.840.3 (37) 41.144.1 (31) 4.3 (26.3 to 17.6)
Week 4 58.148.7 (36) 57.644.9 (30) 1.8 (23.8 to 20.2)
Discharge 74.346.5 (34) 76.143.0 (28) 3.1 (18.9 to 25.2)
Follow-up 103.047.6 (20) 82.148.3 (22) 23.1 (0.21 to 46.0)*
BBS scores (range, 056)
Mean SD (n)
Admission 28.217.7 (37) 32.315.5 (31) 4.1 (10.5 to 2.3)
Week 4 37.116.4 (36) 40.812.9 (30) 3.9 (10.3 to 2.0)
Discharge 46.77.9 (34) 48.07.4 (28) 1.1 (5.2 to 7.6)
Follow-up 50.84.9 (20) 49.18.5 (22) 3.0 (4.1 to 10.1)
Upper-limb MAS scores (range, 018)
Median (IQR) (n)
Admission 5.0 (0.812.0) (37) 10.0 (1.013.0) (31) NA
Week 4 6.5 (1.013.0) (36) 12.0 (1.014.0) (30) NA
Discharge 9.5 (4.814.0) (34) 12.0 (2.014.0) (28) NA
Follow-up 13.0 (7.514.8) (20) 14.0 (2.016.0) (22) NA
No. of subjects rated as independent on the ILAS
N (%) (n)
Admission 7 (18.9) (37) 7 (22.6) (31) NA
Week 4 14 (38.9) (36) 15 (50.0) (30) NA
Discharge 23 (67.6) (34) 26 (92.0) (28)* NA
Follow-up 17 (85.0) (20) 19 (61.3) (22) NA
Responses to the question I have had enough physiotherapy
at follow-up n21 n22
N (%)
Strongly agree 10 (50.0) 13 (59.1) NA
Agree 1 (5.0) 8 (36.4) NA
Disagree 7 (35.0) 1 (4.5) NA
Strongly disagree 2 (10.0) 0 (0.0) NA
LOS (d)
Mean SD (n) 71.344.0 (36) 56.131.1 (28) 15.2 (4.5 to 34.7)
Abbreviations: IRQ, interquartile range; NA, not applicable.
*Statistically signicant between-group difference at P.05.
Table 4: Summary of the Activities of Individual and Circuit Class Subjects Over 20 Treatment Sessions Showing Means and
Between-Groups Differences
Activities Individual Therapy Circuit Class Therapy Mean Difference (95% CI)
Treadmill training 00 5.845.62 5.8 (7.7 to 4.0)*
Gait quality 9.146.49 0.422.16 8.7 (6.3 to 11.1)*
Gait practice 6.275.36 15.195.06 8.9 (11.5 to 6.4)*
Upper-limb functional activities 4.975.24 4.816.30 0.17 (2.7 to 3.0)
Sit to stand 5.705.62 15.066.60 9.4 (12.3 to 6.4)*
Transfer practice

3.784.74 0.320.79 3.5 (1.7 to 5.2)*

*Statistically signicant difference at P.05.

Includes bed-to-chair, bed-to-toilet, and car transfers, but not sit-to-stand.

960 CIRCUIT CLASS THERAPY FOR STROKE REHABILITATION, English
Arch Phys Med Rehabil Vol 88, August 2007
group are unclear. Moreover, these results should be inter-
preted with caution because 36.8% of the sample did not attend
the follow-up assessment and those who did attend were some-
what less disabled at discharge than the nonattendees.
A strength of our study design was that circuit class therapy
comprised a set of core activities, individually adapted and
progressed such that each subject was always challenged to
his/her maximum ability. This allowed the circuit class therapy
to be the sole model of PT service delivery, rather than a
package of treatment delivered in addition to usual therapy.
Thus, the current study was able to demonstrate the feasibility
of circuit class therapy as an alternative sole model of PT
service delivery for a representative sample of persons receiv-
ing inpatient rehabilitation poststroke.
The ability to provide a signicantly greater amount of
therapy time with a lower staff to patient ratio in our study
suggests that circuit class therapy may also be a more cost-
effective method of therapy delivery. In our study the total
amount of therapist time required to provide circuit class ther-
apy for 6 patients was a mean of 130 minutes a day, whereas
the total amount of therapist time required to provide individual
therapy sessions for 6 patients was 222 minutes a day (based on
a mean duration of 37 minutes for individual sessions). This
represents a difference of more than 90 minutes a day of
therapist time. Additionally, circuit class therapy participants
received a signicantly greater amount of therapy a day. This
additional therapy time may have resulted in a shorter hospital
LOS, because although the difference in LOS in our study was
not statistically signicant, the condence interval suggested a
trend in favor of circuit class group subjects (mean difference,
15.2d; 95% CI, 4.5 to 34.7d). Coupled with similar ndings
by Blennerhassett and Dite
15
of a large, but not statistically
signicant, reduction in LOS associated with mobility related
to circuit class therapy, it is clear that future research into the
cost-effectiveness of circuit class therapy as an alternative
method of service provision is required.
There is increasing emphasis being placed on the importance
of patient satisfaction within health care evaluation and evi-
dence based medicine.
41-44
Several studies
34,41-44
have found
that the majority of persons recovering from stroke were not
satised with the medical and rehabilitative care they received.
Similarly, in our study 45% of subjects receiving individual
therapy were not satised with the amount of therapy they
received. Our nding that 95.5% of subjects receiving circuit
class therapy were satised with the amount of PT they re-
ceived is of particular clinical relevance, although perhaps not
surprising, considering the increased amount of therapy time
they received. However, this nding must be interpreted with
caution in view of the large drop-out rate between discharge
and follow-up. Nevertheless, patient satisfaction data col-
lected at follow-up may be a more accurate reection than
that measured during inpatient rehabilitation, given that
patients are often reluctant to express dissatisfaction with
hospital services,
45
and may therefore be more honest in
reporting levels of satisfaction when they are no longer
receiving hospital services.
46
Study Limitations
The heterogeneous nature of the sample was a limitation of
our study. Further research with a larger, more homogeneous
sample of subjects with moderate disability may yield more
denitive results, as it is well established that persons with
stroke resulting in moderate disability demonstrate greater im-
provement in functional abilities during rehabilitation, com-
pared with those with mild or severe impairment.
47
Although
the nonrandom allocation of subjects to groups in our study had
the potential to bias the results, age was the only signicant
difference between the treatment groups at baseline, and the
use of age as a covariant in the analyses did not alter the results.
Although an additional limitation was the rate of subject attri-
tion, the reasons for withdrawal from the study (see table 1)
appeared to be unrelated to the type of therapy provided.
Although 3 subjects suffered falls necessitating withdrawal
from the study, all occurred outside of therapy sessions, mak-
ing it highly improbable that the type of PT the subjects
received was responsible. Additionally, although there were 2
cases of suspected extension of stroke, both occurring in the
circuit class therapy group, neither was conrmed by radio-
logic examination. Some studies in the rat model have sug-
gested that early, intensive therapy within the rst week after
stroke may increase the risk of stroke symptoms worsening.
48
However, there have been no published reports of stroke ex-
tension or worsening stroke symptoms associated with in-
creased intensity of therapy provided to persons more than a
week after stroke. Nevertheless, it would be pertinent for future
studies of circuit class therapy to include assessment of the
incidence and severity of infarct extension. A further limitation
of our study design was that the discharge assessment did not
occur at a standardized time. However, the inclusion of these
data made it possible to compare functional ability at discharge
between treatment groups. These limitations of study design
highlight the difculties inherent in clinical research, in partic-
ular nding a balance between ideal study design, the practi-
calities of clinical research, and the applicability of the ndings
to a clinical setting.
Future research into the effectiveness of circuit class therapy
is clearly warranted. Preferably, such research should involve a
more homogeneous study sample, random allocation to treat-
ment groups, and standardized assessment times. Although
such studies would require signicant nancial support, the
potential for circuit class therapy to be a more cost effective
method of service delivery and to reduce hospital LOS justies
this support.
CONCLUSIONS
Subjects receiving either circuit class therapy or individual
therapy demonstrated a similar degree of recovery on objective
measures of mobility and upper-limb function for person re-
ceiving inpatient rehabilitation after stroke. However, circuit
class therapy was associated with a signicantly greater degree
of independence in walking at discharge from rehabilitation
and signicantly higher patient satisfaction with the amount of
therapy received. Furthermore, the study demonstrated the
feasibility and safety of circuit class therapy as an alternative
sole model of PT service delivery for person receiving inpatient
rehabilitation after stroke.
Acknowledgments: We thank the staff of the Royal Adelaide
Hospital Physiotherapy Department and Medical Rehabilitation Unit
at Hampstead Rehabilitation Centre, in particular Julie McGuiness, for
their support and assistance in conducting the trial.
APPENDIX 1: LIST OF EXERCISES INCLUDED IN
CIRCUIT CLASS THERAPY
Lower-limb exercises
Forward and lateral step raises. (Subject placed affected
leg on a step placed in front or to the side and raised
him/herself onto step.)
Eccentric quads over edge of step. (Subject stood on a step
and lowered unaffected leg to touch the ground. To
progress exercise, subjects touched a foam cup placed on
961 CIRCUIT CLASS THERAPY FOR STROKE REHABILITATION, English
Arch Phys Med Rehabil Vol 88, August 2007
APPENDIX 1: LIST OF EXERCISES INCLUDED
IN CIRCUIT CLASS THERAPY (contd)
the ground in front of the step without crushing it before
returning to the start position.)
Heel raises, either from standing at on the ground or
standing on a wedge.
Squats.
Active hamstrings in sitting. (Subject sat on a chair and
bent affected knee as far as possible. A small towel or
slippery sam material was used to reduce friction to
make the exercise easier and weights were strapped to the
ankle to make the exercise harder.)
Reaching in various directions out of the base of support
in sitting (to activate leg musculature).
Stretches of the gastrocnemius and soleus muscles in
standing.
Riding an exercise bicycle.
Sit-to-stand and walking exercises
Sit-to-stand from various heights including from an ad-
justable plinth, chairs with and without arms, and stools.
To progress the exercise, subjects placed their unaffected
leg on a small step.
Stepping onto and off a step.
Walking indoors, forward, backward, and sideways.
Walking outdoors.
Walking on the treadmill.
Walking up and down stairs.
Walking around obstacle courses including stepping over
and around objects, up and down steps, over soft surfaces,
and picking up objects from the oor. Subjects also ne-
gotiated obstacle courses while carrying a tray of objects
(for dual-task performance).
Exercises to improve postural control in standing
Reaching to touch marks or trace a spiral shape on a
whiteboard. Different stance positions were used includ-
ing feet together and tandem stance.
Stepping grid. Subjects stood with feet in marked areas,
then tapped 1 foot out to touch marks on oor, repeating
with the other foot.
Reaching to pick up objects from low surfaces or the oor.
This exercise was also performed in pairs with subjects
passing objects to each other.
Alternatively tapping toes onto step in front. To progress
the exercise, subjects had to tap a foam cup placed on the
step without deforming it.
Throwing and catching balls in pairs or groups.
Practicing standing on 1 leg.
Walking with a heel-toe gait or braiding (ie, walking
sideways with the trailing leg alternating between crossing
in front of, or behind the leading leg with each step).
Exercises for the upper limb and hand
Prolonged shoulder positioning in either forward exion
or abduction. Where elbow contracture or stiffness was an
issue, a circumferential foam splint was used to hold the
elbow in maximal extension.
Active shoulder girdle movement with the arm supported
on a high surface.
Reaching to grasp and move various size objects on and
off of shelves.
Taking lids on and off jars.
Pegging washing onto a line.
Folding washing.
APPENDIX 1: LIST OF EXERCISES INCLUDED
IN CIRCUIT CLASS THERAPY (contd)
Scooping coins off the edge of a table.
Spooning or pouring water from cup to cup.
Lifting and moving a pen around a marked grid.
Turning over playing cards (this exercise was often per-
formed in pairs).
Active pronation and supination.
Active wrist extension, using small weights strapped to
the hand when appropriate.
Active shoulder external rotation with arm supported on a
table.
Active shoulder internal and external rotation using Thera-
Band for resistance.
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