Lawal et al.

BMC Neurology (2015) 15:88

DOI 10.1186/s12883-015-0348-7

STUDY PROTOCOL Open Access

Effectiveness of a structured circuit class

therapy model in stroke rehabilitation: a
protocol for a randomised controlled trial
Isa U. Lawal1,4*, Susan L. Hillier2†, Talhatu K. Hamzat3† and Anthea Rhoda1†

Abstract
Background: Currently, the key advocacy in neuroscientific studies for stroke rehabilitation is that therapy should
be directed towards task specificity performed with multiple repetitions. Circuit Class Therapy (CCT) is well suited to
accomplish multiple task-specific activities. However, while repetitive task practice is achievable with circuit class
therapy, in stroke survivors repetitive activities may be affected by poor neurologic inputs to motor units, resulting
in decreases in discharging rates which consequently may reduce the efficiency of muscular contraction. To accomplish
multiple repetitions, stroke survivors may require augmented duration of practice. To date, no study has examined the
effect of augmented duration of CCT in stroke rehabilitation, and specifically what duration of CCT is more effective in
influencing functional capacity among stroke survivors.
Methods/design: Using a randomised controlled trial with blinded outcome assessment, this study is aimed at
determining the effectiveness of structured augmented CCT in stroke rehabilitation. Sixty-eight stroke survivors (to be
recruited from a tertiary health institution in Kano, Northwest, Nigeria) will be randomised into one of four groups: three
intervention groups of differing CCT durations namely: 60 min, 90 min, and 120minuntes respectively, and a control
group. Participants will take part in an 8-week structured intensive CCT intervention. Participants will be assessed at
baseline, post-intervention, and six-month follow-up for the effectiveness of the varied durations of therapy, using
standardised tools. Based on the WHO-ICF model, the outcomes are body structure/function, activity limitation, and
participation restriction measures.
Discussion: It is expected that the outcome of this study will clarify whether increasing CCT duration leads to better
recovery of motor function in stroke survivors.
Trial registration: Pan African Clinical Trial Registry (PACTR): PACTR201311000701191
Keywords: Stroke, ICF model, Circuit class therapy, Exercise intensity, Neuro-rehabilitation

Background which are associated with limitations or decline in inde-

Stroke is a growing global health-care crisis, with grave pendent mobility [3–6].
and disabling consequences [1]. In most countries, stroke Substantial evidence suggests that task-specific train-
is the second or third most common cause of death, and ing can assist functional recovery in stroke rehabilitation,
one of the main causes of acquired adult disability [1, 2]. with the goal of achieving true recovery of function
Motor impairments (of upper and lower extremities) are based on motor learning principles, including purpose-
the major recognisable impairments caused by stroke, fulness, multiple repetitions, and intensified activity [7,
8]. Circuit Class Therapy (CCT) is a form of Task Spe-
* Correspondence: [email protected] cific Training (TST) that involves the practice of struc-
†
Equal contributors turing tasks in a circuit or series of workstations. It
1
Department of Physiotherapy, Faculty Community and Health Sciences, satisfies the three key characteristics of an effective and
University of the Western Cape, , Private Bag X17, Bellville 7535, South Africa
4
Department of Physiotherapy, Faculty of Allied Health Sciences, College of efficient skill training programme [9] including: (i) using
Health Sciences, Bayero University, Kano, Private Mail Bag 3011, Nigeria different workstations that allow people to practice
Full list of author information is available at the end of the article

© 2015 Lawal et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://
creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Lawal et al. BMC Neurology (2015) 15:88 Page 2 of 10

intensively in a meaningful and progressive way to suit Clinically, in CCT, participants are exposed to multiple
their respective needs; (ii) efficient utilisation of thera- progressively structured tasks to be accomplished within
pists’/trainees’ time; and (iii) it encompasses group dy- a session, and considering the pathophysiological chal-
namics such as peer support and social support [9, 11]. lenge of stroke survivors, they may need more time to
Several research trials have shown that CCT is effective perform multiple repetitions to enable neuroplastic changes.
in improving balance, transfers, gait, gait-related activ- Rose et al. [35] have proposed that planning the contents
ities (such as climbing stairs) and upper limb functions of a session in advance with predetermined progression of
in stroke survivors [12, 13], especially when applied tasks may allow more time for in-session practice.
within the first six months after stroke [12, 14–16] and In summary, pathophysiological and clinical factors may
even later [10, 13, 17–20]. in isolation or collectively support the need to examine the
The goal of CCT in stroke rehabilitation is to institute effect of augmented therapy time in CCT. However, while
an enduring motor learning in order to optimise motor there is a need to investigate the effect of augmenting the
and functional recovery necessary for the achievement duration of therapy, it is equally imperative to determine
of community reintegration of stroke survivors. To ac- how acceptable these CCT durations are among stroke
complish sustained motor learning, rehabilitation must survivors.
be geared towards a relatively permanent behavioural
change, which is currently believed to manifest as a re- Objective
sult of neuroplastic change in the brain itself [21]. Com- The objective of this study is to investigate the relative
pelling evidence from neuroscientific studies suggest effectiveness of augmented durations of CCT on the
that neuroplastic changes in the cerebral cortex and in functional capacity of stroke survivors. Additionally, the
other parts of the central nervous system (CNS) are the study will investigate the effectiveness of augmented dur-
physiological mechanism for effective motor skill retrain- ation of CCT on upper and lower extremity functions
ing following stroke [22–26]. These studies identified TST (with respect to body structure/function, activity limitation
and intensity of multiple repetitions as critical nexuses to and participation restriction) post-stroke and the accept-
enhancing neural reorganisation and “rewiring” in the ability of the various CCT durations among stroke survi-
CNS. By implication the damaged brain will therefore vors. For these to be achieved outcomes of interest will be
benefit from repeated sensorimotor inputs (efferent-affer- assessed based on the World Health Organisation Inter-
ent feedback loops) in order to remodel effectively for the national Classification of Function, Disability and Health
attainment of motor/functional recovery in stroke survi- model (WHO-ICF) [36].
vors. This signifies the need for rehabilitation professionals
to focus on meaningful, repetitive, and intensive specific Methods/Design
tasks during a rehabilitation session [27]. Study design/setting
Stroke survivors demonstrate poor activity tolerance This study is a randomised controlled trial of the effective-
[28] and performance [29]. These may suggest the need ness of augmented durations of a structured CCT model
for longer duration to tolerate and perform repetitive ac- in the rehabilitation of stroke survivors. All participants
tivities. The need to augment the duration of therapy in will be recruited from Aminu Kano Teaching Hospital
CCT for stroke survivors can be considered based on (AKTH) in Kano State, Northwest of Nigeria. The hospital
pathophysiologic and clinical domains. Pathophysiologic- (AKTH) is a tertiary health institution, situated in Kano,
ally, the sequelae of an upper motor neuron lesion result the most populous state in Nigeria, with over 9 million in-
in hemiparesis/hemiplegia, marred balance and coordin- habitants [37]. It is a 500-bed-capacity hospital that re-
ation and decreased proprioceptive feedback [30]. These ceives patients from within Kano and the neighbouring
put together will negatively affect daily activities and ex- states of Jigawa, Katsina, Kaduna, Bauchi and Zamfara
ercise performance, leading to activity intolerance, in- states. The patronage list comprises primarily the indigen-
creased energy cost of activity, and a decline in overall ous Hausa Fulani tribe, although Nigerians of other tribes
performance after stroke [27]. Cumulatively, these factors such as the Ibo and Yoruba ethnic groups also constitute a
result in longer reaction time and longer time to accom- sizeable number of the clientele.
plish tasks, thus suggesting the need to give adequate time
for the performance of multiple repetitive tasks in stroke Participants
survivors, well beyond age and gender-matched individ- Participants will include all stroke survivors in AKTH re-
uals without history of stroke. Four systematic reviews and ferred for physiotherapy by consulting physicians. How-
one Cochrane review have shown that augmentation of ever, only participants who meet the inclusion criteria will
exercise therapy and/or time of exercise therapy results in be considered for randomisation into the study groups
significant small to moderate gains in ADL, walking ability (involving intervention and control groups). Participants
and walking speed [31–34]. will be considered eligible if: stroke is ascertained to be
Lawal et al. BMC Neurology (2015) 15:88 Page 3 of 10

due to cerebrovascular accident; leading to unilateral at α = 0.05, a total sample size of 56 was generated, using
motor deficits [14]; they provide a written informed con- an estimated standard deviation (SD) for the calculation as
sent; they are adult stroke survivors of ≥18 years of age; on- adopted from a meta-analysis [9]. The 42.3 m was proposed
set of stroke is ≥30 days; they possess sufficient cognition as the minimum clinically important difference in walking
to participate (having a score of ≥24 points on mini-mental distance, based on previous studies of implicit measure-
state examination); they are willing to participate in an 8- ment error following repeated measurement of speed. The
week intensive CCT programme; have the ability to walk generated total sample size of 56, by implication, will give
for 10 m unsupported (walking aid is allowed); and have a 14 participants as samples for each group. To incorporate
minimum active wrist extension (2/5 on manual muscle drop-out to follow-up, we hope to recruit a total of 68 par-
testing). Participants will be considered ineligible if they ticipants (17 participants per group). The power calculation
present with precluding medical comorbidity to exercise, was conducted using G*Power version 3.0.10.
and history of any major surgical procedure significant
enough to interfere with performance (general or ortho- Randomisation and blinding
paedic) in an exercise therapy intervention. Randomisation will be conducted using a computer-
Stroke survivors who meet the eligibility criteria will be generated random allocation sequence schedule held by a
randomised into one of four arms of the study, including third party, who will randomly allocate recruited partici-
three intervention categories (60 min CCT, 90 min CCT pants into the study group (Fig. 1. outline of the study flow
and 120 min CCT) and one control (60 min standard diagram based on CONSORT [38]). To eliminate bias, the
physiotherapy). assessment of outcome will be performed by (experienced/
trained) blinded assessors, who will be blinded to the
Sample size and power calculation nature/type of intervention as well as the intervention
Using power calculations to detect a between-group differ- groups of the participants. Participants will also be
ence of 42.5 m (0.43 effect size) for a 4-group repeated instructed not to disclose their individual intervention
measure MANOVA in walking distance with 90 % power groups to the assessors.

Fig. 1 Outline of study flow diagram

Lawal et al. BMC Neurology (2015) 15:88 Page 4 of 10

Table 1 Study assessment tools

Scales Function/application
Body structure and function assessment
i. Modified Tardieu Scale (MTS)
The MTS measures spasticity [39]. Descriptively, the MTS has two measurements, the
quality of muscle reaction (ordinal scale) and the angle of reaction or angle of catch
(ratio). The quality of muscle is scored from 0–5; 0 implies no resistance to Passive Range
of Movement (PROM) and 5 indicating joint immobile. On the other hand Angle of catch
can be understood via two factors of PROM, the speed of movement and joint angle. The
reporting of MTS summarily, involve the quality of muscle and angle of reaction components
making it to fit into the body structure and function of the ICF absolutely. It has excellent test
retest reliability (ICC = 0.86) in stroke patient [40], with good convergent validity for both
elbow and ankle joints (r = 0.86 and r = 0.62 respectively) [39].
ii. Medical Research Council Manual Muscle Testing (MMT)
MMT will be used to assess muscle strength for upper and lower extremities, attention
will be paid to specific joints of both extremities. For the upper extremity attention will
be focused on shoulder, elbow and wrist joints and for the lower extremity joints hip,
knee and ankle will be measured. MMT is the best known and most frequently employed
muscle strength grading system for manual muscle testing (MMT) [41]. It has a score
range of 0–5, with 0 being the minimum and 5/5 the maximum. An excellent test-retest
reliability for both right and left hip joints (ICC = 0.98 and ICC = 0.97 respectively) with
osteoarthritis [42]. Its convergent validity ranges between adequate to excellent in different
body parts [43].
Activity assessment
i. Modified Rankin Scale (MRS)
The MRS is a hierarchical scale of 0–6 points that indicate “global disability”. It is the most
prevalent functional outcome measure for stroke research. Lower scores on the scale
suggest more independence and higher scores signify increased dependency. Its test-retest
reliability ranged between adequate to excellent (Kappa = 0.67-0.96) [44], with an excellent
convergent validity [45].
ii. Modified Barthel Index (MBI)
The MBI assesses ten functional tasks of daily living (activities of daily living – ADL). It
scores the individual based on independence in each task. Scores range from 0 and 100,
with a higher score indicating greater independence. The inter-rater reliability is sufficient
at the item level (kappa 0.50–0.78) and good for the overall inter-rater agreement (intraclass
correlation coefficient [ICC] 0.77) [46, 47].
iii. Six-minute Walk Test (6MWT)
6MWT is a clinically useful measure of walking ability post stroke, which incorporates the
important requirements of ambulation, such as walking speed, dynamic balance, and
submaximal endurance. It is performed at the individually determined fastest speed
possible during walking, making it ideal for stroke survivors [48]. It measures an individual’s
ability to walk for a maximum distance (meters) within 6 min. This test exhibits excellent
test-retest reliability (ICC = 0.973; 95 % CI = 0.925 to 0.988), a minimal detectable change of
54.1 m, and an acceptable concurrent validity (r = 0.52 to 0.89) [48].
iv. 10 Meter Walk Test (10MWT)
Participants’ gait speed will be measured using 10MWT [48], which will be calculated by
the time required to cover a distance of 10 m. Participants will be asked to walk at their
maximal speed using their regular foot wear and walking aids (for those who use aids).
The test will be performed on a 14 m walkway, to avoid the effects of acceleration and
deceleration, therefore the individual may accelerate 2 m before entering the 10 m
distance and 2 m to decelerate afterward, this will ensure a steady velocity within the
10 m mark. 10MWT shows a high intra-observer reliability (ICC = 0.95) and validity (r = 0.79) in
stroke survivors [49].
v. Action Research Arm Test (ARAT)
The ARAT is a criterion-rated assessment of upper extremity activity limitations [50]. The
ARAT includes 19 items divided into four subscales: grasp, grip, pinch, and gross movement.
The items within each subtest are ranked based on a four-point ordinal scale ranging from
zero to three, where three symbolises normal performance on each item. The items are
ordered in a hierarchy, allowing skipping some items if the person is unable to do an earlier
item normally. A score of 57 indicates normal performance. The test has a good test-retest
reliability for both chronic and acute stroke, ICC = 0.963 [51], internal consistency α = 0.985
[50] and construct validity in relation to the arm section of Fugl Meyer, ICC = 0.925 [51].
Lawal et al. BMC Neurology (2015) 15:88 Page 5 of 10

Table 1 Study assessment tools (Continued)

vi. Motor Activity Log (MAL)
The motor activity log (MAL) is a rating scale that evaluates how the affected hand is
used to perform 30 daily activities (e.g., feeding, turning a door handle). For each activity,
the patient rates how much the affected hand is used (amount of use, AOU) and how
well the activity is performed (quality of movement, QOM). Ratings are usually on a scale
of 0 to 5, with higher scores representing better functions. Scores on each scale are
calculated as the mean of the scored items attempted with the affected arm. Its internal
consistency is good, α > 0.81, with acceptable test retest reliability r > 0.91 and stability
ratio >3 for the QOM and AOU, though not found to be reliable [52].
Participation assessment
Stroke specific Quality of Life Questionnaire (SS-QOL)
SS-QOL is selected to assess community participation. The SS-QOL is a self-report
questionnaire consisting of 49 items cutting across 12 domains of mobility, energy,
upper extremity (UE) function, work/productivity, mood, self-care, social roles, family
roles, vision, language, thinking, and personality specific for stroke survivors. The domains are
graded individually, and a total grade is also rendered [53]. SS-QOL has a good content
validity, kappa coefficient ranged from 0.75-1.00, it demonstrated multiple representations of
the ICF categories and covered a broad range of the ICF components that were meaningful
for the stroke subjects [54].
Acceptability
To assess acceptability participants will complete a purpose-designed questionnaire [55].
The tool is a six-item scale adapted from the original treatment acceptability questionnaire, it
is a seven point scale, with lower score indicating lower acceptability. Possible score on the
scale ranged from 6–42. Participants in all the intervention groups and the control will be
asked to provide information specific to their treatment. The test has not been tested for
reliability and validity.

Procedures descriptive personal and stroke data. Also at this time,

This study has been approved by both the Senate Re- the intervention acceptability measure will also be
search Grants and Study Leave Committee University of applied.
the Western Cape (South Africa) (ethics number 13/9/33) Participant adherence will be duly monitored and re-
and the Human Research Ethics Committee of Aminu corded for each session in terms of attendance (number
Kano Teaching Hospital (Nigeria) (NHREC/21/082008/ of sessions) and amount of practice (within sessions –
AKTH/EC/1232). time spent and repetitions where relevant). Fidelity of
Assessment of participants will be conducted at three the intervention will be monitored by the primary inves-
stages (baseline, post-intervention, and at 6-months tigator performing video recordings of randomly chosen
follow-up). To ensure a comprehensive assessment, we sessions in each arm. Co-investigators will review these
chose a battery of measures covering the WHO-ICF videos for compliance with the established practice pro-
model [36]. We selected certain tools to cover the three tocols. Safety issues and adverse events will be recorded
key domains proposed by the ICF: body structures and by treating staff in each group and monitored by the co-
function, activity and participation. At baseline, partici- investigators. Previous trials using CCT have found no in-
pants will be assessed for socio-demographic characteris- crease in adverse events as compared to usual care [32].
tics which will include personal demographic information
and stroke-specific information. The personal demo- Intervention groups
graphic information will include age, sex, height, weight, The intervention groups are the three intensities (dura-
marital status (pre- and post-stroke), educational qualifica- tions) of CCT namely 60 min, 90 min, and 120 min,
tion, employment (pre- and post-stroke), and tribe. The tagged groups A, B and C respectively. All participants
stroke-specific information will include time since stroke, will be assessed at baseline (prior to the intervention),
type of stroke, hemispheric side of lesion, and use of cane. post-intervention and at six-month follow-up. A total of
This will be followed by ICF-based assessments, all at 10 workstations will be made available in the circuit, ar-
baseline. The outcome measures to be employed for these ranged to progress in complexity. These stations will be
assessments and their function/application are presented made up of task-specific activities for the upper and
in Table 1. lower extremity, structured alternately across the circuit
All baseline measures will be repeated immediately (i.e., after every lower extremity workstation an upper
post-intervention and 6 months follow-up, excluding extremity workstation follows), ensuring a 1:1 ratio of
Lawal et al. BMC Neurology (2015) 15:88 Page 6 of 10

Table 2 Circuit class therapy task specific activities for the intervention
Stations/description Prescribed tasks
Workstation 1
Tasks for warm-up specific for upper extremity
Active flexion- extension of shoulder, elbow and wrist joints
Abduction-adduction of shoulder joint
Upper extremity weight bearing on physiotherapy ball
Push-ups on physiotherapy ball or using chair arm rest
Workstation 2
Tasks for warm-up specific for lower extremity
Stretching the lower extremity (flexion/extension of the limb in supine or sitting position)
Marching on spot
Shuttle walking
Jogging on spot
Workstation 3
Tasks to achieve reaching, gripping and transferring light objects
Sitting with arm supported on high plinth at 90° shoulder flexion
Active protraction to push small objects (light ball) off edge of plinth to target the wall
Sitting same way to push weighted object (a heavier ball)
Active horizontal abduction and adduction to reach object (cup) on the wall
Use of protracted shoulder to open a door with patient standing three feet away from
the door
Wrist flexion/extension in gravity counter balance (provide a target to aim for)
Radial and ulnar deviation (in gravity counter balance) with a target to push (cup)
Picking light objects from table to the wall and back
Workstation 4
Tasks to achieve lower extremity flexibility and function
Timed shuttle walk/Initiation of minimal Shuttle jogging (50 % of time allotted for this
station)
Sit to stand from high chair with arm rest (placing affected leg behind the intact)
Stationary bike riding
Squatting activity using the wall bars
Workstation 5
Task to achieve upper extremity strength/control
Active shoulder flexion, extension and abduction with weight of varying sizes (dumbbells)
Active shoulder flexion, extension and abduction with resistant band to reach for a target
on the wall (cup)
Active shoulder abduction with weights of varying sizes (dumbbells), to reach for a target
on the wall
Active elbow flexion/extension with resistance band. Also substitute with varying weights
Active wrist flexion/extension, ulna/radial deviations with resistance band. Can be
substituted later with weights of varying sizes
Finger to nose movement
Rapid hand alternating movements
Workstation 5
Task to achieve upper extremity strength/control
Active shoulder flexion, extension and abduction with weight of varying sizes (dumbbells)
Lawal et al. BMC Neurology (2015) 15:88 Page 7 of 10

Table 2 Circuit class therapy task specific activities for the intervention (Continued)
Active shoulder flexion, extension and abduction with resistant band to reach for a target
on the wall (cup)
Active shoulder abduction with weights of varying sizes (dumbbells), to reach for a target
on the wall
Active elbow flexion/extension with resistance band. Also substitute with varying weights
Active wrist flexion/extension, ulna/radial deviations with resistance band. Can be
substituted later with weights of varying sizes
Finger to nose movement
Rapid hand alternating movements
Workstation 6
Task to achieve balance/coordination while walking
Sit to stand from lower chair without arm rest (affected leg behind a distant placed intact
leg)
Standing on foam eye closed (safety is key in this activity)
Carrying object while on shuttle walking (a tray with cup of water)
Walk up and down stairs (patient walk backward while coming down stairs)
Sudden stops and turns while walking
Obstacle crossing while walking
Figure 8 walking
Workstation seven
Task to achieve improved grip, precision and dexterity with upper extremity
Draw a line on the white board
Rolling a dumbbell forwards and backwards on a flat surface (table)
Open and close a window
Take lids off bottles
Bring object from table to mouth, vary size and weight of objects
Pour water from jug to cup
Mix water with spoon of various sizes
Take money in and out of a purse
Fold paper and place in an envelop
Trace pattern of different figures on white board
Workstation 8
Task to achieve lower extremity strength/control of gait
Walking different step length of parallel line
Obstacle crossing while walking with a tray of cups filled with water
Walking backward and side ways
Heel lift in standing without and with carrying an object
Walk on toes short distance forward and backward
Workstation 9
Task to achieve advanced motor task with upper extremity
Rolling pin pushing forward and backward
Reach, grasp and move objects to and from different heights
Wipe over windows
Wash, wring and peg clothing on lining rope
Paint sketched objects on cardboard paper
Use key boards to type
Lawal et al. BMC Neurology (2015) 15:88 Page 8 of 10

Table 2 Circuit class therapy task specific activities for the intervention (Continued)
Cut customised foams using knifes of varying sizes
Put-on common clothing and foot wears
Workstation 10
Tasks to achieve improved outdoor activities with lower extremity
Walking while picking objects from the floor
Walking through closely packed obstacles
Walking through tight space
Jumping on foam eyes closed
Walking on joined foams
Reverse walking on straight line
Treadmill walking/jogging
Speed stair climbing
Outdoor walking
NOTE:
1. Tasks within stations are not necessarily convenient and possible for all participants, choice is therefore individualized
2. Tasks in stations vary because it is not necessary for participants to undergo all activities and also to allow room for wide range of opportunities
and choices
3. Progression might be based on activities not initially possible within stations or based on modifications considered necessary by physiotherapist
4. Tasks are performed as structured in the model based on durations allotted for each group
Adapted from circuit class therapy intervention manual version 1.0 [56]

upper to lower extremity activities. This is to allow for methods) and functional activities for both upper and
adequate concentration, specificity of activity choice, and lower extremities. All the activities for the control group
distribution of equal activity duration for both upper and will be implemented by regular therapists (who are simi-
lower extremities. A minute change period (not within lar in qualification/experience to therapist implementing
specified duration of intervention) will be allowed for the CCT programme) in the Physiotherapy Department
crossing from one workstation to the next. of AKTH.
The intervention is an 8-week, 3-times weekly training
programme, giving a total of 24 sessions. Activities will Data analysis
be individualised allowing each participant to perform at Data will be recorded in Microsoft Excel before being
a level based on his/her ability, and progress steadily exported to Statistical Package for Social Science (SPSS).
within the allotted time for each group. Both descriptive and inferential statistics will be used to
The upper extremity task-orientated CCT activities examine the outcomes of the study.
will include activities to improve fine motor skills, grasp Descriptive statistics of frequencies, percentages, mean,
and reach, sensory function, and proximal control. Simi- and standard deviation will all be used to describe baseline
larly, tasks for the lower extremity will be targeted to assessments and demographic characteristics of partici-
balance, strength, cardiovascular endurance, and retrain- pants. Where appropriate, they will also be used at post-
ing of gait mobility. All CCT sessions will be conducted intervention and follow-up to describe relevant findings.
by three trained physiotherapists, with each treatment Between-groups relative mean differences of the dependent
session structured at a 3:1 ratio of patients to therapists. variables, (spasticity, muscle strength, functional independ-
Table 2 (below) presents the CCT task-specific activities ence, ADL, functional capacity, gait speed, upper extremity
to be implemented in this study. function and impairment) will be determined using the
general linear model repeated measures, MANCOVA
Control group (standard physiotherapy) models (for each study domain, adjusted central on base-
The standard physiotherapy group, like the intervention line as covariates). If the MANCOVA is found to be signifi-
groups, will involve the same number of sessions (24), cant (Roy’s largest root), univariate between-groups results
duration (60 min) and frequency per week (3) of therapy. will be reported and pair-wise post hoc analysis will be per-
Standard physiotherapy will comprise one-to-one ther- formed using least significant difference.
apist/patient sessions engaging in impairment-centred A multiple regression analysis will be performed to in-
mobilisation techniques, standing balance (using varying vestigate the relation between improvement at different
Lawal et al. BMC Neurology (2015) 15:88 Page 9 of 10

time periods of CCT and performance in each of the Acknowledgement

specific dependent variables, to detect which of the du- There is no special funding for this study. However, the authors would like to
acknowledge Ms. H. Ellen for editorial assistance.
rations most effectively predicts improvement in such a
variable. Author details
1
Department of Physiotherapy, Faculty Community and Health Sciences,
University of the Western Cape, , Private Bag X17, Bellville 7535, South Africa.
2
International Centre for Allied Health Evidence, School of Health Sciences,
Discussion University of South Australia (City East), Adelaide 5000, Australia.
3
Department of Physiotherapy, Faculty of Clinical Sciences, College of
Augmenting exercise therapy time to improve recovery Medicine University of Ibadan, Queen Elizabeth Road, Private Mail Bag 5017,
outcomes has been supported by some research findings GPO Dugbe, Ibadan, Nigeria. 4Department of Physiotherapy, Faculty of Allied
[31–34]. However, the amount of augmented time is not Health Sciences, College of Health Sciences, Bayero University, Kano, Private
Mail Bag 3011, Nigeria.
known, using CCT as a delivery model. In this era of
evidence-based practice, there is an urgent need to sup- Received: 24 October 2014 Accepted: 29 May 2015
port all facets of implementing CCT with cogent evidence
prior to adoption. The need to augment the duration of
therapy in stroke survivors might not be challenged, but References
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CCT: Circuit class therapy; TST: Task specific training; CNS: Central nervous effectiveness of an upper limb circuit training group on the performance of
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Organization; ICF: International classification of function; AKTH: Aminu Kano 14. English CK, Hillier SL, Stiller KR, Warden-Flood A. Circuit class therapy versus
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IUL, AR and SH conceived the idea for the study and developed the title. 18. Pang MY, Eng JJ, Dawson AS, McKay HA, Harris JE. A community-based
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