Bored and alone –

circuit training in neurorehab

Patients are inactive and alone for more than 60% of the rehabilitation day. They lie in bed bored. In many cases, more therapy is necessary, but is not easily possible under the prevailing conditions in the healthcare system. New concepts are needed. One promising approach is circuit training. Exercising in a group is a lot of fun for patients, promotes social interaction and, above all, is extremely effective. On your marks, get set, go!

Jakob Tiebel

The epidemiological development of neurological diseases around the world is dramatic. This is due mainly to the global demographic trend towards an older population. There is a growing number of patients in hospitals and rehabilitation centres today who need to be cared for by specialists from the field of neurology. In addition to patients with common diseases such as polyneuropathy and migraine, neurology primarily treats patients with neurodegenerative diseases such as Parkinson’s disease and autoimmune diseases such as multiple sclerosis. Stroke care is being brought into focus in particular because there are increasingly better treatment options due to new therapy alternatives (cf. GBD 2017).

According to the WHO, stroke is now the second leading cause of death worldwide, the third leading cause of years of life lost to illness and death, and one of the main reasons for living with permanent disability (cf. GBD 2017, Feigin 2014, Go 2014). The number of people who suffer at least one stroke in their lifetime has risen to 33 million p.a. in the last 20 years (84 per cent, cf. Feigin 2014).

The number of cases is expected to double by 2030 (cf. Lozano et al. 2012, Murray et al. 2012, Krishnamurthi et al. 2013).

Exercise at the performance limit is crucial

While 30 years ago we did not really understand what to do with neurological patients and the focus was on palliation rather than rehabilitation, today there is an increased emphasis on exercise-based therapies to effectively treat sensorimotor and cognitive deficits (Dobkin 2004, Hanlon 1996, Page 2003, van Peppen et al. 2007). The human brain is plastic and remains adaptable into old age. After damage, the brain is able to regenerate itself to a certain extent and is able to compensate for deficits caused by damage (Kleim & Jones 2008). However, the establishment of new movement representations and the reestablishment of motor control abilities requires a performance-limit-oriented, repetitive practice of motor tasks that focus on the skills to be improved (Dobkin 2004, Hanlon 1996, Page 2003, van Peppen et al. 2007).

Although standards are constantly improving and the chances of successful rehabilitation of patients with sometimes severe brain damage are increasing in terms of prognosis, there is a general problem with which neurorehabilitation has to contend: it does not do enough of what it knows!

Stroke patients are sufficiently active for just 64 per cent of the time in a conventional physiotherapy unit. Kaur, English and Hilier were able to prove that specific exercise in particular falls short.

Even fit patients lie in bed all day long

As early as 2012, in their review paper “Physical Activity in Hospitalised Stroke Patients”, West and Bernhard criticised the fact that patients in inpatient facilities spend around 60 per cent of the day alone in their hospital room and are inactive (West & Bernhard 2012). Recent studies also show that, for many patients, the hospital bed is still where they spend most of their time. Even fit individuals often lie in bed all day and only get up when necessary (Lay et al. 2016, Åstrand et al. 2016, Lacroix 2016, Rist et al. 2017). There are few justifications for this. Early activation and mobilisation is feasible and safe (Askim et al. 2012). This is also confirmed in the context of the early rehabilitation of COVID-19 patients, although the implementation of this therapy naturally involves some special features (AWMF 2020, see text below for more information).

Patients are inactive for more than a third of therapy time

Even in therapy sessions where the patient is supposed to break a sweat, there is a disproportionate amount of idle time (Kaur et al. 2012). Stroke patients are sufficiently active for just 64 per cent of the time in a conventional physiotherapy unit. Kaur, English and Hilier were able to prove that specific exercise in particular falls short. Only a quarter of the therapy time is spent working with stroke patients on relevant daily activities such as standing and walking (Kaur et al. 2012). One fifth of the time is spent on non-specific exercise, which according to current scientific knowledge has no significant influence on motor outcome (Verbeek et al. 2014). The required 800 step repetitions (Pohl et al. 2007; ReMoS working group 2015), which a non-ambulatory patient should do in order to regain the ability to walk, are rarely or never achieved (Lang et al. 2009, Kimberly et al. 2010). The average is just 185 steps per day (Kimberley et al 2010). This is not 5 repetitions per minute (Kimberley et al. 2010) and clearly too few for motor learning (ReMoS working group, Verbeek et al. 2014).

Therapists are subject to errors in perception

There is hardly any awareness of the problem. Therapists seem to make errors in their perception and systematically overestimate their patients’ activity levels (Kaur et al. 2013). The discrepancy is often excused by the fact that the patients’ capacity does not allow for the required increase in therapy. This is in contrast to qualitative findings by Luker and colleagues from 2015, which confirm that patients are more likely to believe that they cannot get enough therapy: “The more I did the better it was because this leg never worked. Now it is working!” They often don’t know what to do outside the therapies because there are no offers: “The help was good downstairs [in the physiotherapy gym] but when I come up here, I go to bed again – so what can I do?” And they often feel alone and bored because of this: “What happens during the day? Nothing! It’s boring, very boring!” (Luker et al. 2015).

The Dutch research group led by Kwakkel and Verbeek was already able to prove in 2014 that a specific increase in therapy of 16 hours within the first 6 months after a stroke leads to a significantly better outcome: “The results of the present research synthesis support the hypothesis that augmented exercise therapy has small but favourable effects on ADL (e.g. walking), particularly if therapy input is augmented at least 16 hours within the first 6 months after stroke.” (Verbeek et al. 2014).

The passive culture needs to change urgently

One week in bed equals ten years of muscle ageing. Other departments have already recognised the problem for themselves and started to act. The EndPJparalysis campaign is a positive example of how experts and the whole organisation can help to change the positive behaviour of their patients in hospital in the best possible way, as reported by the Physiotherapy Journal in July 2019. “The challenge started back in April 2018 and so far, more than 760,000 patients in hospital are no longer in pyjamas as a result of the campaign, with nearly 800,000 mobile (as of May 2019). On the campaign website (https://endpjparalysis.org) you can read some moving stories of patients that will encourage and motivate you.”

Structural reorganisation of therapies for improved patient care

In terms of additional training time, it turns out that at least 30 minutes more per day for 5 working days over 6 weeks is needed to significantly improve walking ability. For walking speed and walking distance, an additional training time of more than 60 minutes per week resulted in significant effects.

In neurological rehabilitation, the structural organisation of therapies in particular can contribute to improved patient care and the necessary increase in activity. “People with stroke spend more time in active task practice when physiotherapy rehabilitation is provided in circuit classes compared to individual therapy sessions,” was the key message of a 2014 observational study by Coralie English and colleagues (English et al. 2014). Circuit training is a form of training in which patients perform exercises at different stations one after the other. The individual stations each consist of a specific exercise and are usually arranged in a circle. Depending on the exercises selected and how they are executed, circuit training can focus on training power, endurance, mobility or speed.

Circuit training in stroke rehabilitation – individually or in a group (with more than two patients at a time) – usually consists of a tailored intervention programme with a focus on training functional tasks such as standing and walking. Circuit training is thus a suitable way of integrating different content in different phases of stroke rehabilitation. For therapists, this form of training allows them to keep an eye on both the group and the individual (ReMoS Working Group 2015).

Efficacy proven and well evidenced

Various reviews (including English & Hillier 2010, English et al. 2017, Wevers et al. 2009) and numerous individual studies (Mead et al. 2007, Verma et al. 2011, Mudge et al. 2009, Outermans et al. 2010, Salbach et al. 2004, Yang et al. 2006, Blennerhassett & Dite 2004, van Vliet et al. 2005, Pang et al. 2005) have evaluated the effectiveness of circuit training in relation to lower limb rehabilitation. The evidence shows that additional specific training to improve walking ability, walking speed and walking distance in subacute and chronic patients is very effective. However, not all additional training is equal. It has been found that specific leg function or gait training is necessary to achieve improvements in walking – non-specific functional training cannot do the same. In terms of additional training time, it turns out that at least 30 minutes more per day for 5 working days over 6 weeks is needed to significantly improve walking ability. For walking speed and walking distance, an additional training time of more than 60 minutes per week resulted in significant effects.

Group therapy not completely off-limits during the COVID-19 pandemic

During the COVID-19 pandemic, group therapy is naturally subject to more difficult conditions. Infected patients must be treated while strictly taking applicable isolation measures into account and keeping treating therapists protected. As a rule, the therapy here takes place in the patient’s room, in the case of severely affected patients even in bed (AWMF 2020).

COVID-19 patients can only be admitted for regular (early) rehabilitation treatment without isolation if they have been symptom-free of acute COVID-19 for at least 48 hours, at the earliest 10 days after symptom onset, and if the PCR result from two swabs taken at the same time (one oropharyngeal and one nasopharyngeal swab) is SARS-CoV-2 negative (post COVID-19 cases) or if the Ct value is high and SARS-CoV-2 is non-culturable (AWMF 2020).

For group therapies, maximum group sizes should be defined depending on room size, volume, ventilation options, the physical intensity of the therapies and the use of barrier measures. Crowds of people, e.g. in waiting areas, must be avoided before, as well as when entering and leaving the therapy rooms. This can be organised in part by providing appropriate information or via electronic scheduling (AWMF 2020).

In the case of therapies on equipment that is used alternately by several patients, care must be taken to ensure thorough surface disinfection after use. In the case of cooperative patients, this can also be done by the patients themselves, but supervision is required (AWMF 2020).

A summary of the results

Group therapies in rehabilitation, especially specific circuit training, have proven potential when it comes to increasing treatment dose and intensity. During the COVID-19 pandemic, things are of course a bit more complicated in terms of group therapy, but by no means hopeless, as the recommendations of the cited AWMF guideline show. Stricter hygiene measures must be observed for any provisions and, of course, acutely infected patients are not permitted to participate. For follow-up rehabilitation of post COVID-19 cases, however, the group is once again a promising option.

Because the pandemic is putting therapeutic care in rehabilitation to the test even more, it is necessary to implement offerings that cover the increased need for therapies in a meaningful way. This is where group therapy comes into its own and also has effects that are not provided by an individual setting. These include group cohesion, which, from a psychological point of view, has a not insignificant impact on the success of a healing treatment after a longer period of isolation.


Askim T, Bernhardt J, Løge AD, Indredavik B. Stroke patients do not need to be inactive in the first two-weeks after stroke: results from a stroke unit focused on early rehabilitation. Int J Stroke. 2012 Jan;7(1):25-31.

Åstrand A, Saxin C, Sjöholm A, et al. Poststroke Physical Activity Levels No Higher in Rehabilitation than in the Acute Hospital. J Stroke Cerebrovasc Dis. 2016 Apr;25(4):938-45. AWMF. S2k-LL COVID-19 und (Fru?h-)Rehabilitation – Langversion vom 1.11.2020. Online abgerufen am: 23.12.2020: www.awmf.org/uploads/tx_szleitlinien/080-008l_ S2k_SARS-CoV-2_COVID-19_und__Fru?h-__Rehabilitation_ 2020-11.pdf
Blennerhassett J, Dite W. Additional task-related practice improves mobility and upper limb function early after stroke: a randomised controlled trial. Aust J Physiother 2004; 50:219-24.
Dobkin BH. Strategies for stroke rehabilitation. Lancet Neurol. 2004; 3: 528-536.
English C, Hillier SL. Circuit class therapy for improving mobility after stroke. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD007513.
English C, Hillier SL, Lynch EA. Circuit class therapy for improving mobility after stroke. Cochrane Database Syst Rev. 2017 Jun 2;6:CD007513.
Feigin VL, Forouzanfar MH, Krishnamurthi R, et al. Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet 2014; 383: 245-55.
GBD. Neurological Disorders Collaborator Group. Global, regional, and national burden of neurological disorders during 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Neurol. 2017 Nov;16(11):877-897.
Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics 2014 update: a report from the American Heart Association. Circulation 2014; 129: e28-e292.
Hanlon RE. Motor learning following unilateral stroke. Arch Phys Med Rehabil. 1996; 77: 811-815.
Kaur G, English C, Hillier S. How physically active are people with stroke in physiotherapy sessions aimed at improving motor function? A systematic review. Stroke Res Treat. 2012;2012:820673.
Kaur G, English C, Hillier S. Physiotherapists systematically overestimate the amount of time stroke survivors spend engaged in active therapy rehabilitation: an observational study. J Physiother. 2013 Mar;59(1):45-51.
Kimberley TJ, Samargia S, Moore LG, et al. Comparison of amounts and types of practice during rehabilitation for traumatic brain injury and stroke. J Rehabil Res Dev. 2010;47(9):851-62.
Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res. 2008; 51: S225-S239.
Krishnamurthi RV, Feigin VL, Forouzanfar MH, et al. Global and regional burden of firstever ischaemic and haemorrhagic stroke during 1990-2010: Findings from the Global Burden of Disease Study 2010. Lancet 2013; 1: e259–e281.
Kwakkel G, van Peppen R, Wagenaar RC, et al. Effects of augmented exercise therapy time after stroke: a meta-analysis. Stroke. 2004; 35(11): 2529-39.
Lacroix J, Daviet JC, Borel B, et al. Physical Activity Level Among Stroke Patients Hospitalized in a Rehabilitation Unit. PM R. 2016 Feb;8(2):97-104.
Lang CE, Macdonald JR, Reisman DS, et al. Observation of amounts of movement practice provided during stroke rehabilitation. Arch Phys Med Rehabil. 2009 Oct;90(10):1692-8.
Lay S, Bernhardt J, West T, et al. Is early rehabilitation a myth? Physical inactivity in the first week after myocardial infarction and stroke. Disabil Rehabil. 2016 Jul;38(15):1493-1499.
Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2095–2128.
Luker J, Lynch E, Bernhardsson S, et al. Stroke Survivors‘ Experiences of Physical Rehabilitation: A Systematic Review of Qualitative Studies. Arch Phys Med Rehabil. 2015 Sep;96(9):1698-708.e10.
Mead GE, Greig CA, Cunningham I et al. Stroke: a randomized trial of exercise or relaxation. J Am Geriatr Soc 2007;55:892-99.
Mudge S, Barber PA, Stott NS. Circuit-based rehabilitation improves gait endurance but not usual walking activity in chronic stroke: a randomized controlled trial. Arch Phys Med Rehabil 2009;90:1989-96.
Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2197–2223.
Outermans JC, Van Peppen RP, Wittink H, et al. Effects of a high-intensity task-oriented training on gait performance early after stroke: a pilot study. Clin Rehabil 2010;24:979-87.
Page SJ. Intensity versus task-specificity after stroke: how important is intensity? Am J Phys Med Rehabil. 2003 Sep;82(9):730-2.
Pang MY, Eng JJ, Dawson AS, et al. A community-based fitness and mobility exercise program for older adults with chronic stroke: a randomized, controlled trial. J Am Geriatr Soc 2005;53:1667-74.
Pohl M, Werner C, Holzgraefe M, et al. Repetitive locomotor training and physiotherapy improve walking and basic activities of daily living after stroke: a single-blind, randomized multicentre trial (DEutsche GAngtrainerStudie, DEGAS). Clin Rehabil. 2007 Jan;21(1):17-27.
ReMoS Arbeitsgruppe. S2e Leitlinie zur Rehabilitation der Mobilität nach Schlaganfall (ReMoS). Neurologie und Rehabilitation 2015.
Rist PM, Capistrant BD, Mayeda ER. Physical activity, but not body mass index, predicts less disability before and after stroke. May 02, 2017; 88 (18).
Salbach NM, Mayo NE, Wood-Dauphinee S, et al. A taskorientated intervention enhances walking distance and speed in the first year post stroke: a randomized controlled trial. Clin Rehabil 2004;18:509-19.
van Peppen RP, Hendriks HJ, van Meeteren NL, et al. The development of a clinical practice stroke guideline for physiotherapists in The Netherlands: a systematic review of available evidence. Disabil Rehabil. 2007 May 30; 29(10): 767-83.
van Vliet PM, Lincoln NB, Foxall A. Comparison of Bobath based and movement science based treatment for stroke: a randomised controlled trial. J Neurol Neurosurg Psychiatry 2005;76:503-8.
Verma R, Arya KN, Garg RK, Singh T. Task-oriented circuit class training program with motor imagery for gait rehabilitation in poststroke patients: a randomized controlled trial. Top Stroke Rehabil 2011;18 Suppl 1:620-632.
West T, Bernhardt J. Physical Activity in Hospitalised Stroke Patients. Stroke Research and Treatment. Volume 2012, Article ID 813765, 13 pages.
Wevers L, van de Port I, Vermue M, Mead G, Kwakkel G. Effects of task-oriented circuit class training on walking competency after stroke: a systematic review. Stroke. 2009 Jul;40(7):2450-9.
Yang YR, Wang RY, Lin KH, Chu MY, Chan RC. Task-oriented progressive resistance strength training improves muscle strength and functional performance in individuals with stroke. Clin Rehabil 2006;20:860-870.