The impact of physical therapy on functional outcomes after stroke: What’s the evidence?

VU University Amsterdam, Amsterdamo, North Holland, Netherlands
Clinical Rehabilitation (Impact Factor: 2.24). 01/2005; 18(8):833-62. DOI: 10.1191/0269215504cr843oa
Source: PubMed

ABSTRACT To determine the evidence for physical therapy interventions aimed at improving functional outcome after stroke.
MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, DARE, PEDro, EMBASE and DocOnline were searched for controlled studies. Physical therapy was divided into 10 intervention categories, which were analysed separately. If statistical pooling (weighted summary effect sizes) was not possible due to lack of comparability between interventions, patient characteristics and measures of outcome, a best-research synthesis was performed. This best-research synthesis was based on methodological quality (PEDro score).
In total, 151 studies were included in this systematic review; 123 were randomized controlled trials (RCTs) and 28 controlled clinical trials (CCTs). Methodological quality of all RCTs had a median of 5 points on the 10-point PEDro scale (range 2-8 points). Based on high-quality RCTs strong evidence was found in favour of task-oriented exercise training to restore balance and gait, and for strengthening the lower paretic limb. Summary effect sizes (SES) for functional outcomes ranged from 0.13 (95% Cl 0.03-0.23) for effects of high intensity of exercise training to 0.92 (95% Cl 0.54-1.29) for improving symmetry when moving from sitting to standing. Strong evidence was also found for therapies that were focused on functional training of the upper limb such as constraint-induced movement therapy (SES 0.46; 95% Cl 0.07-0.91), treadmill training with or without body weight support, respectively 0.70 (95% Cl 0.29-1.10) and 1.09 (95% Cl 0.56-1.61), aerobics (SES 0.39; 95% Cl 0.05-0.74), external auditory rhythms during gait (SES 0.91; 95% Cl 0.40-1.42) and neuromuscular stimulation for glenohumeral subluxation (SES 1.41; 95% Cl 0.76-2.06). No or insufficient evidence in terms of functional outcome was found for: traditional neurological treatment approaches; exercises for the upper limb; biofeedback; functional and neuromuscular electrical stimulation aimed at improving dexterity or gait performance; orthotics and assistive devices; and physical therapy interventions for reducing hemiplegic shoulder pain and hand oedema.
This review showed small to large effect sizes for task-oriented exercise training, in particular when applied intensively and early after stroke onset. In almost all high-quality RCTs, effects were mainly restricted to tasks directly trained in the exercise programme.

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Available from: Erik JM Hendriks, Nov 26, 2014
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    • "First of all these different studies continuously backed-up the evidence of the effectiveness of rehabilitation on post-stroke motor recovery: today 467 controlled studies on this topic have been identified amounting to 25,373 patients [12]. Rehabilitation care can improve the recovery of lower limb [9] [16] [17] and upper limb [6] [9] impairments, gait [13] and balance [16] [17], as well as autonomy in activities of daily living [4] [5] [11] [14]. "
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    • "In our experience, RR for UL offers a positive result in neurorehabilitation training, particularly from severe to moderate impaired chronic stroke patients (Bovolenta et al., 2009, 2011). According to many papers, an efficient rehabilitative treatment must be intensive and specific, repetitive, functional, and motivating for the individual to allow a continuous enhancement in the process of learning, acquisition, and generalization (Fasoli et al., 2004; Van Peppen et al., 2004; Krakauer, 2006; Huang and Krakauer, 2009; Mehrholz et al., 2012). As a technology-based tool, RR devices have a number of inherent advantages over conventional, largely manually assisted therapy. "
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    • "Indeed, following a rhythm has been proved to be an effective method to improve gait performance (especially walking speed) of patients affected by Parkinson's disease [McIntosh et al. 1997; Rubinstein et al. 2002; Lim et al. 2005], strokes [Thaut et al. 1993; Thaut et al.1997; Van Peppen et al. 2004; Hayden et al. 2009], multiple sclerosis [Conklyn et al. 2010], and cerebral palsy [Kwak 2007; Kim et al. 2011]. Similarly, there is a growing body of research exploring the effects of interactive auditory feedback while walking in the clinical population, although the study of such rehabilitation techniques in motor therapy is still in its infancy. "
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