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


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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    • "Task oriented training has been proven to be the mainstay for upper limb rehabilitation after stroke (Van Peppen et al., 2004 and Bosch et al., 2014). However, task oriented training requires some degrees of motor ability such as the ability to extend fingers and wrist to 10° and 20° respectively (Sirtori et al., 2009). "
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    ABSTRACT: Background: Task specific training requires some level of function which is not possible in severely paretic upper limb of the post stroke patients. Mental practice and task observation seem to offer beneficial effect to the upper limb of the patients. However, this effect is not so clear probably due to reduced number of repetition of the tasks practiced. Aim: The aim of this study was to find out whether high repetition of mental practice combined with task observation can provide significant improvement in motor function in patients with severe hemiparesis following stroke. Methods: Twenty five subjects comprising of 18 males and 7 females were randomized into experimental (n=15) and control (n=10) groups. The experimental and control groups received mental practice and task observation and traditional therapy respectively, 3 sessions per day, 7 days per week for 6 weeks. The outcome was evaluated using WMFT and MAL at baseline, 4 weeks and 6 weeks post intervention. Statistical analysis was carried out using an independent sample t-test and one-way repeated measures ANOVA. Result: The result showed that there was a significant difference between the experimental and control group at baseline (p<0.05). However, at 4 weeks and 6 weeks, there was no significant difference between the experimental and control group (p>0.05) on both outcome measures. Conclusion: Mental practice combined with task observation is effective in the rehabilitation of severe paretic upper limb of stroke patients when performed several 100 times per day.
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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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    ABSTRACT: La réadaptation des patients victimes d’AVC a connu une véritable révolution au cours des 3 dernières décennies. Les études de cohortes ont toujours souligné l’intérêt de la réadaptation après un AVC pour stimuler la récupération, mais les concepts des méthodes empiriques initialement proposées par les thérapeutes pour rééduquer ces patients n’ont pas résisté à l’analyse clinique critique. Parallèlement, les travaux de neuroimagerie fonctionnelle et les modèles animaux ont permis tout d’abord d’objectiver les mécanismes de la récupération fonctionnelle, puis d’en comprendre les limites ainsi que les modalités d’amélioration. Ces découvertes des neurosciences sont les bases sans lesquelles on ne peut pas comprendre l’apparition des nouvelles technologies : robotique et réalité virtuelle. Cette revue de la littérature se propose de faire une sélection de ces travaux clés qui permettent de mieux comprendre les propositions actuelles.
    Annals of Physical and Rehabilitation Medicine 08/2014; 57(8). DOI:10.1016/
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    • "In recent years, there has been a dramatic increase in stroke rehabilitation research and the evidence-base has grown exponentially. High-intensity, repetitive, task-oriented training demonstrates the best evidence for improving motor recovery after stroke [1-4]. However, it is known that stroke rehabilitation, in its present form, is not achieving the required intensity to maximise recovery after stroke [5,6]. "
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    ABSTRACT: Background The Graded Repetitive Arm Supplementary Program (GRASP) is a hand and arm exercise programme designed to increase the intensity of exercise achieved in inpatient stroke rehabilitation. GRASP was shown to be effective in a randomised controlled trial in 2009 and has since experienced unusually rapid uptake into clinical practice. The aim of this study was to conduct a formative evaluation of the implementation of GRASP to inform the development and implementation of a similar intervention in the United Kingdom.Methods Semi-structured interviews were conducted with therapists who were involved in implementing GRASP at their work site, or who had experience of using GRASP. Normalisation Process Theory (NPT), a sociological theory used to explore the processes of embedding innovations in practice, was used to develop an interview guide. Intervention components outlined within the GRASP Guideline Manual were used to develop prompts to explore how therapists use GRASP in practice. Interview transcripts were analysed using a coding frame based on implementation theory.ResultsTwenty interviews were conducted across eight sites in British Columbia Canada. Therapists identified informal networks and the free online availability of GRASP as key factors in finding out about the intervention. All therapists reported positive opinions about the value of GRASP. At all sites, therapists identified individuals who advocated for the use of GRASP, and in six of the eight sites this was the practice leader or senior therapist. Rehabilitation assistants were identified as instrumental in delivering GRASP in almost all sites as they were responsible for organising the GRASP equipment and assisting patients using GRASP. Almost all intervention components were found to be adapted to some degree when used in clinical practice; coverage was wider, the content adapted, and the dose, when monitored, was less.Conclusions Although GRASP has translated into clinical practice, it is not always used in the way in which it was shown to be effective. This formative evaluation has informed the development of a novel intervention which aims to bridge this evidence-practice gap in upper limb rehabilitation after stroke.
    Implementation Science 08/2014; 9(1):90. DOI:10.1186/s13012-014-0090-3 · 4.12 Impact Factor
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