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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    • "Up to 20% of people with initial impairment have no functional use of the arm at 6 months [3], and only 18% regain unrestricted walking ability [4]. Exercise programs in which movement related to functional activity is directly trained have shown better results than impairment-focused programs [5]. In addition, more intensive therapy has been shown to improve the rate of recovery in activities of daily living (ADL) [6], particularly if a functional approach is adopted [7] [8]. "
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    ABSTRACT: This paper presents the requirement elicitation and development of an innovative telemedicine service for stroke patients, following a user centered design approach. The aim was to develop a usable service which will have a high chance of adoption by the end users. As a starting point for the development, an existing telemedicine service was used that is already in practice for other diagnosis groups, consisting of four modules (information, monitoring, exercising, communication). Additional requirements for the service for stroke patients were established during semi-structured interviews with stroke patients and focus groups with healthcare professionals. Results showed that the functionalities of the existing telemedicine service fits the needs of end-users in stroke rehabilitation quite well, however the clinical content needs some adaptations, especially the exercise module. Requirements from both user groups seemed quite similar and are adapted in the service. The new service fits the needs of all end users, however it should be validated more extensively throughout the organizations.
    Full-text · Conference Paper · Jan 2016
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    • "In the past 10 years, it has also been shown that higher intensities of walking practice result in better outcomes for individuals after stroke (Van Peppen et al., 2004). "
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    ABSTRACT: Robot gait training has the potential to increase the effectiveness of walking therapy. Clinical outcomes after robotic training are often not superior to conventional therapy. We evaluated the effectiveness of a robot training compared with a usual gait training physiotherapy during a standardized rehabilitation protocol in inpatient participants with poststroke hemiparesis. This was a randomized double-blind clinical trial in a postacute physical and rehabilitation medicine hospital. Twenty-eight patients, 39.3% women (72±6 years), with hemiparesis (<6 months after stroke) receiving a conventional treatment according to the Bobath approach were assigned randomly to an experimental or a control intervention of robot gait training to improve walking (five sessions a week for 5 weeks). Outcome measures included the 6-min walk test, the 10 m walk test, Functional Independence Measure, SF-36 physical functioning and the Tinetti scale. Outcomes were collected at baseline, immediately following the intervention period and 3 months following the end of the intervention. The experimental group showed a significant increase in functional independence and gait speed (10 m walk test) at the end of the treatment and follow-up, higher than the minimal detectable change. The control group showed a significant increase in the gait endurance (6-min walk test) at the follow-up, higher than the minimal detectable change. Both treatments were effective in the improvement of gait performances, although the statistical analysis of functional independence showed a significant improvement in the experimental group, indicating possible advantages during generic activities of daily living compared with overground treatment.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.
    Full-text · Article · Oct 2015 · International Journal of Rehabilitation Research
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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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