What is the evidence for physical therapy poststroke? A systematic review and meta-analysis

Janne Marieke Veerbeek, Erwin van Wegen, Roland van Peppen, Philip Jan van der Wees, Erik Hendriks, Marc Rietberg, Gert Kwakkel, Janne Marieke Veerbeek, Erwin van Wegen, Roland van Peppen, Philip Jan van der Wees, Erik Hendriks, Marc Rietberg, Gert Kwakkel

Abstract

Background: Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.

Methods and findings: Randomized controlled trials (RCTs) regarding PT in stroke rehabilitation were retrieved through a systematic search. Outcomes were classified according to the ICF. RCTs with a low risk of bias were quantitatively analyzed. Differences between phases poststroke were explored in subgroup analyses. A best evidence synthesis was performed for neurological treatment approaches. The search yielded 467 RCTs (N = 25373; median PEDro score 6 [IQR 5-7]), identifying 53 interventions. No adverse events were reported. Strong evidence was found for significant positive effects of 13 interventions related to gait, 11 interventions related to arm-hand activities, 1 intervention for ADL, and 3 interventions for physical fitness. Summary Effect Sizes (SESs) ranged from 0.17 (95%CI 0.03-0.70; I(2) = 0%) for therapeutic positioning of the paretic arm to 2.47 (95%CI 0.84-4.11; I(2) = 77%) for training of sitting balance. There is strong evidence that a higher dose of practice is better, with SESs ranging from 0.21 (95%CI 0.02-0.39; I(2) = 6%) for motor function of the paretic arm to 0.61 (95%CI 0.41-0.82; I(2) = 41%) for muscle strength of the paretic leg. Subgroup analyses yielded significant differences with respect to timing poststroke for 10 interventions. Neurological treatment approaches to training of body functions and activities showed equal or unfavorable effects when compared to other training interventions. Main limitations of the present review are not using individual patient data for meta-analyses and absence of correction for multiple testing.

Conclusions: There is strong evidence for PT interventions favoring intensive high repetitive task-oriented and task-specific training in all phases poststroke. Effects are mostly restricted to the actually trained functions and activities. Suggestions for prioritizing PT stroke research are given.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. PRISMA Flow diagram.
Figure 1. PRISMA Flow diagram.
Legend: ADL, Activities of daily living; BLETRAC, Bilateral leg training with rhythmic auditory cueing; CPM, Continuous passive motion; PEDro, Physiotherapy evidence database; PT, Physical therapy; RCTs, Randomized controlled trials; ROM, Range of motion.
Figure 2. Summary effect sizes for physical…
Figure 2. Summary effect sizes for physical therapy interventions – gait and mobility-related functions and activities.
Legend: A green colored diamond indicates that the summary effect size is significant, while a blue colored diamond indicates that the summary effect size is nonsignificant; CI, Confidence interval; EMG-BF, Electromyographic biofeedback; EMG-NMS, Electromyography-triggered neuromuscular stimulation; FES, Functional electrostimulation; GT, Gait training; NA, Not applicable; NMS, Neuromuscular stimulation; TENS, Transcutaneous electrical nerve stimulation; TT, Treadmill training.
Figure 3. Summary effect sizes for physical…
Figure 3. Summary effect sizes for physical therapy interventions – arm-hand activities.
Legend: A green colored diamond indicates that the summary effect size is significant, while a blue colored diamond indicates that the summary effect size is nonsignificant; CI, Confidence Interval; CIMT, Constraint-induced movement therapy; EMG-BF, Electromyographic biofeedback; EMG-NMS, Electromyography-triggered neuromuscular stimulation; GHS, Glenohumeral subluxation; HSP, Hemiplegic shoulder pain; mCIMT, modified Constraint-induced movement therapy; NA, Not applicable; NMS, Neuromuscular stimulation; TENS, Transcutaneous electrical nerve stimulation.
Figure 4. Summary effect sizes for physical…
Figure 4. Summary effect sizes for physical therapy interventions – physical fitness.
Legend: A green colored diamond indicates that the summary effect size is significant, while a blue colored diamond indicates that the summary effect size is nonsignificant; CI, Confidence interval; NA, Not applicable.
Figure 5. Summary effect sizes for physical…
Figure 5. Summary effect sizes for physical therapy interventions – activities of daily living.
Legend: A green colored diamond indicates that the summary effect size is significant, while a blue colored diamond indicates that the summary effect size is nonsignificant; CI, Confidence interval; NA, Not applicable.
Figure 6. Summary effect sizes for physical…
Figure 6. Summary effect sizes for physical therapy interventions – other: inspiratory muscle training.
Legend: C, Control group; CI, Confidence interval; E, Experimental group.
Figure 7. Summary effect sizes for physical…
Figure 7. Summary effect sizes for physical therapy interventions – intensity of practice.
Legend: ADL, Activities of daily living; C, Control group; CI, Confidence interval; E, Experimental group.
Figure 8. Overview of outcomes for which…
Figure 8. Overview of outcomes for which interventions are available with significant summarized effects.
Legend: A green point indicates that the intervention has a significant positive effect on the outcome, while a red point indicates that the intervention has a significant negative effect on the outcome; *, shoulder external rotation; **, dependent walking patients in the early rehabilitation phase; ▵, dependent walking patients when compared to electromechanical-assisted gait training or BWSTT; □, independent walking patients; BWSTT, Body-weight supported treadmill training; CIMT, Constraint-induced movement therapy; EMG-NMS, Electromyography-triggered neuromuscular stimulation; ES, Electrostimulation; mCIMT, modified Constraint-induced movement therapy; NMS, Neuromuscular stimulation; prox., Proximal; TENS, Transcutaneous electrical nerve stimulation.

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