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Cited by 1,203Stroke Rehabilitation and RecoveryMedical Practices and RehabilitationAcute Ischemic Stroke Management

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What Is the Evidence for Physical Therapy Poststroke? A Systematic Review and Meta-Analysis

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Veerbeek, Janne Marieke, van Wegen, Erwin, van Peppen, Roland, van der Wees, Philip Jan, Hendriks, Erik, Rietberg, Marc, Kwakkel, Gert·2014·PLoS ONE
DOI 10.1371/journal.pone.0087987PMC PMC3913786
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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.

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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 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.CC BY · PubMed Central
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 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.CC BY · PubMed Central
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 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.CC BY · PubMed Central
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 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.CC BY · PubMed Central
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 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.CC BY · PubMed Central
Figure 6 Summary effect sizes for physical therapy interventions – other: inspiratory muscle training. Legend: C, Control group; CI, Confidence interval; E, Experimental group.
Figure 6 Summary effect sizes for physical therapy interventions – other: inspiratory muscle training. Legend: C, Control group; CI, Confidence interval; E, Experimental group.CC BY · PubMed Central
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 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.CC BY · PubMed Central
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.
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.CC BY · PubMed Central

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Cites

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Metadata

Authors
Veerbeek, J. M., van Wegen, E., van Peppen, R., van der Wees, P. J., Hendriks, E., Rietberg, M., & Kwakkel, G.
Affiliations
  • Amsterdam Movement Sciences (NL)
  • Maastricht University (NL)
  • Reade (NL)
Corresponding author
Kwakkel, Gert
ORCID
Venue
PLoS ONE
Publisher
Public Library of Science (PLoS)
Published
2014-02-04
Volume
9
Issue
2
Pages
e87987
ISSN
1932-6203 (ISSN-L)
DOI
10.1371/journal.pone.0087987
PMC
PMC3913786
OpenAlex
W2075019019
Cited by
1,203
References
591
Citations by year
2026: 67 · 2025: 101 · 2024: 76 · 2023: 111 · 2022: 130 · 2021: 138 · 2020: 97 · 2019: 102 · 2018: 108 · 2017: 87 · 2016: 95 · 2015: 68 · 2014: 20
FWCI
11.17
Type
journal article
Language
en
Open access
Licence
Locations
  • PLoS ONE (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Research Publications (Maastricht University) (publishedVersion, cc-by)
  • Pure Amsterdam UMC (publishedVersion)
  • Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion)
  • VU Research Portal (publishedVersion, other-oa)
  • RePEc: Research Papers in Economics (submittedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • Figshare (submittedVersion, cc-by)
  • Radboud Repository (Radboud University) (submittedVersion)
  • Radboud Repository (Radboud University) (submittedVersion, other-oa)
  • Research Publications (Maastricht University) (submittedVersion, other-oa)
  • Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
Funders
  • Royal Society
  • Vrije Universiteit Amsterdam
  • Koninklijk Nederlands Genootschap voor Fysiotherapie
Topics
  • Health Sciences › Medicine › Rehabilitation › Stroke Rehabilitation and Recovery
  • Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Medical Practices and Rehabilitation
  • Health Sciences › Medicine › Clinical Neurology › Acute Ischemic Stroke Management
Keywords
physiotherapy, stroke rehabilitation, gait training, activities of daily living, physical fitness, sitting balance, motor function, muscle strength, task-oriented training, repeated practice, rehabilitation timing, International Classification of Functioning, Disability and Health
MeSH terms
Stroke Rehabilitation, Humans, Randomized Controlled Trials as Topic, Stroke, Physical Therapy Modalities, Muscle Strength

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