Enfoques de rehabilitación física para la recuperación de la funcionalidad y la movilidad tras un accidente cerebrovascular
Resumen
Antecedentes
Se pueden utilizar diversos enfoques para la rehabilitación física tras un accidente cerebrovascular y existen considerables controversias y debates en cuanto a la efectividad de los enfoques relativos. Algunos fisioterapeutas basan sus tratamientos en un único enfoque; otros utilizan una mezcla de componentes de varios enfoques diferentes.
Objetivos
Determinar si los enfoques de rehabilitación física son efectivos para la recuperación de la funcionalidad y la movilidad en personas con accidente cerebrovascular, y evaluar si algún enfoque de rehabilitación física es más efectivo que otro.
Para las versiones anteriores de esta revisión, el objetivo fue explorar el efecto de los ‘enfoques terapéuticos de fisioterapia’ basados en las clasificaciones históricas de los principios de aprendizaje ortopédicos, neurofisiológicos o motores, o en una combinación de estos principios de tratamiento. Para esta actualización de la revisión, el objetivo fue explorar los efectos de los enfoques que incorporan componentes individuales del tratamiento, categorizados como entrenamiento en tareas funcionales, intervención musculoesquelética (activa), intervención musculoesquelética (pasiva), intervención neurofisiológica, intervención cardiopulmonar, dispositivo o modalidad de apoyo.
Además, se intentó explorar el impacto del periodo posterior al accidente cerebrovascular, la ubicación geográfica del estudio, la dosis de la intervención, el profesional que proporciona de la intervención y los componentes del tratamiento incluidos dentro de una intervención.
Métodos de búsqueda
Se hicieron búsquedas en el registro de ensayos del Grupo Cochrane de Accidentes Cerebrales Vasculares (Cochrane Stroke Group) (última búsqueda diciembre de 2012), Registro Cochrane central de ensayos controlados (Cochrane Central Register of Controlled Trials; CENTRAL) (La Biblioteca Cochrane número 12, 2012), MEDLINE (1966 hasta diciembre 2012), EMBASE (1980 hasta diciembre de 2012), AMED (1985 hasta diciembre de 2012) y en CINAHL (1982 hasta diciembre de 2012). Se realizaron búsquedas en las listas de referencias y se estableció contacto con expertos e investigadores con interés en la rehabilitación del accidente cerebrovascular.
Criterios de selección
Ensayos controlados aleatorizados (ECA) de los enfoques de rehabilitación física dirigidos a promover la recuperación de la funcionalidad o la movilidad en participantes adultos con diagnóstico clínico de accidente cerebrovascular. Los desenlaces incluyeron medidas de la independencia en las actividades cotidianas (AC), la función motora, el equilibrio, la velocidad de la marcha y la duración de la estancia hospitalaria. Se incluyeron los ensayos que compararon enfoques de rehabilitación física versus ningún tratamiento, atención habitual o control de atención y los que compararon diferentes enfoques de rehabilitación física.
Obtención y análisis de los datos
Dos autores de la revisión de forma independiente clasificaron los ensayos identificados según los criterios de selección, documentaron la calidad metodológica y extrajeron los datos.
Resultados principales
En esta revisión se incluyeron en total 96 estudios (10 401 participantes) . Más de la mitad de los estudios (50/96) se realizaron en China. En general los estudios fueron heterogéneos y muchos se informaron de manera deficiente.
Se encontró que la rehabilitación física tuvo un efecto beneficioso, en comparación con ningún tratamiento, sobre la recuperación funcional después del accidente cerebrovascular (27 estudios, 3423 participantes; diferencia de medias estandarizada [DME] 0,78; intervalo de confianza [IC] del 95%: 0,58 a 0,97, para las escalas de Independencia en las AC), y se observó que este efecto persistía más allá de la duración del período de intervención (nueve estudios, 540 participantes; DME 0,58; IC del 95%: 0,11 a 1,04). El análisis de subgrupos mostró una diferencia significativa basada en la dosis de la intervención (valor de p < 0,0001; para la independencia en las AC), lo cual indica que una dosis de 30 a 60 minutos al día administrada de cinco a siete días por semana es efectiva. Esta evidencia surge principalmente de estudios realizados en China. Los análisis de subgrupos también indican un beneficio significativo asociado con un periodo más corto desde el accidente cerebrovascular (valor de p 0,003; para la independencia en las AC).
Se encontró que la rehabilitación física fue más efectiva que la atención habitual o el control de atención para mejorar la función motora (12 estudios, 887 participantes; DME 0,37; IC del 95%: 0,20 a 0,55), el equilibrio (cinco estudios, 246 participantes; DME 0,31; IC del 95%: 0,05 a 0,56) y la velocidad de la marcha (14 estudios, 1126 participantes; DME 0,46; IC del 95%: 0,32 a 0,60). El análisis de subgrupos demostró una diferencia significativa sobre la base de la dosis de la intervención (valor de p 0,02 para la función motora), lo cual indica que una dosis de 30 a 60 minutos administrada de cinco a siete días por semana proporciona un efecto beneficioso significativo. Los análisis de subgrupos también indican un beneficio significativo asociado con un periodo más corto desde el accidente cerebrovascular (valor de p 0,05; para la independencia en las AC).
Ningún enfoque de rehabilitación física fue más (o menos) efectivo que otro enfoque en cuanto a la mejoría de la independencia en las AC (ocho estudios, 491 participantes; prueba para las diferencias de subgrupos: valor de p 0,71) o la función motora (nueve estudios, 546 participantes; prueba de diferencias entre subgrupos: valor de p = 0,41). Estos hallazgos están respaldados por los análisis de subgrupos realizados para las comparaciones de la intervención versus ningún tratamiento o atención habitual, que no identificaron un efecto significativo de diferentes componentes del tratamiento o categorías de intervenciones.
Conclusiones de los autores
La rehabilitación física, que comprende una selección de los componentes de diferentes enfoques, es efectiva para la recuperación de la funcionalidad y la movilidad tras un accidente cerebrovascular. La evidencia relacionada con la dosis de la fisioterapia es limitada debido a la heterogeneidad significativa y no permite establecer conclusiones consistentes. Ningún enfoque a la rehabilitación física es más (o menos) efectivo para promover la recuperación de la funcionalidad y la movilidad tras un accidente cerebrovascular. Por lo tanto, la evidencia indica que la rehabilitación física no se debe limitar a los enfoques compartimentados nombrados, sino que debe incluir tratamientos físicos claramente definidos, bien descritos y basados en la evidencia, independientemente del origen histórico o filosófico.
PICO
Resumen en términos sencillos
Enfoques de rehabilitación física para la recuperación de la funcionalidad y la movilidad tras un ictus
Pregunta
Se deseaba saber si los enfoques de rehabilitación física son efectivos para la recuperación de la funcionalidad y la movilidad en las personas con ictus, y si algún enfoque de rehabilitación física es más efectivo que otro.
Antecedentes
El ictus puede causar parálisis en algunas partes del cuerpo, así como otras dificultades en diversas funciones físicas. La rehabilitación física es una parte importante de la rehabilitación de las personas con un ictus. Con el transcurso de los años se han desarrollado diversos enfoques a la rehabilitación física, según diferentes ideas acerca de la forma en que las personas se recuperan tras un ictus. A menudo los fisioterapeutas siguen un enfoque particular y excluyen otros, aunque esta práctica en general se basa en la preferencia personal en lugar del fundamento científico. Aún existe mucho debate entre los fisioterapeutas sobre los beneficios relativos de los distintos enfoques; por lo tanto, es importante reunir la evidencia proveniente de los estudios de investigación y destacar cuál debería ser la mejor práctica a la hora de seleccionar estos distintos enfoques.
Características de los estudios
Hasta diciembre de 2012 se identificaron 96 estudios para su inclusión en la revisión. Estos estudios, con 10 401 supervivientes de ictus, investigaron los enfoques de rehabilitación física dirigidos a promover la recuperación de la funcionalidad o la movilidad en participantes adultos con un diagnóstico clínico de ictus en comparación con ningún tratamiento, atención habitual o control de atención o en comparaciones de diferentes enfoques de rehabilitación física. El número medio de participantes en cada estudio fue de 105: la mayoría de los estudios (93%) incluyeron menos de 200 participantes, un estudio tuvo más de 1000 participantes, seis tuvieron entre 250 y 1000 participantes y diez tuvieron 20 o menos participantes. Los desenlaces incluyeron medidas de la independencia en las actividades cotidianas (AC), la función motora (movimiento funcional), el equilibrio, la velocidad de la marcha y la duración de la estancia hospitalaria. Más de la mitad de los estudios (50/96) se realizaron en China. Estos estudios mostraron muchas diferencias con relación al tipo de ictus y su gravedad, así como diferencias en el tratamiento, que variaron según el tipo y duración del tratamiento.
Resultados clave
Esta revisión reúne la evidencia que confirma que la rehabilitación física (a menudo administrada por un fisioterapeuta o terapeuta de rehabilitación) puede mejorar la funcionalidad, el equilibrio y la marcha después de un ictus. Al parecer el efecto más beneficioso se logra cuando el terapeuta selecciona una combinación de diferentes tratamientos para el paciente individual a partir de una gama amplia de tratamientos disponibles.
Fue posible combinar los resultados de 27 estudios (3243 supervivientes de un ictus) que compararon la rehabilitación física frente a ningún tratamiento. Veinticinco de estos 27 estudios se realizaron en China. Los resultados indicaron que la rehabilitación física mejora la recuperación funcional y que dicha mejoría podría prolongarse a largo plazo. Al considerar los estudios que compararon la rehabilitación física adicional frente a la atención habitual o una intervención control, se encontró evidencia que mostró que el tratamiento físico adicional mejoró la función motora (12 estudios, 887 supervivientes de un ictus), el equilibrio al permanecer de pie (cinco estudios, 246 supervivientes de un ictus) y la velocidad de la marcha (14 estudios, 1126 supervivientes de un ictus). La evidencia muy limitada indica que, para las comparaciones de la rehabilitación física frente a ningún tratamiento y frente a la atención habitual, el tratamiento que pareció ser efectivo se administró durante entre 30 y 60 minutos por día, cinco a siete días por semana, aunque se necesitan estudios de investigación adicionales para confirmar estos datos. También se encontró evidencia de un mayor beneficio asociado con un periodo más corto desde el ictus, aunque nuevamente se necesitan estudios de investigación adicionales para confirmar este resultado.
Se encontró evidencia que indica que ningún enfoque de rehabilitación física fue más efectivo que otro. Este hallazgo significa que los fisioterapeutas deben elegir el tratamiento de cada paciente individual según la evidencia disponible para dicho tratamiento específico, y no debe limitar la práctica a un único enfoque «con nombre».
Calidad de la evidencia
Fue difícil valorar la calidad de la evidencia porque la información encontrada fue deficiente, incompleta o breve. Se determinó que menos del 50% de los estudios fueron de buena calidad, y en la mayoría de los estudios la calidad de la evidencia no estuvo clara a partir de la información proporcionada.
Authors' conclusions
Summary of findings
| Physiotherapy intervention compared with no treatment for recovery after stroke | ||||
| Patient or population: adults with stroke Intervention: physiotherapy interventions Comparison: no treatment | ||||
| Outcomes | Standardised mean difference | No. of participants | Quality of the evidence | Comments |
|---|---|---|---|---|
| Independence in ADL scales Immediate outcome | 0.78 (0.58 to 0.97) | 27 studies 3423 participants | ⊕⊕⊕⊝ | Substantial heterogeneity in results. Most studies are at high or unclear risk of bias. Most studies are carried out in China; significant subgroup effect relating to geographical location of the study |
| Independence in ADL scales Persisting outcome | 0.58 (0.11 to 1.04) | 9 studies 540 participants | ⊕⊕⊕⊝ | |
| Motor function scales Immediate outcome | 0.81 (0.58 to 1.04) | 25 studies 4558 participants | ⊕⊕⊕⊝ | Substantial heterogeneity in results. Most studies are at high or unclear risk of bias. Most studies are carried out in China; significant subgroup effect relating to geographical location of the study |
| Motor function scales Persisting outcome | 1.06 (0.37 to 1.75) | 8 studies 1829 participants | ⊕⊕⊕⊝ | |
| Balance (Berg Balance Scale) Immediate outcome | ‐0.04 (‐0.71 to 0.64) | 1 study 34 participants | ⊕⊝⊝⊝ | |
| Balance (Berg Balance Scale) Persisting outcome | ‐0.03 (‐0.70 to 0.65) | 1 study 34 participants | ⊕⊝⊝⊝ | |
| Gait velocity Immediate outcome | 0.05 (‐0.18 to 0.28) | 3 studies 292 participants | ⊕⊕⊝⊝ | |
| Gait velocity Persisting outcome | ‐0.06 (‐0.29 to 0.18) | 3 studies 271 participants | ⊕⊕⊝⊝ | |
| Length of stay | MD ‐2.85 (‐10.47 to 4.76) | 3 studies 318 participants | ⊕⊕⊝⊝ | |
| GRADE Working Group grades of evidence. | ||||
| Physiotherapy intervention compared with usual care or attention control for recovery after stroke | ||||
| Patient or population: adults with stroke Intervention: physiotherapy intervention Comparison: usual care or attention control | ||||
| Outcomes | Standardised mean difference | No. of participants | Quality of the evidence | Comments |
|---|---|---|---|---|
| Independence in ADL scales Immediate outcome | 0.04 (‐0.27 to 0.35) | 6 studies 260 participants | ⊕⊕⊕⊝ | |
| Independence in ADL scales Persisting outcome | No data | |||
| Motor function scales Immediate outcome | 0.42 (0.24 to 0.61) | 13 studies 967 participants | ⊕⊕⊕⊝ | Removing all studies that were judged as unsure or high risk of bias for random sequence generation or allocation concealment left 7 studies (377 participants) demonstrating no significant effect (SMD 0.17, 95% CI ‐0.04 to 0.38) |
| Motor function scales Persisting outcome | ‐0.10 (‐0.42 to 0.23) | 3 studies 160 participants | ⊕⊕⊝⊝ | |
| Balance (Berg Balance Scale) Immediate outcome | 0.31 (0.05 to 0.56) | 5 studies 246 participants | ⊕⊕⊕⊝ | |
| Balance (Berg Balance Scale) Persisting outcome | No data | |||
| Gait velocity Immediate outcome | 0.46 (0.32 to 0.60) | 14 studies 1126 participants | ⊕⊕⊕⊕ | Sensitivity analysis: studies with attention control: 7 studies 251 participants SMD 0.41(0.51 to 0.67) |
| Gait velocity Persisting outcome | 0.38 (0.10 to 0.66) | 5 studies 214 participants | ⊕⊕⊕⊝ | |
| Length of stay | MD ‐10.36 (‐48.09 to 27.36) | 2 studies 105 participants | ⊕⊕⊝⊝ | |
| GRADE Working Group grades of evidence. | ||||
| One active intervention compared with another active intervention for recovery after stroke | ||||
| Patient or population: adults with stroke Intervention: A physiotherapy intervention containing functional task training, neurophysiological or musculoskeletal components Comparison: A physiotherapy intervention that does not contain the same category of treatment components | ||||
| Outcomes | Standardised mean difference | No. of participants | Quality of the evidence | Comments |
|---|---|---|---|---|
| 3.1.1 Includes functional training versus does not include functional training Independence in ADL scales Immediate outcomes | ‐0.03 (‐0.37 to 0.32) | 4 studies (186 participants) | ⊕⊕⊝⊝ | Quality of evidence downgraded from "moderate" to "low" because of the relatively low number of studies/participants |
| 3.1.2 Includes neurophysiological versus does not include neurophysiological Independence in ADL scales Immediate outcomes | ‐0.02 (‐0.26 to 0.22) | 7 studies (451 participants) | ⊕⊕⊕⊝ | Evidence primarily relates to interventions described as Bobath |
| 3.1.3 Includes musculoskeletal versus does not include musculoskeletal Independence in ADL scales Immediate outcomes | ‐0.12 (‐0.58 to 0.34) | 3 studies (103 participants) | ⊕⊕⊝⊝ | Quality of evidence downgraded from "moderate" to "low" because of the relatively low number of studies/participants |
| 3.2.1 Includes functional training versus does not include functional training Motor function scales Immediate outcomes | ‐0.16 (‐0.59 to 0.28) | 4 studies (188 participants) | ⊕⊕⊝⊝ | Quality of evidence downgraded from "moderate" to "low" because of the relatively low number of studies/participants |
| 3.2.2 Includes neurophysiological versus does not include neurophysiological Motor function scales Immediate outcomes | 0.17 (‐0.05 to 0.39) | 8 studies (506 participants) | ⊕⊕⊕⊝ | Evidence primarily relates to interventions described as Bobath |
| 3.2.3 Includes musculoskeletal versus does not include musculoskeletal Motor function scales Immediate outcomes | ‐0.08 (‐0.53 to 0.36) | 4 studies (81 participants) | ⊕⊕⊝⊝ | Quality of evidence downgraded from "moderate" to "low" because of the relatively low number of studies/participants |
| GRADE Working Group grades of evidence. | ||||
Background
Description of the condition
Stroke is a leading cause of death and disability in many Western nations. In Australia, the UK and the USA, it is within the top 10 causes of long‐term physical disability (Fisher 2013; Mathers 2006; Ovbiagele 2011). The most common and widely recognised impairment caused by stroke is motor impairment, which can be regarded as loss or limitation of function in muscle control or movement or limitation in mobility (Wade 1992a). Motor impairment after stroke typically affects the control of movement of the face, arm and leg on one side of the body (Warlow 2008) and is seen in about 80% of patients. Almost two‐thirds of stroke survivors have initial mobility deficits (Jorgensen 1995; Shaughnessy 2005), and six months after a stroke, more than 30% of survivors still cannot walk independently (Jorgensen 1995; Mayo 2002; Patel 2000). Therefore, much of the focus of stroke rehabilitation, in particular, the work of physiotherapists (also known as physical therapists or rehabilitation therapists), is focused on recovery of physical independence and functional ability during activities of daily living; commonly the ultimate goal of therapy is to improve the function of walking and recovery of balance and movement (Langhorne 2009).
Description of the intervention
Various approaches to physical rehabilitation can be used after stroke, and considerable controversy and debate about the relative effectiveness of these approaches are ongoing (Carlisle 2010; Kollen 2009). Descriptions of these approaches are best considered within a historical context.
Before the 1940s, physical rehabilitation approaches primarily consisted of corrective exercises based on orthopaedic principles related to contraction and relaxation of muscles, with emphasis placed on regaining function by compensating with the unaffected limbs (Ashburn 1995; Partridge 1996). In the 1950s and 1960s, techniques based on available neurophysiological knowledge were developed to enhance recovery of the paretic side. These new approaches included the methods of Bobath (Bobath 1990; Davies 1985), Brunnström (Brunnström 1970) and Rood (Goff 1969), as well as the proprioceptive neuromuscular facilitation approach (Knott 1968; Voss 1985). In the 1980s, the potential importance of neuropsychology and motor learning was highlighted (Anderson 1986; Turnbull 1982) and the motor learning, or relearning, approach was proposed (Carr 1982). This suggested that active practice of context‐specific motor tasks with appropriate feedback would promote learning and motor recovery (Carr 1980; Carr 1982; Carr 1987a; Carr 1987b; Carr 1989; Carr 1990; Carr 1998). The practical application of these approaches appeared to result in substantial differences in patient treatment. Approaches based on neurophysiological principles seemingly involved the physiotherapist moving the patient through patterns of movement, with the therapist acting as problem solver and decision maker and the patient being a relatively passive recipient (Lennon 1996). In direct contrast, motor learning approaches stressed the importance of active involvement by the patient (Carr 1982), and orthopaedic approaches emphasised muscle strengthening techniques and compensation with the non‐paretic side.
Since the 1980s, the need to base neurological physiotherapy on scientific research in relevant areas such as medical science, neuroscience, exercise physiology and biomechanics, and to test the outcomes of physical interventions to develop evidence‐based physiotherapy has been increasingly emphasised. However, anecdotal evidence and the results of questionnaire‐based studies suggest that, traditionally, many physiotherapists continued to base their clinical practice around a 'named' treatment approach. From the 1990s, the Bobath approach, based on neurophysiological principles, came to be recognised as the most widely used method in Sweden (Nilsson 1992), Australia (Carr 1994a) and the UK (Davidson 2000; Lennon 2001; Sackley 1996). As a consequence, since this time, physiotherapists have often sought evidence related to these 'named' approaches to the physical rehabilitation of stroke patients.
In some parts of the world, clear preferences for one 'named' approach have prevailed; however in others, physical rehabilitation approaches for stroke have developed with greater eclecticism, resulting in geographical preferences for mixing particular approaches, or components from different approaches, as well as preferences for single 'named' approaches. For example, in China, where stroke rehabilitation is not yet considered standard care (Zhang 2013), standard 'approaches' to rehabilitation have been proposed, including 'standardised tertiary rehabilitation' (Hu 2007 isch; Hu 2007a; Jiang 2006; Research Group 2007; Zhang 2004) and 'standardised three‐phase rehabilitation' (Bai 2008; Fan 2006; Zhu 2004b). These approaches arguably appear to draw on the full range of treatment interventions available from all orthopaedic, neurophysiological and motor learning approaches described in Western literature, while incorporating traditional Chinese therapies such as acupuncture (Zhang 2013; Zhuang 2012).
More recently, calls asking physiotherapists to cease using named approaches and to stop selecting treatments based on historical perspectives have increased. Physiotherapists have been urged to refrain from using compartmentalised, named approaches and to select clearly defined and described techniques and task‐specific treatments, regardless of their historical or philosophical origin (Kollen 2009; Langhammer 2012; Mayston 2000; Pomeroy 2005). Although a move away from named approaches in preference of more evidence‐based approaches has been deliberately implemented in some countries, such as the Netherlands (Kollen 2009; van Peppen 2004), heated debate continues about the evidence for doing this (Carlisle 2010), and some physiotherapists around the world continue to exhibit preferences for particular named approaches (Khan 2012; Tyson 2009a; Tyson 2009b).
Why it is important to do this review
Continued controversy and debate about the relative effectiveness of physical rehabilitation approaches and evidence of clear preferences for particular named approaches in some parts of the world, despite increasing calls for this to change, justify the importance of this review.
Why it is important to address limitations within previous versions of this review
The original versions of this review classified approaches to physiotherapy on the basis of historical principles described in the literature; however we classified interventions as neurophysiological, motor learning, orthopaedic or mixed, according to the descriptor or name of the intervention provided by trialists (Pollock 2007). Table 1 displays the criteria that we used in classifying neurophysiological and motor learning approaches (NB: We are not using these criteria in this updated review.). However, the 2007 version of the review (Pollock 2007) identified several limitations associated with this method of classification.
| Name of approach | Philosophy/theory | Treatment principles | Descriptive terms | Supporting references |
|---|---|---|---|---|
| Rood | Concerned with 'the interaction of somatic, autonomic, and psychic factors, and their role in regulations of motor behaviour'. | Activate/facilitate movement and postural responses of patient in same automatic way as they occur in the normal | Ontogenetic sequences | |
| Proprioceptive neuromuscular facilitation (PNF) or Knott and Voss | Active muscle contractions intended to stimulate afferent proprioceptive discharges into the CNS increased excitation and recruitment of additional motor units | Diagonal and spiral patterns of active and passive movement | Patterns of movement | |
| Brunnström | Uses primitive reflexes to initiate movement and encourages use of mass patterns in early stages of recovery | Use tasks that patient can master or almost master. | Normal development | Brunnström 1956; Brunnström 1961; Brunnström 1970; Perry 1967; Sawner 1992 |
| Bobath or neurodevelopmental approach (NDT) | Aim to control afferent input and facilitate normal postural reactions | Facilitation of normal movement by a therapist, using direct handling of the body at key points such as head and spine, shoulders and pelvic girdle and, distally, feet and hands | Normal movement | Bobath 1959; Bobath 1966; Bobath 1970; Bobath 1978; Bobath 1990; Davies 1985; Davies 1990; Mayston 2000 |
| Johnstone | To control spasticity by inhibiting abnormal patterns and using positioning to influence tone | Use of inflatable splints | Muscle tone | |
| Carr and Shepherd or motor learning or motor relearning or movement science | Assumes that neurologically impaired people learn in the same way as healthy people. | (1) Analysis of task | Motor control | Carr 1980; Carr 1982; Carr 1987a; Carr 1987b; Carr 1990; Carr 1998 |
| Conductive education or Peto | Aims to teach patient strategies for dealing with disabilities in order to encourage them to learn to live with or overcome disabilities | Educational principles and repetition used as a method of rote learning | Education | |
| Affolter | Interaction between individual and environment fundamental part of learning | NB. This approach started from theory, rather than from clinical practice | Perception | |
| Sensory integration or Ayres | Functional limitations compounded by sensory and perceptual impairment | Sensory feedback | Sensory and perceptual impairment |
The criteria listed in this Table are those used in previous versions of this review. These criteria are not used in this updated version of the review. (See Table 2 for the criteria used for classification of interventions within this updated review).
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This classification was based on Western approaches and descriptions of physiotherapy and did not incorporate physical therapy delivered across the whole world. In Pollock 2007, we identified a large number (26) of non–English language (23 Chinese) trials (and classified them as 'studies awaiting assessment'). We stated: "The information currently available from the majority of the Chinese trials awaiting assessment suggests that it is unlikely that the interventions studied in these trials will fit into the western categorisations and classifications of physiotherapy treatment approaches developed for this review. Prior to the next update of this review, the authors intend to seek advice and write additional inclusion and exclusion criteria to deal with the non‐western approaches to physiotherapy for stroke".
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The 'mixed' approach category within the review could potentially incorporate a large number of heterogeneous interventions that may not be meaningful to combine. Pollock 2007 stated: "A limitation of combining all mixed approaches is that this category potentially amalgamates any number of possible combinations of other approaches and techniques".
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We found difficulties in determining the classifications of motor learning and mixed approaches for some studies. Pollock 2007 stated: "difficulty was experienced in distinguishing between a mixed approach (not a mixture of two different approaches, such as Stern 1970 mixing orthopaedic and neurophysiological approaches, but an unclassified mix [where the interventions were not easily classified into a 'named' approach]) and a motor learning approach. The mixed, intensive and focused approach investigated by Richards 1993 and the problem‐solving approach investigated by Green 2002 and Wade 1992 had stated philosophies very similar to those of motor learning approaches. However, the described techniques and the supporting references led the reviewers to classify these interventions as mixed. This highlights a key problem with the classification of the motor learning approach. Although a motor relearning programme has been described by Carr and Shepherd (Carr 1982; Carr 1987b), these authors primarily advocate an approach based on related research in relevant areas such as medical science, neuroscience, exercise physiology and biomechanics. Such an approach is arguably one of research‐based practice, rather than being based on one specific philosophy".
It was therefore essential to plan solutions and strategies to address these limitations before this update of the review was conducted.
Consensus methods to inform update of this review
To address the identified limitations within previous versions of this review, before this update we convened a stakeholder group comprising 13 purposively selected people: three stroke survivors, one carer and nine physiotherapists. Members of this group are listed and acknowledged in the Acknowledgements section. We used formal group consensus methods to reach consensus decisions around review aims and methods, while focusing on clinical relevance, as such methods are recognised to be advantageous when subjective judgements need to be organised (Nair 2011). The consensus methods were based on nominal group techniques, as this method enables the pooling of decisions and judgements from a group of informed experts, leading to votes on a range of options until ultimately group consensus is reached (Sinha 2008; Stapleton 2010). The review authors attended the stakeholder group meetings and contributed to discussions; however we did not participate in the voting process. This approach was taken to ensure that the results of the voting reflected the views of stroke survivors, carers and physiotherapists and were not biased by the opinions of the review authors. The process of stakeholder group involvement is outlined in Figure 1.
The figure summarises the process undertaken by the stakeholder group, which met on three occasions (green circles). The nominal group technique was used to achieve all decisions. The blue circles represent the 'preparation phase,' which included drafting role descriptors for the SG; obtaining local University ethics and recruiting the SG and data extraction exercise of the sample of Chinese studies (n = 10) that had previously been identified in the 2007 version of this review. Purple circles represent the months dedicated to undertaking the systematic review.
The stakeholder group specifically discussed the categorisation of interventions and inclusion of evidence from the international trials listed as awaiting assessment in Pollock 2007, which led to voting on two key statements.
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"The current categories (based on western approaches) are appropriate and clinically relevant".
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"These international trials (which do not fit into the categories of western approaches) should be included in our review of physiotherapy treatment approaches".
We determined the proportion agreeing with each statement. We audio‐recorded and transcribed verbatim the consensus decision meetings. We coded and analysed qualitative data using NVivo software: 84% of group members disagreed with statement 1, and 100% agreed with statement 2. Two key themes and several subthemes emerged from the transcribed data. Key themes were that (1) current categories of rehabilitation approaches should be amended to enable inclusion of all international evidence and (2) current physiotherapy taxonomies have limitations and concerns that have been raised surrounding their relevance to clinical practice in the UK.
Discussion amongst stakeholder group members led to the generation of, and agreement on, a proposal that the optimal way of classifying the 'approaches' for this review consisted of using systematic categorisation of the treatment components described in relation to interventions. This discussion followed a presentation of treatment components described in a sample of 10 Chinese trials that had been listed as 'awaiting assessment' in Pollock 2007 (Chen 2004; Chu 2003; Gong 2003; Huang 2003; Pan 2004; Pang 2003; Xie 2003; Xu 2003a; Zhang 1998; Zhu 2001). On the suggestion of the stakeholder group, to further explore the range of treatment components and reach agreement on definitions of these components, we systematically extracted descriptions of physical rehabilitation approaches from the 20 trials included in Pollock 2007 (Dean 1997; Dean 2000; Duncan 1998; Duncan 2003; Gelber 1995; Green 2002; Hesse 1998; Howe 2005; Langhammer 2000; Lincoln 2003; McClellan 2004; Mudie 2002; Ozdemir 2001; Pollock 1998; Richards 1993; Salbach 2004; Stern 1970; Wade 1992; Wang 2005; Wellmon 1997). The stakeholder group then explored the descriptions of treatment components from these 30 trials. The aim was to include a variety of types and descriptions of physical rehabilitation approaches to allow examination of whether a range of treatment components could be identified and consensus over descriptions and categorisations; this was designed as an exploration, rather than as a comprehensive aggregation. The stakeholder group debated the treatment components described within these trials of physical rehabilitation approaches, reached consensus on key components, agreed on descriptions of these components and determined categorisation for synthesis of evidence within this update of the Cochrane review.
The stakeholder group identified and defined 27 treatment components based on the interventions described within the 30 explored trials. These were grouped into seven categories: functional task training, musculoskeletal intervention (active), musculoskeletal intervention (passive), neurophysiological intervention, cardiopulmonary intervention, assistive device and modality. These categories were informed by the taxonomy described by DeJong 2004. One hundred per cent of the stakeholder group agreed with these treatment component descriptions and categories. The agreed upon categories, treatment components and definitions are listed in Table 2.
| Categories | Treatment component | Description of individual treatment component |
|---|---|---|
| Assistive devices (AD) | Walking aids | Devices to assist walking, including sticks and frames |
| Orthoses for walking | Externally applied orthoses to assist walking, including AFO, knee braces | |
| Resting splints | Externally applied orthoses to maintain or improve limb alignment | |
| Cardiopulmonary interventions (CI) | Aerobic/fitness/endurance training | Activities to improve cardiopulmonary fitness |
| Functional task training (FTT) | ADL training | Practice of tasks relevant to daily life, including both part and whole task practice |
| Sitting &/or standing balance training | Various activities performed sitting &/or standing with the aim of improving the ability to balance safely and independently | |
| Sit‐to‐stand practice | Practice of tasks aimed at improving ability to stand up and sit down safely and independently | |
| Transfer practice | Practice of tasks aimed at improving ability to move from one position to another | |
| Walking | Practice of tasks aimed at improving ambulation | |
| Stair climbing | Practice of tasks aimed at ability to go up and down stairs | |
| Upper limb function training | Practice of tasks aimed at improving the ability to move and use the arm, such as reach, grasp, and hand‐to‐mouth activities | |
| Described as "MRP" (MRP – Motor Relearning Programme) | Described as MRP | |
| Modality (Mo) | Acupuncture | as an adjunct, delivered for either pain relief or movement therapy |
| Physical agents (including hot, cold, TENS – Transcutaneous electrical nerve stimulation) | as an adjunct, delivered for either pain relief or movement therapy | |
| Musculoskeletal intervention (active) | Muscle strengthening | Practice of activities to progressively increase the ability to generate muscle force, including using body weight and external resistance |
| Active & active‐assisted movement | Moving a limb through its range of movement, under the patient’s active control with or without assistance | |
| Musculoskeletal intervention (passive) | Increasing angle of upright sitting | a form of positioning, to promote early sitting |
| Tilt table | To promote early lower limb loading | |
| Passive movement | Moving a limb through it’s range of movement, whilst the patient is passive | |
| Body & limb positioning | placing a limb or body part in a supported position, to maintain optimal alignment | |
| Massage | Manipulation of soft tissue, using the hands or a tool designed for the purpose | |
| Neurophysiological intervention | Hands on facilitation of ('normal') movement (Bobath) | Intervention which is described as facilitation of movement, referenced to Bobath or Davies |
| Inhibition of abnormal muscle tone / normalising tone (Bobath) | Intervention which is described as inhibition of abnormal muscle tone or as normalising muscle tone, referenced to Bobath or Davies | |
| Described as "Bobath" | Described as Bobath | |
| Trunk mobilisations / postural reactions (Bobath) | Intervention which is described as trunk mobilisations or postural reactions to perturbations, referenced to Bobath or Davies | |
| Proprioceptive Neuromuscular facilitation (PNF – proprioceptive neuromuscular facilitation) | Described as PNF | |
| Sensorimotor facilitation | The use of excitatory techniques, such as brushing, striking, tapping, icing, to improve sensory awareness and promote muscle activity |
AD: assistive devices; CPI: cardiopulmonary interventions; FTT: functional task training; MoD: Modality; Musc.(active): musculoskeletal intervention (active); Musc.(passive): musculoskeletal intervention (passive); NP: neurophysiological intervention.
Objectives
To determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.
For the Pollock 2007 version of the review and earlier versions, the objective was to explore the effect of 'physiotherapy treatment approaches' based on historical classifications of orthopaedic, neurophysiological or motor learning principles, or on a mixture of these treatment principles. For this update of the review, the objective was to explore the effects of approaches that incorporate treatment components from each of the categories listed in Table 2, Individual treatment components were categorised as functional task training, musculoskeletal intervention (active), musculoskeletal intervention (passive), neurophysiological intervention, cardiopulmonary intervention, assistive device or modality.
In addition, we sought to explore the impact of time after stroke, geographical location of the study, dose of the intervention, provider of the intervention and treatment components included within an intervention.
Methods
Criteria for considering studies for this review
Types of studies
We included controlled trials if the participants were randomly assigned to one of two or more treatment groups. Random assignment gives each participant entering the trial the same, predetermined, chance of receiving each of the possible treatments (e.g. by using sequentially numbered opaque sealed envelopes or computer‐generated random numbers). We included trials with or without blinding of participants, physiotherapists and assessors. We excluded trials with quasi‐random assignment, thereby excluding a number of trials that had been included in previous versions of this review (Hesse 1998; Ozdemir 2001; Stern 1970).
Types of participants
We included trials enrolling adult participants (over 18 years of age) with a clinical diagnosis of stroke (World Health Organization definition; Hatano 1976), which could be ischaemic or haemorrhagic in origin (confirmation of the clinical diagnosis by imaging was not compulsory).
Types of interventions
We included physical rehabilitation approaches that were aimed at promoting recovery of postural control (balance during maintenance of a posture, restoration of a posture or movement between postures) and lower limb function (including gait), as well as interventions that had a more generalised stated aim, such as improving functional ability. We excluded rehabilitation approaches that were primarily aimed at promoting recovery of upper limb movement or upper limb function.
Types of outcome measures
Primary outcomes
We defined primary outcomes as measures of disability (activity limitations; WHO 2002) and prestated relevant measures as follows.
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Independence in activities of daily living (ADL)* scales. These include Barthel Activities of Daily Living Index (Mahoney 1965), Functional Independence Measure (FIM) (Keith 1987), Modified Rankin Scale (van Swieten 1988), Katz Index of Activities of Daily Living (Katz 1970) and Rehabilitation Activities Profile (van Bennekom 1995).
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Motor function* scales. These include Motor Assessment Scale (MAS) (Carr 1985), Fugl‐Meyer Assessment (lower limb section) (Fugl‐Meyer 1975), Rivermead Mobility Index (Forlander 1999) and Rivermead Motor Assessment (Lincoln 1979).
Secondary outcomes
We were interested in outcomes that were assessed both immediately after the end of an intervention period ('immediate outcome') and at a follow‐up period ('persisting outcomes').
Search methods for identification of studies
See the 'Specialized register' section in the Cochrane Stroke Group module. We searched for trials in all languages and arranged translation of relevant papers published in languages other than English.
Electronic searches
We searched the Cochrane Stroke Group Trials Register, which was last searched in December 2012, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 12, 2012), MEDLINE (Ovid) (1966 to December 2012) (Appendix 1), EMBASE (Ovid) (1980 to December 2012) (Appendix 2), AMED (Ovid) (1985 to December 2012) (Appendix 3) and CINAHL (EBSCO) (1982 to December 2012) (Appendix 4).
With the help of the Cochrane Stroke Group Trials Search Co‐ordinator, we developed comprehensive search strategies for MEDLINE (adapted for CENTRAL), EMBASE, AMED and CINAHL using controlled vocabulary and free text terms. We updated the search strategies for this review to incorporate new vocabulary terms.
Searching other resources
We handsearched the reference lists of all trials found using the above search methods.
For the original version of this review, we contacted relevant experts from the Physiotherapy Researchers Register, held by the Chartered Society of Physiotherapy, and asked whether they knew of any additional, unpublished or ongoing trials of rehabilitation approaches for stroke. We also placed a request on the PHYSIO email discussion list asking the list members (who originate from approximately 35 countries) if they knew of any unpublished or ongoing trials of rehabilitation approaches for stroke. We identified no relevant additional, unpublished or ongoing trials through contact with experts from the Physiotherapy Researchers Register and received no relevant responses from the PHYSIO email discussion list.
For future updates of this review, we plan to expand search resources to include the REHABDATA Database (www.naric.com/?q=en/REHABDATA), Wangfangdata, a database of Chinese studies (www.wanfangdata.com/) and the major ongoing trials and research registers.
Data collection and analysis
Selection of studies
One review author (AP or PC or PLC) read the titles of the identified references and eliminated obviously irrelevant studies. We obtained the abstracts for the remaining studies and then, based on the inclusion criteria (types of studies, types of participants, aims of interventions, outcome measures), two review authors (AP, PC, PLC or GB) independently ranked these as relevant, irrelevant or unsure. We discussed abstracts written in Chinese, with one review author (PLC) translating relevant sections and verbally providing information to other review authors in English (AP, PC). We excluded studies ranked as irrelevant by all review authors and obtained the full text of all remaining studies.
We considered the full texts of studies ranked as relevant or unsure and resolved disagreements through discussion between review authors. We included all trials that were assessed to investigate different physical rehabilitation approaches and excluded all trials of single specific treatments. Single specific treatments included biofeedback, functional electrical stimulation, treadmill walking, acupuncture, ankle‐foot orthoses, continuous passive movement and transcutaneous electrical nerve stimulation. Some of these single specific treatments have been the subject of other Cochrane reviews (e.g. Moseley 2005; Pomeroy 2006).
Data extraction and management
Two review authors independently performed the data extraction, and we contacted study authors to request missing data when possible (AP, GB, PC, PLC). The data extracted included the following (when possible): trial setting (e.g. hospital, community); details of participants (e.g. age, gender, side of hemiplegia, stroke classification, co‐morbid conditions, premorbid disability); inclusion and exclusion criteria; and all assessed outcomes. The review authors resolved disagreements by discussion and contacted study authors for clarification when necessary. For papers published in Chinese, one review author (PLC) performed data extraction and translated relevant sections of text, which a second review author (AP, PC) checked.
Two review authors (AP, PLC) independently scrutinised the descriptions of interventions provided in each included trial and determined the treatment components included within each trial, based on the agreed upon definitions of treatment components (Table 2). Descriptions of interventions that were available only in Chinese were translated (and components classified) by one review author (PLC) and the translated descriptions used for the classification of components by a second review author (AP). We resolved disagreements through discussion and obtained further information from trialists when necessary (and possible).
Assessment of risk of bias in included studies
Two review authors independently documented the methodological quality of the studies, recording the following quality criteria: randomisation (allocation concealment); baseline comparison of groups; blinding of recipients and providers of care to treatment group/study aims; blinding of outcome assessor; possibility of contamination/co‐intervention by the therapists providing the intervention; completeness of follow‐up and other potential confounders (AP, GB, PC, PLC). The review authors resolved disagreements by discussion and contacted study authors for clarification when necessary.
One review author (PLC) translated relevant extracts related to the methodological quality of studies written in Chinese and assessed their methodological quality. A second review author (AP) checked the documentation of methodological quality, based on the translated extracts.
Measures of treatment effect
We presented all analysed outcome measures as continuous data. We calculated standardised mean differences (SMDs) and 95% confidence intervals (CIs), using a random‐effects model for all outcomes analysed, with the exception of length of stay, for which we calculated mean differences (MDs) and 95% CIs, as length of stay was reported in number of days by all studies.
Unit of analysis issues
Dealing with missing data
Assessment of heterogeneity
Assessment of reporting biases
Data synthesis
We changed the comparisons included in the review for this update, based on consensus decisions reached by the expert stakeholder group (see Background). In earlier versions of this review, the comparisons were structured around 'named' rehabilitation approaches, as reported in the included studies (e.g. Bobath, Motor Relearning Programme). For this update, we planned to carry out comparisons of physical rehabilitation approaches that included treatment components within the categories of functional task training, musculoskeletal intervention (active), musculoskeletal intervention (passive), neurophysiological intervention, cardiopulmonary intervention, assistive device and modality (see Table 2). Categories were based on the treatment components described within each included study. We planned to compare active interventions with (1) no treatment, (2) usual care or control and (3) another active intervention.
Subgroup analysis and investigation of heterogeneity
We planned to carry out subgroup analysis to explore the effects of time post stroke of participants, geographical location of the study, dose of the intervention and the profession of the person who delivered the intervention (i.e. physiotherapist, nurse, therapy assistant). We also planned to explore the effects of including different individual treatment components.
Sensitivity analysis
We planned to carry out sensitivity analyses to explore the effects of methodological quality, based on assessment of risk of bias.
Results
Description of studies
Results of the search
Results of the search are displayed in Figure 2.
Study flow diagram.
2007 version
For the 2007 version of this review, we identified 8408 potentially relevant trials by electronic searching; we considered 184 full papers and included 20 trials (1087 participants) (Dean 1997; Dean 2000; Duncan 1998; Duncan 2003; Gelber 1995; Green 2002; Hesse 1998; Howe 2005; Langhammer 2000; Lincoln 2003; McClellan 2004; Mudie 2002; Ozdemir 2001; Pollock 1998; Richards 1993; Salbach 2004; Stern 1970; Wade 1992; Wang 2005; Wellmon 1997).
2013 update
For this update of this review, we identified 11,576 (8120 with duplicates removed) potentially relevant studies. We considered 108 full papers and included 96 trials (10,401 participants) (including the 20 within the 2007 version).
We identified two relevant ongoing studies (see Characteristics of ongoing studies), and we had insufficient information to reach decisions on nine studies (see Characteristics of studies awaiting classification). We excluded three studies that had been included in the 2007 version, as they used quasi‐random assignment (Hesse 1998; Ozdemir 2001; Stern 1970) (see Figure 2).
Included studies
We included a total of 96 studies (10,401 participants) in this review. Two studies divided participants according to type of stroke (ischaemic or haemorrhagic) before randomisation and presented results within these two groups: These have been entered as four separate studies: Hu 2007 haem and Hu 2007 isch, and Zhu 2007 isch and Zhu 2007 haem. The data for Fang 2004 were presented in two groups, according to the age of participants, so these data have also been presented separately (Fang 2004 old and Fang 2004 young). Thus a total of 99 studies are referenced as included studies in this review. Details of these 99 studies are provided in Characteristics of included studies.
The mean number of participants was 105 (SD 151). Ninety‐two of the 99 studies included fewer than 200 participants. One study had more than 1000 participants (Zhang 2004; 1078 participants); and six had between 250 and 1000 participants (Bai 2008, 364; Behrman 2011, 408; Hu 2007 haem, 352; Hu 2007 isch, 965; Kwakkel 2008, 250; Zhao 2003, 300). Ten studies included 20 or fewer participants (Aksu 2001, 20; Allison 2007, 17; Bale 2008, 18; Carlson 2006, 11; Dean 1997, 20; Dean 2000, 12; Dean 2007, 12; Duncan 1998, 20; Kim 2012, 20; Stephenson 2004, 18).
Intervention categories
Details of the categories and treatment components of the active interventions are provided in Table 3. Of the 99 studies, 23 investigated two active interventions (19 of which directly compared two active interventions; and four of which had three intervention groups, of which two were active interventions). Thus a total of 122 active interventions were studied (99 included studies plus 23 studies with a second active intervention).
| Study | Group | Categories (and treatment components) | ||||||
|---|---|---|---|---|---|---|---|---|
| Assistive Devices | Cardiopulmonary intervention | Functional Task Training | Modality | Musculoskeletal intervention (active) | Musculoskeletal intervention (passive) | Neurophysiological intervention | ||
| ‘All groups' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Intervention' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Walking UL function training | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Control' | ‐ | ‐ | Walking UL function training | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Part practice' | ‐ | ‐ | Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Whole practice' | ‐ | ‐ | Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Early rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Functional strength training' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Walking UL function training | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Training as usual' | ‐ | ‐ | ADL training | ‐ | ‐ | ‐ | Hands on facilitation (Bobath) Inhibition of abn musc. tone (Bobath) Described as 'Bobath' Sensorimotor facilitation | |
| ‘Locomotor training program' | ‐ | ‐ | Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Home exercise program' | ‐ | ‐ | Sitting and/or standing balance | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Mobility’ | ‐ | Aerobic, fitness, endurance | Sitting and/or standing balance Sit‐to‐stand practice Walking | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Bobath' | ‐ | Aerobic, fitness, endurance | Walking Stair climbing | ‐ | ‐ | ‐ | Hands on facilitation (Bobath) Trunk mobilisations/ postural reactions (Bobath) PNF | |
| ‘Task practice' | ‐ | Aerobic, fitness, endurance | Walking Stair climbing Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Treatment' | ‐ | ‐ | Sitting and/or standing balance Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Motor relearning' | ‐ | ‐ | Sit‐to‐stand practice Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Conventional therapy' | ‐ | ‐ | Sit‐to‐stand practice | ‐ | ‐ | ‐ | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Walking Stair climbing UL function training | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | Sensorimotor facilitation | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing UL function training | ‐ | ‐ | Passive movement | ‐ | |
| ‘Test' | ‐ | ‐ | Walking | ‐ | Active and active assisted movement | Passive movement | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | Sitting and/or standing balance Transfer practice Walking Stair climbing UL function training | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | Sensorimotor facilitation | |
| ‘Additional conventional therapy (CPT+CPT)' | ‐ | ‐ | ADL training | ‐ | Active and active assisted movement | Passive movement Massage | Sensorimotor facilitation | |
| ‘Functional strength training (FST +CPT)' | ‐ | ‐ | Sit‐to‐stand practice Transfer practice Walking Stair climbing | ‐ | Musc. strengthening Active and active assisted movement | Passive movement Massage | Sensorimotor facilitation | |
| ‘Conventional physiotherapy (CPT)' | ‐ | ‐ | ADL training | ‐ | Active and active assisted movement | Passive movement Massage | Hands on facilitation (Bobath) Sensorimotor facilitation | |
| ‘Motor learning' | ‐ | ‐ | Sitting and/or standing balance Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Motor learning' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Walking Stair climbing Described as 'MRP' | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Experimental' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Walking Stair climbing Described as 'MRP' | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Experimental' | ‐ | ‐ | Sitting and/or standing balance Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Intervention' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking UL training | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | ‐ | |
| ‘Mixed' | ‐ | Aerobic, fitness, endurance | Sitting and/or standing balance Walking UL training | ‐ | Musc. strengthening Active and active assisted movement | PNF | ‐ | |
| ‘Mixed' | ‐ | Aerobic, fitness, endurance | Sitting and/or standing balance Sit‐to‐stand practice Walking UL training | ‐ | Musc. strengthening Active and active assisted movement | PNF | ‐ | |
| ‘Treated' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | ‐ | Active and active assisted movement | Inc. angle of upright sitting Passive movement Body and limb positioning | ‐ | |
| ‘Additional early physiotherapy intervention' | ‐ | ‐ | ‐ | ‐ | ‐ | Passive movement | Described as 'Bobath' | |
| ‘Rehabilitation' | ‐ | ‐ | ‐ | ‐ | ‐ | Passive movement Massage | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | ‐ | ‐ | ‐ | Passive movement Massage | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking | Acupuncture Physical agents | Active and active assisted movement | Massage | Described as 'Bobath' | |
| ‘Neurophysiological (NDT)' | ‐ | ‐ | ADL training | ‐ | ‐ | ‐ | Hands on facilitation (Bobath) Inhibition of abn musc. tone (Bobath) | |
| ‘Orthopaedic (TFR)' | Walking aids Orthoses for walking | ‐ | ADL training | ‐ | Musc. strengthening | Passive movement | ‐ | |
| ‘Mixed' | ADL training Sitting and/or standing balance Walking | |||||||
| ‘Intervention' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Walking | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | Physical agents | Active and active assisted movement | Passive movement Body and limb positioning | Described as 'Bobath' PNF | |
| ‘Mixed' | ‐ | ‐ | Sitting and/or standing balance Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Test' | Details of individual components not available | Details of individual components not available | ||||||
| ‘Test' | Details of individual components not available | Details of individual components not available | ||||||
| ‘Rehabilitation' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing Described as 'MRP' | Acupuncture Physical agents | Active and active assisted movement | Inc. angle of upright sitting Passive movement Body and limb positioning | Described as 'Bobath' PNF | |
| ‘PLBO‐TRT' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Treated' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | Acupuncture | ‐ | Passive movement Body and limb positioning | ‐ | |
| ‘Exercise' | ‐ | ‐ | Sitting and/or standing balance Walking | ‐ | ‐ | Passive movement | PNF | |
| ‘Exercise and OT' | ‐ | ‐ | ADL training Sitting and/or standing balance Transfer practice Walking UL training | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | PNF | |
| ‘PNF' | ‐ | ‐ | ‐ | ‐ | Active and active assisted movement | Passive movement | PNF | |
| ‘General exercise' | ‐ | ‐ | ‐ | ‐ | Active and active assisted movement | Passive movement | ‐ | |
| ‘Experimental' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Walking Stair climbing Described as 'MRP' | ‐ | Musc. strengthening | Passive movement | ‐ | |
| ‘Control' | ‐ | ‐ | Sitting and/or standing balance | ‐ | Musc. strengthening | Passive movement | ‐ | |
| ‘Lower extremities' | ‐ | ‐ | ADL training Sitting and/or standing balance Transfer practice Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Upper extremities' | ‐ | ‐ | UL training | ‐ | ‐ | ‐ | ‐ | |
| ‘Circuit training' | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | ‐ | Musc. strengthening | ‐ | ‐ | ||
| ‘Motor learning' | ‐ | ‐ | Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Neurophysiological (Bobath)' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Intensive exercise' | ‐ | Aerobic, fitness, endurance | ADL training Sitting and/or standing balance Sit‐to‐stand practice Walking Stair climbing | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Bobath' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Gait specific' | ‐ | ‐ | Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Early rehabilitation' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | Described as 'Bobath' | |
| ‘Rehabilitation' | ‐ | ‐ | Sitting and/or standing balance Walking | ‐ | Active and active assisted movement | Passive movement Body and limb positioning Massage | ‐ | |
| ‘Motor learning' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking UL training Described as 'MRP' | Acupuncture Physical agents | ‐ | ‐ | ‐ | |
| ‘Neurodevelopmental therapy' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking | Acupuncture Physical agents | ‐ | Body and limb positioning | Described as 'Bobath' PNF | |
| ‘Treatment' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Walking | ‐ | ‐ | Passive movement Body and limb positioning | Hands on facilitation (Bobath) Trunk mobilisations/ postural reactions (Bobath) | |
| ‘Control' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Walking | ‐ | ‐ | Passive movement Body and limb positioning | ‐ | |
| ‘Neurophysiological (Bobath)' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Motor learning' | ‐ | ‐ | Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | ‐ | |
| ‘Motor learning' | ‐ | ‐ | Sitting and/or standing balance Walking Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Placebo (upper limb control)' | ‐ | ‐ | UL training | ‐ | ‐ | ‐ | ‐ | |
| ‘Exercise' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Feedback' | ‐ | ‐ | Sitting and/or standing balance | Physical agents | ‐ | ‐ | ‐ | |
| ‘Motor learning (Task‐related training)' | ‐ | ‐ | ADL training Sitting and/or standing balance | ‐ | ‐ | ‐ | ‐ | |
| ‘Neurophysiological (Bobath)' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Hands on facilitation (Bobath) Inhibition of abn musc. tone (Bobath) Described as 'Bobath' Trunk mobilisations/ postural reactions (Bobath) | |
| ‘Comprehensive rehabilitation training' | Orthoses for walking | ‐ | Sitting and/or standing balance | Physical agents | ‐ | ‐ | Described as 'Bobath' | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Transfer practice UL training | ‐ | ‐ | Passive movement Body and limb positioning Massage | ‐ | |
| ‘Treatment' | ‐ | ‐ | ‐ | Acupuncture | ‐ | ‐ | Described as 'Bobath' | |
| ‘Mixed' | ‐ | ‐ | Sitting and/or standing balance | ‐ | ‐ | ‐ | ‐ | |
| ‘Neurophysiological (Bobath)' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| 'Treatment' | ‐ | ‐ | ADL training | Acupuncture Physical agents | ‐ | Body and limb positioning | Described as 'Bobath' PNF | |
| ‘Treatment' | ‐ | ‐ | ADL training Walking | Acupuncture Physical agents | ‐ | ‐ | Described as 'Bobath' PNF Sensorimotor facilitation | |
| ‘Experimental' | ‐ | ‐ | Walking | Physical agents | Musc. strengthening | Tilt table | ‐ | |
| 'Early conventional' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| 'Routine conventional' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Motor learning' | ‐ | Aerobic, fitness, endurance | Sitting and/or standing balance Sit‐to‐stand practice Walking Stair climbing Described as 'MRP' | ‐ | Musc. strengthening Active and active assisted movement | ‐ | ‐ | |
| ‘Placebo (upper limb control)' | ‐ | ‐ | UL training Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Combined exercise' | ‐ | Aerobic, fitness, endurance | Sitting and/or standing balance Sit‐to‐stand practice Walking Stair climbing | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Conventional exercise' | ‐ | ‐ | Sitting and/or standing balance Walking Stair climbing | ‐ | Active and active assisted movement | Hands on facilitation (Bobath) Trunk mobilisations/ postural reactions (Bobath) | ||
| ‘Proprioceptive neuromuscular facilitation (PNF)' | ‐ | ‐ | Walking | ‐ | ‐ | ‐ | PNF | |
| ‘Body weight support treadmill training' | ‐ | ‐ | Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Observation' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking | ‐ | ‐ | Passive movement Body and limb positioning | Described as 'Bobath' Sensorimotor facilitation | |
| ‘Control' | ‐ | ‐ | ADL training Transfer practice Walking | ‐ | ‐ | Body and limb positioning | Described as 'Bobath' | |
| ‘Rhythmic auditory stimulation' | ‐ | ‐ | Sitting and/or standing balance Walking Stair climbing | ‐ | ‐ | ‐ | ‐ | |
| ‘Neurodevelopmental therapy (NDT)/Bobath‐based training' | ‐ | ‐ | Walking | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Strategy 1 (S1) (Physiotherapy)' | Walking aids | ‐ | ADL training Sit‐to‐stand practice Transfer practice Walking UL training | ‐ | Musc. strengthening Active and active assisted movement | Passive movement Body and limb positioning | ‐ | |
| ‘Strategy 2 (S2) Education' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | |
| ‘Experimental' | ‐ | ‐ | Sitting and/or standing balance Described as 'MRP' | ‐ | Active and active assisted movement | ‐ | Described as 'Bobath' | |
| ‘Control' | ‐ | ‐ | Described as 'MRP' | Described as 'Bobath' | ||||
| ‘Experimental' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | ‐ | ‐ | ‐ | ||
| ‘Control' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Mixed' | Walking aids | Aerobic, fitness, endurance | ADL training Sitting and/or standing balance Sit‐to‐stand practice Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking UL training Described as 'MRP' | ‐ | ‐ | Passive movement Body and limb positioning | ‐ | |
| ‘Treatment' | ‐ | ‐ | ‐ | Physical agents | Active and active assisted movement | Passive movement Body and limb positioning Massage | Sensorimotor facilitation | |
| 'Control' | ‐ | ‐ | ‐ | ‐ | ‐ | Passive movement Body and limb positioning Massage | ‐ | |
| ‘Neurophysiological' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Hands on facilitation (Bobath) Inhibition of abn musc. tone (Bobath) Described as 'Bobath' Trunk mobilisations/ postural reactions (Bobath) | |
| ‘Orthopaedic' | ‐ | ‐ | ADL training Sit‐to‐stand practice Transfer practice Walking | ‐ | Musc. strengthening Active and active assisted movement | Passive movement | ‐ | |
| ‘Rehabilitation' | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | ‐ | ‐ | Passive movement Body and limb positioning | ||||
| ‘Exercise' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Motor learning' | ‐ | ‐ | Sitting and/or standing balance | ‐ | ‐ | ‐ | ‐ | |
| ‘Control' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | Inhibition of abn musc. tone (Bobath) Described as 'Bobath' PNF | |
| ‘Intensive rehabilitation' | ‐ | ‐ | ‐ | Physical agents | ‐ | ‐ | Described as 'Bobath' PNF | |
| ‘Conventional' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Stair climbing UL training | ‐ | ‐ | Passive movement Body and limb positioning Massage | ‐ | |
| ‘Treatment' | ‐ | ‐ | ADL training Sitting and/or standing balance Transfer practice Walking | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | ‐ | |
| 'Rehabilitation' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Rehabilitation' | ‐ | ‐ | Sitting and/or standing balance Walking | ‐ | Active and active assisted movement | Passive movement Body and limb positioning Massage | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training | ‐ | ‐ | Body and limb positioning | Sensorimotor facilitation | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Transfer practice Walking | ‐ | ‐ | Passive movement Body and limb positioning | Described as 'Bobath' | |
| ‘Training' | ‐ | ‐ | Sit‐to‐stand practice Transfer practice Walking Described as 'MRP' | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | Described as 'Bobath' | |
| ‘Rehabilitation' | Resting splints | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | ‐ | ‐ | Inc. angle of upright sitting Passive movement Body and limb positioning | ‐ | |
| ‘NDT‐based treatment' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Walking | ‐ | ‐ | ‐ | Hands on facilitation (Bobath) Inhibition of abn musc. tone (Bobath) Described as 'Bobath' | |
| ‘Multisensorial' | ‐ | ‐ | Sitting and/or standing balance Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Rehabilitation' | Resting splints | ‐ | Sitting and/or standing balance | ‐ | ‐ | Body and limb positioning | Described as 'Bobath' | |
| ‘Early rehabilitation' | ‐ | ‐ | ADL practice Sitting and/or standing balance Walking Stair climbing | ‐ | Musc. strengthening | Passive movement Body and limb positioning Massage | Sensorimotor facilitation | |
| ‘Rehabilitation' | ‐ | ‐ | ADL practice Sitting and/or standing balance Walking Described as 'MRP' | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | Described as 'Bobath' PNF | |
| ‘Rehabilitation nursing' | ‐ | ‐ | ADL practice Sitting and/or standing balance Sit‐to‐stand practice Walking Stair climbing | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | ADL practice Transfer practice Walking Stair climbing | ‐ | Active and active assisted movement | Passive movement | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Walking Described as 'MRP' | Physical agents | ‐ | Inc. angle of upright sitting Passive movement | Described as 'Bobath' | |
| ‘Treated' | ‐ | ‐ | ADL practice Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing UL training | ‐ | Active and active assisted movement | Inc. angle of upright sitting Passive movement Body and limb positioning | ‐ | |
| ‘Test' | ‐ | ‐ | ADL practice Sitting and/or standing balance Sit‐to‐stand practice Walking Stair climbing UL training | ‐ | ‐ | Inc. angle of upright sitting Passive movement Body and limb positioning | Described as 'Bobath' PNF | |
| ‘Cerebral haemorrhage' | ‐ | ‐ | ADL practice Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing UL training | ‐ | ‐ | Passive movement Body and limb positioning | ‐ | |
| ‘Cerebral infarction' | ‐ | ‐ | ADL practice Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing UL training | ‐ | ‐ | Passive movement Body and limb positioning | ‐ | |
| ‘Acupuncture' | ‐ | ‐ | ‐ | Acupuncture | ‐ | ‐ | ‐ | |
| ‘Physiotherapy' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
Abn: abnormal; ADL: activities of daily living; Inc:increasing; MRP: motor relearning programme; Musc: muscle; Norm: normal; PNF: proprioceptive neuromuscular facilitation; UL: upper limb
The most common intervention category was functional task training, with 101 of the 122 active interventions categorised as including treatment components from functional task training.
-
Of these 101 interventions, 20 included only functional task training components.
-
Of these 101 interventions, 26 included functional task training plus one other category. The second category was neurophysiological for six interventions; modality for two interventions; musculoskeletal (passive) for nine interventions; musculoskeletal (active) for eight interventions and cardiopulmonary for one intervention.
-
Of these 101 interventions, 32 included functional task training plus two other categories. The other categories included neurophysiological for 11 interventions; musculoskeletal (active) and musculoskeletal (passive) for 13 interventions; musculoskeletal (active or passive) plus other categories for seven interventions; and cardiopulmonary and assistive devices for one intervention.
-
Of these 101 interventions, 19 included functional task training plus three other categories. The other categories were neurophysiological plus musculoskeletal (active) plus musculoskeletal (passive) for nine interventions; neurophysiological plus other categories for eight interventions; and musculoskeletal (active) plus musculoskeletal (passive) plus another category for two interventions.
-
Of these 101 interventions, four included functional task training plus four other categories. The other categories were modalities, musculoskeletal (passive), musculoskeletal (active) and neurophysiological for three interventions; assistive devices, musculoskeletal (passive), musculoskeletal (active) and neurophysiological for one intervention; and modalities, musculoskeletal (passive), musculoskeletal (active) and assistive devices for one intervention.
Of the remaining 21 of the 122 interventions, most (17 interventions) included components from the neurophysiological category.
-
Of these 17 interventions, only 12 implemented neurophysiological treatment components.
-
Of these 17 interventions, five implemented neurophysiological plus a combination of musculoskeletal (active), musculoskeletal (passive) and/or modalities.
Of the remaining four interventions:
-
one included musculoskeletal (active) and musculoskeletal (passive) components;
-
two included musculoskeletal (passive) components only; and
-
one included a modality only (this modality was acupuncture; Zhuang 2012).
Comparison groups
The studies included in this review compare an active intervention with:
-
no treatment (55 studies: see Table 4 for further details);
-
usual care (19 studies) or attention control (11 studies) (see Table 5 for further details); or
-
another active intervention (23 studies: see Table 6 for further details).
| Study | Intervention categories for intervention group | Immediate outcomes reported | Persisting outcomes reported | ||||||
|---|---|---|---|---|---|---|---|---|---|
| AD | CPI | FTT | MoD | Musc. (active) | Musc. (passive) | NP | |||
| Baer 2007(a) | x | No data suitable for analysis | No | ||||||
| Baer 2007(b) | x | No data suitable for analysis | No | ||||||
| x | BI, FMA ‐ data not suitable for analysis | BI, FMA ‐ data not suitable for analysis | |||||||
| x | BBS, GV ‐ data not suitable for analysis | BBS, GV ‐ data not suitable for analysis | |||||||
| x | x | x | x | BI | BI | ||||
| x | x | BI | No | ||||||
| x | x | x | x | BI, FMA | No | ||||
| x | x | x | FMA | No | |||||
| x | x | x | No data suitable for analysis | No data suitable for analysis | |||||
| x | x | BI, FMA | BI, FMA | ||||||
| x | BI, FMA | BI, FMA | |||||||
| x | BI, FMA | BI, FMA | |||||||
| x | x | x | x | x | No data suitable for analysis | No | |||
| x | BI, RMA, GV | BI, RMA, GV | |||||||
| x | x | BI, BBS | BI | ||||||
| x | x | x | x | x | BI, BBS | BI, BBS | |||
| x | x | BI | BI | ||||||
| x | x | FMA | No | ||||||
| x | x | x | x | x | FMA | No | |||
| x | BI, FMA | No | |||||||
| x | x | x | No data suitable for analysis | No data suitable for analysis | |||||
| x | No data suitable for analysis | No data suitable for analysis | |||||||
| x | x | x | x | BI, FMA | No | ||||
| x | x | x | No data suitable for analysis | No | |||||
| x | x | x | BI, FMA | No | |||||
| x | x | x | x | FIM, FMA | No | ||||
| x | x | x | x | x | BI, FMA | No | |||
| x | x | BI | No | ||||||
| x | x | BI | No | ||||||
| x | x | x | x | No data suitable for analysis | No | ||||
| x | x | GV | No | ||||||
| x | x | x | BI | BI | |||||
| x | x | x | BI, RMA, GV | BI, RMA, GV | |||||
| x | x | FMA | No | ||||||
| x | x | x | No data suitable for analysis | No | |||||
| x | No outcomes included in analysis. | No | |||||||
| x | x | x | x | BI, FMA | No | ||||
| x | x | BI | No | ||||||
| x | x | x | No outcomes included in analysis. | No | |||||
| x | BI | No | |||||||
| x | x | x | BI, FMA | No | |||||
| x | x | x | BI, FMA | No | |||||
| x | x | x | BI, FMA | No | |||||
| x | x | x | x | BI, FMA | No | ||||
| x | x | x | BI | No | |||||
| x | x | x | x | FMA | No | ||||
| x | x | x | x | BI, FMA | No | ||||
| x | x | x | x | BI, FMA | No | ||||
| x | x | x | BI, FMA | BI, FMA | |||||
| x | x | x | BI | No | |||||
| x | x | x | x | FMA | No | ||||
| x | x | x | No outcomes included in analysis. | No | |||||
| x | x | x | BI, FMA | No | |||||
| x | x | BI, FMA | No | ||||||
| x | x | BI, FMA | No | ||||||
AD: assistive devices; BBS: Berg balance scale; BI: Barthel index; CPI: cardiopulmonary interventions; FMA: Fugl‐Meyer assessment; FTT: functional task training; GV: gait velocity; MAS: motor assessment scale; MoD: modality; Musc.(active): musculoskeletal intervention (active); Musc.(passive): musculoskeletal intervention (passive); NP: neurophysiological intervention; RMA: Rivermead motor assessment.
| Study | Intervention categories for intervention group | Attention control (details) | Usual care (details) | Immediate outcomes reported | Persisting outcomes reported | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| AD | CPI | FTT | MoD | Musc. (active) | Musc. (passive) | NP | |||||
| x | x | FTT Musc. (active) | GV | No | |||||||
| x | x | x | UL training | MAS (UL only), GV | MAS (UL only), GV | ||||||
| x | x | x | Massage | BI, FMA | No | ||||||
| Cooke 2006(a) | x | x | x | x | FTT Musc. (active) Musc. (passive) NP | RMA, GV | RMA, GV | ||||
| Cooke 2006(b) | x | x | x | FTT Musc. (active) Musc. (passive) NP | RMA, GV | RMA, GV | |||||
| x | Cognitive | GV | No | ||||||||
| x | x | UL training | GV | GV | |||||||
| x | x | Cognition, UL training | GV | No | |||||||
| x | Cognition, | GV | GV | ||||||||
| x | x | x | x | FTT Musc. (active) NP | BI, FMA, BBS, GV | No | |||||
| x | x | x | x | FTT Musc. (active) NP | FMA, BBS, GV | No | |||||
| x | NP | No outcomes included in analysis | No | ||||||||
| x | x | x | FTT Musc. (active) Musc. (passive) | BBS, GV | No | ||||||
| x | UL training | Data not suitable for analysis | Data not suitable for analysis | ||||||||
| x | x | x | CPI FTT Musc. (active) | RMA, GV | RMA, GV | ||||||
| x | x | x | Not stated | BI, MAS | No | ||||||
| x | UL training | MAS | MAS | ||||||||
| x | x | Social | RMA, GV | RMA, GV | |||||||
| Mudie 2002(a) | x | Not stated | BI | BI | |||||||
| Mudie 2002(b) | x | Not stated | BI | BI | |||||||
| x | NP | BI | No | ||||||||
| x | x | x | FTT MoD NP | FMA | No | ||||||
| x | x | x | x | NP | BI, FMA, BBS, GV | No | |||||
| x | NP | BI, FMA, BBS, GV | No | ||||||||
| x | x | x | UL training | BBS, GV | No | ||||||
| x | x | x | FTT Musc. (passive) NP | FMA | No | ||||||
| x | x | x | FTT NP | No data suitable for analysis | No | ||||||
| x | x | x | Musc. (passive) | FMA | No | ||||||
| x | Not stated | FMA | No | ||||||||
| x | x | NP | No data suitable for analysis | No | |||||||
AD: assistive devices; BBS: Berg balance scale; BI: Barthel index; CPI: cardiopulmonary interventions; FMA: Fugl‐Meyer assessment; FTT: functional task training; GV: gait velocity; MAS: motor assessment scale; MoD: modality; Musc.(active): musculoskeletal intervention (active); Musc.(passive): musculoskeletal intervention (passive); NP: neurophysiological intervention; RMA: Rivermead motor assessment; UL: upper limb.
| Study | Intervention categories: Active intervention Group 1 | Intervention categories: Active intervention Group 2 | Immediate outcomes reported | Persisting outcomes reported | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| AD | CPI | FTT | MoD | Musc. (active) | Musc. (passive) | NP | AD | CPI | FTT | MoD | Musc. (active) | Musc. (passive) | NP | |||
| x | x | No outcomes included in analysis | No | |||||||||||||
| x | x | x | x | RMA, BBS ‐ data not suitable for analysis | RMA, BBS ‐ data not suitable for analysis | |||||||||||
| x | x | MAS, GV ‐ data not suitable for analysis | No | |||||||||||||
| x | x | x | x | MAS, GV | No | |||||||||||
| x | x | x | x | x | BBS, GV | No | ||||||||||
| x | x | FIM, BBS ‐ as the two active treatment groups were classified as including similar treatment components, data from this study has not been included within the comparisons of one active intervention versus another active intervention | No | |||||||||||||
| x | x | x | x | x | x | x | MAS, GV ‐ as the two active treatment groups were classified as including similar treatment components, data from this study has not been included within the comparisons of one active intervention versus another active intervention | MAS, GV ‐ as the two active treatment groups were classified as including similar treatment components, data from this study has not been included within the comparisons of one active intervention versus another active intervention | ||||||||
| x | x | x | x | x | x | FIM, GV | FIM, GV | |||||||||
| x | x | x | x | x | x | x | BI, FMA ‐ as the two active treatment groups were classified as including similar treatment components, data from this study has not been included within the comparisons of one active intervention versus another active intervention. | BI, FMA ‐ as the two active treatment groups were classified as including similar treatment components, data from this study has not been included within the comparisons of one active intervention versus another active intervention. | ||||||||
| x | x | x | x | x | No data suitable for analysis | No | ||||||||||
| x | x | BI, MAS | No | |||||||||||||
| x | x | x | BI, MAS, RMA, GV ‐ data not suitable for analysis | No | ||||||||||||
| x | x | x | x | x | x | BI | No | |||||||||
| x | x | x | x | x | FMA | No | ||||||||||
| x | x | BI, RMA, GV | BI, RMA, GV | |||||||||||||
| x | x | BI | BI | |||||||||||||
| x | x | x | x | x | BI, FMA, BBS, GV | No | ||||||||||
| x | x | x | x | x | x | BBS | No | |||||||||
| x | x | x | BI, FMA, GV | No | ||||||||||||
| x | x | GV | BI, GV | |||||||||||||
| x | x | x | x | MAS, BBS | No | |||||||||||
| x | x | x | x | FIM, BBS, GV ‐ data not suitable for analysis | FIM, BBS, GV ‐ data not suitable for analysis | |||||||||||
| x | x | BI, FMA | No | |||||||||||||
AD: assistive devices; BBS: Berg balance scale; BI: Barthel index; CPI: cardiopulmonary interventions; FMA: Fugl‐Meyer assessment; FTT: functional task training; GV: gait velocity; MAS: motor assessment scale; MoD: modality; Musc.(active): musculoskeletal intervention (active); Musc.(passive): musculoskeletal intervention (passive); NP: neurophysiological intervention; RMA: Rivermead motor assessment.
A total of 108 comparisons were performed, as five of the 99 studies contributed data on more than one comparison. Four studies contributed data on three comparisons: Cooke 2006, Mudie 2002 and Richards 1993 each compared two active treatments with usual care, and Baer 2007 compared two active treatments with no treatment. Of the 99 studies, one contributed data on two comparisons: Kwakkel 2002 compared an active intervention with both an attention control group and a no treatment group.
Study location
Table 7 lists the geographical locations of the included studies. Of the 99 included studies, 97 recruited participants from one country or continent, and two studies recruited participants from two countries or continents (Brock 2005: Australia and Europe; Thaut 2007: North America and Europe). A total of 54 studies were carried out in China; 17 in Europe; 10 in North America and Canada; seven in Australia and New Zealand; eight in Asia, excluding China and one in South America.
| Study | At recruitment | For intervention | Country |
|---|---|---|---|
| Not stated | Not stated | Turkey | |
| Inpatient stroke rehabilitation unit | Inpatient stroke rehabilitation unit | UK | |
| Not stated | Own homes | UK | |
| Emergency department or Neurology Department | Dependent on stage of rehabilitation and could include own homes,rehabilitation unit, outpatient rehabilitation or community centre | China | |
| Recruited from two rehabilitation units, a hospital ward and a rehabilitation centre | Not stated | Norway | |
| Recruited from multiple community rehabilitation hospitals | Community | USA | |
| Rehabilitation Centre | Rehabilitation centre | Australia | |
| Recruited from multiple rehabilitation centres | Multiple rehabilitation centres | Australia and Germany | |
| Not stated | Not stated | USA | |
| Outpatient rehabilitation centre | Outpatient rehabilitation centre | Hong Kong | |
| Patients in neurological ward/ rehabilitation ward of 4 hospitals in China | Not stated | China | |
| Inpatient University Hospital | Inpatient University Hospital | China | |
| Not stated | Not stated | China | |
| Inpatient, Hospital | Inpatient, Hospital | China | |
| Multiple clinical centres (inpatient) | Multiple clinical centres (inpatient) | England | |
| Own homes (recruited via stroke clubs) | Own homes | Australia | |
| Own homes (recruited from rehabilitation research group database) | Rehabilitation centre (outpatients) | Canada | |
| Own homes (recruited via stroke clubs) | Own homes | Australia | |
| Hospital rehabilitation unit | Hospital rehabilitation unit | Australia | |
| Hospital | Before discharge: within hospital. After discharge: home, outpatient rehabilitation centres | China | |
| Previously inpatients, now discharged? | Own homes | USA | |
| Patients' own homes | Patients' own homes | USA | |
| In hospital | Department of Neurology ward, rehabilitation ward/ centre, community or home setting, depending on stage of rehabilitation | China | |
| Inpatient rehabilitation clinic | Inpatient rehabilitation clinic | China | |
| Hospital | Not stated | China | |
| Hospital | Not stated | China | |
| Rehabilitation department, Hospital | Not stated | China | |
| Acute inpatient ward | Inpatient and outpatient rehabilitation centres | USA | |
| Recruited from hospital and community stroke registers | Outpatient rehabilitation centre; patients' own homes | England | |
| Rehabilitation unit (inpatients) | Outpatient rehabilitation centre; patients' own homes | Sweden | |
| Neurology ward | Neurology ward, rehabilitation zone or rehabilitation centre, own home or community depending on level of rehabilitation | China | |
| Rehabilitation unit (inpatients) | Rehabilitation unit (inpatients) | England | |
| Not stated | Not stated | China | |
| Not stated | Not stated | China | |
| Not stated | Not stated | China | |
| Not stated | Own homes | Hong Kong | |
| Not stated | Neurology ward, rehabilitation ward/ centre, community/home | China | |
| Not stated | Not stated | China | |
| Not stated | Not stated | Korea | |
| Inpatients, Hospital | Not stated | Korea | |
| Rehabilitation centres and nursing homes | Rehabilitation centres and nursing homes | Netherlands | |
| Rehabilitation centres (inpatient) | Multiple outpatient rehabilitation centres | Netherlands | |
| Acute inpatient ward | Acute inpatient ward; rehabilitation units; outpatients; own homes | Norway | |
| Acute inpatient ward | Rehabilitation institutions, community, patients’ homes and nursing homes. | Norway | |
| Not stated | Not stated | Northern Ireland | |
| Not stated | Not stated | China | |
| Inpatient ward | Inpatient ward | China | |
| Not stated | Not stated | China | |
| Not stated | Not stated | China | |
| Rehabilitation unit (inpatients) | Rehabilitation unit (inpatients); outpatients | England | |
| Hospital | ‘All the trainings were done in the bed ward’ | China | |
| Recruited on discharge from physiotherapy services | Outpatients/patients' own homes | Australia | |
| Private rehabilitation clinic | Private rehabilitation clinic | New Zealand | |
| Rehabilitation unit (inpatients) | Rehabilitation unit (inpatients) | Australia | |
| Not stated | Not stated | China | |
| Not stated | Not stated | China | |
| Department of internal Neurology | Department of internal Neurology | China | |
| Not stated | Not stated | China | |
| Stroke unit | Stroke unit | Scotland | |
| Not stated | Not stated | China | |
| Not stated | Not stated | China | |
| Acute inpatient ward | Acute inpatient ward | Canada | |
| Patients' own homes (community) | Outpatients/patients' own homes (self‐practice) | Canada | |
| Outpatient rehabilitation centre | Outpatient rehabilitation centre | Korea | |
| Not stated | Not stated | USA | |
| Not stated | Not stated | China | |
| Not stated | Not stated | Germany and USA | |
| Hospital | Hospital and own homes (following discharge) | Mexico | |
| Inpatient stroke rehabilitation centre | Inpatient stroke rehabilitation centre | Belgium | |
| Inpatient neurology ward | Inpatient rehabilitation and/or outpatient rehabilitation in day care units | India | |
| Community (own homes and residential homes) | Community (own homes and residential homes) | England | |
| Not stated | Bedside and treatment room | China | |
| Not stated | Not stated | China | |
| Rehabilitation unit (inpatients) | Rehabilitation unit (inpatients) | Taiwan | |
| Not stated | Neurology ward, rehabilitation zone, community | China | |
| Hospital inpatients | Hospital inpatients | China | |
| Rehabilitation unit (inpatients) | Rehabilitation unit (inpatients) | USA | |
| Not stated | Ward, rehabilitation ward, community | China | |
| Not stated | Not stated | China | |
| Hospital | Hospital | China | |
| Not stated | Hospital ward, home | China | |
| Not stated | Not stated | China | |
| Hospital | Neurology department | China | |
| Inpatients, Department of Neurology | Inpatients, Department of Neurology | China | |
| Not stated | Not stated | China | |
| Department of Neurology, Yaan People’s Hospital | Not stated | China | |
| Not stated | Hospital ward, rehabilitation centre | China | |
| Multi‐center rehabilitation units | Multi‐center rehabilitation units | France | |
| Neurology Department | Rehabilitation centre, Hospital | China | |
| Not stated | Not stated | China | |
| Not stated | Department of Neurology‐ rehabilitation centres, Department of Rehabilitation, community rehabilitation organisations, home | China | |
| Not stated | Not stated | China | |
| Hospital | Neurology Department, Hospital | China | |
| Not stated | Not stated | China | |
| Not stated | Hospital, outpatient, community, home | China | |
| Not stated | Not stated | China | |
| Not stated | Hospital, rehabilitation centre, home for intervention groups. | China | |
| Not stated | Hospital, rehabilitation centre, home for intervention groups. | China | |
| 'Stroke units in inpatient settings' | 'Stroke units in inpatient settings' | China |
The mean study size was greater in studies carried out in China (mean 138, SD 189 participants) than in other parts of the world (Europe: mean 76, SD 60; North America and Canada: mean 74, SD 122; Australia and New Zealand: mean 48, SD 48; Asia, excluding China: mean 46, SD 30).
The settings for recruitment of participants and for administration of the intervention are summarised in Table 7.
Table 8 illustrates the types of control interventions included in studies in different geographical locations. Of the 54 studies, 44 including a no‐treatment comparison were carried out in China.
| Continent / Control intervention | Europe | Australia & New Zealand | North America & Canda | South America | Asia (China) | Asia (other) | TOTAL |
| No treatment | 5 | 0 | 3 | 1 | 44 | 1 | 54 |
| Usual Care | 6 | 1 | 4 | 0 | 5 | 1 | 17 |
| Attention Control | 1 | 6 | 2 | 0 | 1 | 0 | 10 |
| Active intervention | 10 | 2 | 3 | 0 | 4 | 6 | 25 |
| TOTAL | 22 | 9 | 12 | 1 | 54 | 8 | 106 |
Table shows number of studies with different types of control group, in studies carried out in different continents. Two studies were each carried out in 2 continents; and 5 studies had two comparison interventions. Thus the 99 studies include a total of 106 control interventions on different continents.
Study participants
Table 9 displays details of the participants included in the studies.
| Study | Study group | No. of participants | Sex ‐ male/female | Side ‐ LCVA/RCVA | Age | Time since onset | Type of stroke | No. finished intervention |
|---|---|---|---|---|---|---|---|---|
| Group 1 | 9 | Whole group 9/11 | Not stated | Not stated | Not stated | Not stated | 9 | |
| Group 2 | 7 | As above | Not stated | Not stated | Not stated | Not stated | 7 | |
| Group 3 | 4 | As above | Not stated | Not stated | Not stated | Not stated | 4 | |
| ‘Intervention' | 7 | Whole group 10/7 | Not stated | Mean = 72.4 y SD = 17.9 y Range: 55‐88 y | Mean = 20.6 days SD = 20.5 days Range: 9‐57 days | Not stated | 5 | |
| ‘Control' | 10 | As above | Not stated | Mean = 78 y SD = 7.9 y Range: 65‐92 y | Mean = 15.1 days SD = 16.0 days Range: 6‐58 days | Not stated | 10 | |
| ‘Part practice' | Not stated | Whole group 31/33 | Whole group 26/38 | Whole group Mean = 72.9 y SD = 9.0 y | Whole group Mean = 30.3 months SD = 28.8 months | Not stated | Not stated | |
| 'Whole practice' | Not stated | As above | As above | As above | As above | Not stated | Not stated | |
| 'Control (no treatment)' | Not stated | As above | As above | As above | As above | Not stated | Not stated | |
| 'Early rehabilitation' | 183 | 119/64 | 85/98 | Mean = 61.5 y SD = 9.4 y | Mean = 11.4 days SD = 5.7 days | Not stated | 175 | |
| 'Control (no treatment)' | 181 | 113/68 | 87/94 | Mean = 60.8 y SD = 10.1 y | Mean = 10.9 days SD = 5.5 days | Not stated | 170 | |
| 'Functional strength training' | 8 | 3/5 | 6/2 | Mean = 60.8 y SD = 13 y | Mean = 49.4 days SD = 22.1 days | Cerebral infarct = 4 Haemorrhagic = 4 | 8 | |
| ‘Training as usual' | 10 | 4/6 | 3/7 | Mean = 64.9 y SD = 8.9 y | Mean = 32 days SD = 18.5 days | Cerebral infarct = 8 Haemorrhagic = 2 | 10 | |
| ‘Locomotor training program' | 139 | Not stated | Not stated | Not stated | Not stated | Not stated | 139 | |
| ‘Home exercise program' | 126 | Not stated | Not stated | Not stated | Not stated | Not stated | 126 | |
| ‘Usual care' | 143 | Not stated | Not stated | Not stated | Not stated | Not stated | 143 | |
| ‘Mobility’ | 15 | 8/7 | 8/7 | Mean = 53.9 y SD = 19.8 y | Mean = 36.0 days SD = 25.1 days | Haemorrhagic = 4 Infarct = 11 | 15 | |
| ‘Upper limb’ | 15 | 9/6 | 6/9 | Mean = 56.3 y SD = 10.5 y | Mean = 50.1 days SD = 49.2 days | Haemorrhagic = 4 Infarct = 11 | 15 | |
| ‘Bobath' | 12 | 7/5 | 2/9 Bilateral = 1 | Mean = 61.3 y SD = 13.0 y Range: 35–75 y | Mean = 60.3 days SD = 24.0 days Range: 29–101 days | Haemorrhagic = 2 Infarct = 8 Both = 2 | 12 | |
| ‘Task practice' | 14 | 12/2 | 10/3 Bilateral = 1 | Mean = 56.6 y SD = 15.8 y Range: 29–77 y | Mean = 63.6 days SD = 25.9 days Range: 40–126 days | Haemorrhagic =4 Infarct = 9 Both = 1 | 14 | |
| ‘Treatment' | 6 | Not stated | Not stated | Not stated | Not stated | Not stated | 6 | |
| ‘Control (no treatment)' | 5 | Not stated | Not stated | Not stated | Not stated | Not stated | 5 | |
| ‘Motor relearning' | 33 | 12/14 | 12/14 | Mean = 53.8 y SD = 15.4 y | Mean = 117.7 days SD = not stated | Not stated | 26 | |
| 'Conventional therapy' | 33 | 12/14 | 12/14 | Mean = 54.4 y SD = 13.7 y | Mean = 88.8 days SD = not stated | Not stated | 26 | |
| ‘Rehabilitation' | 39 | 25/14 | Not stated | Mean = 60.95 y SD = 9.74 y | Mean = 9.05 days SD = 5.74 days | Haemorrhagic = 12 Ischaemic = 27 | 39 | |
| ‘Control (no treatment)' | 39 | 24/15 | Not stated | Mean = 62.36 y SD = 9.65 y | Mean = 8.65 days SD = 5.38 days | Haemorrhagic = 12 Ischaemic = 27 | 39 | |
| ‘Rehabilitation' | 25 | 16/9 | Not stated | Mean = 66.2 y SD = 6.8 y | Within 6 months after stroke = 13 Between 6 and 12 months after stroke = 8 More than 12 months after stroke = 4 | Haemorrhagic = 7 Ischaemic = 18 | 25 | |
| ‘Control (no treatment)' | 20 | 12/8 | Not stated | Mean = 67.3 y SD = 5.9 y | Within 6 months after stroke = 11 Between 6 and 12 months after stroke = 5 More than 12 months after stroke = 4 | Haemorrhagic = 8 Ischaemic = 12 | 20 | |
| ‘Test' | 53 | 29/24 | Not stated | Mean = 60.49 y Range = 46‐83 y | Mean = 9.35 days Range = 1‐20 days | Haemorrhagic = 14 Ischaemic = 39 | 53 | |
| ‘Control (no treatment)' | 53 | 28/25 | Not stated | Mean = 62.8 y Range = 41‐85 y | Mean = 9.15 days Range = 1‐21 days | Haemorrhagic = 17 Ischaemic = 36 | 53 | |
| ‘Rehabilitation' | 30 | Whole group 31/27 | Whole group 32/26 | Whole group Mean = 62.4 y Range: 54‐68 y | Not stated | Whole group Haemorrhagic = 26 Ischaemic = 32 | 30 | |
| ‘Control (no treatment)' | 28 | As above | As above | Not stated | 28 | |||
| ‘Additional conventional therapy (CPT+CPT)' | 35 | 22/13 | 13/22 | 67.46 (11.3)y | 32.43 (21.29) days | Not stated | At 6 weeks, n=32; At 3 month follow‐up, n=28 | |
| ‘Functional strength training (FST +CPT)' | 36 | 22/14 | 12/24 | 71.17 (10.6) y | 33.86 (16.50) days | Not stated | At 6 weeks, n=36; At 3 month follow‐up, n=29 | |
| ‘Conventional physiotherapy (CPT)' | 38 | 21/17 | 17/21 | 66.37 (13.7) y | 36.76 (22.41) days | Not stated | At 6 weeks, n=31; At 3 month follow‐up, n=24 | |
| ‘Motor learning' | 10 | 7/3 | 5/5 | Mean = 68.2 y | Mean = 6.7 y | Not stated | 10 | |
| ‘Placebo' | 10 | 7/3 | 6/4 | Mean = 66.9 y | Mean = 5.9 y | Not stated | 9 | |
| ‘Motor learning' | 6 | 3/3 | 3/3 | Mean = 66.2 y | Mean = 2.3 y | Not stated | 5 | |
| ‘Placebo' | 6 | 4/2 | 4/2 | Mean = 62.3 y | Mean = 1.3 y | Not stated | 4 | |
| ‘Experimental' | 76 | 38/38 | 34/42 | Mean = 66.7 y SD = 14.3 y Range: 31‐91 y | Mean = 6.7 y SD = 6.7 y Range: 0.1‐24.8 y | Not stated | 65 | |
| ‘Control' | 75 | 40/35 | 28/47 | Mean = 67.5 y SD = 10.2 y Range: 40‐85 y | Mean = 5.2 y SD = 5.4 y Range: 0.2‐25.1 y | Not stated | 68 | |
| ‘Experimental' | 6 | 5/1 | 3/3 | Mean = 60 y SD = 7 y | Mean = 21 days SD = 8 days Range: 17 ‐ 37 days | Not stated | At 2 weeks, n=6; At 28 week follow‐up, n=5 | |
| ‘Control' | 6 | 4/2 | 1/5 | Mean = 74 y SD = 12 y | Mean = 37 days SD = 23 days Range: 13 ‐ 75 days | Not stated | At 2 weeks, n=6; At 28 week follow‐up, n=4 | |
| ‘Intervention' | 50 | 36/14 | Not stated | Mean = 57.08 y SD = 9.15 y | Stroke onset to admission to hospital: ≤6 hours:n = 31 >6 hours: n = 19 | Not stated | 50 | |
| ‘Control (no treatment)' | 50 | 35/15 | Not stated | Mean = 56.98 y SD = 9.05 y | Stroke onset to admission to hospital: ≤6 hours: n = 30 >6 hours: n = 20 | Not stated | 50 | |
| ‘Mixed' | 10 | Not stated | 4/6 | Mean = 67.3 y | Mean = 66 days | Ischaemic = 10 | 10 | |
| ‘Control' | 10 | Not stated | 4/5 + 1 brainstem | Mean = 67.8 y | Mean = 56 days | Haemorrhagic = 2 Ischaemic = 8 | 10 | |
| ‘Mixed' | 50 (44 completed intervention) | 23/21 | 18/22; 4 bilateral | Mean = 68.5 y | Mean = 77.5 days | Ischaemic = 39 | 44 | |
| ‘Control' | 50 (48 completed intervention) | 27/21 | 22/22; 4 bilateral | Mean = 70.2 y | Mean = 73.5 days | Ischaemic = 44 | 48 | |
| ‘Treated' | 42 | 22/20 | 21/21 | Mean = 64.53 y SD = 10.77 y | Mean = 8.14 days SD = 4.95 days | Haemorrhagic = 15 Ischaemic = 27 | 42 | |
| ‘Control (no treatment)' | 40 | 27/13 | (unable to tell if data pertains to side of lesion or side of hemiplegia) | Mean = 65.82 y SD = 10.61 y | Mean = 8.33 days SD = 3.87 days | Haemorrhagic = 14 Ischaemic = 26 | 38 | |
| ‘Additional early physiotherapy intervention' | 78 | 33/17 | Not stated | Mean = 65.49 y SD = 10.94 y | Not stated | Haemorrhagic = 13 Cerebral infarct = 37 | At day 30, n= 50; at 6 months, n = 12 | |
| ‘Routine therapy' | 78 | 44/34 | Not stated | Mean = 61.8 y SD = 10.94 y | Not stated | Haemorrhagic = 11 Cerebral infarct = 67 | At day 30, n= 78; at 6 months, n = 12 | |
| ‘Rehabilitation' | 25 | 17/8 | Not stated | Whole group mean = 65.49 y SD = 10.94 y | Not stated | Whole group Haemorrhagic = 24 Ischaemic = 102 Mixed = 2 | Whole group: At day 30, n = 45; at 6 months, n= 14 | |
| ‘Control (no treatment)' | 45 | 26/19 | Not stated | Whole group mean = 61.8 y SD = 10.9 y | Not stated | As above | Whole group: At day 30, n = 55; at 6 months, n=12 | |
| ‘Rehabilitation' | 25 | 16/9 | Not stated | As above | Not stated | As above | As above | |
| ‘Control (no treatment)' | 33 | 18/15 | Not stated | As above | Not stated | As above | As above | |
| ‘Rehabilitation' | 20 | 14/6 | Not stated | Mean = 61 y SD = 5 y | Mean = 50 days SD = 22 days | Not stated | Unclear ‐ see notes in characteristics of included studies | |
| ‘Control (no treatment)' | 28 | 20/8 | Not stated | Mean = 60 y SD = 5 y | Mean = 51 days SD = 26 days | Not stated | Unclear ‐ see notes in characteristics of included studies | |
| ‘Neurophysiological (NDT)' | 15 | 9/6 | 8/7 | Mean = 73.7 y | Mean = 11.3 days | Pure motor ischaemic = 15 | 15 | |
| ‘Orthopaedic (TFR)' | 12 | 4/8 | 5/7 | Mean = 69.8 y | Mean = 13.8 days | Pure motor ischaemic = 12 | 12 | |
| ‘Mixed' | 85 | 49/36 | 56/26 + 3 'other' | Mean = 71.5 y SD = 8.7 y | Not stated | Not stated | 81 | |
| ‘Control (no treatment)' | 85 | 46/39 | 44/40 + 1 'other' | Mean = 73.5 y SD = 8.3 y | Not stated | Not stated | 80 | |
| ‘Intervention' | 15 | 9/6 | Not stated | Mean = 77.7 y SD = 7.6 y | Mean = 139.7 days SD= 37.3 days | Cardioembolic stroke = 4 Lacunar infarct = 2 Other specified stroke = 2 Unknown stroke = 6 not applicable (because of intracerebral haemorrhage) =1 | 15 | |
| ‘Control' | 19 | 12/7 | Not stated | Mean = 79.2 y SD = 7.5 y | Mean = 126.8 days SD= 28.2 days | Large artery thrombosis = 4 Cardioembolic stroke = 5 Lacunar infarct = 8 Unknown stroke = 2 | 19 | |
| ‘Rehabilitation' | 40 | 25/15 | Not stated | Mean = 61.38 y SD = 9.99 y | Mean = 9.05 days SD = 5.74 days | Haemorrhagic = 12 Ischaemic = 28 | 40 | |
| ‘Control (no treatment)' | 40 | 24/16 | Not stated | Mean = 62.55 y SD = 9.60 y | Mean = 8.65 days SD = 5.38 days | Haemorrhagic = 12 Ischaemic = 28 | 40 | |
| ‘Mixed' | 17 (15 at 4‐week follow up) | 9/8 | 8/9 | Mean = 71.5 y | Mean = 26.5 days | 2 TACS / 7 PACS / 4 LACS / 1 POCS / 3 other | 15 | |
| ‘Control (neurophysiological)' | 18 (18 at 4‐week follow up) | 9/9 | 7/11 | Mean = 70.7 y | Mean = 23.1 days | 3 TACS / 6 PACS / 4 LACS / 3 POCS / 2 other | 18 | |
| ‘Test (haemorrhagic group)' | 178 | Not stated | Not stated | Whole group Mean = 61 y SD = 10y | Whole group Mean = 11 days SD = 6 days | Not stated | At 1 month after stroke n = 178; at 3 months after stroke, n= 178; at 6 months after stroke, n= 177 | |
| ‘Control (no treatment)' | 174 | Not stated | Not stated | As above | As above | Not stated | At 1 month after stroke n = 174; at 3 months after stroke, n= 168; at 6 months after stroke, n= 168 | |
| ‘Test (ischaemic group)' | 485 | Not stated | Not stated | Whole group Mean = 64 y SD = 10 y | Whole group Mean = 10 days SD = 5 days | Not stated | At 1 month after stroke n = 485; at 3 months after stroke, n= 478; at 6 months after stroke, n= 471 | |
| ‘Control (no treatment)' | 480 | Not stated | Not stated | As above | As above | Not stated | At 1 month after stroke n= 480; at 3 months after stroke, n = 473; at 6 months after stroke, n=469 | |
| ‘Rehabilitation' | 25 | 17/8 | 14/11 | Mean = 64.61 y SD = 12.37 y | Mean = 6.45 days SD = 3.70 days | Haemorrhagic = 5 Ischaemic = 20 | 25 | |
| ‘Control (no treatment)' | 25 | 17/8 | 12/13 | Mean = 65.351 y SD = 11.71 y | Mean = 6.89 days SD = 3.20 days | Haemorrhagic = 5 Ischaemic = 20 | 25 | |
| ‘PLBO+TRT' | 25 | Not stated | Not stated | Whole group mean = 56.6 y SD = 7.9 y | Whole group mean = 4.7 y SD = 3.4 y | Not stated | 25 | |
| ‘Control (no treatment)' | 29 | Not stated | Not stated | As above | As above | Not stated | 29 | |
| ‘Treated' | 42 | 22/20 | 21/21 'location of disease' | Mean = 64.53 y SD = 10.77 y | Mean = 8.14 days SD =4.95 days | Haemorrhagic = 15 Infarction = 27 | Whole group: n=79 at 6 months | |
| ‘Control' | 40 | 27/13 | 15/25 'location of disease' | Mean = 65.82 y SD = 10.61 y | Mean = 8.33 days SD = 3.87 days | Haemorrhagic = 14 Infarction = 26 | As above | |
| ‘Exercise and occupational therapy' | 120 | 69/51 | Whole group 73/87 | Mean = 57.3 y SD = 12.5 y | Mean = 5.2 days SD = 4.2 days | Whole group Haemorrhagic = 66 Ischaemic = 94 | 120 | |
| ‘Exercise therapy' | 40 | 23/17 | As above | Mean = 54.5 y SD = 9.6 y | Mean = 4.6 days SD = 3.7 days | As above | 40 | |
| ‘PNF' | 20 | 17/3 | 12/8 | Mean = 51.4 y SD = 5.7 y | Mean = 22.9 months SD = 12.2 months | Haemorrhagic = 8 Infarction = 12 | 20 | |
| ‘Control' | 20 | 14/6 | 12/8 | Mean = 53.5 y SD = 7.1 y | Mean = 26.8 months SD = 12.8 months | Haemorrhagic = 9 Infarction = 11 | 20 | |
| ‘Experimental' | 10 | Not stated | Not stated | Mean = 52.5 y SD = 11.72 y | Mean = 7.7 y SD = 6.11 y | Not stated | 10 | |
| ‘Control' | 10 | Not stated | Not stated | Mean = 53.4 y SD = 12.11 y | Mean = 13.1 y SD = 10.62 y | Not stated | 10 | |
| ‘Lower extremities' | 17 | 13/4 | 7/10 | Mean = 60.8 y SD = 10.6 y Range: 38‐76 y | Mean = 4.8 weeks SD = 3.1 weeks Range: 2‐9 weeks | TACI =6 PACI =10 LACI =1 | 17 | |
| ‘Upper extremities' | 18 | 9/9 | 8/10 | Mean = 64.3 y SD = 10.6 y Range: 46‐80 y | Mean = 5.9 weeks SD = 3 weeks Range: 2‐10 weeks | TACI =8 PACI =7 LACI =3 | 18 | |
| ‘Control' | 18 | 14/4 | 7/11 | Mean = 62.1 y SD =10.6 y Range: 30‐76 y | Mean = 7.3 weeks SD = 3.6 weeks Range: 2‐10 weeks | TACI =9 PACI =6 LACI =3 | 18 | |
| ‘Circuit training’ | 126 | 82/44 | 49/57 brainstem = 6 cerebellum = 14 | Mean = 56 y SD = 10 y | Mean = 91 days SD = 42 days | Haemorrhagic = 23 Ischaemic = 103 | 125 | |
| ‘Usual physiotherapy’ | 124 | 80/44 | 43/61 brainstem = 14 cerebellum = 6 | Mean = 58 y SD = 10 y | Mean = 103 days SD = 51 days | Haemorrhagic = 24 Ischaemic = 100 | 117 | |
| ‘Neurophysiological (Bobath)' | 28 | 16/12 | 17/11 | Whole group | Not stated | Not stated | 24 | |
| ‘Motor learning' | 33 | 20/13 | 17/16 | See above | Not stated | Not stated | 29 | |
| ‘Intensive exercise' | 35 | Not stated | 16/19 | Mean = 76 y SD = 12.7 y | Not stated | 'Cause of the stroke was thrombosis or embolism with 29 such cases in the intensive exercise group & 6 being haemorrhages' | 32 | |
| ‘Regular exercise' | 40 | Not stated | 21/19 | Mean = 72 y SD = 13.6 y | Not stated | 'Cause of the stroke was thrombosis or embolism with 36 such cases in the regular exercise group and 4 being haemorrhages' | 32 | |
| ‘Bobath' | 30 | Not stated | Not stated | Not stated | Not stated | Not stated | 30 | |
| ‘Gait specific group' | 31 | Not stated | Not stated | Not stated | Not stated | Not stated | 31 | |
| ‘Early rehabilitation' | 30 | Not stated | Not stated | Mean = 58.1 y SD = 11.9 y | Not stated | Haemorrhagic = 12 Ischaemic = 18 | 30 | |
| ‘Control (no treatment)' | 31 | Not stated | Not stated | Mean = 59.20 SD = 10.2 y | Not stated | Haemorrhagic = 12 Ischaemic = 19 | 31 | |
| ‘Rehabilitation' | 87 | 49/38 | Not stated | Mean = 63 y SD = 1 y | Not stated | Not stated | 87 | |
| ‘Control (no treatment) group' | 87 | 35/52 | Not stated | Not stated | Not stated | Not stated | 87 | |
| ‘Motor relearning' | 31 | Not stated | Not stated | Mean =51.4 y SD = 8.9 y | Mean = 8.8 days SD = 6.0 days | Not stated | 31 | |
| 'Neurodevelopmental therapy' | 30 | Not stated | Not stated | Mean = 54.6 y SD = 9.9 y | Mean = 8.3 days SD = 5.3 days | Not stated | 30 | |
| ‘Treatment' | 48 | 28/20 | 16/32 'location of disease' | Mean = 62.3 y SD = 7.2 y | Mean = 7.81 days SD = 4.65 days | Haemorrhagic = 18 Ischaemic = 30 | 48 | |
| ‘Control' | 48 | 26/22 | 18/30 'location of disease' | Mean = 63.4 y SD = 6.8 y | Mean = 7.94 days SD = 4.51 days | Haemorrhagic = 16 Ischaemic = 32 | 48 | |
| ‘Neurophysiological (Bobath)' | 60 | 27/33 | 30/29; 1 bilateral | Mean = 73.3 y | Inclusion criteria: | 9 TACS / 29 PACS / 14 LACS / 4 POCS / 4 unsure | At 1 month ‐ 52 | |
| ‘Motor Learning' | 60 | 33/27 | 31/27; 2 bilateral | Mean = 75.0 y | Inclusion criteria: | 8 TACS / 32 PACS / 11 LACS / 6 POCS / 3 unsure | At 1 month ‐ 47 | |
| ‘Rehabilitation' | 60 | 38/22 | Not stated | Mean = 62 y SD = 10 y | ‘The rehabilitation group started to accept the treatment in 3‐5 days after attack ..’ | Haemorrhagic = 19 Ischaemic = 41 | 60 | |
| ‘Control (no treatment)' | 60 | 35/25 | Not stated | Mean = 61 y SD = 9 y | Not stated | Haemorrhagic = 20 Ischaemic = 40 | 60 | |
| ‘Motor learning' | 15 | 10/3 | 8/5 | Mean = 69 y | Median = 6.5 mo | 13 | ||
| ‘Placebo (upper limb control)' | 11 | 2/8 | 3/6; 1 bilateral | Mean = 72 y | Median = 4.5 mo | 10 | ||
| ‘Exercise' | 31 | 19/12 | 11/20 | Median = 76.0 y Range = 39.0–89.0 y | Median = 3.33 y Range = 0.6–13.3 y | Not stated | At 3 month follow‐up ‐ 27 | |
| ‘Control' | 27 | 13/14 | 12/14 1 brainstem | Median = 71.0 y Range = 44.0–86.0 y | Median = 5.8 Range = 0.5–18.7 y | Not stated | At 3 month follow‐up ‐ 23 | |
| ‘Motor learning' | 10 | 21/19 for total of 40 recruited | 22/18 for total of 40 recruited | Mean = 72.4 y | Range 2 to 6 weeks (for total of 40 recruits) | MCA infarct = 22 | 10 | |
| ‘Neurophysiological' | 10 | 21/19 for total of 40 recruited | 22/18 for total of 40 recruited | Mean = 72.4 y | Range = 2 to 6 weeks (for total of 40 recruits) | MCA infarct = 22 | 9 | |
| ‘Control (no treatment)' | 10 | 21/19 for total of 40 recruited | 22/18 for total of 40 recruited | Mean = 72.4 y | Range 2 to 6 weeks (for total of 40 recruits) | MCA infarct = 22 | 6 | |
| ‘Comprehensive rehabilitation training' | 34 | 26/8 | Not stated | Mean = 55.56 y SD = 17.64 y | Mean = 19.21 days SD = 7.59 days | Ischaemic = 19 Haemorrhagic = 15 | 34 | |
| ‘Control (no treatment)' | 34 | 23/11 | Not stated | Mean = 53.25 y SD = 13.46 y | Mean = 18.31 days SD = 9.64 days | Ischaemic = 20 Haemorrhagic = 14 | 34 | |
| ‘Rehabilitation' | 48 | 36/12 | 26/22 | Mean = 64.2 y SD= 11.5 y | Not stated | Ischaemic = 30 Haemorrhagic = 18 | 48 | |
| ‘Control' | 48 | 32/16 | 22/26 | Mean = 62.5 y SD = 13.7 y | Not stated | Ischaemic = 32 Haemorrhagic = 16 | 48 | |
| ‘Rehabilitation' | 50 | 32/18 | Not stated | Mean = 61.4 y Range: 37‐76 y | Not stated | Haemorrhagic = 21 Infarction = 29 | 50 | |
| ‘Control (no treatment)' | 36 | 25/11 | Not stated | Mean = 60 y Range: 39‐75 y | Not stated | Haemorrhagic = 15 Infarction = 21 | 36 | |
| ‘Treatment' | 41 | Not stated | Not stated | Not stated | Not stated | Not stated | 41 | |
| ‘Control (no treatment)' | 39 | Not stated | Not stated | Not stated | Not stated | Not stated | 37 | |
| ‘Neurophysiological (Bobath)' | 19 | 12/7 | 10/9 | Mean = 68.4 y | Inclusion criteria: "less than six weeks previously" | 6 TACS / 3 PACS / 5 LACS / 2 POCS/ 3 PICH | 11 | |
| ‘Mixed (Neurophysiological + motor learning)' | 9 | 0 /9 | 7/2 | Mean = 73.1 y | Inclusion criteria: "less than six weeks previously" | 2 TACS / 3 PACS / 4 LACS / 0 POCS / 0 PICH | 5 | |
| ‘Treatment' | 23 | 11/12 | Not stated | Mean = 62.8 y SD = 14.3 y | Mean = 13.9 days SD = 8.5 days | Ischaemic = 15 Haemorrhagic = 8 | 23 | |
| ‘Control (no treatment)' | 19 | 9/10 | Not stated | Mean = 62.8 y SD = 17.2 y | Mean = 12.1 days SD = 9.7 days | Ischaemic = 14 Haemorrhagic = 5 | 19 | |
| ‘Treatment' | 20 | 11/9 | Not stated | Mean = 63.5 y SD = 15.5 y | Mean = 13.8 days SD = 5.8 days | Ischaemic = 12 Haemorrhagic = 8 | 20 | |
| ‘Control' | 20 | 12/8 | Not stated | Mean = 63.7 y SD = 16.3 y | Mean = 13.5 days SD = 7.3 days | Ischaemic = 14 Haemorrhagic = 6 | 20 | |
| ‘Mixed (early)' | 10 | 5/5 | 2/8 | Mean = 69.6 y | Mean = 8.3 days | Canadian Stroke Score (maximum score = 15) | 9 | |
| ‘Neurophysiological (early)' | 8 | 2/6 | 6/2 | Mean = 67.3 y | Mean = 8.8 days | Canadian Stroke Score (maximum score = 15) | 6 | |
| ‘Neurophysiological (conventional)' | 9 | 6/3 | 3/6 | Mean = 70.3 y | Mean = 13.0 days | Canadian Stroke Score (maximum score = 15) | 8 | |
| ‘Motor learning' | 44 | 26/18 | 27/17 | Mean = 71 y | Mean = 239 days | Mild gait deficit = 19 | 41 | |
| ‘Placebo (upper limb control)' | 47 | 30/17 | 24/22; 1 bilateral | Mean = 73 y | Mean = 217 days | Mild gait deficit = 17 | 43 | |
| ‘Combined Exercise' | 11 | 5/6 | 8/3 | Mean = 58.1 y SD = 4.6 y | Not stated | Not stated | 11 | |
| ‘Conventional Exercise' | 10 | 3/7 | 5/5 | Mean = 57.3 y SD = 4.4 y | Not stated | Not stated | 10 | |
| ‘Body Weight Support Treadmill Training' | 6 | Not stated | Not stated | Whole group Mean = 59.8 y Range: 42‐80 y | Not stated | Not stated | 6 | |
| ‘Proprioceptive Neuromuscular Facilitation‐PNF training' | 6 | Not stated | Not stated | See above | Not stated | Not stated | 6 | |
| ‘Control (no treatment)' | 6 | Not stated | Not stated | See above | Not stated | Not stated | 6 | |
| ‘Observation' | 35 | 11/9 | Not stated | Whole group mean = 61.98 y Range: 44‐75 y | Not stated | Not stated | 35 | |
| ‘Control' | 35 | 12/8 | Not stated | See above | Not stated | Not stated | 35 | |
| ‘Rhythmic auditory stimulation' | 43 | 22/21 | 20/23 | Mean = 69.2 y SD = 11 y | Mean = 21.3 days SD = 11 days | Location of stroke: MCA = 35 Internal capsule = 4 Basal ganglia/thalamus = 3 Subdural haematoma = 1 | 43 | |
| ‘Neurodevelopmental therapy (NDT)/Bobath− | 35 | 19/16 | 16/19 | Mean = 69.7 y SD = 11 y | Mean = 22.2 days SD = 12 days | Location of stroke: MCA = 30 Internal capsule = 4 Basal ganglia/thalamus = 1 | 35 | |
| ‘Strategy 1' | 59 | 16/43 | Not stated | Mean = 69.4 y SD = 12 y | Mean = 7.1 days SD = 5.9 days | Not stated | At 6 month follow‐up = 32 | |
| ‘Strategy 2' | 51 | 21/30 | Not stated | Mean = 69.8 y SD = 8.8 y | Mean = 6.3 days SD = 3.1 days | Not stated | At 6 month follow‐up = 35 | |
| ‘Experimental' | 17 | 11/6 | 9/8 | Mean = 55 y SD = 11 y | Mean = 53 days SD = 24 days | Haemorrhagic = 2 Ischaemic = 15 | 17 | |
| ‘Control' | 16 | 9/7 | 7/9 | Mean = 62 y SD = 14 y | Mean = 49 days SD = 28 days | Haemorrhagic = 3 Ischaemic = 13 | 16 | |
| ‘Experimental' | 15 | 10/5 | 8/7 | Mean = 53.27 y SD = 8.53 y | Mean = 6.07 weeks SD = 3.30 weeks | Haemorrhagic = 4 Ischaemic = 11 | 15 | |
| ‘Control' | 15 | 12/3 | 7/8 | Mean = 55.07 y SD = 6.80 y | Mean = 6.60 weeks SD = 3.20 weeks | Haemorrhagic = 3 Ischaemic = 12 | 15 | |
| ‘Mixed' | 49 | 27/22 | 25/19 | Mean = 72.3 y | Mean = 53.1mo | 48 | ||
| ‘Control (no treatment)' | 45 | 20/25 | 21/21 | Mean = 72.0 y | Mean = 59.6 mo | 41 | ||
| ‘Rehabilitation' | 70 | 36/30 | Not stated | Mean = 63.1 y SD = 9.8 y | Not stated | Not stated | 66 | |
| ‘Control (no treatment)' | 35 | 18/14 | Not stated | Mean = 65.2 y SD = 11.3 y | Not stated | Not stated | 32 | |
| ‘Treatment' | 25 | 16/9 | Not stated | Mean = 62.1 y SD = 10.2 y | Mean = 54.2 days SD = 37.5 days | Haemorrhagic = 11 Ischaemic = 14 | 25 | |
| ‘Control (no treatment)' | 25 | 15/10 | Not stated | Mean = 59.5 y SD = 11.4 y | Mean = 55.7 days SD = 35.3 days | Haemorrhagic = 9 Ischaemic = 16 | 25 | |
| ‘Neurophysiological' | 21 | 14/7 | 11/10 | Patients with spasticity | Patients with spasticity | Haemorrhagic = 7 | 21 | |
| ‘Orthopaedic' | 23 | 14/9 | 9/14 | Patients with spasticity | Patients with spasticity | Haemorrhagic = 7 | 23 | |
| ‘Rehabilitation' | 40 | 25/15 | Not stated | Mean = 61.38 y SD = 9.99 y | Mean = 9.05 days SD = 5.74 days | Ischaemic = 28 Haemorrhagic = 12 | 40 | |
| ‘Control (no treatment)' | 40 | 24/16 | Not stated | Mean = 62.55 y SD = 9.60 y | Mean = 8.65 days SD = 5.38 days | Ischaemic = 28 Haemorrhagic = 12 | 40 | |
| ‘Exercise' | 40 | 30/10 | Not stated | Mean = 58 y SD = not stated Range: 44‐74 y | Mean = 41.95 days SD = 23.4 days | Haemorrhagic = 20 Thrombosis = 20 | 40 | |
| ‘Control group' | 40 | 27/13 | Not stated | Mean = 58 y SD = not stated Range: 38‐74 y | Mean = 40.2 days SD = 24.15 days | Haemorrhagic = 18 Thrombosis = 22 | 40 | |
| ‘Motor learning' | 12 | Inclusion criteria: CVA less than 150 days previously | 12 | |||||
| ‘Control (no treatment)' | 9 | Inclusion criteria: CVA less than 150 days previously | 9 | |||||
| ‘Rehabilitation' | 50 | 29/19 | 21/27 'location of disease' | Mean = 61.81 y SD = 8.69 y | Mean = 7.38 days SD = 5.83 days | Haemorrhagic = 14 Ischaemic = 34 | 48 | |
| ‘Control (no treatment)' | 50 | 35/13 | 27/25 'location of disease' | Mean = 63.13 y SD = 7.79 y | Mean = 6.33 days SD = 5.00 days | Haemorrhagic = 13 Ischaemic = 35 | 48 | |
| ‘Intensive rehabilitation' | 67 | 45/22 | Not stated | Mean = 62.9 y SD = 1.4 y | Mean = 14.7 days SD = 1.3 days | Haemorrhagic = 20 Ischaemic = 47 | 67 | |
| ‘Conventional (no treatment)' | 67 | 47/20 | Not stated | Mean = 65.5 y SD = 1.1 y | Mean = 12.9 days SD = 0.9 days | Haemorrhagic = 23 Ischaemic = 44 | 67 | |
| ‘Rehabilitation' | 32 | Whole group 35/29 | Not stated | Whole group mean = 60 y SD = 8 y Range: 51 ‐ 72 y | Whole group mean = 17 hours SD = 7 hours Range: 6‐52 hours | Whole group Cerebral infarct = 52 Cerebral haemorrhage = 12 | 32 | |
| ‘Control (no treatment)' | 32 | As above | Not stated | As above | As above | As above | 32 | |
| ‘Rehabilitation' | 35 | 21/14 | Not stated | Mean = 67.2 y SD = 9.9 y | Not stated | Haemorrhagic = 10 Ischaemic = 25 | 35 | |
| ‘Control (no treatment)' | 35 | 18/17 | Not stated | Mean = 64.7 y SD = 9.2 y | Not stated | Haemorrhagic = 10 Ischaemic = 25 | 35 | |
| ‘Rehabilitation' | 32 | 24/8 | Not stated | Mean = 55 y Range: 37‐69 y | Not stated | Haemorrhagic = 14 Ischaemic = 18 | 32 | |
| ‘Control (no treatment)' | 30 | 20/10 | Not stated | Mean = 57 y Range: 38‐72 y | Not stated | Haemorrhagic = 16 Ischaemic = 14 | 30 | |
| ‘Rehabilitation' | 94 | 48/46 | Mean = 58.3 y SD = not stated | 'Mean time from onset of disease to hospitalisation was 3.5 days' | Not stated | 94 | ||
| ‘Control (no treatment)' | 92 | 45/47 | Not stated | Mean = 55.4 y SD = not stated | 'Mean time from onset of disease to hospitalisation was 4 days' | Not stated | 92 | |
| ‘Rehabilitation' | 92 | 48/44 | 42/50 | Mean = 57.6 y SD = not stated | Mean = 2.3 days SD = not stated | Infarct in 66 cases in basal ganglion, 16 cases in lobar and 10 cases in corona radiate and oval center | 92 | |
| ‘Control (no treatment)' | 88 | 45/43 | 40/48 | Mean = 56.9 y SD = not stated | Mean = 2.5 days SD = not stated | Infarct in 64 cases in b asal ganglion, 15 cases in lobar and 9 cases in corona radiate and oval center | 88 | |
| ‘Rehabilitation' | 30 | 21/9 | 9/21 | Mean = 59.8 y SD = 10.0 y | Mean = 14.8 days SD = 3.7 days | Haemorrhagic = 2 Ischaemic = 28 | 30 | |
| ‘Control (no treatment)' | 27 | 18/19 | 9/18 | Mean = 63.3 y SD = 8.7 y | Mean = 15.1 days SD = 4.3 days | Haemorrhagic = 1 Ischaemic = 26 | 27 | |
| ‘Training' | 78 | 44/34 | Not stated | Mean = 58 y SD = 11 y | Not stated | Haemorrhagic = 37 Infarct = 41 | 78 | |
| ‘Control (no treatment)' | 72 | 40/32 | Not stated | Mean = 59 y SD = 10 y | Not stated | Haemorrhagic = 34 Infarct = 38 | 72 | |
| ‘Rehabilitation' | 40 | 25/15 | 16/24 | Mean = 62.5 y SD = not stated | Mean = 14.8 days SD = 3.7 days | Haemorrhagic = 14 Ischaemic = 26 | 40 | |
| ‘Control (no treatment)' | 38 | 24/14 | 16/22 | Mean = 60.3 y SD = not stated | Mean = 15.1 days SD = 4.3 days | Haemorrhagic = 11 Ischaemic = 27 | 38 | |
| ‘NDT‐based treatment' | 35 | 22/13 | 17/16 | Mean = 54.9 y SD = 11.8 y Range: 26.5‐77.3 y | Mean = 218.4 days SD = 93.4 days | Ischaemic = 24 Not stated = 11 | 35 | |
| ‘Multisensorial' | 33 | 22/11 | 20/15 | Mean = 55.5 y SD = 11.6 y Range: 32.5‐78.3 y | Mean = 217.2 days SD = 92.9 days | Ischaemic = 25 Not stated = 8 | 33 | |
| ‘Rehabilitation' | 30 | 26/4 | Not stated | Mean = 68 y SD = not stated | Not stated | Not stated | 30 | |
| ‘Rehabilitation with therapy with intermediate frequency' | 30 | 24/6 | Not stated | Mean = 65 y SD = not stated | Not stated | Not stated | 30 | |
| ‘Control (no treatment)' | 30 | 21/9 | Not stated | Mean = 66 y SD = not stated Max age <80 y | Not stated | Not stated | 30 | |
| ‘Early rehabilitation' | 29 | Not stated | Not stated | Mean = 66 y SD = not stated | Not stated | Not stated | 29 | |
| ‘Control (no treatment)' | 27 | Not stated | Not stated | Mean = 63 y SD = not stated | Not stated | Not stated | 27 | |
| ‘Rehabilitation' | 439 | 266/173 | Not stated | Mean = 61 y SD = 11 y | Not stated | Haemorrhage = 61 Ischaemic = 278 | 439 | |
| 'Control (no treatment)' | 463 | 281/182 | Not stated | Mean = 60 y SD = 11 y | Not stated | Haemorrhage = 172 Ischaemic = 291 | 463 | |
| 'Rehabilitation nursing' | 100 | 58/42 | 39/61 | Mean = 55.2 y SD = 8.4 y | Not stated | Not stated | 100 | |
| ‘Control (no treatment)' | 80 | 42/38 | 34/46 | 5Mean = 6.6 y SD = 9.2 y | Not stated | Not stated | 80 | |
| ‘Rehabilitation' | 150 | 91/59 | 82/68 | Mean = 57 y SD = not stated Range: 36‐81 y | Not stated | 'cerebral infarction' | 150 | |
| ‘Control (no treatment)' | 150 | 82/68 | 79/71 | Mean = 59 y SD = not stated Range: 41‐76 y | Not stated | 'cerebral infarction' | 150 | |
| ‘Rehabilitation' | 72 | 57/15 | Not stated | Mean = 64.51 y SD = 8.87 y | Mean = 9.51 days SD = 5.36 days | Bleeding after decompression surgery = 1 Haemorrhagic = 20 Ischaemic = 51 | 72 | |
| ‘Control (no treatment)' | 53 | 35/17 Mismatch in the gender data reported in the paper compared to group data reported elsewhere | Not stated | Mean = 66.04 y SD = 8.80 y | Mean = 9.91 days SD = 7.90 days | Bleeding after decompression surgery = 1 Haemorrhagic = 12 Ischaemic = 40 | 53 | |
| ‘Treated' | 26 | 14/12 | Not stated | Mean = 66 y SD = 11 y | Mean = 8 days SD = 5 days | Haemorrhagic = 10 Ischaemic = 16 | 26 | |
| ‘Controlled (no treatment)' | 26 | 18/8 | Not stated | Mean = 65 y SD = 11 y | Mean = 8 days SD = 4 days | Haemorrhagic = 10 Ischaemic = 16 | 26 | |
| ‘Test' | 35 | 19/16 | Not stated | Mean = 61.3 y SD = 6.8 y | Mean = 30.4 days SD = 6.8 days | Haemorrhagic = 8 Ischaemic = 27 | 35 | |
| ‘Controlled (no treatment)' | 35 | 20/15 | Not stated | Mean = 62.1 y SD = 5.9 y | Mean = 31.6 days SD = 6.2 days | Haemorrhagic = 7 Ischaemic = 28 | 35 | |
| ‘Cerebral haemorrhage rehabilitation' | 12 | 10/2 | 4/8 | Mean = 61 y SD = 10 y | Mean = 16 days SD = 5 days | Haemorrhagic = 12 | 12 | |
| ‘Cerebral haemorrhage control' | 10 | 8/2 | 3/7 | Mean = 63 y SD = 13 y | Mean = 17 days SD = 7 days | Haemorrhagic = 10 | 10 | |
| ‘Cerebral infarction rehabilitation' | 28 | 14/14 | 8/20 | Mean = 63 y SD = 10 y | Mean = 14 days SD = 6 days | Ischaemic = 28 | 28 | |
| ‘Cerebral infarction control' | 28 | 14/14 | 11/17 | Mean = 61 y SD = 10 y | Mean = 16 days SD = 5 days | Ischaemic = 28 | 28 | |
| ‘Physiotherapy' | 86 | 54/32 | 47/39 | Mean = 64.29 y SD = 8.42 y Range: 42‐75 y | Mean = 34.24 days SD = 21.53 days Range: 15‐86 days | Ischaemic encephalic | 86 | |
| ‘Acupuncture' | 91 | 61/30 | 50/41 | Mean = 63.87 y SD = 9.23 y Range: 42‐75 y | Mean = 30.89 days SD = 21.67 days Range: 15‐80 days | Ischaemic encephalic | 91 | |
| ‘Combination therapy' | 97 | 63/34 | 51/48 | Mean = 64.03 y SD = 9.19 y Range: 40‐75 y | Mean = 29.73 days SD = 18.57 days Range: 16‐88 days | Ischaemic encephalic | 97 |
LCVA: left cerebrovascular accident
IQR: interquartile range
LACS: lacunar stroke
MCA: middle cerebral artery
mo: months
PACS: partial anterior circulation stroke
POCS: posterior circulation stroke
PICH: primary intracerebral haemorrhage
RCVA: right cerebrovascular accident
SD: standard deviation
SEM: standard error of the mean
TACS: total anterior circulation stroke
y: years
In 38 of the 99 studies, the time since stroke was 30 days or less (Allison 2007; Bai 2008; Chen 2004; Chen 2010; Dean 2007; Deng 2011; Fan 2006; Gelber 1995; Hou 2006; Howe 2005; Hu 2007 haem; Hu 2007 isch; Huang 2003; Jiang 2006; Jing 2006; Li 2005; Liao 2006; Lincoln 2003; Liu 2003; Ni 1997; Qian 2004; Qian 2005; Richards 1993; Thaut 2007; Torres‐Arreola 2009; Wang 2005; Wang 2006; Wu 2006; Xiao 2003; Xie 2003; Xu 2003a; Xu 2003b; Xu 2004; Yan 2002; Zhu 2001; Zhu 2004b; Zhu 2007 isch; Zhu 2007 haem).
In 12 of the 99 studies, the time since stroke was 90 days or less (Bale 2008; Cooke 2006; Duncan 1998; Ge 2003; Mudie 2002; Pollock 1998; Verheyden 2006; Verma 2011; Wang 2004b; Wei 1998; Zhu 2006; Zhuang 2012).
In eight of the 99 studies, the time since stroke was six months or less (Blennerhassett 2004; Brock 2005; Chan 2006; Duncan 2003; Holmgren 2006; Kwakkel 2002; Kwakkel 2008; Wellmon 1997).
In three of the 99 studies, the time since stroke was 12 months or less (McClellan 2004; Salbach 2004; Yelnik 2008).
In 10 of the 99 studies, the time since stroke was longer than 12 months (Baer 2007; Chen 2006; Dean 1997; Dean 2000; Dean 2006; Hui‐Chan 2009; Kim 2011; Kim 2012; Mudge 2009; Wade 1992).
The time since stroke was not stated in 28 of the 99 studies (Aksu 2001; Behrman 2011; Carlson 2006; Chu 2003; Fang 2003; Fang 2004 old; Fang 2004 young; Green 2002; Langhammer 2000; Langhammer 2007; Lennon 2006; Li 1999; Li 2003; Pan 2004; Pang 2003; Pang 2006; Shin 2011; Stephenson 2004; Tang 2009; Wang 2004a; Xie 2005; Xu 1999; Xue 2006; Yin 2003a; Zhang 1998; Zhang 2004; Zhao 2002; Zhao 2003).
Dose of intervention
The duration of the intervention period was 28 days or less in 35 studies (Allison 2007; Baer 2007; Bale 2008; Blennerhassett 2004; Brock 2005; Carlson 2006; Chen 2010; Dean 1997; Dean 2000; Dean 2007; Fang 2003; Fang 2004 old; Fang 2004 young; Howe 2005; Hui‐Chan 2009; Kim 2012; Lennon 2006; Liao 2006; Liu 2003; Mudge 2009; Pang 2003; Pollock 1998; Shin 2011; Stephenson 2004; Thaut 2007; Verma 2011; Wang 2004b; Wang 2005; Wellmon 1997; Xiao 2003; Xu 2003a; Xu 2003b; Yelnik 2008; Zhao 2003; Zhuang 2012); 12 weeks or less in 24 studies (Chan 2006; Chen 2004; Chen 2006; Cooke 2006; Deng 2011; Duncan 1998; Holmgren 2006; Huang 2003; Kim 2011; Kwakkel 2008; Li 1999; McClellan 2004; Mudie 2002; Ni 1997; Salbach 2004; Tang 2009; Verheyden 2006; Wang 2004a; Wei 1998; Xu 1999; Xu 2004; Xue 2006; Yan 2002; Zhao 2002); between 12 weeks and six months in 16 studies (Bai 2008; Behrman 2011; Duncan 2003; Green 2002; Hou 2006; Hu 2007 haem; Hu 2007 isch; Jiang 2006; Kwakkel 2002; Pang 2006; Torres‐Arreola 2009; Wang 2006; Wu 2006; Xie 2005; Zhang 2004; Zhu 2004b) and over six months in three studies (Chu 2003; Dean 2006; Langhammer 2007). The intervention period was unclear in 21 of the 99 studies (Aksu 2001; Fan 2006; Ge 2003; Gelber 1995; Jing 2006; Langhammer 2000; Li 2003; Li 2005; Lincoln 2003; Pan 2004; Qian 2004; Qian 2005; Richards 1993; Wade 1992; Xie 2003; Yin 2003a; Zhang 1998; Zhu 2001; Zhu 2006; Zhu 2007 isch; Zhu 2007 haem).
The frequency of intervention was more than once per day in 22 studies (Blennerhassett 2004; Carlson 2006; Fan 2006; Hou 2006; Jiang 2006; Kim 2012; Li 1999; Liu 2003; McClellan 2004; Ni 1997; Pan 2004; Pang 2003; Wang 2004a; Wellmon 1997; Xie 2003; Xie 2005; Xu 1999; Xue 2006; Yan 2002; Zhu 2004b; Zhu 2007 isch; Zhu 2007 haem); once per day for five to seven days per week for 30 to 60 minutes in 33 studies (Allison 2007; Bai 2008; Bale 2008; Chu 2003; Dean 1997; Dean 2007; Deng 2011; Fang 2003; Fang 2004 old; Fang 2004 young; Holmgren 2006; Hui‐Chan 2009; Kim 2011; Kwakkel 2002; Langhammer 2000; Lennon 2006; Li 2005; Liao 2006; Mudie 2002; Pang 2006; Pollock 1998; Shin 2011; Thaut 2007; Verma 2011; Wang 2004b; Wang 2005; Wei 1998; Xu 2004; Yelnik 2008; Zhao 2002; Zhu 2001; Zhu 2006; Zhuang 2012); three to four times per week in 12 studies (Brock 2005; Chan 2006; Cooke 2006; Dean 2000; Dean 2006; Duncan 1998; Duncan 2003; Mudge 2009; Salbach 2004; Stephenson 2004; Verheyden 2006; Xiao 2003); one to two times per week in two studies (Chen 2006; Kwakkel 2008) and less frequent than once per week in one study (Baer 2007). The frequency was unclear in 29 of the 99 studies (Aksu 2001; Behrman 2011; Chen 2004; Chen 2010; Ge 2003; Gelber 1995; Green 2002; Howe 2005; Hu 2007 haem; Hu 2007 isch; Huang 2003; Jing 2006; Langhammer 2007; Li 2003; Lincoln 2003; Qian 2004; Qian 2005; Richards 1993; Tang 2009; Torres‐Arreola 2009; Wade 1992; Wang 2006; Wu 2006; Xu 2003a; Xu 2003b; Yin 2003a; Zhang 1998; Zhang 2004; Zhao 2003).
Table 10 displays the length and dose of intervention for those studies with Independence in ADL or motor function data in comparisons with no treatment, and Table 11 displays this information for studies with comparisons with usual care or attention control.
| Study | Length of intervention period | Frequency of sessions | Length of sessions |
|---|---|---|---|
| Not stated | Not stated | Not stated | |
| 3 months | 2/week | Not stated | |
| 20 days ‐ 14 months (mean 41.3 days) | Daily | 40‐60 minutes | |
| 6 weeks | 2/week | 60 minutes | |
| 3 months | 2/week | Not stated | |
| 3 days | Daily | 45 minutes | |
| 3 days | Daily | 45 minutes | |
| Maximum 13 weeks | Minimum 3 contacts; | Median number of treatments per patient was three (IQR 2–7, range 0–22) and the mean duration of every treatment was 44 min (SD 21, range 10–90). | |
| 6 months | 1‐2 times/day, 5/week; increasing to 2/day, 5‐6/week | 30‐40 minutes | |
| Not stated | Not stated | Not stated | |
| Not stated | Not stated | Not stated | |
| 30 days | Daily | 45 minutes | |
| 1 month | 2/day | 30 minutes | |
| 15 days | 4/day | 30 minutes | |
| Average of 2 months | 2/day | 30‐45 minutes | |
| Not stated | 3‐4/day | 30 minutes | |
| 10 sessions | 5/week | 30 minutes | |
| Mean visits = 4 (range 1‐11); 73% patients were seen one to six times. | Not stated | Ranged from 1 hour 10 minutes to 3 hours 10 minutes (mean = 2 hours 4 minutes) | |
| 30 days | 1‐2/day | 45 minutes | |
| 6 months | Daily | Not stated | |
| 1 month | 2/day | 60 minutes | |
| Not stated | Massage 5‐6/day; ADL 2/day | Massage 15‐20 minutes; ADL 30 minutes | |
| 21 days | Daily | Not stated | |
| 4 weeks | Daily | 60 minutes | |
| 1 month | 5/week | 40‐50 minutes | |
| 1 month | 3/day | 30 minutes | |
| 38 days | Dependent on phase of recovery: Early phase: 2/day; Rehabilitative treatment (on bed): 2/day, increasing to 3‐4/day if participants had no discomfort; Rehabilitative treatment (after leaving bed): 2/day | Dependent on phase of recovery: Early phase: 15min/session; Rehabilitative treatment (on bed): 30 min/session; Rehabilitative treatment (after leaving bed): 60 minutes | |
| Not stated | Daily | 40 minutes | |
| Not stated | Daily | 60 minutes | |
| 6 months | Not stated | Not stated | |
| Mean 31.6 days (SD 11.2 days) | 5/week | 30‐45 minutes | |
| PT and OT: ‘10 days as a treatment course, persisting 2 courses' | Daily | 30‐40 minutes | |
| Not stated | 5/week | 45 minutes (plus 20 minutes electrotherapy) | |
| Not stated | 5/week | 60 minutes | |
| Not stated | 5/week | 45 minutes | |
| Not stated | 5/week | 45 minutes |
OT: occupational therapy; PT = physical therapy
| Study | Length of intervention period | Frequency of sessions | Length of sessions |
|---|---|---|---|
| 4 weeks | Not stated | Not stated | |
| 6 weeks | 4/week | 60 minutes | |
| 8 weeks (then 4 weeks without therapist) | 3/week | 90 minutes | |
| 12‐14 weeks | 36 sessions total | 90 minutes | |
| 12 weeks | 2/week | 90 minutes | |
| Four 3 month sessions | 2‐3/week | Minimum 20 hours total | |
| 6 weeks | 2/week | Not stated | |
| 4 weeks | 3/week | Not stated | |
| 6 weeks | 5/week | 30 minutes | |
| 4 weeks | 5/week | 60 minutes | |
| Not stated | Daily | 60 minutes | |
| Whilst in‐patient | Not stated | Not stated | |
| 8 weeks | Daily | 45 minutes | |
| 4 weeks | 5/week | 30‐45 minutes | |
| 12 weeks | 5/week | 45‐60 minutes |
Definition of dose
We preplanned subgroup analyses to explore the effect of dose of intervention. We defined dose as including the components of (1) length of a single treatment session, (2) frequency of treatment sessions and (3) duration of the intervention period. However, because of the availability of data and the complexities associated with variations in these three components, our subgroup analyses of dose explored only the combination of (1) length of a single treatment session and (2) frequency of treatment sessions. We also performed additional sensitivity analyses to explore the impact of (3) duration of intervention period on subgroup analysis results.
Outcome measures for analysis
The included trials used a large number of heterogeneous outcome measures. The many diverse outcome measures recorded in the included studies made it impossible for review authors to analyse all of the documented data. Based on the prestated groupings of relevant outcomes and the availability of data from specific measures in the included trials, the review authors for the previous version of the review made the decision to concentrate data analysis on independence in ADL,* motor function,* balance, muscle strength, gait velocity and length of rehabilitation stay. For this update, we decided to remove the muscle strength outcome, as this outcome was rarely reported in the included studies.
*Independence in ADL was called 'global dependency' and motor function was called 'functional independence in mobility' in previous versions of this review. See Differences between protocol and review.
Outcome measures were recorded at several different time points during and after the intervention period. For the analyses in the review, we classed 'immediate outcomes' as data that were recorded at the end of the treatment period or at the time point nearest to the end of the treatment period. If the intervention comprised a change in treatment throughout the whole of a participant's rehabilitation period, then data were recorded from the outcome measures noted at the time of discharge from rehabilitation or at the time point nearest to discharge. When studies also reported follow‐up data, we included these as analysis of 'persisting outcome'. The time points at which data were recorded are clearly documented and stated for each trial in the Characteristics of included studies table and are summarised in Table 4, Table 5 and Table 6.
Of the 99 studies, 79 included outcome measures suitable for inclusion in an analysis of immediate outcomes, and 27 provided a follow‐up outcome measure. Details of these outcome measures are provided below.
Studies included in meta‐analysis
Independence in ADL scales
Forty‐nine studies reported 'immediate outcome' data for a measure of independence in ADL. This was the Barthel Index (or modified Barthel Index) for 45 studies (Chen 2004; Chen 2006; Chen 2010; Chu 2003; Duncan 1998; Fang 2003; Fang 2004 old; Fang 2004 young; Green 2002; Holmgren 2006; Hou 2006; Huang 2003; Jing 2006; Langhammer 2007; Langhammer 2000; Lennon 2006; Li 1999; Li 2005; Lincoln 2003; Liu 2003; Mudie 2002; Pan 2004; Pang 2003; Pang 2006; Pollock 1998; Richards 1993; Thaut 2007; Torres‐Arreola 2009; Wade 1992; Wu 2006; Xie 2003; Xu 1999; Xu 2003a; Xu 2003b; Xu 2004; Xue 2006; Yan 2002; Zhang 1998; Zhang 2004; Zhao 2002; Zhao 2003; Zhu 2006; Zhu 2007 isch; Zhu 2007 haem; Zhuang 2012) and the Functional Independence Measure (FIM) for four studies (Chan 2006; Gelber 1995; Ni 1997; Yelnik 2008).
Sixteen studies reported 'persisting outcome' data for a measure of independence in ADL. This was the Barthel Index (or modified Barthel Index) for 14 studies (Chen 2004; Fang 2003; Fang 2004 old; Fang 2004 young; Green 2002; Holmgren 2006; Hou 2006; Jing 2006; Lincoln 2003; Mudie 2002; Torres‐Arreola 2009; Verma 2011; Wade 1992; Zhao 2003) and the FIM for two studies (Gelber 1995; Yelnik 2008). Verma 2011 reported a follow‐up measurement but not an immediate measurement for the Barthel Index.
Standard deviations for Zhu 2007 isch and Zhu 2007 haem were estimated from the reported range, and data for Chen 2010 and Zhao 2003 were estimated from categorical data; it was preplanned to explore the effect of including these studies.
Motor function scales
Fifty studies reported 'immediate outcome' data for a measure of motor function. This was the Rivermead Motor Assessment for six studies (Cooke 2006; Green 2002; Kwakkel 2008; Lincoln 2003; Mudge 2009; Wade 1992); the Motor Assessment Scale for six studies (Bale 2008; Langhammer 2007; Langhammer 2000; Lennon 2006; McClellan 2004; Wang 2005) and the Fugl‐Meyer Assessment for 38 studies (Chen 2010; Chu 2003; Deng 2011; Duncan 1998; Duncan 2003; Fang 2003; Fang 2004 old; Fang 2004 young; Hu 2007 haem; Hu 2007 isch; Huang 2003; Jing 2006; Li 1999; Liao 2006; Liu 2003; Ni 1997; Pan 2004; Qian 2005; Richards 1993; Tang 2009; Thaut 2007; Wang 2004a; Wang 2004b; Wei 1998; Wu 2006; Xu 2003a; Xu 2003b; Xu 2004; Xue 2006; Yin 2003a; Zhang 1998; Zhang 2004; Zhao 2002; Zhu 2001; Zhu 2006; Zhu 2007 isch; Zhu 2007 haem; Zhuang 2012).
Twelve studies reported 'persisting outcome' data for a measure of motor function. This was the Rivermead Motor Assessment for six studies (Cooke 2006; Green 2002; Kwakkel 2008; Lincoln 2003; Mudge 2009; Wade 1992); the Motor Assessment Scale for one study (McClellan 2004); the Rivermead Mobility Index for one study (Cooke 2006) and the Fugl‐Meyer Assessment for five studies (Fang 2003; Fang 2004 old; Fang 2004 young; Jing 2006; Zhao 2002).
Richards 1993 and Yin 2003a included two active treatment groups so are entered twice into analyses, with the control group data 'shared' as the comparison group for the two active interventions. Standard deviations for Green 2002, Mudge 2009, Zhu 2007 isch and Zhu 2007 haem were estimated from the reported range, it was preplanned to explore the effect of including these studies. Data from Jing 2006 were not included in analyses of one approach versus another, as both of the two treatment groups were assessed as including similar treatment components.
Balance (Berg Balance Scale)
Eleven studies reported 'immediate outcome' data for measures of balance (Brock 2005; Chan 2006; Duncan 1998; Duncan 2003; Holmgren 2006; Kim 2012; Richards 1993; Salbach 2004; Shin 2011; Wang 2005; Yelnik 2008). Holmgren 2006 and Yelnik 2008 also reported 'persisting outcome' data.
Richards 1993 included two active treatment groups so is entered twice into analyses, with the control group data 'shared' as the comparison group for the two active interventions. The data for Holmgren 2006 standard deviations were calculated from the reported confidence intervals.
Gait velocity
Twenty‐three studies reported 'immediate outcome' data for measures of gait velocity (Bale 2008; Blennerhassett 2004; Brock 2005; Cooke 2006; Dean 1997; Dean 2000; Dean 2006; Dean 2007; Duncan 1998; Duncan 2003; Gelber 1995; Green 2002; Hui‐Chan 2009; Kim 2012; Kwakkel 2008; Lincoln 2003; Richards 1993; Salbach 2004; Stephenson 2004; Thaut 2007; Verma 2011; Wade 1992; Yelnik 2008), and 13 studies reported 'persisting outcome' data (Blennerhassett 2004; Cooke 2006; Dean 2000; Dean 2007; Gelber 1995; Green 2002; Hui‐Chan 2009; Kwakkel 2008; Lincoln 2003; Mudge 2009; Verma 2011; Wade 1992; Yelnik 2008).
Cooke 2006 and Richards 1993 included two active treatment groups so are entered twice into analyses, with the control group data 'shared' as the comparison group for the two active interventions. Standard deviations for Green 2002 and Mudge 2009 were estimated from the reported range, and data for Bale 2008 were estimated from categorical data; it was preplanned to explore the effect of including these studies.
Length of stay
Eight studies reported data relating to length of stay (Blennerhassett 2004; Gelber 1995; Holmgren 2006; Langhammer 2000; Langhammer 2007; Li 2003; Li 2005; Torres‐Arreola 2009).
Studies included in meta‐analysis comparisons
Intervention versus no treatment
Of the 54 studies included in this review that compared an active intervention with no treatment, 41 included data suitable for inclusion in meta‐analysis. These were 'immediate outcome' data relating to Independence in ADL for 28 studies; motor function for 28 studies; balance for one study and gait velocity for three studies. Three of these studies reported length of stay. 'Persisting outcome' data were available relating to independence in ADL for 10 studies; motor function for 10 studies; balance for one study and gait velocity for three studies. (See Table 4 for further details.)
Intervention versus attention control or usual care
Of the 27 studies included in this review that compared an active intervention with usual care (17) or attention control (10), 22 included data suitable for inclusion in meta‐analysis. These were 'immediate outcome' data relating to independence in ADL for eight studies; motor function for 13 studies; balance for six studies and gait velocity for 16 studies. Two of these studies reported length of stay. 'Persisting outcome' data were available relating to independence in ADL for no studies; motor function for four studies; balance for no studies and gait velocity for six studies. (See Table 5 for further details.)
One active intervention versus another active intervention
Of the 23 studies included in this review that compared two different active interventions, 13 included data suitable for inclusion in meta‐analysis. These were 'immediate outcome' data relating to independence in ADL for seven studies; motor function for eight studies; balance for four studies and gait velocity for seven studies. Four of these studies reported length of stay. 'Persisting outcome' data were available relating to independence in ADL for two studies; motor function for no studies; balance for no studies and gait velocity for two studies. (See Table 6 for further details.)
Data from three studies comparing one active intervention with another active intervention (Chen 2006; Cooke 2006; Jing 2006) were available but were not included in meta‐analyses, as the two active treatment groups were classified as including similar treatment components.
Excluded studies
Studies listed in the Characteristics of excluded studies table were limited to those for which discussions were required between review authors to reach consensus. Thirty‐nine studies are listed; we considered a further 147 as full papers but excluded them, as we agreed that they clearly did not meet the inclusion criteria. We needed to look at full papers because insufficient details were provided in the abstracts; the main reasons for excluding studies at this stage were that they were not randomised controlled trials (RCTs) or that they investigated a single specific treatment (such as electrical stimulation or treadmill training).
Risk of bias in included studies
Details of the methodological quality of the studies are provided in Characteristics of included studies, and risk of bias is summarised in Figure 3 and Figure 4. We assessed only 40 of the 99 studies to have low risk of bias for sequence generation; 29 of 99 for allocation concealment and 51 of 99 for blinding of outcome assessor. Poor reporting led to our assigning 'unclear' risk of bias in most cases, with 56 of 99, 59 of 99 and 39 of 99 studies having unclear risk of bias for sequence generation, allocation concealment and blinding of outcome assessor, respectively. We assessed a larger proportion (72 of 99) to have low risk of bias for being 'free of systematic differences in baseline characteristics of groups,' as this information could generally be determined from tables of characteristics of participants. When no systematic differences in baseline characteristics of groups were noted, there was no need for study authors to adjust for baseline characteristics; this was also therefore assessed to show low risk of bias for a similar number of studies.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Effects of interventions
See: Summary of findings 1 Summary of findings: intervention versus no treatment; Summary of findings 2 Summary of findings: intervention versus usual care or attention control; Summary of findings 3 Summary of findings: one active intervention versus another active intervention
The results are described below under the comparisons carried out for each of the explored outcomes (1. Independence in ADL scale; 2. Motor function scale; 3. Balance; 4. Gait velocity and 5. Length of stay) for both immediate and persisting outcomes. Table 12 provides a summary of the analyses performed, stating the numbering of analyses; Table 13 provides a summary of the subgroup analyses performed, along with the numbering of subgroup analyses.
| Comparison | Intervention vs no treatment | Intervention vs usual care or control | One active intervention vs another | |||
| Outcome | Immediate | Persisting | Immediate | Persisting | Immediate | Persisting |
| Independence in ADL | ||||||
| Motor Function | ||||||
| Balance | ||||||
| Gait velocity | ||||||
| Length of stay | ||||||
| Comparison / Outcome | Intervention vs no treatment | Intervention vs usual care or control | ||
| SUBGROUP | Independence in ADL | Motor Function | Independence in ADL | Motor Function |
| Time after stroke | ||||
| Study geographical location | ||||
| Dose of intervention | ||||
| Provider of intervention | ||||
| Treatment components included | ||||
| Comparison / Outcome | One active intervention vs another | |||
| SUBGROUP | Independence in ADL | Motor Function | ||
| Functional task training components | ||||
| Neurophysiological components | ||||
| Musculoskeletal components | ||||
(Section numbering corresponds to numbering of relevant analyses. Four 'empty' forest plots are provided, for which no data were available. These include the following: Analysis 5.1—Intervention versus usual care; persisting outcomes—global dependency; Analysis 5.3—Intervention versus usual care; persisting outcomes—balance; Analysis 6.2—One intervention versus another; persisting outcomes—functional independence and Analysis 6.3—One intervention versus another; persisting outcomes—balance. Despite the absence of data, these forest plots have been left, as this maintains the consistency of numbering of the section headings and analyses, which we believe aids the accessibility of this section.)
1. Comparison 1. Intervention versus no treatment, immediate outcomes
1.1. Independence in ADL scale
We pooled data from 27 studies (3423 participants) in the analysis, demonstrating that the intervention had a significantly beneficial effect compared with no intervention (SMD 0.78, 95% CI 0.58 to 0.97). However, substantial heterogeneity was found (I2 = 85%).
Significant differences were noted between the subgroups of different categories of treatment components (P value < 0.00001).
For the subgroup of studies that combined functional task training and musculoskeletal components (Analysis 1.1.2; nine studies, 967 participants) and for studies that combined functional task training and neurophysiological and musculoskeletal components (Analysis 1.1.6; 12 studies, 1838 participants), a significant effect of the intervention compared with no intervention was seen (SMD 0.97, 95% CI 0.67 to 1.27, I2 = 76%; and SMD 0.96, 95% CI 0.66 to 1.27, I2 = 86%, respectively). See Analysis 1.1.
Sensitivity analysis: risk of bias
Removing studies judged to be at high risk of bias for at least one assessed quality of component led to our removing Chu 2003, Fang 2003, Fang 2004 old, Fang 2004 young, Hu 2007 haem, Hu 2007 isch, Li 1999, Wu 2006, Xue 2006, Yin 2003a and Zhu 2006. Data from the remaining 17 studies (2655 participants) demonstrated a similar direction of effect (SMD 0.98, 95% CI 0.63 to 1.34, I2 = 94%); additionally, removing the studies for which data had been estimated from reported ranges (Green 2002; Zhu 2007 haem; Zhu 2007 isch) left data from 15 studies (2346 participants), demonstrating a similar direction of effect (SMD 1.07, 95% CI 0.66 to 1.47, I2 = 95%).
Removing all studies judged as having unclear or high risk of bias for random sequence generation or allocation concealment left only two studies (Green 2002; Wade 1992; 150 participants), which showed no significant benefit of intervention versus no treatment (SMD ‐0.06, 95% CI ‐0.30 to 0.19, I2 = 0%). (These sensitivity analyses are not illustrated within forest plots.)
Subgroup analysis: time after stroke
A significant difference between subgroups was noted according to time post stroke (P value 0.003), with a suggestion of greater effect in studies with participants who were within 30 days post stroke. See Analysis 7.1.
Subgroup analysis: study geographical location
Twenty‐five (3173 participants) of the 27 studies were carried out in China, and only two studies (250 participants) were carried out in Europe (Green 2002; Wade 1992). A significant difference between these subgroups was noted (P value < 0.00001). See Analysis 7.2.
Subgroup analysis: dose of intervention
Eight studies (711 participants) provided the intervention more than once per day; 11 studies (1027 participants) provided daily intervention five to seven days per week for between 30 and 60 minutes; four studies provided a less frequent intervention than this and the dose was not stated in another four studies (see Table 10). When the studies in which the dose was not stated were excluded (as it was not appropriate to include this group), a significant difference between subgroups was noted (P value < 0.00001) (analysis not shown). A significant difference was also seen between the subgroup of more than one intervention per day and the subgroup receiving daily intervention (P value 0.02) (analysis not shown). The effect size was greater in studies with a greater dose of intervention, with an indication that a dose of between 30 and 60 minutes once per day for five to seven days a week was beneficial, but that more than once‐daily intervention may provide even greater benefit. See Analysis 7.3.
Sensitivity analysis: dose and duration of the intervention period
We explored the effect of the length of the intervention period for studies that provided the intervention once per day or provided daily interventions five to seven days per week for between 30 and 60 minutes (19 studies). The order of these studies within Analysis 7.3.1 and 7.3.2 is from least to most intervention (with studies for which length of intervention is not stated at the 'most' end). Six studies did not state the length of intervention and were removed from the analysis (Pan 2004; Xie 2003; Zhang 1998; Zhu 2006; Zhu 2007 haem; Zhu 2007 isch). Four studies (298 participants) (Fang 2004 old; Fang 2004 young; Liu 2003; Pang 2006) had a length of intervention of 15 days or less: including only these studies leads to a non‐significant effect (SMD 0.54, 95% CI ‐0.01 to 1.09), but with very substantial heterogeneity (I2 = 80%). Eight studies (938 participants) (Huang 2003; Li 1999; Xu 1999; Xu 2003b; Xu 2004; Xue 2006; Yan 2002; Zhao 2003) had a length of intervention of approximately one month; including only these studies demonstrated a significant effect of the intervention (SMD 1.06, 95% CI 0.63 to 1.48), with very substantial heterogeneity (I2 = 88%). (These sensitivity analyses are not illustrated within forest plots.)
Subgroup analysis: provider of the intervention
Five studies (1158 participants) stated that the intervention was provided by a 'therapist'; six studies (429 participants) stated that it was provided by a therapist with help from family members (although in three of these studies, the role of the 'therapist' is not explicit; Xu 1999; Xu 2004; Zhang 1998). Two of the studies stated that it was a 'physiotherapist' and two stated 'nurse' or 'rehabilitation nurse.' In some cases it was stated that another professional, such as an occupational therapist (Wade 1992) or a doctor (Zhang 2004), also contributed. The provider was not stated in 12 studies. When studies in which the provider was not stated were excluded (as it was not appropriate to include this group), a significant difference between subgroups was noted (P value 0.0001) (analysis not shown), with an indication of greater effect when the provider was 'therapist' or 'therapist plus family.' However, each of the other subgroups contained only two studies. See Analysis 7.4.
Subgroup analysis: treatment components included
Twenty‐three studies (3055 participants) included functional task training components; 15 studies (2106 participants) included neurophysiological training components and 23 studies (3033 participants) included musculoskeletal components. No significant difference between these subgroups was observed (P value 0.99). See Analysis 7.5.
1.2. Motor function scale
We pooled data from 25 studies (4558 participants) in the analysis, demonstrating that the intervention had a significantly beneficial effect compared with no intervention (SMD 0.81, 95% CI 0.58 to 1.04). However, considerable heterogeneity was present (I2 = 92%). Significant differences between the subgroups of different categories of treatment components were noted (P value < 0.0001). See Analysis 1.2.
Sensitivity analysis: risk of bias
Removing studies judged to be at high risk of bias for at least one assessed quality of component led us to remove Chu 2003, Fang 2003, Fang 2004 old, Hu 2007 isch, Li 1999, Xue 2006, Yin 2003a and Zhu 2006. Data from the remaining 18 studies (2655 participants) demonstrated a similar direction of effect (SMD 0.95, 95% CI 0.60 to 1.29, I2 = 93%); additionally removing the studies for which data had been estimated from reported ranges (Green 2002; Zhu 2007 isch; Zhu 2007 haem) left data from 15 studies (2416 participants), also demonstrating a similar direction of effect (SMD 1.02, 95% CI 0.63 to 1.14, I2 = 94%). Removing the one study that was visually a clear outlier (Zhao 2002) left 14 studies (2236 participants) and still demonstrated a similar direction of effect (SMD 0.79, 95% CI 0.54 to 1.03, I2 = 84%).
Removing all studies judged as having unclear or high risk of bias for random sequence generation or allocation concealment left only two studies (Green 2002; Wade 1992; 250 participants), which showed no significant benefit of intervention versus no treatment (SMD 0.14, 95% CI ‐0.31 to 0.58, I2 = 67%). (These sensitivity analyses are not illustrated within forest plots.)
Subgroup analysis: time after stroke
A significant difference between subgroups was noted according to time post stroke (P value 0.02). However, when studies in which the time after stroke was not stated were excluded, no significant difference between subgroups was noted (P value 0.06) (analysis not shown). See Analysis 9.1.
Subgroup analysis: study geographical location
Twenty‐three (4308 participants) of the 25 studies were carried out in China, and only two studies (250 participants) were carried out in Europe (Green 2002; Wade 1992). A significant difference between these subgroups was reported (P value 0.005). See Analysis 9.2.
Subgroup analysis: dose of intervention
Four studies (434 participants) provided the intervention more than once per day; 11 studies (1080 participants) provided daily intervention five to seven days per week for between 30 and 60 minutes; five studies provided less frequent interventions than this and the dose was not stated in another four studies (see Table 10). When studies in which the dose was not stated were excluded (as it was not appropriate to include this group), a significant difference between subgroups was noted (P value 0.0007) (analysis not shown). However, no significant differences between the subgroup of more than one intervention per day and the subgroup receiving daily intervention was noted (P value 0.20) (analysis not shown). The effect size was greater with studies with a greater dose of intervention, with an indication that a dose of at least 30 to 60 minutes once per day for five to seven days a week was beneficial. See Analysis 9.3.
Sensitivity analysis: dose and duration of the intervention period
We explored the effect of the length of the intervention period for studies that provided the intervention once per day or provided daily intervention five to seven days per week for between 30 and 60 minutes (17 studies). The order of these studies within Analysis 9.3.1 and 9.3.2 is from least to most intervention (with studies for which length of intervention is not stated at the 'most' end). Seven studies did not state the length of intervention, and we removed them from the analysis (Pan 2004; Yin 2003a; Zhang 1998; Zhu 2001; Zhu 2006; Zhu 2007 haem; Zhu 2007 isch). Three studies (220 participants) (Fang 2004 old; Fang 2004 young; Liu 2003) had a length of intervention of 15 days or less; including only these studies leads to a non‐significant effect (SMD 0.71, 95% CI ‐0.36 to 1.79), but with very substantial heterogeneity (I2 = 92%). Six studies (716 participants) (Chu 2003; Huang 2003; Wang 2004a; Xu 2003b; Xue 2006; Zhao 2002) had a length of intervention of approximately one month; including only these studies demonstrates a significant effect of intervention (SMD 1.45, 95% CI 0.39 to 2.51), with very considerable heterogeneity (I2 = 97%). (These sensitivity analyses are not illustrated within forest plots.)
Subgroup analysis: provider of the intervention
Seven studies (1356 participants) stated that the intervention was provided by a 'therapist'; two studies (152 participants) stated that it was provided by a therapist with help from family members (although the role of the 'therapist' was not explicit in Zhang 1998). Two of the studies stated that it was a 'physiotherapist' and three stated 'nurse' or 'rehabilitation nurse.' In some cases it was stated that another professional, such as an occupational therapist (Wade 1992) or a doctor (Zhang 2004), also contributed. The provider was not stated in 11 studies. When studies in which the provider was not stated were excluded (as it was not appropriate to include this group), a significant difference between subgroups was noted (P value 0.004) (analysis not shown). However, excluding the group stating 'physiotherapist' demonstrated no significant difference between the remaining groups (P value 0.15) (analysis not shown). See Analysis 9.4.
Subgroup analysis: treatment components included
Twenty‐three studies (4330 participants) included functional task training components; 13 studies (2033 participants) included neurophysiological training components and 22 studies (4240 participants) included musculoskeletal components. No significant differences between these subgroups were reported (P value 0.74). See Analysis 9.5.
1.3. Balance (Berg Balance Scale)
Only one study (34 participants) reported a Berg Balance Scale score for a comparison of intervention versus no treatment (SMD ‐0.04, 95% CI ‐0.71 to 0.64).
1.4. Gait velocity
Three studies (292 participants), all investigating functional task training interventions, reported gait velocity, demonstrating no significant benefit of intervention compared with no treatment (SMD 0.05, 95% CI ‐0.18 to 0.28), with no statistical heterogeneity (I2 = 0%).
1.5. Length of stay
Three studies (318 participants), all investigating functional task training plus musculoskeletal interventions, reported length of stay. Analysis demonstrated no statistically significant effect of the intervention on length of stay (MD ‐2.85, 95% CI ‐10.47 to 4.76), with very considerable heterogeneity (I2 = 96%).
2. Comparison 2. Intervention versus attention control or usual care, immediate outcomes
2.1. Independence in ADL scale
We pooled data from six studies (260 participants) in this analysis. For all six studies, the control intervention was categorised as 'usual care' and the intervention was given in addition to this usual care. Two studies each compared two active intervention groups with usual care; both active intervention groups were included in the analysis, with the control group participants 'shared' between these comparisons (Mudie 2002; Richards 1993). The meta‐analysis found no evidence that the addition of the active intervention had any significant effect compared with usual care only (SMD 0.04, 95% CI ‐0.27 to 0.35), with low heterogeneity (I2 = 21%). See Analysis 2.1.
Sensitivity analysis: comparison group
The comparison group was classed as usual care for five studies and as attention control for one study (Chen 2010). In two studies the usual care was categorised as comprising neurophysiological components (Pollock 1998; Richards 1993); in one study it was categorised as comprising functional task training and neurophysiological and musculoskeletal components (Duncan 1998). No details of the usual care were provided for Mudie 2002 or for Langhammer 2007. The attention control intervention in another study was Traditional Chinese Medicine (TCM) massage therapy (Chen 2010). Sensitivity analyses to explore the effects of these different types of 'usual care' or attention control found no effect on the direction of these results, although it was noted that the study with the TCM massage therapy comparison intervention (Chen 2010; 106 participants) did find a significant benefit of active intervention as compared with TCM massage therapy (SMD 0.53, 95% CI 0.14 to 0.92). (These sensitivity analyses are not illustrated within forest plots.)
Sensitivity analysis: risk of bias
Removing studies judged to be at high risk of bias for at least one assessed quality of component led to the removal of Pollock 1998 but did not alter the direction of the results (SMD 0.03, 95% CI ‐0.32 to 0.38); additionally removing Chen 2010, as these data were estimated from categorical data, did not alter the direction of the results (SMD ‐0.19, 95% CI ‐0.53 to 0.15). (These sensitivity analyses are not illustrated within forest plots.) No further studies were removed by excluding those judged as unsure or high risk of bias for random sequence generation or allocation concealment.
Subgroup analysis: time after stroke
A significant difference between subgroups was noted according to time post stroke (P value 0.05), suggesting that a greater effect may occur with a smaller time after stroke. See Analysis 8.1.
Subgroup analysis: study geographical location
A significant difference between subgroups was noted based on study geographical location (P value 0.04). The only study with a positive effect was carried out in China. See Analysis 8.2.
Subgroup analysis: dose of intervention
Two studies (46 participants) provided daily intervention five to seven days per week for between 30 and 60 minutes; two studies (85 participants) provided two to three interventions per week and the dose was not stated in another three studies (see Table 11). When studies in which the dose was not stated were excluded (as it was not appropriate to include this group), no significant difference between subgroups was noted (P value 0.58) (analysis not shown). See Analysis 8.3.
Data were insufficient to enable sensitivity analyses to explore length of intervention. The length of the intervention period in the four studies that stated this information was four weeks (Pollock 1998), six weeks (Mudie 2002), eight weeks (Duncan 1998) and four three‐month sessions (Langhammer 2007).
Subgroup analysis: provider of intervention
Four studies (124 participants) stated that the intervention was provided by a 'physiotherapist'; one study stated that it was a 'Bobath‐trained physiotherapist.' In Duncan 1998 an occupational therapist also contributed. The provider was not stated in one study. When studies in which the provider was not stated were excluded (as it was not appropriate to include this group), no significant difference between subgroups was noted (P value 0.43) (analysis not shown). See Analysis 8.4.
Subgroup analysis: treatment components included
Six studies (244 participants) included functional task training components; three studies (54 participants) included neurophysiological training components and four studies (208 participants) included musculoskeletal components. No significant difference between these subgroups was reported (P value 0.58). See Analysis 8.5.
2.2. Motor function scale
We pooled data from 13 studies (967 participants) in this analysis. Each of two studies compared two active intervention groups with usual care; both active intervention groups were included in the analysis, and the control group participants were 'shared' between these comparisons (Cooke 2006; Richards 1993). Meta‐analysis demonstrated a significant effect of intervention compared with usual care (SMD 0.42, 95% CI 0.24 to 0.61), with moderate heterogeneity (I2 = 42%).
Significant differences between the subgroups of different categories of treatment components were noted (P value 0.02), with some indication of greater effect when neurophysiological components were included.
For the subgroup of studies that combined functional task training and neurophysiological and musculoskeletal components (Analysis 2.2.6; four studies, 281 participants), a significant effect of intervention compared with usual care was reported (SMD 0.46, 95% CI 0.21 to 0.70), with no statistical heterogeneity (I2 = 0%). See Analysis 2.2.
Sensitivity analysis: comparison group
The comparison group was classed as usual care for 11 studies and as attention control for two studies. Usual care included both functional task training and neurophysiological components (plus other components) for four studies (Cooke 2006; Duncan 1998; Qian 2005; Tang 2009); functional task training (plus other components) for two studies (Duncan 2003; Kwakkel 2008); neurophysiological (with or without other components) for one study (Richards 1993); musculoskeletal (passive) for one study (Wang 2004b) and was not described for three studies (Langhammer 2007; McClellan 2004; Wei 1998). The attention control was TCM massage therapy for one study (Chen 2010) and a social intervention for another study (Mudge 2009). Sensitivity analyses to explore the effects of these different types of 'usual care' or attention control found no effect on the direction of these results. (These sensitivity analyses are not illustrated within forest plots.)
Sensitivity analysis: risk of bias
Removing studies judged to be at high risk of bias for at least one assessed quality of component led to the removal of Duncan 1998, Duncan 2003 and Qian 2005, and left data from nine studies (733 participants), which did not alter the direction of the results (SMD 0.31, 95% CI 0.13 to 0.49); additionally removing Mudge 2009 (as these data were estimated from the range) and Chen 2010 (as these data were estimated from categorical data) did not alter the direction of the results (seven studies, 569 participants; SMD 0.31, 95% CI 0.10 to 0.53).
However, removing all studies judged as unclear or high risk of bias for random sequence generation or allocation concealment led to the removal of Chen 2010, Kwakkel 2008, Qian 2005, Tang 2009, Wang 2004b and Wei 1998, leaving seven studies (377 participants) and demonstrating no significant effect of intervention compared with usual care or control (SMD 0.17, 95% CI ‐0.04 to 0.38), with no statistical heterogeneity (I2 = 0%). (These sensitivity analyses are not illustrated within forest plots.)
Subgroup analysis: time after stroke
No statistically significant difference between subgroups was noted according to time post stroke (P value 0.34). See Analysis 10.1.
Subgroup analysis: study geographical location
Five studies (348 participants) were carried out in China; three (405 participants) in Europe; three (75 participants) in North America and Canada and two (79 participants) in Austalia and New Zealand. A significant difference between these subgroups was reported (P value 0.002), with studies carried out in China having a greater effect size. See Analysis 10.2.
Subgroup analysis: dose of intervention
No studies provided the intervention more than once per day; four studies (242 participants) provided daily intervention five to seven days per week for between 30 and 60 minutes; four studies (269 participants) provided intervention three or four times per week and three studies (327 participants) provided intervention twice weekly (see Table 11). The dose was not stated in another two studies. When studies in which the dose was not stated were excluded (as it was not appropriate to include this group), a significant difference between subgroups was noted (P value 0.002) (analysis not shown), with a greater effect size in studies with a greater dose of intervention. No significant difference between the subgroup of three to four interventions per week and the subgroup with one to two interventions per week was reported (P value 0.39) (analysis not shown). See Analysis 10.3.
Sensitivity analysis: dose and duration of intervention period
The effect of the length of the intervention period was explored by ordering studies within Analysis 9.3 from least to most intervention (with studies in which length of intervention is not stated at the 'most' end). One study did not state the length of intervention (Qian 2005) and was removed from the analyses. Four studies (228 participants) (Cooke 2006; McClellan 2004; Mudge 2009; Wang 2004b) had a length of intervention of four to six weeks; including only these studies leads to a non‐significant effect (SMD 0.22, 95% CI ‐0.08 to 0.51), with low heterogeneity (I2 = 14%). Five studies (504 participants) (Duncan 1998; Duncan 2003; Kwakkel 2008; Tang 2009; Wei 1998) had a length of intervention of eight to 14 weeks; including only these studies demonstrates a significant effect of intervention (SMD 0.57, 95% CI 0.34 to 0.80), with moderate heterogeneity (I2 = 31%). (These sensitivity analyses are not illustrated within forest plots.)
Subgroup analysis: provider of intervention
Eight studies (619 participants) stated that the intervention was provided by a 'physiotherapist'; two stated the provider was a 'therapist' and one a 'nurse.' In Duncan 1998 and Duncan 2003, an occupational therapist also contributed; in Kwakkel 2008 a sports therapist contributed and in Mudge 2009, physiotherapy students contributed. In Cooke 2006 the provider was described as a 'research physiotherapist.' The provider was not stated in two studies. When studies in which the provider was not stated were excluded (as it was not appropriate to include this group), a significant difference between subgroups was reported (P value 0.02) (analysis not shown), but the low number of studies in some groups makes it difficult to determine the direction of effect. See Analysis 10.4.
Subgroup analysis: treatment components included
Eleven studies (827 participants) included functional task training components; eight studies (467 participants) included neurophysiological training components and 10 studies (818 participants) included musculoskeletal components. No significant difference between these subgroups was noted (P value 0.12). See Analysis 10.5.
2.3. Balance (Berg Balance Scale)
We pooled the data from five studies (246 participants) in this analysis. One study compared two active intervention groups with usual care; both active intervention groups were included in the analysis, with control group participants 'shared' between these comparisons (Richards 1993).
Meta‐analysis demonstrated a significant effect of intervention compared with usual care (SMD 0.31, 95% CI 0.05 to 0.56), with no statistical heterogeneity (I2 = 0%).
No significant differences between the subgroups of different categories of treatment components were reported (P value 0.90). See Analysis 2.3.
Sensitivity analysis: comparison group
The comparison group was classed as usual care for four studies and as attention control for one study. The usual care included functional task training and neurophysiological components in one study (Duncan 1998), functional task training (plus other components) in two studies (Duncan 2003; Kim 2012) and only neurophysiological components in one study (Richards 1993). The attention control comprised upper limb training (Salbach 2004). Sensitivity analyses to explore the effects of these different types of 'usual care' or attention control found no effect on the direction of these results. (These sensitivity analyses are not illustrated within forest plots.)
Sensitivity analysis: risk of bias
Removing studies judged to be at high risk of bias for at least one assessed quality of component led to the removal of all studies apart from Richards 1993 and did not demonstrate a significant effect (SMD 0.40, 95% CI ‐0.48 to 1.28). However, removing all studies judged as unclear or high risk of bias for random sequence generation or allocation concealment led to the removal of only Kim 2012 and had no effect on the direction of the results. (These sensitivity analyses are not illustrated within forest plots.)
2.4. Gait velocity
We pooled data from 14 studies (1126 participants) in this analysis. Two studies compared two active intervention groups with usual care; both active intervention groups were included in the analysis, with control group participants 'shared' between these comparisons (Cooke 2006; Richards 1993).
Meta‐analysis demonstrated a significant effect of intervention compared with usual care (SMD 0.46, 95% CI 0.32 to 0.60), with little heterogeneity (I2 = 14%).
No significant differences between the subgroups of different categories of treatment components were reported (P value 0.86). See Analysis 2.4.
Sensitivity analysis: comparison group
The comparison group was classed as usual care for seven studies and as attention control for seven studies. The usual care included functional task training and musculoskeletal and neurophysiological components in two studies (Cooke 2006; Duncan 1998), functional task training and musculoskeletal components for three studies (Behrman 2011; Duncan 2003; Kim 2012); functional task training and musculoskeletal and cardiopulmonary components for one study (Kwakkel 2008) and only neurophysiological components for one study (Richards 1993). The attention control comprised upper limb training for three studies (Blennerhassett 2004; Dean 2000; Dean 2006); cognitive training for two studies (Dean 1997; Dean 2007) and a social intervention for one study (Mudge 2009). Sensitivity analyses to explore the effects of these different types of 'usual care' or attention control found no effect on the direction of these results. When only the studies with attention control comparisons were included, seven studies (251 participants) found a significant effect in favour of the intervention compared with attention control (SMD 0.41, 95% CI 0.15 to 0.67), with low heterogeneity (I2 = 20%). When only the studies with usual care comparisons were included, seven studies (775 participants) also found a significant effect in favour of the intervention compared with usual care (SMD 0.50, 95% CI 0.34 to 0.67), with low heterogeneity (I2 = 9%). (These sensitivity analyses are not illustrated within forest plots.)
Sensitivity analysis: risk of bias
Removing studies judged to be at high risk of bias for at least one assessed quality of component led to the removal of Dean 1997, Dean 2000, Duncan 1998, Duncan 2003 and Kim 2012, leaving data from eight studies (876 participants), which did not alter the direction of the results (SMD 0.53. 95% CI 0.39 to 0.67); additionally removing Mudge 2009 (as these data were estimated from the range) did not alter the direction of the results (seven studies, 818 participants; SMD 0.52, 95% CI 0.35 to 0.68).
Removing all studies judged as unclear or high risk of bias for random sequence generation or allocation concealment led to the removal of Behrman 2011, Dean 1997, Dean 2000, Kim 2012 and Kwakkel 2008, leaving nine studies (568 participants), and did not alter the direction of the results (SMD 0.42, 95% CI 0.25 to 0.59). (These sensitivity analyses are not illustrated within forest plots.)
2.5. Length of stay
Two studies (105 participants), both investigating functional task training plus musculoskeletal interventions, reported length of stay. This analysis demonstrated no statistically significant effect of intervention on reported length of stay (MD ‐10.36, 95% CI ‐48.09 to 27.36), with substantial heterogeneity (I2 = 83%). See Analysis 2.5.
3. Comparison 3. One active intervention versus another active intervention, immediate outcomes
3.1. Independence in ADL scale
3.1.1. Includes functional task training versus does not include functional task training
Four studies (186 participants) compared a group receiving an intervention that contained functional task training components with a group receiving an alternative intervention. In all four studies, the alternative intervention comprised neurophysiological components (Langhammer 2000; Lincoln 2003; Mudie 2002; Richards 1993). Three of the studies investigated only functional task training components (Langhammer 2000; Lincoln 2003; Mudie 2002), and one investigated functional task training plus musculoskeletal components and modalities (Richards 1993). This analysis demonstrated no significant differences between interventions comprising the different types of components (SMD ‐0.03, 95% CI ‐0.37 to 0.32), with low heterogeneity (I2 = 19%). Sensitivity analysis to remove the one study with additional components (Richards 1993) did not change the direction of the results. See Analysis 3.1.
Subgroup analysis: functional task training components
Analysis 11.1 explores the effect of different functional task training components. No significant differences between these subgroups were reported (P value 0.59).
3.1.2. Includes neurophysiological versus does not include neurophysiological
Seven studies (451 participants) compared a group receiving an intervention that contained neurophysiological components with a group that received an alternative intervention. Five of the studies investigated the effect of neurophysiological components only (Langhammer 2000; Lincoln 2003; Mudie 2002; Richards 1993; Zhuang 2012); one of the studies investigated neurophysiological components combined with functional task training, modalities and musculoskeletal (passive) (Li 2005) and one investigated neurophysiological plus functional task training (Gelber 1995). In all seven studies, the neurophysiological component included components described as 'Bobath.' In six of the studies, the alternative intervention included functional task training: functional task training only in three studies (Langhammer 2000; Lincoln 2003; Mudie 2002); functional task training plus musculoskeletal components in two studies (Gelber 1995; Richards 1993) and functional task training plus modalities in one study (Li 2005). In one study the alternative intervention was a modality (acupuncture) (Zhuang 2012). This analysis demonstrated no significant differences between interventions, which did or did not include neurophysiological/Bobath treatment (SMD ‐0.02, 95% CI ‐0.26 to 0.22), with low heterogeneity (I2 = 28%). Sensitivity analyses to explore the effects of different comparison components did not change the direction of the results. We preplanned sensitivity analysis to explore the effects of including Zhuang 2012, as the alternative intervention group did not receive active physical rehabilitation in addition to acupuncture; removing this study did not lead to significant differences in the direction of the results. See Analysis 3.1.
Subgroup analysis: neurophysiological components
Analysis 11.2 explores the effects of different neurophysiological components. No significant differences between these subgroups were noted (P value 0.45).
3.1.3. Includes musculoskeletal versus does not include musculoskeletal
Three studies (103 participants) compared a group that received an intervention containing musculoskeletal components with a group that received an alternative intervention. All three studies combined musculoskeletal components with components from other categories. Gelber 1995 and Richards 1993 combined both active and passive musculoskeletal components with functional task training and modalities or assistive devices. In both of these studies, the musculoskeletal components included muscle strengthening. Li 2005 implemented only passive musculoskeletal components (passive movement and body positioning) combined with functional task training, neurophysiological and modalities. The alternative intervention comprised only neurophysiological components in one study (Richards 1993); functional task training and neurophysiological in one study (Gelber 1995) and functional task training and modality in one study (Li 2005). This analysis demonstrated no significant differences between interventions that did or did not include musculoskeletal components (SMD ‐0.12, 95% CI ‐0.58 to 0.34), with low heterogeneity (I2 = 21%). Sensitivity analyses to explore the effects of different components did not change the direction of the results. See Analysis 3.1.
Subgroup analysis: musculoskeletal components
Analysis 11.3 explores the effects of different musculoskeletal components. No significant differences between these subgroups were reported (P value 0.11). However, this finding is based on a low number of studies.
Sensitivity analysis: risk of bias
Removing studies judged to be at high risk of bias for at least one assessed quality of component led to the removal of Gelber 1995 and Li 2005 and did not alter the direction of the results for any of the subgroups.
Removing studies judged as unclear or high risk of bias for random sequence generation or allocation concealment led to the removal of Li 2005 and did not alter the direction of the results. (These sensitivity analyses are not illustrated within forest plots.)
3.2. Motor function scale
3.2.1. Includes functional task training versus does not include functional task training
Four studies (188 participants) compared a group receiving an intervention that contained functional task training components with a group that received an alternative intervention. In all four studies, the alternative intervention comprised neurophysiological components (Langhammer 2000; Lincoln 2003; Richards 1993; Wang 2005). Two of the studies investigated only functional task training components (Langhammer 2000; Lincoln 2003); one investigated functional task training plus musculoskeletal components (Wang 2005) and one investigated functional task training plus musculoskeletal components and modalities (Richards 1993). This analysis demonstrated no significant differences between interventions comprising the different types of components (SMD ‐0.16, 95% CI ‐0.59 to 0.28), with moderate heterogeneity (I2 = 45%). Sensitivity analyses to explore the effects of different components did not change the direction of the results. See Analysis 3.2.
Subgroup analysis: functional task training components
Analysis 12.1 explores the effects of different functional task training components. No significant differences between these subgroups were reported (P value 0.48).
3.2.2. Includes neurophysiological versus does not include neurophysiological
Eight studies (506 participants) compared a group that received an intervention containing neurophysiological components with a group that received an alternative intervention. Five of the studies investigated the effect of neurophysiological components only (Langhammer 2000; Lincoln 2003; Richards 1993; Wang 2005; Zhuang 2012); two of the studies investigated neurophysiological components combined with functional task training (Bale 2008; Gelber 1995) and one investigated neurophysiological components combined with functional task training and passive musculoskeletal components (Liao 2006). In all eight studies, the neurophysiological component included components described as 'Bobath.' In seven of the studies, the alternative intervention included functional task training: functional task training only in two studies (Langhammer 2000; Lincoln 2003); functional task training plus musculoskeletal components in three studies (Bale 2008; Liao 2006; Wang 2005) and functional task training plus musculoskeletal components and modalities or assistive devices in two studies (Gelber 1995; Richards 1993). In one study the alternative intervention was a modality (acupuncture) (Zhuang 2012). This analysis demonstrated no significant differences between interventions that did or did not include neurophysiological or Bobath treatment (SMD 0.17, 95% CI ‐0.05 to 0.39), with low heterogeneity (I2 = 24%). Sensitivity analyses to explore the effects of different comparison components did not change the direction of the results. We preplanned a sensitivity analysis to explore the effect of including Zhuang 2012, as the alternative intervention group did not receive active physical rehabilitation in addition to acupuncture; removing this study did not result in significant differences in the direction of the results. See Analysis 3.2.
Subgroup analysis: neurophysiological components
Analysis 12.2 explores the effects of different neurophysiological components. No significant differences between these subgroups were reported (P value 0.76).
3.2.3. Includes musculoskeletal versus does not include musculoskeletal
Four studies (81 participants) compared a group that received an intervention containing musculoskeletal components with a group that received an alternative intervention. All four studies combined musculoskeletal components with components from other categories. Bale 2008 combined active musculoskeletal components with functional task training, and Gelber 1995, Richards 1993 and Wang 2005 combined both active and passive musculoskeletal components with functional task training (with or without modalities or assistive devices). In all four studies, the musculoskeletal components included muscle strengthening. The alternative intervention comprised only neurophysiological in two studies (Richards 1993; Wang 2005) and functional task training and neurophysiological in two studies (Bale 2008; Gelber 1995). This analysis demonstrated no significant differences between interventions that did or did not include musculoskeletal components (SMD ‐0.08, 95% CI ‐0.53 to 0.36), with no statistical heterogeneity (I2 = 0%). Sensitivity analyses to explore the effects of different components did not change the direction of the results. See Analysis 3.2.
Subgroup analysis: musculoskeletal components
Analysis 12.3 explores the effects of different musculoskeletal components. No significant differences between these subgroups were reported (P value 0.15). However, this finding is based on a low number of studies.
Sensitivity analysis: risk of bias
No studies were judged to be at high risk of bias for at least one assessed quality component. Removing Bale 2008, as these data were estimated from categorical data, did not alter the direction of the results.
Removing studies judged as unclear or high risk of bias for random sequence generation or allocation concealment led to the removal of Bale 2008, Gelber 1995 and Liao 2006 from the analyses but did not alter the direction of the results. (These sensitivity analyses are not illustrated within forest plots.)
3.3. Balance (Berg Balance Scale)
Four studies (83 participants) compared one active intervention with another active intervention and reported a measure of balance (Brock 2005; Richards 1993; Shin 2011; Wang 2005). No significant differences were found for comparisons of interventions containing different categories of treatment components (see Analysis 3.3).
3.4. Gait velocity
3.4.1. Includes functional task training versus does not include functional task training
Three studies (73 participants) compared a group receiving an intervention that contained functional task training components with a group that received an alternative intervention. In all three studies, the alternative intervention comprised neurophysiological components (Lincoln 2003; Richards 1993; Verma 2011). Two of the studies investigated only functional task training components (Lincoln 2003; Verma 2011), and one investigated functional task training plus musculoskeletal components and modalities (Richards 1993). This analysis demonstrated no significant differences between interventions comprising the different types of components (SMD 0.43, 95% CI ‐0.37 to 1.22), with substantial heterogeneity (I2 = 73%). Sensitivity analyses to explore the effects of different components did not change the direction of the results. See Analysis 3.4.
3.4.2. Includes neurophysiological versus does not include neurophysiological
Seven studies (278 participants) compared a group receiving an intervention that contained neurophysiological components with a group that received an alternative intervention. Four of the studies investigated the effect of neurophysiological components only (Lincoln 2003; Richards 1993; Thaut 2007; Verma 2011); two studies investigated neurophysiological components combined with functional task training (Bale 2008; Gelber 1995) and one investigated neurophysiological components combined with functional task training and cardiovascular training components (Brock 2005). In all seven studies, the neurophysiological component included components described as 'Bobath.' In all of the studies, the alternative intervention included functional task training: functional task training only in three studies (Lincoln 2003; Thaut 2007; Verma 2011); functional task training plus musculoskeletal components in one study (Bale 2008); functional task training plus musculoskeletal components and modalities or assistive devices in two studies (Gelber 1995; Richards 1993) and functional task training plus cardiovascular training components in one study (Brock 2005). Analysis demonstrated no significant differences between interventions that did or did not include neurophysiological or Bobath treatments (SMD ‐0.12, 95% CI ‐0.95 to 0.70), with substantial heterogeneity (I2 = 89%). Sensitivity analyses to explore the effects of different comparison components did not change the direction of the results. See Analysis 3.4.
3.4.3. Includes musculoskeletal versus does not include musculoskeletal
Three studies (45 participants) compared a group receiving an intervention that contained musculoskeletal components with a group that received an alternative intervention (Bale 2008; Gelber 1995; Richards 1993). Analysis demonstrated no significant differences between interventions that did or did not include musculoskeletal components (SMD ‐0.47, 95% CI ‐1.67 to 0.74), with substantial heterogeneity (I2 = 71%). Sensitivity analyses to explore the effects of different components did not change the direction of the results. See Analysis 3.4.
3.5. Length of stay
3.5.1. Includes functional task training versus does not include functional task training
One study (53 participants) compared a group receiving an intervention containing functional task training components with a group that received an alternative intervention. This study demonstrated that the functional task training intervention resulted in a reduced length of stay. See Analysis 3.5.
3.5.2. Includes neurophysiological versus does not include neurophysiological
Three studies (141 participants) compared a group receiving an intervention that contained neurophysiological components with a group that received an alternative intervention. This analysis demonstrated a significantly reduced length of stay (MD 11.36, 95% CI 1.52 to 21.19) for the groups that did not receive the neurophysiological components, with substantial heterogeneity (I2 = 74%). See Analysis 3.5.
3.5.3. Includes musculoskeletal versus does not include musculoskeletal
Two studies (88 participants) compared a group receiving an intervention that contained musculoskeletal components with a group that received an alternative intervention. This analysis demonstrated no significant differences between interventions that did or did not include musculoskeletal components (MD 8.71, 95% CI ‐12.92 to 30.34), with considerable heterogeneity (I2 = 91%). It should be noted that both of these studies are also included in comparison 3.5.2, but that Gelber 1995 compared musculoskeletal components with neurophysiological components, whilst Li 2005 combined musculoskeletal and neurophysiological components. See Analysis 3.5.
4. Comparison 4. Intervention versus no treatment, persisting outcomes
4.1. Independence in ADL scale
We pooled data from nine studies (540 participants) in this analysis, which demonstrated that intervention had a significantly beneficial effect compared with no intervention (SMD 0.58, 95% CI 0.11 to 1.04). However, substantial heterogeneity was found (I2 = 83%). See Analysis 4.1.
Significant differences between the subgroups of different categories of treatment components were found (P value 0.0002).
These results are similar to the results for immediate Independence in ADL outcomes (Analysis 1.1).
Sensitivity analysis to explore the effects of studies with high or uncertain risk of bias did not alter the direction of the results.
4.2. Motor function scale
We pooled data from eight studies (1829 participants) in this analysis, which demonstrated that intervention had a significantly beneficial effect compared with no treatment (SMD 1.06, 95% CI 0.37 to 1.75), with very considerable heterogeneity (I2 = 97%). Significant differences between the subgroups of different categories of treatment components were reported (P value 0.002). See Analysis 4.2.
Sensitivity analysis to explore the effects of studies with high or uncertain risk of bias demonstrated that the significant effect was not maintained if studies with high or uncertain risk of bias were removed (SMD 1.67, 95% CI ‐0.25 to 3.59).
4.3. Balance (Berg Balance Scale)
Only one study (Holmgren 2006) reported follow‐up data for balance outcomes (see Analysis 4.3).
4.4. Gait velocity
The three studies that reported immediate outcomes for gait velocity also reported follow‐up outcomes. Similar to the analysis of immediate outcomes, no statistically significant effect was found for intervention versus no treatment (SMD ‐0.06, 95% CI ‐0.29 to 0.18). See Analysis 4.4.
5. Comparison 5. Intervention versus attention control or usual care, persisting outcomes
5.1. Independence in ADL scale
No studies comparing intervention with control or usual care reported a follow‐up outcome for an independence in ADL scale.
5.2. Motor function scale
We pooled data from three studies (160 participants) in this analysis, which demonstrated no significant differences between intervention and control (SMD ‐0.10, 95% CI ‐0.42 to 0.23), with no statistical heterogeneity (I2 = 0%). See Analysis 5.2.
5.3. Balance (Berg Balance Scale)
No studies comparing intervention with control or usual care reported a follow‐up outcome for the Berg Balance Scale.
5.4. Gait velocity
We pooled data from five studies (214 participants) in this analysis, which demonstrates that intervention had a significantly beneficial effect compared with usual care or control (SMD 0.38, 95% CI 0.10 to 0.66), with no statistical heterogeneity (I2 = 0%). See Analysis 5.4.
This result is similar to the results for the immediate gait velocity outcomes (Analysis 1.4).
6. Comparison 6. One active intervention versus another active intervention, persisting outcomes
6.1. Independence in ADL scale
6.1.1. Includes functional task training versus does not include functional task training
One study (Verma 2011; 30 participants) compared a group receiving an intervention that contained functional task training components with a group that received an alternative intervention. This study did not contribute data to the analysis of immediate outcomes, as only follow‐up data were provided. Follow‐up was at six weeks, after a two‐week intervention period. The data suggest a significant benefit of functional task training (SMD 1.33, 95% CI 0.52 to 2.13). See Analysis 6.1.
6.1.2. Includes neurophysiological versus does not include neurophysiological
Two studies (57 participants) compared a group receiving an intervention that contained neurophysiological components with a group that received an alternative intervention. This analysis demonstrated a significant detrimental effect of the intervention that included neurophysiological or Bobath treatments (SMD ‐0.95, 95% CI ‐1.67 to ‐0.22).See Analysis 6.1.
6.1.3. Includes musculoskeletal versus does not include musculoskeletal
One study (27 participants) compared a group receiving an intervention that contained musculoskeletal components with a group that received an alternative intervention. The data showed no significant differences between groups that did and did not receive musculoskeletal components (SMD 0.58, 95% CI ‐0.19 to 1.36). See Analysis 6.1.
Subgroup analysis
A statistically significant difference was reported between subgroups including different types of components (P value 0.0001), with an indication of greater beneficial effect of interventions that included functional task training or musculoskeletal components.
6.2. Motor function scale
No studies comparing two different active interventions reported a follow‐up outcome for a motor function scale.
6.3. Balance (Berg Balance Scale)
No studies comparing two different active interventions reported a follow‐up outcome for the Berg Balance Scale.
6.4. Gait velocity
6.4.1. Includes functional task training versus does not include functional task training
One study (Verma 2011; 30 participants) compared a group receiving an intervention that contained functional task training components with a group that received an alternative intervention containing neurophysiological components. This study did not contribute data to the analysis of immediate outcomes, as only follow‐up data were provided. Follow‐up was at six weeks, after a two‐week intervention period. The data suggest significant benefits of functional task training (SMD 1.14, 95% CI 0.36 to 1.92). See Analysis 6.4.
6.4.2. Includes neurophysiological versus does not include neurophysiological
Two studies (43 participants) compared a group receiving an intervention that contained neurophysiological components with a group that received an alternative intervention (containing functional task training for Verma 2011 and functional task training plus musculoskeletal components for Gelber 1995). This analysis demonstrated a significant detrimental effect of the intervention that included neurophysiological or Bobath treatments (SMD ‐0.82, 95% CI ‐1.60 to ‐0.05). See Analysis 6.4.
6.4.3. Includes musculoskeletal versus does not include musculoskeletal
One study (14 participants) compared a group that received an intervention containing musculoskeletal components with a group that received an alternative intervention, which contained neurophysiological components. The data show no significant differences between groups that did and did not receive musculoskeletal components (SMD 0.33, 95% CI ‐0.74 to 1.40). See Analysis 6.4.
Subgroup analysis
A statistically significant difference was noted between the subgroups including different types of components (P value 0.002), with an indication of greater beneficial effect of interventions that included functional task training or musculoskeletal components.
Discussion
Key findings
This review included 96 studies (10,401 participants) that explored the effects of different physical rehabilitation approaches. More than half of the studies (50/99) were carried out in China. Fifty‐one studies compared a physiotherapy intervention with no treatment; 42 of these studies were carried out in China. Twenty‐seven studies compared a physiotherapy intervention with usual care or attention control. Twenty‐four studies compared two different active physical rehabilitation approaches. Data were available for meta‐analysis from 34 studies comparing intervention with no treatment; 16 studies comparing intervention with usual care or attention control and 14 studies comparing two different active interventions. Key findings arising from meta‐analyses were as follows.
Intervention versus no treatment
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Moderate‐quality evidence showed a beneficial effect of physical rehabilitation on measures of independence in ADL and motor function. This finding was sustained at follow‐up assessments, although the size of the benefit was reduced. Quality of reporting of studies within this comparison was generally poor, and risk of bias was frequently unclear for key methodological criteria.
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There was insufficient evidence to support conclusions relating to the effect of physical rehabilitation on balance, gait velocity or length of stay.
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A significant difference between subgroups based on time since stroke was noted, with an indication of benefit associated with shorter time since stroke.
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A significant difference between subgroups based on geographical location was reported, but most studies were carried out in China with participants who were within 30 days post stroke. All studies carried out in China were assessed at high or unclear risk of bias.
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A significant difference between subgroups based on dose of intervention was noted, with an indication that a dose of between 30 and 60 minutes once per day for five to seven days a week was beneficial, but that more than once‐daily intervention may provide even greater benefit. It was not possible to draw conclusions relating to duration of the intervention period, with substantial heterogeneity within analyses.
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Significant differences between subgroups based on provider of intervention were noted, but it is difficult to reach generalised conclusions from these subgroup analyses.
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Results of the subgroup analyses must be interpreted with caution, as a complex interrelationship between some of the subgroups is likely. For example, studies with the least time since stroke were carried out in China, meaning that reported effects attributed to geographical location may be related to time since stroke (and vice versa).
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No significant differences were noted between studies that investigated different components or categories of intervention.
In summary, moderate‐quality evidence indicates that physical rehabilitation has a beneficial effect on independence in ADL and motor function after stroke, and that this effect persists beyond the end of the intervention period, when compared with no treatment. Evidence shows greater benefit associated with a shorter time since stroke. Evidence also suggests that a dose of 30 to 60 minutes per day delivered five to seven days per week is effective, and that more frequent or increased doses may provide even greater benefit. Substantial heterogeneity was observed between the studies included in these analyses, and most of the studies were at high or uncertain risk of bias.
This evidence principally arises from China, where a particular healthcare system and cultures and beliefs are associated with health and disease. In China, physiotherapy or rehabilitation traditionally has not been routinely provided within acute hospital settings; therefore this evidence is highly relevant to stroke care settings in China. Arguably this evidence does not have any direct implications for settings in which no treatment would not be considered to be an ethical alternative for hospitalised patients with stroke, but the indirect implications of this evidence base may have universal relevance. Evidence suggests that 30 to 60 minutes of physical rehabilitation per day, delivered five to seven days per week, is beneficial for recovery of function, but that no one individual approach to physical rehabilitation is better than any other approach.
Intervention versus usual care or attention control
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Moderate‐ to high‐quality evidence shows a beneficial effect of physical rehabilitation on measures of motor function, balance and gait velocity. Moderate‐quality evidence also shows that this beneficial effect was maintained at follow‐up for gait velocity, but insufficient data were available at follow‐up to permit conclusions for other outcomes.
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No evidence was found of any benefit of intervention on measures of independence in ADL, but relatively few studies included data for this outcome.
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A significant difference between subgroups was noted based on time since stroke, with an indication of benefit associated with a shorter time since stroke. No evidence of this effect was seen in follow‐up data.
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For measures of motor function, a significant difference between subgroups based on dose of intervention was observed, with an indication that a dose of 30 to 60 minutes five to seven days per week was significantly more beneficial than an intervention delivered three to four times per week. No difference between subgroups was described for measures of independence in ADL. It was not possible to draw conclusions relating to duration of the intervention period, with substantial heterogeneity within analyses.
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No significant differences were reported between studies that investigated different components or categories of intervention.
In summary, moderate‐ to high‐quality evidence shows that physical rehabilitation is more effective than usual care or attention control in improving motor function, balance and gait velocity. Evidence suggests greater benefit associated with a shorter time since stroke. Evidence also suggests that a dose of 30 to 60 minutes delivered five to seven days a week provides significant benefit. In particular, high‐quality evidence indicates that physical rehabilitation has an impact on gait, with significant increases in gait velocity maintained at follow‐up assessments. Some evidence suggests that benefit may be greater if rehabilitation is carried out earlier after stroke, but these findings should be interpreted cautiously. As with the comparison of intervention versus no treatment, this evidence suggests that no one individual approach to physical rehabilitation is better than any other approach for recovery of function or mobility.
One active intervention versus another active intervention
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Moderate‐quality evidence shows no difference between interventions that include neurophysiological components and interventions that do not include neurophysiological components. This evidence primarily arose from interventions that were described as 'Bobath.' Very limited evidence indicates that interventions including neurophysiological components resulted in a longer hospital stay.
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Low‐quality evidence shows no differences between interventions that include components of functional task training and interventions that do not include components of functional task training. No evidence suggests that any specific functional task training components are more effective than other interventions.
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Low‐quality evidence shows no differences between interventions that include musculoskeletal components and interventions that do not include musculoskeletal components. No evidence suggests that any specific musculoskeletal components are more effective than other interventions.
In summary, evidence suggests that no one physical rehabilitation approach is more effective in promoting recovery of function or mobility after stroke than any other approach. These findings are supported by the subgroup analyses carried out for the comparisons of intervention versus no treatment or usual care, which found no significant effects of different treatment components or categories of intervention.
Physical rehabilitation approaches and components synthesised within this review
This review synthesises evidence relating to the effectiveness of different physical rehabilitation approaches. The original focus of the comparisons within this review (2007 and earlier versions) was the effectiveness of different named approaches to physiotherapy, based on a historical perspective. The original review was carried out in direct response to a consultation exercise conducted in Scotland that aimed to identify the 'burning questions' of Scottish stroke rehabilitation workers, and that identified 'different (named) treatment approaches' to be amongst the most important questions posed by physiotherapists (Legg 2000). Following consultation with key stakeholders (physiotherapists, stroke survivors and carers), the focus for this update of the review was determined to be the individual treatment components that constitute physical rehabilitation approaches. This is an important, albeit arguably subtle, shift, enabling synthesis of evidence based on different philosophies and from different cultures, with systematic categorisation of individual treatment components, regardless of their philosophical or theoretical origin. This change in focus is in line with recommendations made within the 2007 version of this review.
The studies within this review included 121 active interventions; most of these (99 interventions) included treatment components categorised as functional task training. Most of the interventions incorporated treatment components from at least two different categories of intervention, with only 33 interventions focusing on just one category of intervention (20 interventions focused on functional task training only; 13 focused on neurophysiological interventions only). The finding that most studies include a combination of different treatment components, generally arising from at least two of the different categories defined for this review, highlights this fact: Physiotherapists appear to be basing their interventions not on one single historical or philosophical approach, but rather on a pragmatic eclectic approach that utilises a range of different treatment components, often regardless of their historical or philosophical origins. This pragmatic approach, which adopts a mix of components from different approaches, was supported by the previous version of this review, which concluded that a mix of components from different approaches was significantly more effective than no treatment or placebo in recovery of functional independence following stroke, and provides justification for the decision to change the focus of the review for this update.
Identification of relevant trials
The identification of all relevant trials was confounded by several factors.
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Inconsistent and poorly defined terminology: Electronic searching was difficult because the names given to different physiotherapy rehabilitation approaches are poorly documented, often have several derivations and have varied over time. Furthermore, the interventions were not always described as 'physiotherapy' or 'physical therapy,' but sometimes were described as 'rehabilitation,' 'training' or 'exercise.' This was particularly true for studies emerging from China, which frequently described interventions as 'early rehabilitation.' Studies investigating circuit training or exercise classes sometimes met the inclusion criteria for this review; again, identification of these was made difficult by lack of use of the term 'physiotherapy' or 'physical therapy.'
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Change in focus of the review: As described above, for this update of the review, a subtle change in focus was applied—from 'named' rehabilitation approaches to the individual treatment components that constitute physical rehabilitation approaches. No change to the search strategy or to selection criteria was implemented, and we do not believe that any changes would be justified. It could be argued that decisions made relating to the exclusion of studies from the search results for previous versions of this review may be different in light of the changed focus. However, selection of relevant trials for this review has always been challenging, and we do not believe that the change in focus of the review has affected study selection in one direction or another.
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Lack of detail within the abstracts: Lack of information on study methods, participants and interventions potentially increases the chance that a relevant trial may be excluded. However, when uncertainty arose, we obtained full papers.
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Material published in journals not included in electronic databases, and unpublished material: Although substantial effort was made to identify unpublished material and material in journals not cited in the databases searched, relevant trials may not have been identified.
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Material published in Chinese: A substantial number of the included studies were carried out in China and were published in Chinese. Our electronic searching successfully identified studies for which an abstract was available in Chinese, as well as a number of studies based on English titles. However, we believe it is likely that we will not have identified all relevant Chinese trials, in particular those for which only English titles were available and those not published in journals included in the electronic databases that we searched.
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Different cultures and healthcare systems: Decisions were made to include some studies in which the provider of the intervention was not clearly a physiotherapist or a physical therapist; these decisions were often related to the fact that physiotherapists may not be routinely found in all healthcare settings around the world. This provided additional challenges in relation to determining whether a study was investigating a 'physical rehabilitation' approach. In particular, many studies in China simply referred to a 'therapist,' but in some instances, the provider was a doctor or a nurse. We carried out subgroup analyses to explore the effect of the stated intervention provider on outcome. However, many studies did not explicitly state this, which limited conclusions that could be made from this subgroup analysis.
Completeness of published studies
Many of the relevant trials that we included were published only as abstracts or as brief reports. This was frequently the case for studies published in Chinese, for which published versions were often less than two pages long. Although we contacted study authors, when possible, to confirm study eligibility, we did not have the time or resources to contact all study authors for further information on trial design or study results. Thus, in general the completeness of study information is low, resulting in a high number of studies for which risk of bias is classed as 'unclear' and a high number of studies that do not contribute data to the analyses.
Relatively few studies followed up with participants after the intervention had ended: Data were available immediately at the end of intervention for 49 studies for the independence in ADL outcome and for 50 studies for the motor function outcome, but only for 16 and 12 studies, respectively, for a longer‐term follow‐up outcome. Follow‐up data from studies comparing intervention with no treatment demonstrate that significant benefit of intervention is maintained, but the size of the benefit was observed to lessen. In the comparison of intervention versus usual care or control, lack of follow‐up data limits the ability of review authors to draw any generalisable conclusions relating to whether observed benefits are maintained.
Descriptions of interventions
Clear, concise documentation of complex physical interventions is exceptionally difficult to achieve. The written information provided by study authors regarding interventions administered in the included trials is included in the Characteristics of included studies table. Although many of the included studies attempt to describe all administered interventions, the available documentation is often insufficient to allow confident and accurate repetition of the applied rehabilitation approach. Problems with documentation of interventions generally are not the fault of researchers or therapists, but rather are due to the fundamental problem of recording methods of physical handling skills and techniques, and the nature of the often intimate relationship between stroke survivor and physiotherapist. Documentation of this process would generally be complex and 'wordy'; therefore often it is not possible to present within research papers with limitations on length. These problems are confounded by the fact that treatments applied are often ultimately the decision of a single physiotherapist, based on an individual assessment of a unique stroke survivor's movement disorders.
Furthermore, the common basis of physical rehabilitation 'approaches' is that they are holistic. All body parts and movements can be assessed and treated based on the selected approach; however, a physiotherapist may select to concentrate on the treatment of one particular body part or movement during a treatment session. Subsequently, treatments given to specific stroke survivors by individual therapists may vary enormously. This review attempted to limit this variation slightly by excluding trials that had provided interventions only to the upper limb. Nevertheless, although we grouped together studies that included treatment components within similar categories, it is conceivable that substantial differences exist between the physical interventions given to participants within the same treatment group.
Categorisation of treatment components within interventions
The comparisons carried out within the review relied on categorisation of treatment components that were described within the published papers. Two independent review authors categorised the described treatments using agreed definitions of individual treatment components. This process relied on adequate descriptions within published papers. Papers that published only very brief descriptions of interventions therefore may have resulted in categorisations that were not truly reflective of the intervention delivered.
Furthermore, this process of categorisation was highly dependent on the language and terminology provided within a written description. For example, an author may state "activities aimed at improved gait." This description would result in categorisation only within the functional task training component of "walking." However, in practice, this intervention could have included components such as active or active‐assisted movement, sensorimotor facilitation and muscle strengthening. Therefore our method of categorisation is likely to have underestimated rather than overestimated the numbers of treatment components and intervention categories. Hence, if any inaccuracy exists, the interventions are likely to be more "mixed" and eclectic than has been captured by our method of categorisation.
A number of difficulties were encountered in distinguishing between interventions that included only functional task training components and those that also included musculoskeletal (active) components. In particular, the review authors encountered difficulties in determining whether an intervention focused on a functional task might also include active or active‐assisted movement. This reality was due to the fact that all functional task training necessitates active movement, and overlap between practice of an active‐movement and practice of a functional task can be inevitable. This is an area that we recommend for further exploration in relation to the descriptions and definitions of treatment components proposed for this review.
Discussion also focused on whether the categories of 'assistive devices' and 'modalities' would be better combined into one joint category. The separate categories were agreed and defined by the stakeholder group participants, which is why they have been used within this review. However, we recommend that merging of these categories be explored before future updates of this review are prepared.
Treatment components within named approaches
We were aware when developing the definitions for categorisation of described interventions that a number of studies have stated a named approach (e.g. 'Bobath,' 'Motor‐relearning programme') without providing any description of the treatment components included within the approach. We therefore wrote definitions such that these studies could be captured by our system of categorisation of individual treatment components. However, including studies that have provided only the name of an approach without providing any descriptions potentially introduces a number of biases. These biases occur as a result of the fact that the content of named approaches potentially changes over time and in keeping with geographical or personal preferences and biases. In particular, several studies reported that the intervention was 'Bobath,' and much debate has surrounded the content of physiotherapy interventions based on the Bobath concept. This debate arises largely from the fact that the content of the Bobath approach has changed over time, published descriptions are limited, and the content of current therapy is variable (Carr 1994a; DeJong 2004; Langhammer 2012; Mayston 2008; Nilsson 1992; Pomeroy 2001b; Sackley 1996; Tyson 2009b; Turner 1995). A summary of the philosophy or theory of some of the key named approaches was drawn up for the first version of this review and is provided in Table 1.
Translation of descriptions of interventions
Thirty‐eight of the included full papers were published in languages other than English; all were published in Chinese. For these papers, we sought translation of the intervention description into English. In addition, several included studies were carried out in China and the papers published in English, but by authors for whom English clearly was not the first language. These translations provided a number of challenges in relation to interpretation of meanings and subsequent classification of treatment components. For example, in several papers, it was unclear whether 'standing up training' referred to activities carried out in standing (i.e. training to promote standing balance) or to sit‐to‐stand training. In these cases, decisions were made based on discussion between two review authors (one of whom was a Chinese‐speaking physiotherapist (PLC)).
Geographical location of studies
Subgroup analyses found evidence of an association between effect size and geographical location, with an indication that studies carried out in China may have a greater effect size. This finding may be due to reporting biases and may reflect biases associated with publication, location, citation and language. This finding may also reflect a true difference in the effects of interventions carried out in different geographical locations, which may be a result of differences in culture, traditions, training and implementation of interventions. However, this difference may also be related to the comparison interventions, especially if they consist of no treatment or usual care. All studies that compared intervention against no treatment in the acute phase of stroke were carried out in China; this is a reflection of the fact that 'usual care' can comprise no rehabilitation within these geographical settings. Consequently, the finding that intervention is more effective than no treatment in improving independence in ADL and in motor function may, arguably, be applicable only to settings in China. Evidence shows that usual care can vary considerably, both regionally and nationally as well as internationally. Hence, geographical location could be a confounding variable in the comparison of intervention against usual care.
Risk of bias of included studies
Judgement of quality of evidence was very difficult because of poor, incomplete or brief reporting of information. Less than 50% of the studies were judged to be at low risk of bias for selection, detection and attrition bias; however, for most of the studies, this information was unclear, and risk of bias was judged to be high in less than 10% of the studies. Sensitivity analyses were carried out to explore the effect of including studies with high or unclear risk of bias. These sensitivity analyses generally found that removal of studies with high or unclear risk of bias did not alter the direction (or significance) of the results. Thus, although the quality of most of the evidence included in this review remains uncertain, the fact that inclusion of these studies does not affect the direction of results gives us greater confidence in our findings. The main message arising from this review in relation to quality of the evidence is that it is essential that reporting of methodological features of RCTs of physiotherapy interventions is improved, and that studies are reported using the CONSORT guidelines for reporting (Schulz 2010).
Studies that used quasi‐random assignment were excluded from this update of the review (previous versions had included quasi‐randomised trials). This led to exclusion of three studies that had been included in the 2007 version (Hesse 1998; Ozdemir 2001; Stern 1970). However, we found information about the method of randomisation particularly difficult to judge in a number of studies included in this review, particularly studies published in Chinese, in which use of the term 'random' in English abstracts did not always reflect the descriptions provided in Chinese versions of the study. There is an urgent need for trialists to address the issue of adequate reporting of methods of randomisation. It is possible that we have inadvertently included in this review trials that used quasi‐random assignment, rather than true random assignment.
In most studies, it was unclear whether participants were blinded to the study group and aims. The nature of rehabilitation interventions and the ethical requirement to obtain informed consent often make it difficult, if not impossible, to blind participants. If the aims and objectives of the study were apparent to the participants, this could confound the study results. It is generally impossible to blind the treating therapist because treating therapists have to be familiar with the intervention they are administering. Therapists who strongly favoured one approach over another could introduce performance bias. In several studies, the same therapist administered treatment to participants in both study groups; this potentially introduced considerable contamination between groups. The 'beliefs' of stroke survivors and therapists may further contribute to biases within many of these studies, and the large number of different geographical locations in which studies were carried out means that the studies were carried out with participants living in a wide variety of cultures, which could potentially impact the response to physical rehabilitation. Many of the included trials did not state that they used a blinded assessor. Lack of blinding of assessors potentially introduces considerable bias into the study results. This is particularly important in studies in which therapists often have strong beliefs in support of a particular approach.
Heterogeneity of included trials
In addition to limitations of the study methods, the trials included in the review had considerable heterogeneity. The key areas of heterogeneity were related to interventions and to participants.
-
Interventions: Although attempts have been made to categorise the interventions using a systematic, rigorous and valid method, considerable variation may still exist between studies that have used similar types of treatment components. Furthermore, substantial variations in dose and intensity and in length of the treatment period were noted. Also different is the fact that some interventions were carried out only when a therapist is present, whilst in other studies, independent practice of activities outside therapy sessions was encouraged.
-
Participants: The participant populations in the different included studies were heterogeneous. They varied from limited populations (e.g. pure motor stroke only) to those inclusive of all stroke survivors. Considerable variation in the time since stroke was also noted. The validity of combining results from such heterogeneous samples is debatable. We recommend that future updates consider subgroup analysis to explore the initial impairment of included participants.
Although we have carried out subgroup analyses to explore issues relating to the heterogeneity of both the interventions (i.e. dose, components) and the participants (time since stroke) and other issues (geographical location, provider of intervention), it is likely that a complex interrelationship exists between some of the subgroups that we have been unable to explore. For example, studies carried out in China tended to be those with the least time since stroke, meaning that effects found that have been attributed to geographical location could be due equally to time since stroke (and vice versa). We believe that this will be true for a number of other variables. We recommend that future updates of this review plan to explore issues associated with the interrelationship of these variables.
Potential biases in the review process
Publication bias
As has been discussed above, the identification of all relevant trials was confounded by a number of factors, and, despite a rigorous search strategy, we are not fully confident that we will have successfully identified all studies. Consequently, this review may be biased towards particular types of studies and publications. For example, we are not confident that we will have successfully identified all relevant studies published in China, or in Chinese. Similarly, we may be missing other non‐English studies or studies published in journals that are not included in the electronic databases that we searched.
Treatment components and categorisation of interventions
We introduced a method of categorisation of interventions that was agreed by a stakeholder group of physiotherapists, stroke survivors and carers. This method of categorisation has not been tested or explored further, and such testing is necessary to confirm the relevance and validity of the identified categories. In the absence of any other suitable method of categorisation of treatment components, we believe that we have adopted a robust, justifiable method—based on consensus between physiotherapists, stroke survivors and carers. We argue that the involvement of this expert stakeholder group has considerably enhanced our review and is substantially advantageous compared with the alternative of having researchers make decisions over the categorisation of interventions and the structure of comparisons. Feedback from the stakeholder group members confirms that the group perceived that their input benefited the format of the review and made the review more clinically relevant. However, because of the limited nature of our resources, most members of the stakeholder group were based in Scotland. Given known differences in physiotherapy practice in different parts of the world, we recommend that the proposed categorises are explored and amended to reflect international practices in relation to stroke rehabilitation.
We recognise that the terminology used, particularly in the titles of the categories, may not be universally accepted or understood. We acknowledge that the appropriateness of terms such as 'functional,' 'neurophysiological' and 'musculoskeletal' can be debated when used in the way we have used them within this review. However, these terms were selected by the stakeholder group to have clinical meaning and were informed by the terminology used by DeJong 2004.
Appraisal of quality in non–English language papers
Non‐English (Chinese) papers included in the review were appraised and assessed for risk of bias by one review author with the language skills to translate relevant sections of the papers. This review author also possessed the necessary quality appraisal skills and had detailed expertise of physiotherapy and stroke rehabilitation. A second review author then considered the assessment of risk of bias by the first review author, based on the translations of relevant extracts provided by the first review author. Thus, although two review authors did consider the quality of these non–English language papers, the assessment of the second review author was based entirely on the translation provided by the first review author. This method means that if the first review author made any errors in translation, or missed information provided in the non‐English text, the second review author will not have identified this. Thus, although having two review authors for these papers offers advantages, it does not provide the same level of 'independence' as the process of having two independent review authors for the English language papers. However, given the volume of non‐English papers that we have included, and the available resources for this review, we believe that we have taken all steps available to us to minimise potential biases in this process.
Conclusions arising from this review
Following completion of the analyses and results of this review, this information was presented to our stakeholder group, which comprised physiotherapists, stroke survivors and carers. For each of the three main comparisons and associated subgroup analyses, group members discussed the clinical implications and key messages arising from the results. The points discussed have been incorporated within the Discussion and Authors' conclusions sections of this review. In particular, the stakeholder group members highlighted the need to specifically draw out information pertaining to the dose of interventions delivered within the studies, as this was believed to have important implications for clinical practice. We believe that this process of consultation considerably removes potential biases from the process of reaching conclusions from this review, as the conclusions reflect the views of expert clinicians, stroke survivors and carers, rather than the potentially biased viewpoints of researchers and academics.
Previous versions of this review
The previous (2007) version of this review concluded that "no one physiotherapy approach has been shown to be more advantageous to the promotion of recovery of lower limb function or postural control" and that "physiotherapy using a mix of components from different approaches is more beneficial than no treatment or placebo control for the recovery of functional independence after stroke." These findings supported the conclusion that "this evidence provides a sound scientific rationale for physiotherapists to use a selection of treatments, regardless of their philosophical or theoretical origin." This updated review agrees with, and adds considerable evidence to, these previous conclusions. Although the 2007 version concluded that evidence was insufficient to suggest that one approach was superior to another, this review can now conclude that moderate‐quality evidence indicates that there is no difference between approaches.
Other reviews
A number of other published reviews agree with the conclusion that physiotherapists should not use compartmentalised, named approaches, but should select clearly defined and described techniques and task‐specific treatments, regardless of their historical or philosophical origin (Kollen 2009; Langhammer 2012; Mayston 2008; Pomeroy 2005).
This review is in agreement with a review of evidence relating specifically to the Bobath approach (Kollen 2009), which concluded that there was "no evidence for the superiority of Bobath therapy or any other approach on sensorimotor control of the upper and lower limb, dexterity, mobility, ADL, HRQOL, and cost‐effectiveness."
Zhang 2013 recently completed a review that has similarities to our comparison of physiotherapy treatment versus no treatment. Zhang 2013 aimed specifically to review RCTs that compared rehabilitation versus standard care after stroke in China. This review pooled evidence from 31 trials (5220 participants) that reported independence in ADL (Barthel Index) and 27 trials (4501 participants) that reported motor function (Fugl‐Meyer Assessment). In contrast, we identified and pooled the results of 27 studies (3423 participants) and 25 studies (4558 participants), respectively. (NB: Our figures also include non‐Chinese studies.) We are unclear whether the differences in included trials reflected a more effective strategy for identification of Chinese studies by Zhang 2013; differences in selection criteria between reviews or a combination of these. Before future updates of our review, we plan to speak to the authors of Zhang 2013 to discuss differences in identification and selection of trials between the reviews. Despite differences in the numbers of trials included, the results and conclusions of our review were in agreement with those of Zhang 2013, which concluded that "there is some evidence that rehabilitation post stroke is more effective than no rehabilitation, improving activities of daily living and reducing disability." Both Zhang 2013 and our review highlight the limitations relating to low reporting quality and study heterogeneity. A key difference between our review and Zhang 2013 is that Zhang 2013 did not attempt to explore the specific treatment components investigated by the studies.
The figure summarises the process undertaken by the stakeholder group, which met on three occasions (green circles). The nominal group technique was used to achieve all decisions. The blue circles represent the 'preparation phase,' which included drafting role descriptors for the SG; obtaining local University ethics and recruiting the SG and data extraction exercise of the sample of Chinese studies (n = 10) that had previously been identified in the 2007 version of this review. Purple circles represent the months dedicated to undertaking the systematic review.
Study flow diagram.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Comparison 1: Intervention versus no treatment: immediate outcomes, Outcome 1: Independence in ADL scales
Comparison 1: Intervention versus no treatment: immediate outcomes, Outcome 2: Motor function scales
Comparison 1: Intervention versus no treatment: immediate outcomes, Outcome 3: Balance (Berg Balance Scale)
Comparison 1: Intervention versus no treatment: immediate outcomes, Outcome 4: Gait velocity
Comparison 1: Intervention versus no treatment: immediate outcomes, Outcome 5: Length of stay
Comparison 2: Intervention versus usual care or attention control: immediate outcomes, Outcome 1: Independence in ADL scales
Comparison 2: Intervention versus usual care or attention control: immediate outcomes, Outcome 2: Motor function scales
Comparison 2: Intervention versus usual care or attention control: immediate outcomes, Outcome 3: Balance (Berg Balance Scale)
Comparison 2: Intervention versus usual care or attention control: immediate outcomes, Outcome 4: Gait velocity
Comparison 2: Intervention versus usual care or attention control: immediate outcomes, Outcome 5: Length of stay
Comparison 3: One active intervention versus another active intervention: immediate outcomes, Outcome 1: Independence in ADL scales
Comparison 3: One active intervention versus another active intervention: immediate outcomes, Outcome 2: Motor function scales
Comparison 3: One active intervention versus another active intervention: immediate outcomes, Outcome 3: Balance (Berg Balance Scale)
Comparison 3: One active intervention versus another active intervention: immediate outcomes, Outcome 4: Gait velocity
Comparison 3: One active intervention versus another active intervention: immediate outcomes, Outcome 5: Length of stay
Comparison 4: Intervention versus no treatment: persisting outcomes, Outcome 1: Independence in ADL scales
Comparison 4: Intervention versus no treatment: persisting outcomes, Outcome 2: Motor function scales
Comparison 4: Intervention versus no treatment: persisting outcomes, Outcome 3: Balance (Berg Balance Scale)
Comparison 4: Intervention versus no treatment: persisting outcomes, Outcome 4: Gait velocity
Comparison 5: Intervention versus usual care or attention control: persisting outcomes, Outcome 1: Independence in ADL scales
Comparison 5: Intervention versus usual care or attention control: persisting outcomes, Outcome 2: Motor function scales
Comparison 5: Intervention versus usual care or attention control: persisting outcomes, Outcome 3: Balance (Berg Balance Scale)
Comparison 5: Intervention versus usual care or attention control: persisting outcomes, Outcome 4: Gait velocity
Comparison 6: One active intervention versus another active intervention: persisting outcomes, Outcome 1: Independence in ADL scales
Comparison 6: One active intervention versus another active intervention: persisting outcomes, Outcome 2: Motor function scales
Comparison 6: One active intervention versus another active intervention: persisting outcomes, Outcome 3: Balance (Berg Balance Scale)
Comparison 6: One active intervention versus another active intervention: persisting outcomes, Outcome 4: Gait velocity
Comparison 7: Subgroups. Intervention versus no treatment: immediate outcome: independence in ADL, Outcome 1: Time after stroke
Comparison 7: Subgroups. Intervention versus no treatment: immediate outcome: independence in ADL, Outcome 2: Study geographical location
Comparison 7: Subgroups. Intervention versus no treatment: immediate outcome: independence in ADL, Outcome 3: Dose of intervention
Comparison 7: Subgroups. Intervention versus no treatment: immediate outcome: independence in ADL, Outcome 4: Provider of intervention
Comparison 7: Subgroups. Intervention versus no treatment: immediate outcome: independence in ADL, Outcome 5: Treatment components included
Comparison 8: Subgroups. Intervention versus attention control or usual care: immediate outcome: independence in ADL, Outcome 1: Time after stroke
Comparison 8: Subgroups. Intervention versus attention control or usual care: immediate outcome: independence in ADL, Outcome 2: Study geographical location
Comparison 8: Subgroups. Intervention versus attention control or usual care: immediate outcome: independence in ADL, Outcome 3: Dose of intervention
Comparison 8: Subgroups. Intervention versus attention control or usual care: immediate outcome: independence in ADL, Outcome 4: Provider of intervention
Comparison 8: Subgroups. Intervention versus attention control or usual care: immediate outcome: independence in ADL, Outcome 5: Treatment components included
Comparison 9: Subgroups. Intervention versus no treatment: immediate outcome: motor function, Outcome 1: Time after stroke
Comparison 9: Subgroups. Intervention versus no treatment: immediate outcome: motor function, Outcome 2: Study geographical location
Comparison 9: Subgroups. Intervention versus no treatment: immediate outcome: motor function, Outcome 3: Dose of intervention
Comparison 9: Subgroups. Intervention versus no treatment: immediate outcome: motor function, Outcome 4: Provider of intervention
Comparison 9: Subgroups. Intervention versus no treatment: immediate outcome: motor function, Outcome 5: Treatment components included
Comparison 10: Subgroups. Intervention versus attention control or usual care: immediate outcome: motor function, Outcome 1: Time after stroke
Comparison 10: Subgroups. Intervention versus attention control or usual care: immediate outcome: motor function, Outcome 2: Study geographical location
Comparison 10: Subgroups. Intervention versus attention control or usual care: immediate outcome: motor function, Outcome 3: Dose of intervention
Comparison 10: Subgroups. Intervention versus attention control or usual care: immediate outcome: motor function, Outcome 4: Provider of intervention
Comparison 10: Subgroups. Intervention versus attention control or usual care: immediate outcome: motor function, Outcome 5: Treatment components included
Comparison 11: Subgroups. One active intervention versus another active intervention: immediate outcomes: independence in ADL, Outcome 1: Functional task training components
Comparison 11: Subgroups. One active intervention versus another active intervention: immediate outcomes: independence in ADL, Outcome 2: Neurophysiological components
Comparison 11: Subgroups. One active intervention versus another active intervention: immediate outcomes: independence in ADL, Outcome 3: Musculoskeletal components
Comparison 12: Subgroups. One active intervention versus another active intervention: immediate outcomes: motor function, Outcome 1: Functional task training components
Comparison 12: Subgroups. One active intervention versus another active intervention: immediate outcomes: motor function, Outcome 2: Neurophysiological components
Comparison 12: Subgroups. One active intervention versus another active intervention: immediate outcomes: motor function, Outcome 3: Musculoskeletal components
| Physiotherapy intervention compared with no treatment for recovery after stroke | ||||
| Patient or population: adults with stroke Intervention: physiotherapy interventions Comparison: no treatment | ||||
| Outcomes | Standardised mean difference | No. of participants | Quality of the evidence | Comments |
|---|---|---|---|---|
| Independence in ADL scales Immediate outcome | 0.78 (0.58 to 0.97) | 27 studies 3423 participants | ⊕⊕⊕⊝ | Substantial heterogeneity in results. Most studies are at high or unclear risk of bias. Most studies are carried out in China; significant subgroup effect relating to geographical location of the study |
| Independence in ADL scales Persisting outcome | 0.58 (0.11 to 1.04) | 9 studies 540 participants | ⊕⊕⊕⊝ | |
| Motor function scales Immediate outcome | 0.81 (0.58 to 1.04) | 25 studies 4558 participants | ⊕⊕⊕⊝ | Substantial heterogeneity in results. Most studies are at high or unclear risk of bias. Most studies are carried out in China; significant subgroup effect relating to geographical location of the study |
| Motor function scales Persisting outcome | 1.06 (0.37 to 1.75) | 8 studies 1829 participants | ⊕⊕⊕⊝ | |
| Balance (Berg Balance Scale) Immediate outcome | ‐0.04 (‐0.71 to 0.64) | 1 study 34 participants | ⊕⊝⊝⊝ | |
| Balance (Berg Balance Scale) Persisting outcome | ‐0.03 (‐0.70 to 0.65) | 1 study 34 participants | ⊕⊝⊝⊝ | |
| Gait velocity Immediate outcome | 0.05 (‐0.18 to 0.28) | 3 studies 292 participants | ⊕⊕⊝⊝ | |
| Gait velocity Persisting outcome | ‐0.06 (‐0.29 to 0.18) | 3 studies 271 participants | ⊕⊕⊝⊝ | |
| Length of stay | MD ‐2.85 (‐10.47 to 4.76) | 3 studies 318 participants | ⊕⊕⊝⊝ | |
| GRADE Working Group grades of evidence. | ||||
| Physiotherapy intervention compared with usual care or attention control for recovery after stroke | ||||
| Patient or population: adults with stroke Intervention: physiotherapy intervention Comparison: usual care or attention control | ||||
| Outcomes | Standardised mean difference | No. of participants | Quality of the evidence | Comments |
|---|---|---|---|---|
| Independence in ADL scales Immediate outcome | 0.04 (‐0.27 to 0.35) | 6 studies 260 participants | ⊕⊕⊕⊝ | |
| Independence in ADL scales Persisting outcome | No data | |||
| Motor function scales Immediate outcome | 0.42 (0.24 to 0.61) | 13 studies 967 participants | ⊕⊕⊕⊝ | Removing all studies that were judged as unsure or high risk of bias for random sequence generation or allocation concealment left 7 studies (377 participants) demonstrating no significant effect (SMD 0.17, 95% CI ‐0.04 to 0.38) |
| Motor function scales Persisting outcome | ‐0.10 (‐0.42 to 0.23) | 3 studies 160 participants | ⊕⊕⊝⊝ | |
| Balance (Berg Balance Scale) Immediate outcome | 0.31 (0.05 to 0.56) | 5 studies 246 participants | ⊕⊕⊕⊝ | |
| Balance (Berg Balance Scale) Persisting outcome | No data | |||
| Gait velocity Immediate outcome | 0.46 (0.32 to 0.60) | 14 studies 1126 participants | ⊕⊕⊕⊕ | Sensitivity analysis: studies with attention control: 7 studies 251 participants SMD 0.41(0.51 to 0.67) |
| Gait velocity Persisting outcome | 0.38 (0.10 to 0.66) | 5 studies 214 participants | ⊕⊕⊕⊝ | |
| Length of stay | MD ‐10.36 (‐48.09 to 27.36) | 2 studies 105 participants | ⊕⊕⊝⊝ | |
| GRADE Working Group grades of evidence. | ||||
| One active intervention compared with another active intervention for recovery after stroke | ||||
| Patient or population: adults with stroke Intervention: A physiotherapy intervention containing functional task training, neurophysiological or musculoskeletal components Comparison: A physiotherapy intervention that does not contain the same category of treatment components | ||||
| Outcomes | Standardised mean difference | No. of participants | Quality of the evidence | Comments |
|---|---|---|---|---|
| 3.1.1 Includes functional training versus does not include functional training Independence in ADL scales Immediate outcomes | ‐0.03 (‐0.37 to 0.32) | 4 studies (186 participants) | ⊕⊕⊝⊝ | Quality of evidence downgraded from "moderate" to "low" because of the relatively low number of studies/participants |
| 3.1.2 Includes neurophysiological versus does not include neurophysiological Independence in ADL scales Immediate outcomes | ‐0.02 (‐0.26 to 0.22) | 7 studies (451 participants) | ⊕⊕⊕⊝ | Evidence primarily relates to interventions described as Bobath |
| 3.1.3 Includes musculoskeletal versus does not include musculoskeletal Independence in ADL scales Immediate outcomes | ‐0.12 (‐0.58 to 0.34) | 3 studies (103 participants) | ⊕⊕⊝⊝ | Quality of evidence downgraded from "moderate" to "low" because of the relatively low number of studies/participants |
| 3.2.1 Includes functional training versus does not include functional training Motor function scales Immediate outcomes | ‐0.16 (‐0.59 to 0.28) | 4 studies (188 participants) | ⊕⊕⊝⊝ | Quality of evidence downgraded from "moderate" to "low" because of the relatively low number of studies/participants |
| 3.2.2 Includes neurophysiological versus does not include neurophysiological Motor function scales Immediate outcomes | 0.17 (‐0.05 to 0.39) | 8 studies (506 participants) | ⊕⊕⊕⊝ | Evidence primarily relates to interventions described as Bobath |
| 3.2.3 Includes musculoskeletal versus does not include musculoskeletal Motor function scales Immediate outcomes | ‐0.08 (‐0.53 to 0.36) | 4 studies (81 participants) | ⊕⊕⊝⊝ | Quality of evidence downgraded from "moderate" to "low" because of the relatively low number of studies/participants |
| GRADE Working Group grades of evidence. | ||||
| Name of approach | Philosophy/theory | Treatment principles | Descriptive terms | Supporting references |
|---|---|---|---|---|
| Rood | Concerned with 'the interaction of somatic, autonomic, and psychic factors, and their role in regulations of motor behaviour'. | Activate/facilitate movement and postural responses of patient in same automatic way as they occur in the normal | Ontogenetic sequences | |
| Proprioceptive neuromuscular facilitation (PNF) or Knott and Voss | Active muscle contractions intended to stimulate afferent proprioceptive discharges into the CNS increased excitation and recruitment of additional motor units | Diagonal and spiral patterns of active and passive movement | Patterns of movement | |
| Brunnström | Uses primitive reflexes to initiate movement and encourages use of mass patterns in early stages of recovery | Use tasks that patient can master or almost master. | Normal development | Brunnström 1956; Brunnström 1961; Brunnström 1970; Perry 1967; Sawner 1992 |
| Bobath or neurodevelopmental approach (NDT) | Aim to control afferent input and facilitate normal postural reactions | Facilitation of normal movement by a therapist, using direct handling of the body at key points such as head and spine, shoulders and pelvic girdle and, distally, feet and hands | Normal movement | Bobath 1959; Bobath 1966; Bobath 1970; Bobath 1978; Bobath 1990; Davies 1985; Davies 1990; Mayston 2000 |
| Johnstone | To control spasticity by inhibiting abnormal patterns and using positioning to influence tone | Use of inflatable splints | Muscle tone | |
| Carr and Shepherd or motor learning or motor relearning or movement science | Assumes that neurologically impaired people learn in the same way as healthy people. | (1) Analysis of task | Motor control | Carr 1980; Carr 1982; Carr 1987a; Carr 1987b; Carr 1990; Carr 1998 |
| Conductive education or Peto | Aims to teach patient strategies for dealing with disabilities in order to encourage them to learn to live with or overcome disabilities | Educational principles and repetition used as a method of rote learning | Education | |
| Affolter | Interaction between individual and environment fundamental part of learning | NB. This approach started from theory, rather than from clinical practice | Perception | |
| Sensory integration or Ayres | Functional limitations compounded by sensory and perceptual impairment | Sensory feedback | Sensory and perceptual impairment | |
| The criteria listed in this Table are those used in previous versions of this review. These criteria are not used in this updated version of the review. (See Table 2 for the criteria used for classification of interventions within this updated review). | ||||
| Categories | Treatment component | Description of individual treatment component |
|---|---|---|
| Assistive devices (AD) | Walking aids | Devices to assist walking, including sticks and frames |
| Orthoses for walking | Externally applied orthoses to assist walking, including AFO, knee braces | |
| Resting splints | Externally applied orthoses to maintain or improve limb alignment | |
| Cardiopulmonary interventions (CI) | Aerobic/fitness/endurance training | Activities to improve cardiopulmonary fitness |
| Functional task training (FTT) | ADL training | Practice of tasks relevant to daily life, including both part and whole task practice |
| Sitting &/or standing balance training | Various activities performed sitting &/or standing with the aim of improving the ability to balance safely and independently | |
| Sit‐to‐stand practice | Practice of tasks aimed at improving ability to stand up and sit down safely and independently | |
| Transfer practice | Practice of tasks aimed at improving ability to move from one position to another | |
| Walking | Practice of tasks aimed at improving ambulation | |
| Stair climbing | Practice of tasks aimed at ability to go up and down stairs | |
| Upper limb function training | Practice of tasks aimed at improving the ability to move and use the arm, such as reach, grasp, and hand‐to‐mouth activities | |
| Described as "MRP" (MRP – Motor Relearning Programme) | Described as MRP | |
| Modality (Mo) | Acupuncture | as an adjunct, delivered for either pain relief or movement therapy |
| Physical agents (including hot, cold, TENS – Transcutaneous electrical nerve stimulation) | as an adjunct, delivered for either pain relief or movement therapy | |
| Musculoskeletal intervention (active) | Muscle strengthening | Practice of activities to progressively increase the ability to generate muscle force, including using body weight and external resistance |
| Active & active‐assisted movement | Moving a limb through its range of movement, under the patient’s active control with or without assistance | |
| Musculoskeletal intervention (passive) | Increasing angle of upright sitting | a form of positioning, to promote early sitting |
| Tilt table | To promote early lower limb loading | |
| Passive movement | Moving a limb through it’s range of movement, whilst the patient is passive | |
| Body & limb positioning | placing a limb or body part in a supported position, to maintain optimal alignment | |
| Massage | Manipulation of soft tissue, using the hands or a tool designed for the purpose | |
| Neurophysiological intervention | Hands on facilitation of ('normal') movement (Bobath) | Intervention which is described as facilitation of movement, referenced to Bobath or Davies |
| Inhibition of abnormal muscle tone / normalising tone (Bobath) | Intervention which is described as inhibition of abnormal muscle tone or as normalising muscle tone, referenced to Bobath or Davies | |
| Described as "Bobath" | Described as Bobath | |
| Trunk mobilisations / postural reactions (Bobath) | Intervention which is described as trunk mobilisations or postural reactions to perturbations, referenced to Bobath or Davies | |
| Proprioceptive Neuromuscular facilitation (PNF – proprioceptive neuromuscular facilitation) | Described as PNF | |
| Sensorimotor facilitation | The use of excitatory techniques, such as brushing, striking, tapping, icing, to improve sensory awareness and promote muscle activity | |
| AD: assistive devices; CPI: cardiopulmonary interventions; FTT: functional task training; MoD: Modality; Musc.(active): musculoskeletal intervention (active); Musc.(passive): musculoskeletal intervention (passive); NP: neurophysiological intervention. | ||
| Study | Group | Categories (and treatment components) | ||||||
|---|---|---|---|---|---|---|---|---|
| Assistive Devices | Cardiopulmonary intervention | Functional Task Training | Modality | Musculoskeletal intervention (active) | Musculoskeletal intervention (passive) | Neurophysiological intervention | ||
| ‘All groups' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Intervention' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Walking UL function training | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Control' | ‐ | ‐ | Walking UL function training | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Part practice' | ‐ | ‐ | Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Whole practice' | ‐ | ‐ | Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Early rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Functional strength training' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Walking UL function training | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Training as usual' | ‐ | ‐ | ADL training | ‐ | ‐ | ‐ | Hands on facilitation (Bobath) Inhibition of abn musc. tone (Bobath) Described as 'Bobath' Sensorimotor facilitation | |
| ‘Locomotor training program' | ‐ | ‐ | Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Home exercise program' | ‐ | ‐ | Sitting and/or standing balance | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Mobility’ | ‐ | Aerobic, fitness, endurance | Sitting and/or standing balance Sit‐to‐stand practice Walking | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Bobath' | ‐ | Aerobic, fitness, endurance | Walking Stair climbing | ‐ | ‐ | ‐ | Hands on facilitation (Bobath) Trunk mobilisations/ postural reactions (Bobath) PNF | |
| ‘Task practice' | ‐ | Aerobic, fitness, endurance | Walking Stair climbing Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Treatment' | ‐ | ‐ | Sitting and/or standing balance Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Motor relearning' | ‐ | ‐ | Sit‐to‐stand practice Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Conventional therapy' | ‐ | ‐ | Sit‐to‐stand practice | ‐ | ‐ | ‐ | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Walking Stair climbing UL function training | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | Sensorimotor facilitation | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing UL function training | ‐ | ‐ | Passive movement | ‐ | |
| ‘Test' | ‐ | ‐ | Walking | ‐ | Active and active assisted movement | Passive movement | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | Sitting and/or standing balance Transfer practice Walking Stair climbing UL function training | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | Sensorimotor facilitation | |
| ‘Additional conventional therapy (CPT+CPT)' | ‐ | ‐ | ADL training | ‐ | Active and active assisted movement | Passive movement Massage | Sensorimotor facilitation | |
| ‘Functional strength training (FST +CPT)' | ‐ | ‐ | Sit‐to‐stand practice Transfer practice Walking Stair climbing | ‐ | Musc. strengthening Active and active assisted movement | Passive movement Massage | Sensorimotor facilitation | |
| ‘Conventional physiotherapy (CPT)' | ‐ | ‐ | ADL training | ‐ | Active and active assisted movement | Passive movement Massage | Hands on facilitation (Bobath) Sensorimotor facilitation | |
| ‘Motor learning' | ‐ | ‐ | Sitting and/or standing balance Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Motor learning' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Walking Stair climbing Described as 'MRP' | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Experimental' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Walking Stair climbing Described as 'MRP' | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Experimental' | ‐ | ‐ | Sitting and/or standing balance Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Intervention' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking UL training | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | ‐ | |
| ‘Mixed' | ‐ | Aerobic, fitness, endurance | Sitting and/or standing balance Walking UL training | ‐ | Musc. strengthening Active and active assisted movement | PNF | ‐ | |
| ‘Mixed' | ‐ | Aerobic, fitness, endurance | Sitting and/or standing balance Sit‐to‐stand practice Walking UL training | ‐ | Musc. strengthening Active and active assisted movement | PNF | ‐ | |
| ‘Treated' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | ‐ | Active and active assisted movement | Inc. angle of upright sitting Passive movement Body and limb positioning | ‐ | |
| ‘Additional early physiotherapy intervention' | ‐ | ‐ | ‐ | ‐ | ‐ | Passive movement | Described as 'Bobath' | |
| ‘Rehabilitation' | ‐ | ‐ | ‐ | ‐ | ‐ | Passive movement Massage | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | ‐ | ‐ | ‐ | Passive movement Massage | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking | Acupuncture Physical agents | Active and active assisted movement | Massage | Described as 'Bobath' | |
| ‘Neurophysiological (NDT)' | ‐ | ‐ | ADL training | ‐ | ‐ | ‐ | Hands on facilitation (Bobath) Inhibition of abn musc. tone (Bobath) | |
| ‘Orthopaedic (TFR)' | Walking aids Orthoses for walking | ‐ | ADL training | ‐ | Musc. strengthening | Passive movement | ‐ | |
| ‘Mixed' | ADL training Sitting and/or standing balance Walking | |||||||
| ‘Intervention' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Walking | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | Physical agents | Active and active assisted movement | Passive movement Body and limb positioning | Described as 'Bobath' PNF | |
| ‘Mixed' | ‐ | ‐ | Sitting and/or standing balance Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Test' | Details of individual components not available | Details of individual components not available | ||||||
| ‘Test' | Details of individual components not available | Details of individual components not available | ||||||
| ‘Rehabilitation' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing Described as 'MRP' | Acupuncture Physical agents | Active and active assisted movement | Inc. angle of upright sitting Passive movement Body and limb positioning | Described as 'Bobath' PNF | |
| ‘PLBO‐TRT' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Treated' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | Acupuncture | ‐ | Passive movement Body and limb positioning | ‐ | |
| ‘Exercise' | ‐ | ‐ | Sitting and/or standing balance Walking | ‐ | ‐ | Passive movement | PNF | |
| ‘Exercise and OT' | ‐ | ‐ | ADL training Sitting and/or standing balance Transfer practice Walking UL training | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | PNF | |
| ‘PNF' | ‐ | ‐ | ‐ | ‐ | Active and active assisted movement | Passive movement | PNF | |
| ‘General exercise' | ‐ | ‐ | ‐ | ‐ | Active and active assisted movement | Passive movement | ‐ | |
| ‘Experimental' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Walking Stair climbing Described as 'MRP' | ‐ | Musc. strengthening | Passive movement | ‐ | |
| ‘Control' | ‐ | ‐ | Sitting and/or standing balance | ‐ | Musc. strengthening | Passive movement | ‐ | |
| ‘Lower extremities' | ‐ | ‐ | ADL training Sitting and/or standing balance Transfer practice Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Upper extremities' | ‐ | ‐ | UL training | ‐ | ‐ | ‐ | ‐ | |
| ‘Circuit training' | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | ‐ | Musc. strengthening | ‐ | ‐ | ||
| ‘Motor learning' | ‐ | ‐ | Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Neurophysiological (Bobath)' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Intensive exercise' | ‐ | Aerobic, fitness, endurance | ADL training Sitting and/or standing balance Sit‐to‐stand practice Walking Stair climbing | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Bobath' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Gait specific' | ‐ | ‐ | Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Early rehabilitation' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | Described as 'Bobath' | |
| ‘Rehabilitation' | ‐ | ‐ | Sitting and/or standing balance Walking | ‐ | Active and active assisted movement | Passive movement Body and limb positioning Massage | ‐ | |
| ‘Motor learning' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking UL training Described as 'MRP' | Acupuncture Physical agents | ‐ | ‐ | ‐ | |
| ‘Neurodevelopmental therapy' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking | Acupuncture Physical agents | ‐ | Body and limb positioning | Described as 'Bobath' PNF | |
| ‘Treatment' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Walking | ‐ | ‐ | Passive movement Body and limb positioning | Hands on facilitation (Bobath) Trunk mobilisations/ postural reactions (Bobath) | |
| ‘Control' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Walking | ‐ | ‐ | Passive movement Body and limb positioning | ‐ | |
| ‘Neurophysiological (Bobath)' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Motor learning' | ‐ | ‐ | Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | ‐ | |
| ‘Motor learning' | ‐ | ‐ | Sitting and/or standing balance Walking Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Placebo (upper limb control)' | ‐ | ‐ | UL training | ‐ | ‐ | ‐ | ‐ | |
| ‘Exercise' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Feedback' | ‐ | ‐ | Sitting and/or standing balance | Physical agents | ‐ | ‐ | ‐ | |
| ‘Motor learning (Task‐related training)' | ‐ | ‐ | ADL training Sitting and/or standing balance | ‐ | ‐ | ‐ | ‐ | |
| ‘Neurophysiological (Bobath)' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Hands on facilitation (Bobath) Inhibition of abn musc. tone (Bobath) Described as 'Bobath' Trunk mobilisations/ postural reactions (Bobath) | |
| ‘Comprehensive rehabilitation training' | Orthoses for walking | ‐ | Sitting and/or standing balance | Physical agents | ‐ | ‐ | Described as 'Bobath' | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Transfer practice UL training | ‐ | ‐ | Passive movement Body and limb positioning Massage | ‐ | |
| ‘Treatment' | ‐ | ‐ | ‐ | Acupuncture | ‐ | ‐ | Described as 'Bobath' | |
| ‘Mixed' | ‐ | ‐ | Sitting and/or standing balance | ‐ | ‐ | ‐ | ‐ | |
| ‘Neurophysiological (Bobath)' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| 'Treatment' | ‐ | ‐ | ADL training | Acupuncture Physical agents | ‐ | Body and limb positioning | Described as 'Bobath' PNF | |
| ‘Treatment' | ‐ | ‐ | ADL training Walking | Acupuncture Physical agents | ‐ | ‐ | Described as 'Bobath' PNF Sensorimotor facilitation | |
| ‘Experimental' | ‐ | ‐ | Walking | Physical agents | Musc. strengthening | Tilt table | ‐ | |
| 'Early conventional' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| 'Routine conventional' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Motor learning' | ‐ | Aerobic, fitness, endurance | Sitting and/or standing balance Sit‐to‐stand practice Walking Stair climbing Described as 'MRP' | ‐ | Musc. strengthening Active and active assisted movement | ‐ | ‐ | |
| ‘Placebo (upper limb control)' | ‐ | ‐ | UL training Described as 'MRP' | ‐ | ‐ | ‐ | ‐ | |
| ‘Combined exercise' | ‐ | Aerobic, fitness, endurance | Sitting and/or standing balance Sit‐to‐stand practice Walking Stair climbing | ‐ | Musc. strengthening | ‐ | ‐ | |
| ‘Conventional exercise' | ‐ | ‐ | Sitting and/or standing balance Walking Stair climbing | ‐ | Active and active assisted movement | Hands on facilitation (Bobath) Trunk mobilisations/ postural reactions (Bobath) | ||
| ‘Proprioceptive neuromuscular facilitation (PNF)' | ‐ | ‐ | Walking | ‐ | ‐ | ‐ | PNF | |
| ‘Body weight support treadmill training' | ‐ | ‐ | Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Observation' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking | ‐ | ‐ | Passive movement Body and limb positioning | Described as 'Bobath' Sensorimotor facilitation | |
| ‘Control' | ‐ | ‐ | ADL training Transfer practice Walking | ‐ | ‐ | Body and limb positioning | Described as 'Bobath' | |
| ‘Rhythmic auditory stimulation' | ‐ | ‐ | Sitting and/or standing balance Walking Stair climbing | ‐ | ‐ | ‐ | ‐ | |
| ‘Neurodevelopmental therapy (NDT)/Bobath‐based training' | ‐ | ‐ | Walking | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Strategy 1 (S1) (Physiotherapy)' | Walking aids | ‐ | ADL training Sit‐to‐stand practice Transfer practice Walking UL training | ‐ | Musc. strengthening Active and active assisted movement | Passive movement Body and limb positioning | ‐ | |
| ‘Strategy 2 (S2) Education' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | |
| ‘Experimental' | ‐ | ‐ | Sitting and/or standing balance Described as 'MRP' | ‐ | Active and active assisted movement | ‐ | Described as 'Bobath' | |
| ‘Control' | ‐ | ‐ | Described as 'MRP' | Described as 'Bobath' | ||||
| ‘Experimental' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | ‐ | ‐ | ‐ | ||
| ‘Control' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Mixed' | Walking aids | Aerobic, fitness, endurance | ADL training Sitting and/or standing balance Sit‐to‐stand practice Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking UL training Described as 'MRP' | ‐ | ‐ | Passive movement Body and limb positioning | ‐ | |
| ‘Treatment' | ‐ | ‐ | ‐ | Physical agents | Active and active assisted movement | Passive movement Body and limb positioning Massage | Sensorimotor facilitation | |
| 'Control' | ‐ | ‐ | ‐ | ‐ | ‐ | Passive movement Body and limb positioning Massage | ‐ | |
| ‘Neurophysiological' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Hands on facilitation (Bobath) Inhibition of abn musc. tone (Bobath) Described as 'Bobath' Trunk mobilisations/ postural reactions (Bobath) | |
| ‘Orthopaedic' | ‐ | ‐ | ADL training Sit‐to‐stand practice Transfer practice Walking | ‐ | Musc. strengthening Active and active assisted movement | Passive movement | ‐ | |
| ‘Rehabilitation' | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | ‐ | ‐ | Passive movement Body and limb positioning | ||||
| ‘Exercise' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Motor learning' | ‐ | ‐ | Sitting and/or standing balance | ‐ | ‐ | ‐ | ‐ | |
| ‘Control' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | Inhibition of abn musc. tone (Bobath) Described as 'Bobath' PNF | |
| ‘Intensive rehabilitation' | ‐ | ‐ | ‐ | Physical agents | ‐ | ‐ | Described as 'Bobath' PNF | |
| ‘Conventional' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Stair climbing UL training | ‐ | ‐ | Passive movement Body and limb positioning Massage | ‐ | |
| ‘Treatment' | ‐ | ‐ | ADL training Sitting and/or standing balance Transfer practice Walking | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | ‐ | |
| 'Rehabilitation' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| ‘Rehabilitation' | ‐ | ‐ | Sitting and/or standing balance Walking | ‐ | Active and active assisted movement | Passive movement Body and limb positioning Massage | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training | ‐ | ‐ | Body and limb positioning | Sensorimotor facilitation | |
| ‘Rehabilitation' | ‐ | ‐ | ADL training Sitting and/or standing balance Transfer practice Walking | ‐ | ‐ | Passive movement Body and limb positioning | Described as 'Bobath' | |
| ‘Training' | ‐ | ‐ | Sit‐to‐stand practice Transfer practice Walking Described as 'MRP' | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | Described as 'Bobath' | |
| ‘Rehabilitation' | Resting splints | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing | ‐ | ‐ | Inc. angle of upright sitting Passive movement Body and limb positioning | ‐ | |
| ‘NDT‐based treatment' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Walking | ‐ | ‐ | ‐ | Hands on facilitation (Bobath) Inhibition of abn musc. tone (Bobath) Described as 'Bobath' | |
| ‘Multisensorial' | ‐ | ‐ | Sitting and/or standing balance Walking | ‐ | ‐ | ‐ | ‐ | |
| ‘Rehabilitation' | Resting splints | ‐ | Sitting and/or standing balance | ‐ | ‐ | Body and limb positioning | Described as 'Bobath' | |
| ‘Early rehabilitation' | ‐ | ‐ | ADL practice Sitting and/or standing balance Walking Stair climbing | ‐ | Musc. strengthening | Passive movement Body and limb positioning Massage | Sensorimotor facilitation | |
| ‘Rehabilitation' | ‐ | ‐ | ADL practice Sitting and/or standing balance Walking Described as 'MRP' | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | Described as 'Bobath' PNF | |
| ‘Rehabilitation nursing' | ‐ | ‐ | ADL practice Sitting and/or standing balance Sit‐to‐stand practice Walking Stair climbing | ‐ | Active and active assisted movement | Passive movement Body and limb positioning | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | ADL practice Transfer practice Walking Stair climbing | ‐ | Active and active assisted movement | Passive movement | ‐ | |
| ‘Rehabilitation' | ‐ | ‐ | Sitting and/or standing balance Sit‐to‐stand practice Walking Described as 'MRP' | Physical agents | ‐ | Inc. angle of upright sitting Passive movement | Described as 'Bobath' | |
| ‘Treated' | ‐ | ‐ | ADL practice Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing UL training | ‐ | Active and active assisted movement | Inc. angle of upright sitting Passive movement Body and limb positioning | ‐ | |
| ‘Test' | ‐ | ‐ | ADL practice Sitting and/or standing balance Sit‐to‐stand practice Walking Stair climbing UL training | ‐ | ‐ | Inc. angle of upright sitting Passive movement Body and limb positioning | Described as 'Bobath' PNF | |
| ‘Cerebral haemorrhage' | ‐ | ‐ | ADL practice Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing UL training | ‐ | ‐ | Passive movement Body and limb positioning | ‐ | |
| ‘Cerebral infarction' | ‐ | ‐ | ADL practice Sitting and/or standing balance Sit‐to‐stand practice Transfer practice Walking Stair climbing UL training | ‐ | ‐ | Passive movement Body and limb positioning | ‐ | |
| ‘Acupuncture' | ‐ | ‐ | ‐ | Acupuncture | ‐ | ‐ | ‐ | |
| ‘Physiotherapy' | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Described as 'Bobath' | |
| Abn: abnormal; ADL: activities of daily living; Inc:increasing; MRP: motor relearning programme; Musc: muscle; Norm: normal; PNF: proprioceptive neuromuscular facilitation; UL: upper limb | ||||||||
| Study | Intervention categories for intervention group | Immediate outcomes reported | Persisting outcomes reported | ||||||
|---|---|---|---|---|---|---|---|---|---|
| AD | CPI | FTT | MoD | Musc. (active) | Musc. (passive) | NP | |||
| Baer 2007(a) | x | No data suitable for analysis | No | ||||||
| Baer 2007(b) | x | No data suitable for analysis | No | ||||||
| x | BI, FMA ‐ data not suitable for analysis | BI, FMA ‐ data not suitable for analysis | |||||||
| x | BBS, GV ‐ data not suitable for analysis | BBS, GV ‐ data not suitable for analysis | |||||||
| x | x | x | x | BI | BI | ||||
| x | x | BI | No | ||||||
| x | x | x | x | BI, FMA | No | ||||
| x | x | x | FMA | No | |||||
| x | x | x | No data suitable for analysis | No data suitable for analysis | |||||
| x | x | BI, FMA | BI, FMA | ||||||
| x | BI, FMA | BI, FMA | |||||||
| x | BI, FMA | BI, FMA | |||||||
| x | x | x | x | x | No data suitable for analysis | No | |||
| x | BI, RMA, GV | BI, RMA, GV | |||||||
| x | x | BI, BBS | BI | ||||||
| x | x | x | x | x | BI, BBS | BI, BBS | |||
| x | x | BI | BI | ||||||
| x | x | FMA | No | ||||||
| x | x | x | x | x | FMA | No | |||
| x | BI, FMA | No | |||||||
| x | x | x | No data suitable for analysis | No data suitable for analysis | |||||
| x | No data suitable for analysis | No data suitable for analysis | |||||||
| x | x | x | x | BI, FMA | No | ||||
| x | x | x | No data suitable for analysis | No | |||||
| x | x | x | BI, FMA | No | |||||
| x | x | x | x | FIM, FMA | No | ||||
| x | x | x | x | x | BI, FMA | No | |||
| x | x | BI | No | ||||||
| x | x | BI | No | ||||||
| x | x | x | x | No data suitable for analysis | No | ||||
| x | x | GV | No | ||||||
| x | x | x | BI | BI | |||||
| x | x | x | BI, RMA, GV | BI, RMA, GV | |||||
| x | x | FMA | No | ||||||
| x | x | x | No data suitable for analysis | No | |||||
| x | No outcomes included in analysis. | No | |||||||
| x | x | x | x | BI, FMA | No | ||||
| x | x | BI | No | ||||||
| x | x | x | No outcomes included in analysis. | No | |||||
| x | BI | No | |||||||
| x | x | x | BI, FMA | No | |||||
| x | x | x | BI, FMA | No | |||||
| x | x | x | BI, FMA | No | |||||
| x | x | x | x | BI, FMA | No | ||||
| x | x | x | BI | No | |||||
| x | x | x | x | FMA | No | ||||
| x | x | x | x | BI, FMA | No | ||||
| x | x | x | x | BI, FMA | No | ||||
| x | x | x | BI, FMA | BI, FMA | |||||
| x | x | x | BI | No | |||||
| x | x | x | x | FMA | No | ||||
| x | x | x | No outcomes included in analysis. | No | |||||
| x | x | x | BI, FMA | No | |||||
| x | x | BI, FMA | No | ||||||
| x | x | BI, FMA | No | ||||||
| AD: assistive devices; BBS: Berg balance scale; BI: Barthel index; CPI: cardiopulmonary interventions; FMA: Fugl‐Meyer assessment; FTT: functional task training; GV: gait velocity; MAS: motor assessment scale; MoD: modality; Musc.(active): musculoskeletal intervention (active); Musc.(passive): musculoskeletal intervention (passive); NP: neurophysiological intervention; RMA: Rivermead motor assessment. | |||||||||
| Study | Intervention categories for intervention group | Attention control (details) | Usual care (details) | Immediate outcomes reported | Persisting outcomes reported | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| AD | CPI | FTT | MoD | Musc. (active) | Musc. (passive) | NP | |||||
| x | x | FTT Musc. (active) | GV | No | |||||||
| x | x | x | UL training | MAS (UL only), GV | MAS (UL only), GV | ||||||
| x | x | x | Massage | BI, FMA | No | ||||||
| Cooke 2006(a) | x | x | x | x | FTT Musc. (active) Musc. (passive) NP | RMA, GV | RMA, GV | ||||
| Cooke 2006(b) | x | x | x | FTT Musc. (active) Musc. (passive) NP | RMA, GV | RMA, GV | |||||
| x | Cognitive | GV | No | ||||||||
| x | x | UL training | GV | GV | |||||||
| x | x | Cognition, UL training | GV | No | |||||||
| x | Cognition, | GV | GV | ||||||||
| x | x | x | x | FTT Musc. (active) NP | BI, FMA, BBS, GV | No | |||||
| x | x | x | x | FTT Musc. (active) NP | FMA, BBS, GV | No | |||||
| x | NP | No outcomes included in analysis | No | ||||||||
| x | x | x | FTT Musc. (active) Musc. (passive) | BBS, GV | No | ||||||
| x | UL training | Data not suitable for analysis | Data not suitable for analysis | ||||||||
| x | x | x | CPI FTT Musc. (active) | RMA, GV | RMA, GV | ||||||
| x | x | x | Not stated | BI, MAS | No | ||||||
| x | UL training | MAS | MAS | ||||||||
| x | x | Social | RMA, GV | RMA, GV | |||||||
| Mudie 2002(a) | x | Not stated | BI | BI | |||||||
| Mudie 2002(b) | x | Not stated | BI | BI | |||||||
| x | NP | BI | No | ||||||||
| x | x | x | FTT MoD NP | FMA | No | ||||||
| x | x | x | x | NP | BI, FMA, BBS, GV | No | |||||
| x | NP | BI, FMA, BBS, GV | No | ||||||||
| x | x | x | UL training | BBS, GV | No | ||||||
| x | x | x | FTT Musc. (passive) NP | FMA | No | ||||||
| x | x | x | FTT NP | No data suitable for analysis | No | ||||||
| x | x | x | Musc. (passive) | FMA | No | ||||||
| x | Not stated | FMA | No | ||||||||
| x | x | NP | No data suitable for analysis | No | |||||||
| AD: assistive devices; BBS: Berg balance scale; BI: Barthel index; CPI: cardiopulmonary interventions; FMA: Fugl‐Meyer assessment; FTT: functional task training; GV: gait velocity; MAS: motor assessment scale; MoD: modality; Musc.(active): musculoskeletal intervention (active); Musc.(passive): musculoskeletal intervention (passive); NP: neurophysiological intervention; RMA: Rivermead motor assessment; UL: upper limb. | |||||||||||
| Study | Intervention categories: Active intervention Group 1 | Intervention categories: Active intervention Group 2 | Immediate outcomes reported | Persisting outcomes reported | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| AD | CPI | FTT | MoD | Musc. (active) | Musc. (passive) | NP | AD | CPI | FTT | MoD | Musc. (active) | Musc. (passive) | NP | |||
| x | x | No outcomes included in analysis | No | |||||||||||||
| x | x | x | x | RMA, BBS ‐ data not suitable for analysis | RMA, BBS ‐ data not suitable for analysis | |||||||||||
| x | x | MAS, GV ‐ data not suitable for analysis | No | |||||||||||||
| x | x | x | x | MAS, GV | No | |||||||||||
| x | x | x | x | x | BBS, GV | No | ||||||||||
| x | x | FIM, BBS ‐ as the two active treatment groups were classified as including similar treatment components, data from this study has not been included within the comparisons of one active intervention versus another active intervention | No | |||||||||||||
| x | x | x | x | x | x | x | MAS, GV ‐ as the two active treatment groups were classified as including similar treatment components, data from this study has not been included within the comparisons of one active intervention versus another active intervention | MAS, GV ‐ as the two active treatment groups were classified as including similar treatment components, data from this study has not been included within the comparisons of one active intervention versus another active intervention | ||||||||
| x | x | x | x | x | x | FIM, GV | FIM, GV | |||||||||
| x | x | x | x | x | x | x | BI, FMA ‐ as the two active treatment groups were classified as including similar treatment components, data from this study has not been included within the comparisons of one active intervention versus another active intervention. | BI, FMA ‐ as the two active treatment groups were classified as including similar treatment components, data from this study has not been included within the comparisons of one active intervention versus another active intervention. | ||||||||
| x | x | x | x | x | No data suitable for analysis | No | ||||||||||
| x | x | BI, MAS | No | |||||||||||||
| x | x | x | BI, MAS, RMA, GV ‐ data not suitable for analysis | No | ||||||||||||
| x | x | x | x | x | x | BI | No | |||||||||
| x | x | x | x | x | FMA | No | ||||||||||
| x | x | BI, RMA, GV | BI, RMA, GV | |||||||||||||
| x | x | BI | BI | |||||||||||||
| x | x | x | x | x | BI, FMA, BBS, GV | No | ||||||||||
| x | x | x | x | x | x | BBS | No | |||||||||
| x | x | x | BI, FMA, GV | No | ||||||||||||
| x | x | GV | BI, GV | |||||||||||||
| x | x | x | x | MAS, BBS | No | |||||||||||
| x | x | x | x | FIM, BBS, GV ‐ data not suitable for analysis | FIM, BBS, GV ‐ data not suitable for analysis | |||||||||||
| x | x | BI, FMA | No | |||||||||||||
| AD: assistive devices; BBS: Berg balance scale; BI: Barthel index; CPI: cardiopulmonary interventions; FMA: Fugl‐Meyer assessment; FTT: functional task training; GV: gait velocity; MAS: motor assessment scale; MoD: modality; Musc.(active): musculoskeletal intervention (active); Musc.(passive): musculoskeletal intervention (passive); NP: neurophysiological intervention; RMA: Rivermead motor assessment. | ||||||||||||||||
| Study | At recruitment | For intervention | Country |
|---|---|---|---|
| Not stated | Not stated | Turkey | |
| Inpatient stroke rehabilitation unit | Inpatient stroke rehabilitation unit | UK | |
| Not stated | Own homes | UK | |
| Emergency department or Neurology Department | Dependent on stage of rehabilitation and could include own homes,rehabilitation unit, outpatient rehabilitation or community centre | China | |
| Recruited from two rehabilitation units, a hospital ward and a rehabilitation centre | Not stated | Norway | |
| Recruited from multiple community rehabilitation hospitals | Community | USA | |
| Rehabilitation Centre | Rehabilitation centre | Australia | |
| Recruited from multiple rehabilitation centres | Multiple rehabilitation centres | Australia and Germany | |
| Not stated | Not stated | USA | |
| Outpatient rehabilitation centre | Outpatient rehabilitation centre | Hong Kong | |
| Patients in neurological ward/ rehabilitation ward of 4 hospitals in China | Not stated | China | |
| Inpatient University Hospital | Inpatient University Hospital | China | |
| Not stated | Not stated | China | |
| Inpatient, Hospital | Inpatient, Hospital | China | |
| Multiple clinical centres (inpatient) | Multiple clinical centres (inpatient) | England | |
| Own homes (recruited via stroke clubs) | Own homes | Australia | |
| Own homes (recruited from rehabilitation research group database) | Rehabilitation centre (outpatients) | Canada | |
| Own homes (recruited via stroke clubs) | Own homes | Australia | |
| Hospital rehabilitation unit | Hospital rehabilitation unit | Australia | |
| Hospital | Before discharge: within hospital. After discharge: home, outpatient rehabilitation centres | China | |
| Previously inpatients, now discharged? | Own homes | USA | |
| Patients' own homes | Patients' own homes | USA | |
| In hospital | Department of Neurology ward, rehabilitation ward/ centre, community or home setting, depending on stage of rehabilitation | China | |
| Inpatient rehabilitation clinic | Inpatient rehabilitation clinic | China | |
| Hospital | Not stated | China | |
| Hospital | Not stated | China | |
| Rehabilitation department, Hospital | Not stated | China | |
| Acute inpatient ward | Inpatient and outpatient rehabilitation centres | USA | |
| Recruited from hospital and community stroke registers | Outpatient rehabilitation centre; patients' own homes | England | |
| Rehabilitation unit (inpatients) | Outpatient rehabilitation centre; patients' own homes | Sweden | |
| Neurology ward | Neurology ward, rehabilitation zone or rehabilitation centre, own home or community depending on level of rehabilitation | China | |
| Rehabilitation unit (inpatients) | Rehabilitation unit (inpatients) | England | |
| Not stated | Not stated | China | |
| Not stated | Not stated | China | |
| Not stated | Not stated | China | |
| Not stated | Own homes | Hong Kong | |
| Not stated | Neurology ward, rehabilitation ward/ centre, community/home | China | |
| Not stated | Not stated | China | |
| Not stated | Not stated | Korea | |
| Inpatients, Hospital | Not stated | Korea | |
| Rehabilitation centres and nursing homes | Rehabilitation centres and nursing homes | Netherlands | |
| Rehabilitation centres (inpatient) | Multiple outpatient rehabilitation centres | Netherlands | |
| Acute inpatient ward | Acute inpatient ward; rehabilitation units; outpatients; own homes | Norway | |
| Acute inpatient ward | Rehabilitation institutions, community, patients’ homes and nursing homes. | Norway | |
| Not stated | Not stated | Northern Ireland | |
| Not stated | Not stated | China | |
| Inpatient ward | Inpatient ward | China | |
| Not stated | Not stated | China | |
| Not stated | Not stated | China | |
| Rehabilitation unit (inpatients) | Rehabilitation unit (inpatients); outpatients | England | |
| Hospital | ‘All the trainings were done in the bed ward’ | China | |
| Recruited on discharge from physiotherapy services | Outpatients/patients' own homes | Australia | |
| Private rehabilitation clinic | Private rehabilitation clinic | New Zealand | |
| Rehabilitation unit (inpatients) | Rehabilitation unit (inpatients) | Australia | |
| Not stated | Not stated | China | |
| Not stated | Not stated | China | |
| Department of internal Neurology | Department of internal Neurology | China | |
| Not stated | Not stated | China | |
| Stroke unit | Stroke unit | Scotland | |
| Not stated | Not stated | China | |
| Not stated | Not stated | China | |
| Acute inpatient ward | Acute inpatient ward | Canada | |
| Patients' own homes (community) | Outpatients/patients' own homes (self‐practice) | Canada | |
| Outpatient rehabilitation centre | Outpatient rehabilitation centre | Korea | |
| Not stated | Not stated | USA | |
| Not stated | Not stated | China | |
| Not stated | Not stated | Germany and USA | |
| Hospital | Hospital and own homes (following discharge) | Mexico | |
| Inpatient stroke rehabilitation centre | Inpatient stroke rehabilitation centre | Belgium | |
| Inpatient neurology ward | Inpatient rehabilitation and/or outpatient rehabilitation in day care units | India | |
| Community (own homes and residential homes) | Community (own homes and residential homes) | England | |
| Not stated | Bedside and treatment room | China | |
| Not stated | Not stated | China | |
| Rehabilitation unit (inpatients) | Rehabilitation unit (inpatients) | Taiwan | |
| Not stated | Neurology ward, rehabilitation zone, community | China | |
| Hospital inpatients | Hospital inpatients | China | |
| Rehabilitation unit (inpatients) | Rehabilitation unit (inpatients) | USA | |
| Not stated | Ward, rehabilitation ward, community | China | |
| Not stated | Not stated | China | |
| Hospital | Hospital | China | |
| Not stated | Hospital ward, home | China | |
| Not stated | Not stated | China | |
| Hospital | Neurology department | China | |
| Inpatients, Department of Neurology | Inpatients, Department of Neurology | China | |
| Not stated | Not stated | China | |
| Department of Neurology, Yaan People’s Hospital | Not stated | China | |
| Not stated | Hospital ward, rehabilitation centre | China | |
| Multi‐center rehabilitation units | Multi‐center rehabilitation units | France | |
| Neurology Department | Rehabilitation centre, Hospital | China | |
| Not stated | Not stated | China | |
| Not stated | Department of Neurology‐ rehabilitation centres, Department of Rehabilitation, community rehabilitation organisations, home | China | |
| Not stated | Not stated | China | |
| Hospital | Neurology Department, Hospital | China | |
| Not stated | Not stated | China | |
| Not stated | Hospital, outpatient, community, home | China | |
| Not stated | Not stated | China | |
| Not stated | Hospital, rehabilitation centre, home for intervention groups. | China | |
| Not stated | Hospital, rehabilitation centre, home for intervention groups. | China | |
| 'Stroke units in inpatient settings' | 'Stroke units in inpatient settings' | China |
| Continent / Control intervention | Europe | Australia & New Zealand | North America & Canda | South America | Asia (China) | Asia (other) | TOTAL |
| No treatment | 5 | 0 | 3 | 1 | 44 | 1 | 54 |
| Usual Care | 6 | 1 | 4 | 0 | 5 | 1 | 17 |
| Attention Control | 1 | 6 | 2 | 0 | 1 | 0 | 10 |
| Active intervention | 10 | 2 | 3 | 0 | 4 | 6 | 25 |
| TOTAL | 22 | 9 | 12 | 1 | 54 | 8 | 106 |
| Table shows number of studies with different types of control group, in studies carried out in different continents. Two studies were each carried out in 2 continents; and 5 studies had two comparison interventions. Thus the 99 studies include a total of 106 control interventions on different continents. | |||||||
| Study | Study group | No. of participants | Sex ‐ male/female | Side ‐ LCVA/RCVA | Age | Time since onset | Type of stroke | No. finished intervention |
|---|---|---|---|---|---|---|---|---|
| Group 1 | 9 | Whole group 9/11 | Not stated | Not stated | Not stated | Not stated | 9 | |
| Group 2 | 7 | As above | Not stated | Not stated | Not stated | Not stated | 7 | |
| Group 3 | 4 | As above | Not stated | Not stated | Not stated | Not stated | 4 | |
| ‘Intervention' | 7 | Whole group 10/7 | Not stated | Mean = 72.4 y SD = 17.9 y Range: 55‐88 y | Mean = 20.6 days SD = 20.5 days Range: 9‐57 days | Not stated | 5 | |
| ‘Control' | 10 | As above | Not stated | Mean = 78 y SD = 7.9 y Range: 65‐92 y | Mean = 15.1 days SD = 16.0 days Range: 6‐58 days | Not stated | 10 | |
| ‘Part practice' | Not stated | Whole group 31/33 | Whole group 26/38 | Whole group Mean = 72.9 y SD = 9.0 y | Whole group Mean = 30.3 months SD = 28.8 months | Not stated | Not stated | |
| 'Whole practice' | Not stated | As above | As above | As above | As above | Not stated | Not stated | |
| 'Control (no treatment)' | Not stated | As above | As above | As above | As above | Not stated | Not stated | |
| 'Early rehabilitation' | 183 | 119/64 | 85/98 | Mean = 61.5 y SD = 9.4 y | Mean = 11.4 days SD = 5.7 days | Not stated | 175 | |
| 'Control (no treatment)' | 181 | 113/68 | 87/94 | Mean = 60.8 y SD = 10.1 y | Mean = 10.9 days SD = 5.5 days | Not stated | 170 | |
| 'Functional strength training' | 8 | 3/5 | 6/2 | Mean = 60.8 y SD = 13 y | Mean = 49.4 days SD = 22.1 days | Cerebral infarct = 4 Haemorrhagic = 4 | 8 | |
| ‘Training as usual' | 10 | 4/6 | 3/7 | Mean = 64.9 y SD = 8.9 y | Mean = 32 days SD = 18.5 days | Cerebral infarct = 8 Haemorrhagic = 2 | 10 | |
| ‘Locomotor training program' | 139 | Not stated | Not stated | Not stated | Not stated | Not stated | 139 | |
| ‘Home exercise program' | 126 | Not stated | Not stated | Not stated | Not stated | Not stated | 126 | |
| ‘Usual care' | 143 | Not stated | Not stated | Not stated | Not stated | Not stated | 143 | |
| ‘Mobility’ | 15 | 8/7 | 8/7 | Mean = 53.9 y SD = 19.8 y | Mean = 36.0 days SD = 25.1 days | Haemorrhagic = 4 Infarct = 11 | 15 | |
| ‘Upper limb’ | 15 | 9/6 | 6/9 | Mean = 56.3 y SD = 10.5 y | Mean = 50.1 days SD = 49.2 days | Haemorrhagic = 4 Infarct = 11 | 15 | |
| ‘Bobath' | 12 | 7/5 | 2/9 Bilateral = 1 | Mean = 61.3 y SD = 13.0 y Range: 35–75 y | Mean = 60.3 days SD = 24.0 days Range: 29–101 days | Haemorrhagic = 2 Infarct = 8 Both = 2 | 12 | |
| ‘Task practice' | 14 | 12/2 | 10/3 Bilateral = 1 | Mean = 56.6 y SD = 15.8 y Range: 29–77 y | Mean = 63.6 days SD = 25.9 days Range: 40–126 days | Haemorrhagic =4 Infarct = 9 Both = 1 | 14 | |
| ‘Treatment' | 6 | Not stated | Not stated | Not stated | Not stated | Not stated | 6 | |
| ‘Control (no treatment)' | 5 | Not stated | Not stated | Not stated | Not stated | Not stated | 5 | |
| ‘Motor relearning' | 33 | 12/14 | 12/14 | Mean = 53.8 y SD = 15.4 y | Mean = 117.7 days SD = not stated | Not stated | 26 | |
| 'Conventional therapy' | 33 | 12/14 | 12/14 | Mean = 54.4 y SD = 13.7 y | Mean = 88.8 days SD = not stated | Not stated | 26 | |
| ‘Rehabilitation' | 39 | 25/14 | Not stated | Mean = 60.95 y SD = 9.74 y | Mean = 9.05 days SD = 5.74 days | Haemorrhagic = 12 Ischaemic = 27 | 39 | |
| ‘Control (no treatment)' | 39 | 24/15 | Not stated | Mean = 62.36 y SD = 9.65 y | Mean = 8.65 days SD = 5.38 days | Haemorrhagic = 12 Ischaemic = 27 | 39 | |
| ‘Rehabilitation' | 25 | 16/9 | Not stated | Mean = 66.2 y SD = 6.8 y | Within 6 months after stroke = 13 Between 6 and 12 months after stroke = 8 More than 12 months after stroke = 4 | Haemorrhagic = 7 Ischaemic = 18 | 25 | |
| ‘Control (no treatment)' | 20 | 12/8 | Not stated | Mean = 67.3 y SD = 5.9 y | Within 6 months after stroke = 11 Between 6 and 12 months after stroke = 5 More than 12 months after stroke = 4 | Haemorrhagic = 8 Ischaemic = 12 | 20 | |
| ‘Test' | 53 | 29/24 | Not stated | Mean = 60.49 y Range = 46‐83 y | Mean = 9.35 days Range = 1‐20 days | Haemorrhagic = 14 Ischaemic = 39 | 53 | |
| ‘Control (no treatment)' | 53 | 28/25 | Not stated | Mean = 62.8 y Range = 41‐85 y | Mean = 9.15 days Range = 1‐21 days | Haemorrhagic = 17 Ischaemic = 36 | 53 | |
| ‘Rehabilitation' | 30 | Whole group 31/27 | Whole group 32/26 | Whole group Mean = 62.4 y Range: 54‐68 y | Not stated | Whole group Haemorrhagic = 26 Ischaemic = 32 | 30 | |
| ‘Control (no treatment)' | 28 | As above | As above | Not stated | 28 | |||
| ‘Additional conventional therapy (CPT+CPT)' | 35 | 22/13 | 13/22 | 67.46 (11.3)y | 32.43 (21.29) days | Not stated | At 6 weeks, n=32; At 3 month follow‐up, n=28 | |
| ‘Functional strength training (FST +CPT)' | 36 | 22/14 | 12/24 | 71.17 (10.6) y | 33.86 (16.50) days | Not stated | At 6 weeks, n=36; At 3 month follow‐up, n=29 | |
| ‘Conventional physiotherapy (CPT)' | 38 | 21/17 | 17/21 | 66.37 (13.7) y | 36.76 (22.41) days | Not stated | At 6 weeks, n=31; At 3 month follow‐up, n=24 | |
| ‘Motor learning' | 10 | 7/3 | 5/5 | Mean = 68.2 y | Mean = 6.7 y | Not stated | 10 | |
| ‘Placebo' | 10 | 7/3 | 6/4 | Mean = 66.9 y | Mean = 5.9 y | Not stated | 9 | |
| ‘Motor learning' | 6 | 3/3 | 3/3 | Mean = 66.2 y | Mean = 2.3 y | Not stated | 5 | |
| ‘Placebo' | 6 | 4/2 | 4/2 | Mean = 62.3 y | Mean = 1.3 y | Not stated | 4 | |
| ‘Experimental' | 76 | 38/38 | 34/42 | Mean = 66.7 y SD = 14.3 y Range: 31‐91 y | Mean = 6.7 y SD = 6.7 y Range: 0.1‐24.8 y | Not stated | 65 | |
| ‘Control' | 75 | 40/35 | 28/47 | Mean = 67.5 y SD = 10.2 y Range: 40‐85 y | Mean = 5.2 y SD = 5.4 y Range: 0.2‐25.1 y | Not stated | 68 | |
| ‘Experimental' | 6 | 5/1 | 3/3 | Mean = 60 y SD = 7 y | Mean = 21 days SD = 8 days Range: 17 ‐ 37 days | Not stated | At 2 weeks, n=6; At 28 week follow‐up, n=5 | |
| ‘Control' | 6 | 4/2 | 1/5 | Mean = 74 y SD = 12 y | Mean = 37 days SD = 23 days Range: 13 ‐ 75 days | Not stated | At 2 weeks, n=6; At 28 week follow‐up, n=4 | |
| ‘Intervention' | 50 | 36/14 | Not stated | Mean = 57.08 y SD = 9.15 y | Stroke onset to admission to hospital: ≤6 hours:n = 31 >6 hours: n = 19 | Not stated | 50 | |
| ‘Control (no treatment)' | 50 | 35/15 | Not stated | Mean = 56.98 y SD = 9.05 y | Stroke onset to admission to hospital: ≤6 hours: n = 30 >6 hours: n = 20 | Not stated | 50 | |
| ‘Mixed' | 10 | Not stated | 4/6 | Mean = 67.3 y | Mean = 66 days | Ischaemic = 10 | 10 | |
| ‘Control' | 10 | Not stated | 4/5 + 1 brainstem | Mean = 67.8 y | Mean = 56 days | Haemorrhagic = 2 Ischaemic = 8 | 10 | |
| ‘Mixed' | 50 (44 completed intervention) | 23/21 | 18/22; 4 bilateral | Mean = 68.5 y | Mean = 77.5 days | Ischaemic = 39 | 44 | |
| ‘Control' | 50 (48 completed intervention) | 27/21 | 22/22; 4 bilateral | Mean = 70.2 y | Mean = 73.5 days | Ischaemic = 44 | 48 | |
| ‘Treated' | 42 | 22/20 | 21/21 | Mean = 64.53 y SD = 10.77 y | Mean = 8.14 days SD = 4.95 days | Haemorrhagic = 15 Ischaemic = 27 | 42 | |
| ‘Control (no treatment)' | 40 | 27/13 | (unable to tell if data pertains to side of lesion or side of hemiplegia) | Mean = 65.82 y SD = 10.61 y | Mean = 8.33 days SD = 3.87 days | Haemorrhagic = 14 Ischaemic = 26 | 38 | |
| ‘Additional early physiotherapy intervention' | 78 | 33/17 | Not stated | Mean = 65.49 y SD = 10.94 y | Not stated | Haemorrhagic = 13 Cerebral infarct = 37 | At day 30, n= 50; at 6 months, n = 12 | |
| ‘Routine therapy' | 78 | 44/34 | Not stated | Mean = 61.8 y SD = 10.94 y | Not stated | Haemorrhagic = 11 Cerebral infarct = 67 | At day 30, n= 78; at 6 months, n = 12 | |
| ‘Rehabilitation' | 25 | 17/8 | Not stated | Whole group mean = 65.49 y SD = 10.94 y | Not stated | Whole group Haemorrhagic = 24 Ischaemic = 102 Mixed = 2 | Whole group: At day 30, n = 45; at 6 months, n= 14 | |
| ‘Control (no treatment)' | 45 | 26/19 | Not stated | Whole group mean = 61.8 y SD = 10.9 y | Not stated | As above | Whole group: At day 30, n = 55; at 6 months, n=12 | |
| ‘Rehabilitation' | 25 | 16/9 | Not stated | As above | Not stated | As above | As above | |
| ‘Control (no treatment)' | 33 | 18/15 | Not stated | As above | Not stated | As above | As above | |
| ‘Rehabilitation' | 20 | 14/6 | Not stated | Mean = 61 y SD = 5 y | Mean = 50 days SD = 22 days | Not stated | Unclear ‐ see notes in characteristics of included studies | |
| ‘Control (no treatment)' | 28 | 20/8 | Not stated | Mean = 60 y SD = 5 y | Mean = 51 days SD = 26 days | Not stated | Unclear ‐ see notes in characteristics of included studies | |
| ‘Neurophysiological (NDT)' | 15 | 9/6 | 8/7 | Mean = 73.7 y | Mean = 11.3 days | Pure motor ischaemic = 15 | 15 | |
| ‘Orthopaedic (TFR)' | 12 | 4/8 | 5/7 | Mean = 69.8 y | Mean = 13.8 days | Pure motor ischaemic = 12 | 12 | |
| ‘Mixed' | 85 | 49/36 | 56/26 + 3 'other' | Mean = 71.5 y SD = 8.7 y | Not stated | Not stated | 81 | |
| ‘Control (no treatment)' | 85 | 46/39 | 44/40 + 1 'other' | Mean = 73.5 y SD = 8.3 y | Not stated | Not stated | 80 | |
| ‘Intervention' | 15 | 9/6 | Not stated | Mean = 77.7 y SD = 7.6 y | Mean = 139.7 days SD= 37.3 days | Cardioembolic stroke = 4 Lacunar infarct = 2 Other specified stroke = 2 Unknown stroke = 6 not applicable (because of intracerebral haemorrhage) =1 | 15 | |
| ‘Control' | 19 | 12/7 | Not stated | Mean = 79.2 y SD = 7.5 y | Mean = 126.8 days SD= 28.2 days | Large artery thrombosis = 4 Cardioembolic stroke = 5 Lacunar infarct = 8 Unknown stroke = 2 | 19 | |
| ‘Rehabilitation' | 40 | 25/15 | Not stated | Mean = 61.38 y SD = 9.99 y | Mean = 9.05 days SD = 5.74 days | Haemorrhagic = 12 Ischaemic = 28 | 40 | |
| ‘Control (no treatment)' | 40 | 24/16 | Not stated | Mean = 62.55 y SD = 9.60 y | Mean = 8.65 days SD = 5.38 days | Haemorrhagic = 12 Ischaemic = 28 | 40 | |
| ‘Mixed' | 17 (15 at 4‐week follow up) | 9/8 | 8/9 | Mean = 71.5 y | Mean = 26.5 days | 2 TACS / 7 PACS / 4 LACS / 1 POCS / 3 other | 15 | |
| ‘Control (neurophysiological)' | 18 (18 at 4‐week follow up) | 9/9 | 7/11 | Mean = 70.7 y | Mean = 23.1 days | 3 TACS / 6 PACS / 4 LACS / 3 POCS / 2 other | 18 | |
| ‘Test (haemorrhagic group)' | 178 | Not stated | Not stated | Whole group Mean = 61 y SD = 10y | Whole group Mean = 11 days SD = 6 days | Not stated | At 1 month after stroke n = 178; at 3 months after stroke, n= 178; at 6 months after stroke, n= 177 | |
| ‘Control (no treatment)' | 174 | Not stated | Not stated | As above | As above | Not stated | At 1 month after stroke n = 174; at 3 months after stroke, n= 168; at 6 months after stroke, n= 168 | |
| ‘Test (ischaemic group)' | 485 | Not stated | Not stated | Whole group Mean = 64 y SD = 10 y | Whole group Mean = 10 days SD = 5 days | Not stated | At 1 month after stroke n = 485; at 3 months after stroke, n= 478; at 6 months after stroke, n= 471 | |
| ‘Control (no treatment)' | 480 | Not stated | Not stated | As above | As above | Not stated | At 1 month after stroke n= 480; at 3 months after stroke, n = 473; at 6 months after stroke, n=469 | |
| ‘Rehabilitation' | 25 | 17/8 | 14/11 | Mean = 64.61 y SD = 12.37 y | Mean = 6.45 days SD = 3.70 days | Haemorrhagic = 5 Ischaemic = 20 | 25 | |
| ‘Control (no treatment)' | 25 | 17/8 | 12/13 | Mean = 65.351 y SD = 11.71 y | Mean = 6.89 days SD = 3.20 days | Haemorrhagic = 5 Ischaemic = 20 | 25 | |
| ‘PLBO+TRT' | 25 | Not stated | Not stated | Whole group mean = 56.6 y SD = 7.9 y | Whole group mean = 4.7 y SD = 3.4 y | Not stated | 25 | |
| ‘Control (no treatment)' | 29 | Not stated | Not stated | As above | As above | Not stated | 29 | |
| ‘Treated' | 42 | 22/20 | 21/21 'location of disease' | Mean = 64.53 y SD = 10.77 y | Mean = 8.14 days SD =4.95 days | Haemorrhagic = 15 Infarction = 27 | Whole group: n=79 at 6 months | |
| ‘Control' | 40 | 27/13 | 15/25 'location of disease' | Mean = 65.82 y SD = 10.61 y | Mean = 8.33 days SD = 3.87 days | Haemorrhagic = 14 Infarction = 26 | As above | |
| ‘Exercise and occupational therapy' | 120 | 69/51 | Whole group 73/87 | Mean = 57.3 y SD = 12.5 y | Mean = 5.2 days SD = 4.2 days | Whole group Haemorrhagic = 66 Ischaemic = 94 | 120 | |
| ‘Exercise therapy' | 40 | 23/17 | As above | Mean = 54.5 y SD = 9.6 y | Mean = 4.6 days SD = 3.7 days | As above | 40 | |
| ‘PNF' | 20 | 17/3 | 12/8 | Mean = 51.4 y SD = 5.7 y | Mean = 22.9 months SD = 12.2 months | Haemorrhagic = 8 Infarction = 12 | 20 | |
| ‘Control' | 20 | 14/6 | 12/8 | Mean = 53.5 y SD = 7.1 y | Mean = 26.8 months SD = 12.8 months | Haemorrhagic = 9 Infarction = 11 | 20 | |
| ‘Experimental' | 10 | Not stated | Not stated | Mean = 52.5 y SD = 11.72 y | Mean = 7.7 y SD = 6.11 y | Not stated | 10 | |
| ‘Control' | 10 | Not stated | Not stated | Mean = 53.4 y SD = 12.11 y | Mean = 13.1 y SD = 10.62 y | Not stated | 10 | |
| ‘Lower extremities' | 17 | 13/4 | 7/10 | Mean = 60.8 y SD = 10.6 y Range: 38‐76 y | Mean = 4.8 weeks SD = 3.1 weeks Range: 2‐9 weeks | TACI =6 PACI =10 LACI =1 | 17 | |
| ‘Upper extremities' | 18 | 9/9 | 8/10 | Mean = 64.3 y SD = 10.6 y Range: 46‐80 y | Mean = 5.9 weeks SD = 3 weeks Range: 2‐10 weeks | TACI =8 PACI =7 LACI =3 | 18 | |
| ‘Control' | 18 | 14/4 | 7/11 | Mean = 62.1 y SD =10.6 y Range: 30‐76 y | Mean = 7.3 weeks SD = 3.6 weeks Range: 2‐10 weeks | TACI =9 PACI =6 LACI =3 | 18 | |
| ‘Circuit training’ | 126 | 82/44 | 49/57 brainstem = 6 cerebellum = 14 | Mean = 56 y SD = 10 y | Mean = 91 days SD = 42 days | Haemorrhagic = 23 Ischaemic = 103 | 125 | |
| ‘Usual physiotherapy’ | 124 | 80/44 | 43/61 brainstem = 14 cerebellum = 6 | Mean = 58 y SD = 10 y | Mean = 103 days SD = 51 days | Haemorrhagic = 24 Ischaemic = 100 | 117 | |
| ‘Neurophysiological (Bobath)' | 28 | 16/12 | 17/11 | Whole group | Not stated | Not stated | 24 | |
| ‘Motor learning' | 33 | 20/13 | 17/16 | See above | Not stated | Not stated | 29 | |
| ‘Intensive exercise' | 35 | Not stated | 16/19 | Mean = 76 y SD = 12.7 y | Not stated | 'Cause of the stroke was thrombosis or embolism with 29 such cases in the intensive exercise group & 6 being haemorrhages' | 32 | |
| ‘Regular exercise' | 40 | Not stated | 21/19 | Mean = 72 y SD = 13.6 y | Not stated | 'Cause of the stroke was thrombosis or embolism with 36 such cases in the regular exercise group and 4 being haemorrhages' | 32 | |
| ‘Bobath' | 30 | Not stated | Not stated | Not stated | Not stated | Not stated | 30 | |
| ‘Gait specific group' | 31 | Not stated | Not stated | Not stated | Not stated | Not stated | 31 | |
| ‘Early rehabilitation' | 30 | Not stated | Not stated | Mean = 58.1 y SD = 11.9 y | Not stated | Haemorrhagic = 12 Ischaemic = 18 | 30 | |
| ‘Control (no treatment)' | 31 | Not stated | Not stated | Mean = 59.20 SD = 10.2 y | Not stated | Haemorrhagic = 12 Ischaemic = 19 | 31 | |
| ‘Rehabilitation' | 87 | 49/38 | Not stated | Mean = 63 y SD = 1 y | Not stated | Not stated | 87 | |
| ‘Control (no treatment) group' | 87 | 35/52 | Not stated | Not stated | Not stated | Not stated | 87 | |
| ‘Motor relearning' | 31 | Not stated | Not stated | Mean =51.4 y SD = 8.9 y | Mean = 8.8 days SD = 6.0 days | Not stated | 31 | |
| 'Neurodevelopmental therapy' | 30 | Not stated | Not stated | Mean = 54.6 y SD = 9.9 y | Mean = 8.3 days SD = 5.3 days | Not stated | 30 | |
| ‘Treatment' | 48 | 28/20 | 16/32 'location of disease' | Mean = 62.3 y SD = 7.2 y | Mean = 7.81 days SD = 4.65 days | Haemorrhagic = 18 Ischaemic = 30 | 48 | |
| ‘Control' | 48 | 26/22 | 18/30 'location of disease' | Mean = 63.4 y SD = 6.8 y | Mean = 7.94 days SD = 4.51 days | Haemorrhagic = 16 Ischaemic = 32 | 48 | |
| ‘Neurophysiological (Bobath)' | 60 | 27/33 | 30/29; 1 bilateral | Mean = 73.3 y | Inclusion criteria: | 9 TACS / 29 PACS / 14 LACS / 4 POCS / 4 unsure | At 1 month ‐ 52 | |
| ‘Motor Learning' | 60 | 33/27 | 31/27; 2 bilateral | Mean = 75.0 y | Inclusion criteria: | 8 TACS / 32 PACS / 11 LACS / 6 POCS / 3 unsure | At 1 month ‐ 47 | |
| ‘Rehabilitation' | 60 | 38/22 | Not stated | Mean = 62 y SD = 10 y | ‘The rehabilitation group started to accept the treatment in 3‐5 days after attack ..’ | Haemorrhagic = 19 Ischaemic = 41 | 60 | |
| ‘Control (no treatment)' | 60 | 35/25 | Not stated | Mean = 61 y SD = 9 y | Not stated | Haemorrhagic = 20 Ischaemic = 40 | 60 | |
| ‘Motor learning' | 15 | 10/3 | 8/5 | Mean = 69 y | Median = 6.5 mo | 13 | ||
| ‘Placebo (upper limb control)' | 11 | 2/8 | 3/6; 1 bilateral | Mean = 72 y | Median = 4.5 mo | 10 | ||
| ‘Exercise' | 31 | 19/12 | 11/20 | Median = 76.0 y Range = 39.0–89.0 y | Median = 3.33 y Range = 0.6–13.3 y | Not stated | At 3 month follow‐up ‐ 27 | |
| ‘Control' | 27 | 13/14 | 12/14 1 brainstem | Median = 71.0 y Range = 44.0–86.0 y | Median = 5.8 Range = 0.5–18.7 y | Not stated | At 3 month follow‐up ‐ 23 | |
| ‘Motor learning' | 10 | 21/19 for total of 40 recruited | 22/18 for total of 40 recruited | Mean = 72.4 y | Range 2 to 6 weeks (for total of 40 recruits) | MCA infarct = 22 | 10 | |
| ‘Neurophysiological' | 10 | 21/19 for total of 40 recruited | 22/18 for total of 40 recruited | Mean = 72.4 y | Range = 2 to 6 weeks (for total of 40 recruits) | MCA infarct = 22 | 9 | |
| ‘Control (no treatment)' | 10 | 21/19 for total of 40 recruited | 22/18 for total of 40 recruited | Mean = 72.4 y | Range 2 to 6 weeks (for total of 40 recruits) | MCA infarct = 22 | 6 | |
| ‘Comprehensive rehabilitation training' | 34 | 26/8 | Not stated | Mean = 55.56 y SD = 17.64 y | Mean = 19.21 days SD = 7.59 days | Ischaemic = 19 Haemorrhagic = 15 | 34 | |
| ‘Control (no treatment)' | 34 | 23/11 | Not stated | Mean = 53.25 y SD = 13.46 y | Mean = 18.31 days SD = 9.64 days | Ischaemic = 20 Haemorrhagic = 14 | 34 | |
| ‘Rehabilitation' | 48 | 36/12 | 26/22 | Mean = 64.2 y SD= 11.5 y | Not stated | Ischaemic = 30 Haemorrhagic = 18 | 48 | |
| ‘Control' | 48 | 32/16 | 22/26 | Mean = 62.5 y SD = 13.7 y | Not stated | Ischaemic = 32 Haemorrhagic = 16 | 48 | |
| ‘Rehabilitation' | 50 | 32/18 | Not stated | Mean = 61.4 y Range: 37‐76 y | Not stated | Haemorrhagic = 21 Infarction = 29 | 50 | |
| ‘Control (no treatment)' | 36 | 25/11 | Not stated | Mean = 60 y Range: 39‐75 y | Not stated | Haemorrhagic = 15 Infarction = 21 | 36 | |
| ‘Treatment' | 41 | Not stated | Not stated | Not stated | Not stated | Not stated | 41 | |
| ‘Control (no treatment)' | 39 | Not stated | Not stated | Not stated | Not stated | Not stated | 37 | |
| ‘Neurophysiological (Bobath)' | 19 | 12/7 | 10/9 | Mean = 68.4 y | Inclusion criteria: "less than six weeks previously" | 6 TACS / 3 PACS / 5 LACS / 2 POCS/ 3 PICH | 11 | |
| ‘Mixed (Neurophysiological + motor learning)' | 9 | 0 /9 | 7/2 | Mean = 73.1 y | Inclusion criteria: "less than six weeks previously" | 2 TACS / 3 PACS / 4 LACS / 0 POCS / 0 PICH | 5 | |
| ‘Treatment' | 23 | 11/12 | Not stated | Mean = 62.8 y SD = 14.3 y | Mean = 13.9 days SD = 8.5 days | Ischaemic = 15 Haemorrhagic = 8 | 23 | |
| ‘Control (no treatment)' | 19 | 9/10 | Not stated | Mean = 62.8 y SD = 17.2 y | Mean = 12.1 days SD = 9.7 days | Ischaemic = 14 Haemorrhagic = 5 | 19 | |
| ‘Treatment' | 20 | 11/9 | Not stated | Mean = 63.5 y SD = 15.5 y | Mean = 13.8 days SD = 5.8 days | Ischaemic = 12 Haemorrhagic = 8 | 20 | |
| ‘Control' | 20 | 12/8 | Not stated | Mean = 63.7 y SD = 16.3 y | Mean = 13.5 days SD = 7.3 days | Ischaemic = 14 Haemorrhagic = 6 | 20 | |
| ‘Mixed (early)' | 10 | 5/5 | 2/8 | Mean = 69.6 y | Mean = 8.3 days | Canadian Stroke Score (maximum score = 15) | 9 | |
| ‘Neurophysiological (early)' | 8 | 2/6 | 6/2 | Mean = 67.3 y | Mean = 8.8 days | Canadian Stroke Score (maximum score = 15) | 6 | |
| ‘Neurophysiological (conventional)' | 9 | 6/3 | 3/6 | Mean = 70.3 y | Mean = 13.0 days | Canadian Stroke Score (maximum score = 15) | 8 | |
| ‘Motor learning' | 44 | 26/18 | 27/17 | Mean = 71 y | Mean = 239 days | Mild gait deficit = 19 | 41 | |
| ‘Placebo (upper limb control)' | 47 | 30/17 | 24/22; 1 bilateral | Mean = 73 y | Mean = 217 days | Mild gait deficit = 17 | 43 | |
| ‘Combined Exercise' | 11 | 5/6 | 8/3 | Mean = 58.1 y SD = 4.6 y | Not stated | Not stated | 11 | |
| ‘Conventional Exercise' | 10 | 3/7 | 5/5 | Mean = 57.3 y SD = 4.4 y | Not stated | Not stated | 10 | |
| ‘Body Weight Support Treadmill Training' | 6 | Not stated | Not stated | Whole group Mean = 59.8 y Range: 42‐80 y | Not stated | Not stated | 6 | |
| ‘Proprioceptive Neuromuscular Facilitation‐PNF training' | 6 | Not stated | Not stated | See above | Not stated | Not stated | 6 | |
| ‘Control (no treatment)' | 6 | Not stated | Not stated | See above | Not stated | Not stated | 6 | |
| ‘Observation' | 35 | 11/9 | Not stated | Whole group mean = 61.98 y Range: 44‐75 y | Not stated | Not stated | 35 | |
| ‘Control' | 35 | 12/8 | Not stated | See above | Not stated | Not stated | 35 | |
| ‘Rhythmic auditory stimulation' | 43 | 22/21 | 20/23 | Mean = 69.2 y SD = 11 y | Mean = 21.3 days SD = 11 days | Location of stroke: MCA = 35 Internal capsule = 4 Basal ganglia/thalamus = 3 Subdural haematoma = 1 | 43 | |
| ‘Neurodevelopmental therapy (NDT)/Bobath− | 35 | 19/16 | 16/19 | Mean = 69.7 y SD = 11 y | Mean = 22.2 days SD = 12 days | Location of stroke: MCA = 30 Internal capsule = 4 Basal ganglia/thalamus = 1 | 35 | |
| ‘Strategy 1' | 59 | 16/43 | Not stated | Mean = 69.4 y SD = 12 y | Mean = 7.1 days SD = 5.9 days | Not stated | At 6 month follow‐up = 32 | |
| ‘Strategy 2' | 51 | 21/30 | Not stated | Mean = 69.8 y SD = 8.8 y | Mean = 6.3 days SD = 3.1 days | Not stated | At 6 month follow‐up = 35 | |
| ‘Experimental' | 17 | 11/6 | 9/8 | Mean = 55 y SD = 11 y | Mean = 53 days SD = 24 days | Haemorrhagic = 2 Ischaemic = 15 | 17 | |
| ‘Control' | 16 | 9/7 | 7/9 | Mean = 62 y SD = 14 y | Mean = 49 days SD = 28 days | Haemorrhagic = 3 Ischaemic = 13 | 16 | |
| ‘Experimental' | 15 | 10/5 | 8/7 | Mean = 53.27 y SD = 8.53 y | Mean = 6.07 weeks SD = 3.30 weeks | Haemorrhagic = 4 Ischaemic = 11 | 15 | |
| ‘Control' | 15 | 12/3 | 7/8 | Mean = 55.07 y SD = 6.80 y | Mean = 6.60 weeks SD = 3.20 weeks | Haemorrhagic = 3 Ischaemic = 12 | 15 | |
| ‘Mixed' | 49 | 27/22 | 25/19 | Mean = 72.3 y | Mean = 53.1mo | 48 | ||
| ‘Control (no treatment)' | 45 | 20/25 | 21/21 | Mean = 72.0 y | Mean = 59.6 mo | 41 | ||
| ‘Rehabilitation' | 70 | 36/30 | Not stated | Mean = 63.1 y SD = 9.8 y | Not stated | Not stated | 66 | |
| ‘Control (no treatment)' | 35 | 18/14 | Not stated | Mean = 65.2 y SD = 11.3 y | Not stated | Not stated | 32 | |
| ‘Treatment' | 25 | 16/9 | Not stated | Mean = 62.1 y SD = 10.2 y | Mean = 54.2 days SD = 37.5 days | Haemorrhagic = 11 Ischaemic = 14 | 25 | |
| ‘Control (no treatment)' | 25 | 15/10 | Not stated | Mean = 59.5 y SD = 11.4 y | Mean = 55.7 days SD = 35.3 days | Haemorrhagic = 9 Ischaemic = 16 | 25 | |
| ‘Neurophysiological' | 21 | 14/7 | 11/10 | Patients with spasticity | Patients with spasticity | Haemorrhagic = 7 | 21 | |
| ‘Orthopaedic' | 23 | 14/9 | 9/14 | Patients with spasticity | Patients with spasticity | Haemorrhagic = 7 | 23 | |
| ‘Rehabilitation' | 40 | 25/15 | Not stated | Mean = 61.38 y SD = 9.99 y | Mean = 9.05 days SD = 5.74 days | Ischaemic = 28 Haemorrhagic = 12 | 40 | |
| ‘Control (no treatment)' | 40 | 24/16 | Not stated | Mean = 62.55 y SD = 9.60 y | Mean = 8.65 days SD = 5.38 days | Ischaemic = 28 Haemorrhagic = 12 | 40 | |
| ‘Exercise' | 40 | 30/10 | Not stated | Mean = 58 y SD = not stated Range: 44‐74 y | Mean = 41.95 days SD = 23.4 days | Haemorrhagic = 20 Thrombosis = 20 | 40 | |
| ‘Control group' | 40 | 27/13 | Not stated | Mean = 58 y SD = not stated Range: 38‐74 y | Mean = 40.2 days SD = 24.15 days | Haemorrhagic = 18 Thrombosis = 22 | 40 | |
| ‘Motor learning' | 12 | Inclusion criteria: CVA less than 150 days previously | 12 | |||||
| ‘Control (no treatment)' | 9 | Inclusion criteria: CVA less than 150 days previously | 9 | |||||
| ‘Rehabilitation' | 50 | 29/19 | 21/27 'location of disease' | Mean = 61.81 y SD = 8.69 y | Mean = 7.38 days SD = 5.83 days | Haemorrhagic = 14 Ischaemic = 34 | 48 | |
| ‘Control (no treatment)' | 50 | 35/13 | 27/25 'location of disease' | Mean = 63.13 y SD = 7.79 y | Mean = 6.33 days SD = 5.00 days | Haemorrhagic = 13 Ischaemic = 35 | 48 | |
| ‘Intensive rehabilitation' | 67 | 45/22 | Not stated | Mean = 62.9 y SD = 1.4 y | Mean = 14.7 days SD = 1.3 days | Haemorrhagic = 20 Ischaemic = 47 | 67 | |
| ‘Conventional (no treatment)' | 67 | 47/20 | Not stated | Mean = 65.5 y SD = 1.1 y | Mean = 12.9 days SD = 0.9 days | Haemorrhagic = 23 Ischaemic = 44 | 67 | |
| ‘Rehabilitation' | 32 | Whole group 35/29 | Not stated | Whole group mean = 60 y SD = 8 y Range: 51 ‐ 72 y | Whole group mean = 17 hours SD = 7 hours Range: 6‐52 hours | Whole group Cerebral infarct = 52 Cerebral haemorrhage = 12 | 32 | |
| ‘Control (no treatment)' | 32 | As above | Not stated | As above | As above | As above | 32 | |
| ‘Rehabilitation' | 35 | 21/14 | Not stated | Mean = 67.2 y SD = 9.9 y | Not stated | Haemorrhagic = 10 Ischaemic = 25 | 35 | |
| ‘Control (no treatment)' | 35 | 18/17 | Not stated | Mean = 64.7 y SD = 9.2 y | Not stated | Haemorrhagic = 10 Ischaemic = 25 | 35 | |
| ‘Rehabilitation' | 32 | 24/8 | Not stated | Mean = 55 y Range: 37‐69 y | Not stated | Haemorrhagic = 14 Ischaemic = 18 | 32 | |
| ‘Control (no treatment)' | 30 | 20/10 | Not stated | Mean = 57 y Range: 38‐72 y | Not stated | Haemorrhagic = 16 Ischaemic = 14 | 30 | |
| ‘Rehabilitation' | 94 | 48/46 | Mean = 58.3 y SD = not stated | 'Mean time from onset of disease to hospitalisation was 3.5 days' | Not stated | 94 | ||
| ‘Control (no treatment)' | 92 | 45/47 | Not stated | Mean = 55.4 y SD = not stated | 'Mean time from onset of disease to hospitalisation was 4 days' | Not stated | 92 | |
| ‘Rehabilitation' | 92 | 48/44 | 42/50 | Mean = 57.6 y SD = not stated | Mean = 2.3 days SD = not stated | Infarct in 66 cases in basal ganglion, 16 cases in lobar and 10 cases in corona radiate and oval center | 92 | |
| ‘Control (no treatment)' | 88 | 45/43 | 40/48 | Mean = 56.9 y SD = not stated | Mean = 2.5 days SD = not stated | Infarct in 64 cases in b asal ganglion, 15 cases in lobar and 9 cases in corona radiate and oval center | 88 | |
| ‘Rehabilitation' | 30 | 21/9 | 9/21 | Mean = 59.8 y SD = 10.0 y | Mean = 14.8 days SD = 3.7 days | Haemorrhagic = 2 Ischaemic = 28 | 30 | |
| ‘Control (no treatment)' | 27 | 18/19 | 9/18 | Mean = 63.3 y SD = 8.7 y | Mean = 15.1 days SD = 4.3 days | Haemorrhagic = 1 Ischaemic = 26 | 27 | |
| ‘Training' | 78 | 44/34 | Not stated | Mean = 58 y SD = 11 y | Not stated | Haemorrhagic = 37 Infarct = 41 | 78 | |
| ‘Control (no treatment)' | 72 | 40/32 | Not stated | Mean = 59 y SD = 10 y | Not stated | Haemorrhagic = 34 Infarct = 38 | 72 | |
| ‘Rehabilitation' | 40 | 25/15 | 16/24 | Mean = 62.5 y SD = not stated | Mean = 14.8 days SD = 3.7 days | Haemorrhagic = 14 Ischaemic = 26 | 40 | |
| ‘Control (no treatment)' | 38 | 24/14 | 16/22 | Mean = 60.3 y SD = not stated | Mean = 15.1 days SD = 4.3 days | Haemorrhagic = 11 Ischaemic = 27 | 38 | |
| ‘NDT‐based treatment' | 35 | 22/13 | 17/16 | Mean = 54.9 y SD = 11.8 y Range: 26.5‐77.3 y | Mean = 218.4 days SD = 93.4 days | Ischaemic = 24 Not stated = 11 | 35 | |
| ‘Multisensorial' | 33 | 22/11 | 20/15 | Mean = 55.5 y SD = 11.6 y Range: 32.5‐78.3 y | Mean = 217.2 days SD = 92.9 days | Ischaemic = 25 Not stated = 8 | 33 | |
| ‘Rehabilitation' | 30 | 26/4 | Not stated | Mean = 68 y SD = not stated | Not stated | Not stated | 30 | |
| ‘Rehabilitation with therapy with intermediate frequency' | 30 | 24/6 | Not stated | Mean = 65 y SD = not stated | Not stated | Not stated | 30 | |
| ‘Control (no treatment)' | 30 | 21/9 | Not stated | Mean = 66 y SD = not stated Max age <80 y | Not stated | Not stated | 30 | |
| ‘Early rehabilitation' | 29 | Not stated | Not stated | Mean = 66 y SD = not stated | Not stated | Not stated | 29 | |
| ‘Control (no treatment)' | 27 | Not stated | Not stated | Mean = 63 y SD = not stated | Not stated | Not stated | 27 | |
| ‘Rehabilitation' | 439 | 266/173 | Not stated | Mean = 61 y SD = 11 y | Not stated | Haemorrhage = 61 Ischaemic = 278 | 439 | |
| 'Control (no treatment)' | 463 | 281/182 | Not stated | Mean = 60 y SD = 11 y | Not stated | Haemorrhage = 172 Ischaemic = 291 | 463 | |
| 'Rehabilitation nursing' | 100 | 58/42 | 39/61 | Mean = 55.2 y SD = 8.4 y | Not stated | Not stated | 100 | |
| ‘Control (no treatment)' | 80 | 42/38 | 34/46 | 5Mean = 6.6 y SD = 9.2 y | Not stated | Not stated | 80 | |
| ‘Rehabilitation' | 150 | 91/59 | 82/68 | Mean = 57 y SD = not stated Range: 36‐81 y | Not stated | 'cerebral infarction' | 150 | |
| ‘Control (no treatment)' | 150 | 82/68 | 79/71 | Mean = 59 y SD = not stated Range: 41‐76 y | Not stated | 'cerebral infarction' | 150 | |
| ‘Rehabilitation' | 72 | 57/15 | Not stated | Mean = 64.51 y SD = 8.87 y | Mean = 9.51 days SD = 5.36 days | Bleeding after decompression surgery = 1 Haemorrhagic = 20 Ischaemic = 51 | 72 | |
| ‘Control (no treatment)' | 53 | 35/17 Mismatch in the gender data reported in the paper compared to group data reported elsewhere | Not stated | Mean = 66.04 y SD = 8.80 y | Mean = 9.91 days SD = 7.90 days | Bleeding after decompression surgery = 1 Haemorrhagic = 12 Ischaemic = 40 | 53 | |
| ‘Treated' | 26 | 14/12 | Not stated | Mean = 66 y SD = 11 y | Mean = 8 days SD = 5 days | Haemorrhagic = 10 Ischaemic = 16 | 26 | |
| ‘Controlled (no treatment)' | 26 | 18/8 | Not stated | Mean = 65 y SD = 11 y | Mean = 8 days SD = 4 days | Haemorrhagic = 10 Ischaemic = 16 | 26 | |
| ‘Test' | 35 | 19/16 | Not stated | Mean = 61.3 y SD = 6.8 y | Mean = 30.4 days SD = 6.8 days | Haemorrhagic = 8 Ischaemic = 27 | 35 | |
| ‘Controlled (no treatment)' | 35 | 20/15 | Not stated | Mean = 62.1 y SD = 5.9 y | Mean = 31.6 days SD = 6.2 days | Haemorrhagic = 7 Ischaemic = 28 | 35 | |
| ‘Cerebral haemorrhage rehabilitation' | 12 | 10/2 | 4/8 | Mean = 61 y SD = 10 y | Mean = 16 days SD = 5 days | Haemorrhagic = 12 | 12 | |
| ‘Cerebral haemorrhage control' | 10 | 8/2 | 3/7 | Mean = 63 y SD = 13 y | Mean = 17 days SD = 7 days | Haemorrhagic = 10 | 10 | |
| ‘Cerebral infarction rehabilitation' | 28 | 14/14 | 8/20 | Mean = 63 y SD = 10 y | Mean = 14 days SD = 6 days | Ischaemic = 28 | 28 | |
| ‘Cerebral infarction control' | 28 | 14/14 | 11/17 | Mean = 61 y SD = 10 y | Mean = 16 days SD = 5 days | Ischaemic = 28 | 28 | |
| ‘Physiotherapy' | 86 | 54/32 | 47/39 | Mean = 64.29 y SD = 8.42 y Range: 42‐75 y | Mean = 34.24 days SD = 21.53 days Range: 15‐86 days | Ischaemic encephalic | 86 | |
| ‘Acupuncture' | 91 | 61/30 | 50/41 | Mean = 63.87 y SD = 9.23 y Range: 42‐75 y | Mean = 30.89 days SD = 21.67 days Range: 15‐80 days | Ischaemic encephalic | 91 | |
| ‘Combination therapy' | 97 | 63/34 | 51/48 | Mean = 64.03 y SD = 9.19 y Range: 40‐75 y | Mean = 29.73 days SD = 18.57 days Range: 16‐88 days | Ischaemic encephalic | 97 | |
| LCVA: left cerebrovascular accident | ||||||||
| Study | Length of intervention period | Frequency of sessions | Length of sessions |
|---|---|---|---|
| Not stated | Not stated | Not stated | |
| 3 months | 2/week | Not stated | |
| 20 days ‐ 14 months (mean 41.3 days) | Daily | 40‐60 minutes | |
| 6 weeks | 2/week | 60 minutes | |
| 3 months | 2/week | Not stated | |
| 3 days | Daily | 45 minutes | |
| 3 days | Daily | 45 minutes | |
| Maximum 13 weeks | Minimum 3 contacts; | Median number of treatments per patient was three (IQR 2–7, range 0–22) and the mean duration of every treatment was 44 min (SD 21, range 10–90). | |
| 6 months | 1‐2 times/day, 5/week; increasing to 2/day, 5‐6/week | 30‐40 minutes | |
| Not stated | Not stated | Not stated | |
| Not stated | Not stated | Not stated | |
| 30 days | Daily | 45 minutes | |
| 1 month | 2/day | 30 minutes | |
| 15 days | 4/day | 30 minutes | |
| Average of 2 months | 2/day | 30‐45 minutes | |
| Not stated | 3‐4/day | 30 minutes | |
| 10 sessions | 5/week | 30 minutes | |
| Mean visits = 4 (range 1‐11); 73% patients were seen one to six times. | Not stated | Ranged from 1 hour 10 minutes to 3 hours 10 minutes (mean = 2 hours 4 minutes) | |
| 30 days | 1‐2/day | 45 minutes | |
| 6 months | Daily | Not stated | |
| 1 month | 2/day | 60 minutes | |
| Not stated | Massage 5‐6/day; ADL 2/day | Massage 15‐20 minutes; ADL 30 minutes | |
| 21 days | Daily | Not stated | |
| 4 weeks | Daily | 60 minutes | |
| 1 month | 5/week | 40‐50 minutes | |
| 1 month | 3/day | 30 minutes | |
| 38 days | Dependent on phase of recovery: Early phase: 2/day; Rehabilitative treatment (on bed): 2/day, increasing to 3‐4/day if participants had no discomfort; Rehabilitative treatment (after leaving bed): 2/day | Dependent on phase of recovery: Early phase: 15min/session; Rehabilitative treatment (on bed): 30 min/session; Rehabilitative treatment (after leaving bed): 60 minutes | |
| Not stated | Daily | 40 minutes | |
| Not stated | Daily | 60 minutes | |
| 6 months | Not stated | Not stated | |
| Mean 31.6 days (SD 11.2 days) | 5/week | 30‐45 minutes | |
| PT and OT: ‘10 days as a treatment course, persisting 2 courses' | Daily | 30‐40 minutes | |
| Not stated | 5/week | 45 minutes (plus 20 minutes electrotherapy) | |
| Not stated | 5/week | 60 minutes | |
| Not stated | 5/week | 45 minutes | |
| Not stated | 5/week | 45 minutes | |
| OT: occupational therapy; PT = physical therapy | |||
| Study | Length of intervention period | Frequency of sessions | Length of sessions |
|---|---|---|---|
| 4 weeks | Not stated | Not stated | |
| 6 weeks | 4/week | 60 minutes | |
| 8 weeks (then 4 weeks without therapist) | 3/week | 90 minutes | |
| 12‐14 weeks | 36 sessions total | 90 minutes | |
| 12 weeks | 2/week | 90 minutes | |
| Four 3 month sessions | 2‐3/week | Minimum 20 hours total | |
| 6 weeks | 2/week | Not stated | |
| 4 weeks | 3/week | Not stated | |
| 6 weeks | 5/week | 30 minutes | |
| 4 weeks | 5/week | 60 minutes | |
| Not stated | Daily | 60 minutes | |
| Whilst in‐patient | Not stated | Not stated | |
| 8 weeks | Daily | 45 minutes | |
| 4 weeks | 5/week | 30‐45 minutes | |
| 12 weeks | 5/week | 45‐60 minutes |
| Comparison | Intervention vs no treatment | Intervention vs usual care or control | One active intervention vs another | |||
| Outcome | Immediate | Persisting | Immediate | Persisting | Immediate | Persisting |
| Independence in ADL | ||||||
| Motor Function | ||||||
| Balance | ||||||
| Gait velocity | ||||||
| Length of stay | ||||||
| Comparison / Outcome | Intervention vs no treatment | Intervention vs usual care or control | ||
| SUBGROUP | Independence in ADL | Motor Function | Independence in ADL | Motor Function |
| Time after stroke | ||||
| Study geographical location | ||||
| Dose of intervention | ||||
| Provider of intervention | ||||
| Treatment components included | ||||
| Comparison / Outcome | One active intervention vs another | |||
| SUBGROUP | Independence in ADL | Motor Function | ||
| Functional task training components | ||||
| Neurophysiological components | ||||
| Musculoskeletal components | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1.1 Independence in ADL scales Show forest plot | 28 | 3423 | Std. Mean Difference (IV, Random, 95% CI) | 0.78 [0.58, 0.97] |
| 1.1.1 Functional task training | 2 | 250 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.06 [‐0.30, 0.19] |
| 1.1.2 Functional task training + musculoskeletal | 9 | 967 | Std. Mean Difference (IV, Random, 95% CI) | 0.97 [0.67, 1.27] |
| 1.1.3 Neurophysiological | 2 | 140 | Std. Mean Difference (IV, Random, 95% CI) | 0.79 [0.45, 1.14] |
| 1.1.4 Neurophysiological + musculoskeletal | 1 | 128 | Std. Mean Difference (IV, Random, 95% CI) | 0.02 [‐0.34, 0.37] |
| 1.1.5 Functional training + neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.1.6 Functional training + neurophysiological + musculoskeletal | 12 | 1838 | Std. Mean Difference (IV, Random, 95% CI) | 0.96 [0.66, 1.27] |
| 1.1.7 Musculoskeletal | 2 | 100 | Std. Mean Difference (IV, Random, 95% CI) | 0.06 [‐0.34, 0.45] |
| 1.2 Motor function scales Show forest plot | 27 | 4558 | Std. Mean Difference (IV, Random, 95% CI) | 0.81 [0.58, 1.04] |
| 1.2.1 Functional task training | 2 | 250 | Std. Mean Difference (IV, Random, 95% CI) | 0.14 [‐0.31, 0.58] |
| 1.2.2 Functional task training + musculoskeletal | 10 | 2175 | Std. Mean Difference (IV, Random, 95% CI) | 1.13 [0.61, 1.66] |
| 1.2.3 Neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.2.4 Neurophysiological + musculoskeletal | 1 | 128 | Std. Mean Difference (IV, Random, 95% CI) | 0.17 [‐0.19, 0.52] |
| 1.2.5 Functional training + neurophysiological | 1 | 68 | Std. Mean Difference (IV, Random, 95% CI) | 1.49 [0.95, 2.03] |
| 1.2.6 Functional training + neurophysiological + musculoskeletal | 11 | 1837 | Std. Mean Difference (IV, Random, 95% CI) | 0.76 [0.54, 0.97] |
| 1.2.7 Musculoskeletal | 2 | 100 | Std. Mean Difference (IV, Random, 95% CI) | 0.22 [‐0.21, 0.64] |
| 1.3 Balance (Berg Balance Scale) Show forest plot | 1 | 34 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.04 [‐0.71, 0.64] |
| 1.3.1 Functional task training + musculoskeletal | 1 | 34 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.04 [‐0.71, 0.64] |
| 1.3.2 Functional task training | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.3.3 Neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.3.4 Neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.3.5 Functional training + neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.3.6 Functional training + neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.3.7 Musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.4 Gait velocity Show forest plot | 3 | 292 | Std. Mean Difference (IV, Random, 95% CI) | 0.05 [‐0.18, 0.28] |
| 1.4.1 Functional task training | 3 | 292 | Std. Mean Difference (IV, Random, 95% CI) | 0.05 [‐0.18, 0.28] |
| 1.4.2 Functional task training + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.4.3 Neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.4.4 Neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.4.5 Functional training + neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.4.6 Functional training + neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.4.7 Musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.5 Length of stay Show forest plot | 3 | 318 | Mean Difference (IV, Random, 95% CI) | ‐2.85 [‐10.47, 4.76] |
| 1.5.1 Functional task training | 0 | 0 | Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.5.2 Functional task training + musculoskeletal | 3 | 318 | Mean Difference (IV, Random, 95% CI) | ‐2.85 [‐10.47, 4.76] |
| 1.5.3 Neurophysiological | 0 | 0 | Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.5.4 Neurophysiological + musculoskeletal | 0 | 0 | Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.5.5 Functional training + neurophysiological | 0 | 0 | Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.5.6 Functional training + neurophysiological + musculoskeletal | 0 | 0 | Mean Difference (IV, Random, 95% CI) | Not estimable |
| 1.5.7 Musculoskeletal | 0 | 0 | Mean Difference (IV, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 2.1 Independence in ADL scales Show forest plot | 6 | 260 | Std. Mean Difference (IV, Random, 95% CI) | 0.04 [‐0.27, 0.35] |
| 2.1.1 Functional task training | 2 | 31 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.39 [‐1.16, 0.38] |
| 2.1.2 Functional task training + musculoskeletal | 3 | 184 | Std. Mean Difference (IV, Random, 95% CI) | 0.15 [‐0.41, 0.71] |
| 2.1.3 Neurophysiological | 2 | 25 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.22 [‐1.04, 0.61] |
| 2.1.4 Neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 2.1.5 Functional training + neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 2.1.6 Functional training + neurophysiological + musculoskeletal | 1 | 20 | Std. Mean Difference (IV, Random, 95% CI) | 0.08 [‐0.80, 0.96] |
| 2.1.7 Musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 2.2 Motor function scales Show forest plot | 13 | 967 | Std. Mean Difference (IV, Random, 95% CI) | 0.42 [0.24, 0.61] |
| 2.2.1 Functional task training | 1 | 21 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.34 [‐1.21, 0.53] |
| 2.2.2 Functional task training + musculoskeletal | 5 | 483 | Std. Mean Difference (IV, Random, 95% CI) | 0.24 [‐0.01, 0.50] |
| 2.2.3 Neurophysiological | 2 | 90 | Std. Mean Difference (IV, Random, 95% CI) | 0.86 [0.42, 1.29] |
| 2.2.4 Neurophysiological + musculoskeletal | 1 | 50 | Std. Mean Difference (IV, Random, 95% CI) | 0.65 [0.08, 1.22] |
| 2.2.5 Functional training + neurophysiological | 1 | 42 | Std. Mean Difference (IV, Random, 95% CI) | 1.09 [0.43, 1.74] |
| 2.2.6 Functional training + neurophysiological + musculoskeletal | 4 | 281 | Std. Mean Difference (IV, Random, 95% CI) | 0.46 [0.21, 0.70] |
| 2.2.7 Musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 2.3 Balance (Berg Balance Scale) Show forest plot | 5 | 246 | Std. Mean Difference (IV, Random, 95% CI) | 0.31 [0.05, 0.56] |
| 2.3.1 Functional task training | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 2.3.2 Functional task training + musculoskeletal | 3 | 124 | Std. Mean Difference (IV, Random, 95% CI) | 0.31 [‐0.04, 0.67] |
| 2.3.3 Neurophysiological | 1 | 10 | Std. Mean Difference (IV, Random, 95% CI) | 0.60 [‐0.71, 1.91] |
| 2.3.4 Neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 2.3.5 Functional training + neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 2.3.6 Functional training + neurophysiological + musculoskeletal | 2 | 112 | Std. Mean Difference (IV, Random, 95% CI) | 0.28 [‐0.10, 0.65] |
| 2.3.7 Musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 2.4 Gait velocity Show forest plot | 14 | 1126 | Std. Mean Difference (IV, Random, 95% CI) | 0.46 [0.32, 0.60] |
| 2.4.1 Functional task training | 2 | 30 | Std. Mean Difference (IV, Random, 95% CI) | 0.68 [‐0.51, 1.86] |
| 2.4.2 Functional task training + musculoskeletal | 9 | 865 | Std. Mean Difference (IV, Random, 95% CI) | 0.45 [0.25, 0.65] |
| 2.4.3 Neurophysiological | 1 | 10 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.06 [‐1.32, 1.21] |
| 2.4.4 Neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 2.4.5 Functional training + neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 2.4.6 Functional training + neurophysiological + musculoskeletal | 3 | 221 | Std. Mean Difference (IV, Random, 95% CI) | 0.45 [0.17, 0.72] |
| 2.4.7 Musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 2.5 Length of stay Show forest plot | 2 | 105 | Mean Difference (IV, Random, 95% CI) | ‐10.36 [‐48.09, 27.36] |
| 2.5.1 Functional task training | 0 | 0 | Mean Difference (IV, Random, 95% CI) | Not estimable |
| 2.5.2 Functional task training + musculoskeletal | 2 | 105 | Mean Difference (IV, Random, 95% CI) | ‐10.36 [‐48.09, 27.36] |
| 2.5.3 Neurophysiological | 0 | 0 | Mean Difference (IV, Random, 95% CI) | Not estimable |
| 2.5.4 Neurophysiological + musculoskeletal | 0 | 0 | Mean Difference (IV, Random, 95% CI) | Not estimable |
| 2.5.5 Functional training + neurophysiological | 0 | 0 | Mean Difference (IV, Random, 95% CI) | Not estimable |
| 2.5.6 Functional training + neurophysiological + musculoskeletal | 0 | 0 | Mean Difference (IV, Random, 95% CI) | Not estimable |
| 2.5.7 Musculoskeletal | 0 | 0 | Mean Difference (IV, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 3.1 Independence in ADL scales Show forest plot | 7 | Std. Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 3.1.1 Includes functional training versus does not include functional training | 4 | 186 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.03 [‐0.37, 0.32] |
| 3.1.2 Includes neurophysiological versus does not include neurophysiological | 7 | 451 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.02 [‐0.26, 0.22] |
| 3.1.3 Includes musculoskeletal versus does not include musculoskeletal | 3 | 103 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.12 [‐0.58, 0.34] |
| 3.2 Motor function scales Show forest plot | 8 | Std. Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 3.2.1 Includes functional training versus does not include functional training | 4 | 188 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.16 [‐0.59, 0.28] |
| 3.2.2 Includes neurophysiological versus does not include neurophysiological | 8 | 506 | Std. Mean Difference (IV, Random, 95% CI) | 0.17 [‐0.05, 0.39] |
| 3.2.3 Includes musculoskeletal versus does not include musculoskeletal | 4 | 81 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.08 [‐0.53, 0.36] |
| 3.3 Balance (Berg Balance Scale) Show forest plot | 4 | Std. Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 3.3.1 Includes functional training versus does not include functional training | 2 | 36 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.16 [‐0.82, 0.51] |
| 3.3.2 Includes neurophysiological versus does not include neurophysiological | 4 | 83 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.01 [‐0.44, 0.43] |
| 3.3.3 Includes musculoskeletal versus does not include musculoskeletal | 2 | 36 | Std. Mean Difference (IV, Random, 95% CI) | 0.14 [‐0.52, 0.80] |
| 3.4 Gait velocity Show forest plot | 7 | Std. Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 3.4.1 Includes functional training versus does not include functional training | 3 | 144 | Std. Mean Difference (IV, Random, 95% CI) | 0.43 [‐0.37, 1.22] |
| 3.4.2 Includes neurophysiological versus does not include neurophysiological | 7 | 278 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.12 [‐0.95, 0.70] |
| 3.4.3 Includes musculoskeletal versus does not include musculoskeletal | 3 | 45 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.47 [‐1.67, 0.74] |
| 3.5 Length of stay Show forest plot | 3 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 3.5.1 Includes functional training versus does not include functional training | 1 | 53 | Mean Difference (IV, Random, 95% CI) | ‐13.00 [‐20.80, ‐5.20] |
| 3.5.2 Includes neurophysiological versus does not include neurophysiological | 3 | 141 | Mean Difference (IV, Random, 95% CI) | 11.36 [1.52, 21.19] |
| 3.5.3 Includes musculoskeletal versus does not include musculoskeletal | 2 | 88 | Mean Difference (IV, Random, 95% CI) | 8.71 [‐12.92, 30.34] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 4.1 Independence in ADL scales Show forest plot | 10 | 540 | Std. Mean Difference (IV, Random, 95% CI) | 0.58 [0.11, 1.04] |
| 4.1.1 Functional task training | 2 | 232 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.07 [‐0.33, 0.19] |
| 4.1.2 Functional task training + musculoskeletal | 4 | 178 | Std. Mean Difference (IV, Random, 95% CI) | 1.13 [0.44, 1.82] |
| 4.1.3 Neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 4.1.4 Neurophysiological + musculoskeletal | 1 | 26 | Std. Mean Difference (IV, Random, 95% CI) | 0.14 [‐0.63, 0.91] |
| 4.1.5 Functional training + neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 4.1.6 Functional training + neurophysiological + musculoskeletal | 1 | 78 | Std. Mean Difference (IV, Random, 95% CI) | 1.02 [0.54, 1.49] |
| 4.1.7 Musculoskeletal | 2 | 26 | Std. Mean Difference (IV, Random, 95% CI) | 0.09 [‐0.70, 0.89] |
| 4.2 Motor function scales Show forest plot | 10 | 1829 | Std. Mean Difference (IV, Random, 95% CI) | 1.06 [0.37, 1.75] |
| 4.2.1 Functional task training | 2 | 234 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.07 [‐0.33, 0.18] |
| 4.2.2 Functional task training + musculoskeletal | 5 | 1543 | Std. Mean Difference (IV, Random, 95% CI) | 2.07 [0.99, 3.15] |
| 4.2.3 Neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 4.2.4 Neurophysiological + musculoskeletal | 1 | 26 | Std. Mean Difference (IV, Random, 95% CI) | 0.10 [‐0.67, 0.87] |
| 4.2.5 Functional training + neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 4.2.6 Functional training + neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 4.2.7 Musculoskeletal | 2 | 26 | Std. Mean Difference (IV, Random, 95% CI) | 0.07 [‐0.91, 1.06] |
| 4.3 Balance (Berg Balance Scale) Show forest plot | 1 | 34 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.03 [‐0.70, 0.65] |
| 4.3.1 Functional task training | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 4.3.2 Functional task training + musculoskeletal | 1 | 34 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.03 [‐0.70, 0.65] |
| 4.3.3 Neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 4.3.4 Neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 4.3.5 Functional training + neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 4.3.6 Functional training + neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 4.3.7 Musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 4.4 Gait velocity Show forest plot | 3 | 271 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.06 [‐0.29, 0.18] |
| 4.4.1 Functional task training | 3 | 271 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.06 [‐0.29, 0.18] |
| 4.4.2 Functional task training + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 4.4.3 Neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 4.4.4 Neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 4.4.5 Functional training + neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 4.4.6 Functional training + neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 4.4.7 Musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 5.1 Independence in ADL scales Show forest plot | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.1.1 Functional task training | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.1.2 Functional task training + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.1.3 Neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.1.4 Neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.1.5 Functional training + neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.1.6 Functional training + neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.2 Motor function scales Show forest plot | 3 | 160 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.10 [‐0.42, 0.23] |
| 5.2.1 Functional task training | 1 | 23 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.16 [‐0.99, 0.66] |
| 5.2.2 Functional task training + musculoskeletal | 1 | 58 | Std. Mean Difference (IV, Random, 95% CI) | 0.00 [‐0.52, 0.52] |
| 5.2.3 Neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.2.4 Neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.2.5 Functional training + neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.2.6 Functional training + neurophysiological + musculoskeletal | 1 | 79 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.16 [‐0.65, 0.32] |
| 5.3 Balance (Berg Balance Scale) Show forest plot | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.3.1 Functional task training | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.3.2 Functional task training + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.3.3 Neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.3.4 Neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.3.5 Functional training + neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.3.6 Functional training + neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.4 Gait velocity Show forest plot | 5 | 214 | Std. Mean Difference (IV, Random, 95% CI) | 0.38 [0.10, 0.66] |
| 5.4.1 Functional task training | 1 | 9 | Std. Mean Difference (IV, Random, 95% CI) | 1.15 [‐0.34, 2.65] |
| 5.4.2 Functional task training + musculoskeletal | 3 | 96 | Std. Mean Difference (IV, Random, 95% CI) | 0.52 [0.11, 0.93] |
| 5.4.3 Neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.4.4 Neurophysiological + musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.4.5 Functional training + neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 5.4.6 Functional training + neurophysiological + musculoskeletal | 1 | 109 | Std. Mean Difference (IV, Random, 95% CI) | 0.19 [‐0.21, 0.58] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 6.1 Independence in ADL scales Show forest plot | 2 | Std. Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 6.1.1 Includes functional training versus does not include functional training | 1 | 30 | Std. Mean Difference (IV, Random, 95% CI) | 1.33 [0.52, 2.13] |
| 6.1.2 Includes neurophysiological versus does not include neurophysiological | 2 | 57 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.95 [‐1.67, ‐0.22] |
| 6.1.3 Includes musculoskeletal versus does not include musculoskeletal | 1 | 27 | Std. Mean Difference (IV, Random, 95% CI) | 0.58 [‐0.19, 1.36] |
| 6.2 Motor function scales Show forest plot | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 6.2.1 Includes functional training versus does not include functional training | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 6.2.2 Includes neurophysiological versus does not include neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 6.2.3 Includes musculoskeletal versus does not include musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 6.3 Balance (Berg Balance Scale) Show forest plot | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 6.3.1 Includes functional training versus does not include functional training | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 6.3.2 Includes neurophysiological versus does not include neurophysiological | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 6.3.3 Includes musculoskeletal versus does not include musculoskeletal | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 6.4 Gait velocity Show forest plot | 2 | Std. Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 6.4.1 Includes functional training versus does not include functional training | 1 | 30 | Std. Mean Difference (IV, Random, 95% CI) | 1.14 [0.36, 1.92] |
| 6.4.2 Includes neurophysiological versus does not include neurophysiological | 2 | 44 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.82 [‐1.60, ‐0.05] |
| 6.4.3 Includes musculoskeletal versus does not include musculoskeletal | 1 | 14 | Std. Mean Difference (IV, Random, 95% CI) | 0.33 [‐0.74, 1.40] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 7.1 Time after stroke Show forest plot | 28 | 3423 | Std. Mean Difference (IV, Random, 95% CI) | 0.78 [0.58, 0.97] |
| 7.1.1 < 30 days post stroke | 13 | 1195 | Std. Mean Difference (IV, Random, 95% CI) | 0.86 [0.61, 1.11] |
| 7.1.2 < 3 months post stroke | 1 | 70 | Std. Mean Difference (IV, Random, 95% CI) | 0.27 [‐0.20, 0.74] |
| 7.1.3 < 1 year post stroke | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 7.1.4 > 1 year post stroke | 3 | 295 | Std. Mean Difference (IV, Random, 95% CI) | 0.12 [‐0.29, 0.53] |
| 7.1.5 Time not stated | 11 | 1863 | Std. Mean Difference (IV, Random, 95% CI) | 0.89 [0.56, 1.22] |
| 7.2 Study geographical location Show forest plot | 28 | 3423 | Std. Mean Difference (IV, Random, 95% CI) | 0.78 [0.58, 0.97] |
| 7.2.1 Europe | 2 | 250 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.06 [‐0.30, 0.19] |
| 7.2.2 Australia | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 7.2.3 Asia: China | 26 | 3173 | Std. Mean Difference (IV, Random, 95% CI) | 0.85 [0.66, 1.04] |
| 7.2.4 Asia: other | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 7.2.5 North America | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 7.3 Dose of intervention Show forest plot | 28 | 3423 | Std. Mean Difference (IV, Random, 95% CI) | 0.78 [0.58, 0.97] |
| 7.3.1 > once/d, with total of 60 to 120 minutes | 8 | 711 | Std. Mean Difference (IV, Random, 95% CI) | 1.23 [1.01, 1.45] |
| 7.3.2 Once/d, 5 to 7×/wk, for 30 to 60 minutes | 12 | 1027 | Std. Mean Difference (IV, Random, 95% CI) | 0.77 [0.46, 1.08] |
| 7.3.3 2×/wk | 2 | 173 | Std. Mean Difference (IV, Random, 95% CI) | 0.32 [‐0.35, 0.98] |
| 7.3.4 1 to 11 visits (to assess/give exercises for self practice) | 2 | 250 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.06 [‐0.30, 0.19] |
| 7.3.5 Dose not stated | 4 | 1262 | Std. Mean Difference (IV, Random, 95% CI) | 0.62 [0.31, 0.92] |
| 7.4 Provider of intervention Show forest plot | 28 | 3423 | Std. Mean Difference (IV, Random, 95% CI) | 0.78 [0.58, 0.97] |
| 7.4.1 Physiotherapist | 2 | 250 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.06 [‐0.30, 0.19] |
| 7.4.2 Therapist | 5 | 1158 | Std. Mean Difference (IV, Random, 95% CI) | 0.79 [0.32, 1.26] |
| 7.4.3 Therapist + family | 6 | 429 | Std. Mean Difference (IV, Random, 95% CI) | 0.83 [0.47, 1.20] |
| 7.4.4 Nurse | 2 | 128 | Std. Mean Difference (IV, Random, 95% CI) | 0.93 [‐0.39, 2.24] |
| 7.4.5 Not stated | 13 | 1458 | Std. Mean Difference (IV, Random, 95% CI) | 0.87 [0.59, 1.15] |
| 7.5 Treatment components included Show forest plot | 28 | Std. Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 7.5.1 Contains functional training | 23 | 3055 | Std. Mean Difference (IV, Random, 95% CI) | 0.87 [0.66, 1.08] |
| 7.5.2 Contains neurophysiological | 15 | 2106 | Std. Mean Difference (IV, Random, 95% CI) | 0.87 [0.61, 1.14] |
| 7.5.3 Contains musculoskeletal | 24 | 3033 | Std. Mean Difference (IV, Random, 95% CI) | 0.85 [0.65, 1.05] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 8.1 Time after stroke Show forest plot | 6 | 260 | Std. Mean Difference (IV, Random, 95% CI) | 0.04 [‐0.27, 0.35] |
| 8.1.1 < 30 days post stroke | 2 | 129 | Std. Mean Difference (IV, Random, 95% CI) | 0.42 [0.07, 0.77] |
| 8.1.2 < 3 months post stroke | 3 | 66 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.20 [‐0.71, 0.31] |
| 8.1.3 < 1 year post stroke | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 8.1.4 > 1 year post stroke | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 8.1.5 Time not stated | 1 | 65 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.19 [‐0.68, 0.30] |
| 8.2 Study geographical location Show forest plot | 6 | 260 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.11 [‐0.14, 0.36] |
| 8.2.1 Europe | 2 | 81 | Std. Mean Difference (IV, Fixed, 95% CI) | ‐0.17 [‐0.62, 0.27] |
| 8.2.2 Australia | 1 | 30 | Std. Mean Difference (IV, Fixed, 95% CI) | ‐0.47 [‐1.24, 0.31] |
| 8.2.3 Asia: China | 1 | 106 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.53 [0.14, 0.92] |
| 8.2.4 Asia: other | 0 | 0 | Std. Mean Difference (IV, Fixed, 95% CI) | Not estimable |
| 8.2.5 North America | 2 | 43 | Std. Mean Difference (IV, Fixed, 95% CI) | ‐0.02 [‐0.63, 0.60] |
| 8.3 Dose of intervention Show forest plot | 6 | 260 | Std. Mean Difference (IV, Random, 95% CI) | 0.04 [‐0.27, 0.35] |
| 8.3.1 > once/d, with total of 60 to 120 minutes | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 8.3.2 Once/d, 5 to 7×/wk, for 30 to 60 minutes | 2 | 46 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.34 [‐0.96, 0.29] |
| 8.3.3 2 to 3×/wk | 2 | 85 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.13 [‐0.55, 0.30] |
| 8.3.4 1 to 11 visits (to assess/give exercises for self practice) | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 8.3.5 Dose not stated | 2 | 129 | Std. Mean Difference (IV, Random, 95% CI) | 0.42 [0.07, 0.77] |
| 8.4 Provider of intervention Show forest plot | 6 | 260 | Std. Mean Difference (IV, Random, 95% CI) | 0.04 [‐0.27, 0.35] |
| 8.4.1 Physiotherapist | 4 | 124 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.12 [‐0.48, 0.24] |
| 8.4.2 Bobath‐trained physiotherapist | 1 | 30 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.47 [‐1.24, 0.31] |
| 8.4.3 Not stated | 1 | 106 | Std. Mean Difference (IV, Random, 95% CI) | 0.53 [0.14, 0.92] |
| 8.5 Treatment components included Show forest plot | 6 | Std. Mean Difference (IV, Fixed, 95% CI) | Subtotals only | |
| 8.5.1 Contains functional training | 6 | 244 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.12 [‐0.14, 0.37] |
| 8.5.2 Contains neurophysiological | 3 | 54 | Std. Mean Difference (IV, Fixed, 95% CI) | ‐0.11 [‐0.64, 0.43] |
| 8.5.3 Contains musculoskeletal | 4 | 208 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.21 [‐0.07, 0.48] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 9.1 Time after stroke Show forest plot | 27 | 4558 | Std. Mean Difference (IV, Random, 95% CI) | 0.81 [0.58, 1.04] |
| 9.1.1 < 30 days post stroke | 15 | 2635 | Std. Mean Difference (IV, Random, 95% CI) | 0.68 [0.47, 0.89] |
| 9.1.2 < 3 months post stroke | 1 | 70 | Std. Mean Difference (IV, Random, 95% CI) | 0.32 [‐0.15, 0.79] |
| 9.1.3 < 1 year post stroke | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 9.1.4 > 1 year post stroke | 2 | 250 | Std. Mean Difference (IV, Random, 95% CI) | 0.14 [‐0.31, 0.58] |
| 9.1.5 Time not stated | 9 | 1603 | Std. Mean Difference (IV, Random, 95% CI) | 1.26 [0.65, 1.88] |
| 9.2 Study geographical location Show forest plot | 27 | 4558 | Std. Mean Difference (IV, Random, 95% CI) | 0.81 [0.58, 1.04] |
| 9.2.1 Europe | 2 | 250 | Std. Mean Difference (IV, Random, 95% CI) | 0.14 [‐0.31, 0.58] |
| 9.2.2 Australia | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 9.2.3 Asia: China | 25 | 4308 | Std. Mean Difference (IV, Random, 95% CI) | 0.87 [0.63, 1.10] |
| 9.2.4 Asia: other | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 9.2.5 North America | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 9.3 Dose of intervention Show forest plot | 27 | 4558 | Std. Mean Difference (IV, Random, 95% CI) | 0.81 [0.58, 1.04] |
| 9.3.1 > once/d, with total of 60 to 120 minutes | 4 | 434 | Std. Mean Difference (IV, Random, 95% CI) | 1.31 [0.98, 1.64] |
| 9.3.2 Once/d, 5 to 7×/wk, for 30 to 60 minutes | 13 | 1084 | Std. Mean Difference (IV, Random, 95% CI) | 0.89 [0.35, 1.44] |
| 9.3.3 2×/wk | 3 | 289 | Std. Mean Difference (IV, Random, 95% CI) | 0.80 [0.08, 1.52] |
| 9.3.4 1 to 11 visits (to assess/give exercises for self practice) | 2 | 250 | Std. Mean Difference (IV, Random, 95% CI) | 0.14 [‐0.31, 0.58] |
| 9.3.5 Dose not stated | 5 | 2501 | Std. Mean Difference (IV, Random, 95% CI) | 0.52 [0.32, 0.71] |
| 9.4 Provider of intervention Show forest plot | 27 | 4558 | Std. Mean Difference (IV, Random, 95% CI) | 0.81 [0.58, 1.04] |
| 9.4.1 Physiotherapist | 2 | 250 | Std. Mean Difference (IV, Random, 95% CI) | 0.14 [‐0.31, 0.58] |
| 9.4.2 Therapist | 7 | 1356 | Std. Mean Difference (IV, Random, 95% CI) | 0.74 [0.45, 1.03] |
| 9.4.3 Therapist + family | 2 | 152 | Std. Mean Difference (IV, Random, 95% CI) | 1.13 [0.78, 1.47] |
| 9.4.4 Nurse | 3 | 308 | Std. Mean Difference (IV, Random, 95% CI) | 2.08 [‐0.27, 4.43] |
| 9.4.5 Not stated | 13 | 2492 | Std. Mean Difference (IV, Random, 95% CI) | 0.65 [0.43, 0.87] |
| 9.5 Treatment components included Show forest plot | 27 | Std. Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 9.5.1 Contains functional training | 24 | 4330 | Std. Mean Difference (IV, Random, 95% CI) | 0.88 [0.64, 1.13] |
| 9.5.2 Contains neurophysiological | 13 | 2033 | Std. Mean Difference (IV, Random, 95% CI) | 0.76 [0.54, 0.98] |
| 9.5.3 Contains musculoskeletal | 24 | 4240 | Std. Mean Difference (IV, Random, 95% CI) | 0.84 [0.60, 1.08] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 10.1 Time after stroke Show forest plot | 13 | 967 | Std. Mean Difference (IV, Random, 95% CI) | 0.42 [0.24, 0.61] |
| 10.1.1 < 30 days post stroke | 3 | 171 | Std. Mean Difference (IV, Random, 95% CI) | 0.60 [0.29, 0.91] |
| 10.1.2 < 3 months post stroke | 4 | 291 | Std. Mean Difference (IV, Random, 95% CI) | 0.52 [0.23, 0.82] |
| 10.1.3 < 1 year post stroke | 3 | 313 | Std. Mean Difference (IV, Random, 95% CI) | 0.35 [‐0.04, 0.74] |
| 10.1.4 > 1 year post stroke | 1 | 58 | Std. Mean Difference (IV, Random, 95% CI) | 0.00 [‐0.52, 0.52] |
| 10.1.5 Time not stated | 2 | 134 | Std. Mean Difference (IV, Random, 95% CI) | 0.26 [‐0.61, 1.13] |
| 10.2 Study geographical location Show forest plot | 13 | 967 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.42 [0.29, 0.55] |
| 10.2.1 Europe | 3 | 405 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.26 [0.06, 0.46] |
| 10.2.2 Australia | 2 | 79 | Std. Mean Difference (IV, Fixed, 95% CI) | ‐0.09 [‐0.53, 0.36] |
| 10.2.3 Asia: China | 5 | 348 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.72 [0.50, 0.94] |
| 10.2.4 Asia: other | 0 | 0 | Std. Mean Difference (IV, Fixed, 95% CI) | Not estimable |
| 10.2.5 North America | 3 | 135 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.45 [0.10, 0.79] |
| 10.3 Dose of intervention Show forest plot | 13 | 967 | Std. Mean Difference (IV, Random, 95% CI) | 0.42 [0.24, 0.61] |
| 10.3.1 > once/d, with total of 60 to 120 minutes | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 10.3.2 Once/d, 5 to 7×/wk, for 30 to 60 minutes | 4 | 242 | Std. Mean Difference (IV, Random, 95% CI) | 0.83 [0.57, 1.09] |
| 10.3.3 3 to 4×/wk | 4 | 269 | Std. Mean Difference (IV, Random, 95% CI) | 0.29 [0.04, 0.53] |
| 10.3.4 2×/wk | 3 | 327 | Std. Mean Difference (IV, Random, 95% CI) | 0.05 [‐0.44, 0.53] |
| 10.3.5 Dose not stated | 2 | 129 | Std. Mean Difference (IV, Random, 95% CI) | 0.46 [0.11, 0.82] |
| 10.4 Provider of intervention Show forest plot | 13 | 967 | Std. Mean Difference (IV, Random, 95% CI) | 0.42 [0.24, 0.61] |
| 10.4.1 Physiotherapist | 8 | 619 | Std. Mean Difference (IV, Random, 95% CI) | 0.25 [0.09, 0.42] |
| 10.4.2 Therapist | 2 | 112 | Std. Mean Difference (IV, Random, 95% CI) | 0.84 [0.45, 1.23] |
| 10.4.3 Nurse | 1 | 50 | Std. Mean Difference (IV, Random, 95% CI) | 0.65 [0.08, 1.22] |
| 10.4.4 Not stated | 2 | 186 | Std. Mean Difference (IV, Random, 95% CI) | 0.69 [0.25, 1.14] |
| 10.5 Treatment components included Show forest plot | 13 | Std. Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 10.5.1 Contains functional training | 11 | 827 | Std. Mean Difference (IV, Random, 95% CI) | 0.36 [0.16, 0.55] |
| 10.5.2 Contains neurophysiological | 8 | 467 | Std. Mean Difference (IV, Random, 95% CI) | 0.61 [0.40, 0.81] |
| 10.5.3 Contains musculoskeletal | 10 | 818 | Std. Mean Difference (IV, Random, 95% CI) | 0.36 [0.20, 0.52] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 11.1 Functional task training components Show forest plot | 4 | Std. Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 11.1.1 Described as motor relearning programme | 2 | 152 | Std. Mean Difference (IV, Random, 95% CI) | 0.05 [‐0.50, 0.60] |
| 11.1.2 One functional treatment component | 1 | 15 | Std. Mean Difference (IV, Random, 95% CI) | 0.15 [‐0.88, 1.19] |
| 11.1.3 > 1 functional treatment component | 1 | 19 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.46 [‐1.38, 0.45] |
| 11.2 Neurophysiological components Show forest plot | 6 | Std. Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 11.2.1 Described as Bobath | 5 | 325 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.07 [‐0.41, 0.26] |
| 11.2.2 Describes interventions that may be Bobath | 2 | 46 | Std. Mean Difference (IV, Random, 95% CI) | 0.05 [‐0.66, 0.76] |
| 11.2.3 Proprioceptive neuromuscular facilitation (PNF) | 1 | 61 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.42 [‐0.92, 0.09] |
| 11.2.4 Sensorimotor facilitation | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 11.3 Musculoskeletal components Show forest plot | 3 | Std. Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 11.3.1 Active movement + muscle strengthening | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 11.3.2 Active and active‐assisted movement | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 11.3.3 Muscle strengthening | 2 | 42 | Std. Mean Difference (IV, Random, 95% CI) | 0.23 [‐0.39, 0.84] |
| 11.3.4 Passive only | 1 | 61 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.42 [‐0.92, 0.09] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 12.1 Functional task training components Show forest plot | 4 | Std. Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 12.1.1 Described as motor relearning programme | 2 | 152 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.08 [‐0.75, 0.60] |
| 12.1.2 One functional treatment component | 1 | 15 | Std. Mean Difference (IV, Random, 95% CI) | 0.12 [‐0.91, 1.16] |
| 12.1.3 > 1 functional treatment component | 1 | 21 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.64 [‐1.52, 0.24] |
| 12.2 Neurophysiological components Show forest plot | 8 | Std. Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 12.2.1 Described as Bobath | 6 | 383 | Std. Mean Difference (IV, Random, 95% CI) | 0.13 [‐0.10, 0.36] |
| 12.2.2 Describes interventions that may be Bobath | 4 | 162 | Std. Mean Difference (IV, Random, 95% CI) | 0.27 [‐0.12, 0.66] |
| 12.2.3 Proprioceptive neuromuscular facilitation (PNF) | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 12.2.4 Sensorimotor facilitation | 1 | 18 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.04 [‐0.97, 0.88] |
| 12.3 Musculoskeletal components Show forest plot | 4 | Std. Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 12.3.1 Active movement + muscle strengthening | 1 | 21 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.64 [‐1.52, 0.24] |
| 12.3.2 Active and active‐assisted movement | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
| 12.3.3 Muscle strengthening | 3 | 60 | Std. Mean Difference (IV, Random, 95% CI) | 0.10 [‐0.41, 0.62] |
| 12.3.4 Passive only | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | Not estimable |
