Trends in stroke survival incidence rates in older Australians in the new millennium and forecasts into the future

Comparing the Effectiveness of Physical Rehabilitation Interventions for Post-Stroke Function and Mobility Recovery: A Meta-Analysis

Various interventions to physical rehabilitation have been used after stroke, including musculoskeletal, neurophysiological, and motor learning interventions, with ongoing debates and controversies about their relative effectiveness. In this systematic review, we searched 3 international electronic databases (MEDLINE, Embase, and Cochrane Library) to identify relevant studies. We included only randomized controlled trials (RCTs) that directly compared motor relearning, neurophysiological, and musculoskeletal interventions for improving motor function in adult stroke patients. Risk of bias (RoB) assessment was performed using Cochrane's RoB tool, and meta-analysis was conducted using Revman 5.4 with a random effects model. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations method. The meta-analysis for immediate outcome for physical rehabilitation included 9 RCTs for balance, 10 RCTs for gait velocity, 7 RCTs for lower extremity motor function and 8 RCTs for performance of activities of daily living. There was no statistically significant different on improvement of balance, gait velocity, lower extremity motor function and performance of activity among physical rehabilitation interventions. Moderate-level evidence supports that no single intervention is superior. Clinicians and therapist should consider individual patient characteristics, preferences, and available resources when selecting the intervention for stroke rehabilitation.

An Efficient Bedside Measure Yields Prognostic Implications for Language Recovery in Acute Stroke Patients

BACKGROUND

It is estimated that ∼30% of stroke survivors have aphasia, a language disorder resulting from damage to left-hemisphere language networks. In acute care settings, efficient identification of aphasia is critical, but there is a paucity of efficient bedside assessments.

OBJECTIVE

To determine whether objective measures on a picture description task administered within 48 hours post stroke (a) predict language recovery, (b) estimate left-hemisphere lesion volume and location, and (c) correlate with other bedside language assessments.

METHOD

Behavioral data were scored at acute and chronic time points. Neuroimaging data were used to determine associations between the picture description task, other language assessments, and lesion volume and location.

RESULTS

Acute content units, age, and total lesion volume predicted communication recovery; F3,18 = 3.98, P = 0.024; r = 0.40. Significant correlations were found between the picture description task and lesion volume and location. Picture description outcomes were also associated with other clinical language assessments.

DISCUSSION

This picture description task quickly predicted the language performance (communication recovery and outcome) for patients who suffered a left-hemisphere stroke. Picture description task measures correlated with damage in the left hemisphere and with other, more time-consuming and cumbersome language assessments that are typically administered acutely at bedside.

CONCLUSION

The predictive value of this picture description task and correlations with existing language assessments substantiate the clinical importance of a reliable yet rapid bedside measure for acute stroke patients that can be administered by a variety of health care professionals.

Clinical Implementation of Transcranial Direct Current Stimulation in Aphasia: A Survey of Speech-Language Pathologists

Purpose The objectives of this study are to (a) identify speech-language pathologists' (SLPs') familiarity with transcranial direct current stimulation (tDCS), (b) quantify what SLPs consider necessary tDCS-related improvement in aphasia severity (i.e., tDCS enhancement; desired improvement above and beyond traditional behavioral therapy) to implement this adjuvant therapy for the clinical management of aphasia, and (c) identify concerns that could potentially hinder the clinical adoption of tDCS. Method A brief (14-question) survey was disseminated via e-mail and social media outlets targeting SLPs working with individuals with aphasia. Results Two hundred twenty-one individuals responded, and 155 valid surveys were analyzed. Seventy-one percent of participants reported familiarity with tDCS prior to taking the survey. Clinicians reported a desired mean enhancement of 22.9% additional points on the Western Aphasia Battery-Revised Aphasia Quotient. Importantly, 94.2% of SLPs reported concerns regarding the implementation of tDCS in clinical settings (i.e., safety, cost, administrative approval, reimbursement and training). Conclusions This is the first study to identify SLPs' perspectives regarding the clinical adoption of tDCS. Results suggest the majority of queried SLPs were familiar with tDCS prior to taking the survey. Although SLPs report a desired improvement of approximately 23% additional points on the Western Aphasia Battery-Revised Aphasia Quotient to consider adopting tDCS into practice, many SLPs reported concerns regarding clinical adoption. Responses from the current survey offer important preliminary evidence to begin bridging the research-to-practice gap as it relates to the clinical implementation of tDCS. Relatedly, these results will inform future clinical trials.

Prevalence and Impact of Aphasia among Patients Admitted with Acute Ischemic Stroke

OBJECTIVE

Aphasia is one of the most severe symptoms in stroke patients, affecting one-third of acute stroke patients. We aimed to investigate the prevalence and outcomes of aphasia in patients with acute ischemic stroke (AIS).

METHODS

We computed the weighted prevalence of aphasia in AIS patients using the 2003 to 2014 National Inpatient Sample databases. Crude regression model, multivariable regression model, and propensity score matching were used to evaluate the impact of aphasia on the clinical outcomes in AIS patients. We performed the Subpopulation Treatment Effect Pattern Plot (STEPP) analyses in propensity score matching cohort to visually display the effect of interaction between aphasia and age on the clinical outcomes.

RESULTS

A total of 16.93% of 4,339,156 AIS patients identified were with aphasia. The proportion of patients with comorbid aphasia increased from 13.34% in 2003 to 21.94% in 2014 (P < .0001). The results of both multivariable regression model and propensity score matching analyses indicated aphasia in AIS as a risk factor for in-hospital deaths. Aphasia was linked to prolonged length of stay (0.66 day, P < .0001) and high hospitalization cost ($971.35, P < .0001). In the STEPP analyses, in-hospital mortality rate increased with age, and the rate was higher in patients with aphasia, but the ratios decreased with an increase in age.

CONCLUSIONS

Prevalence of comorbid aphasia with AIS is increasing, and it has a significant impact on clinical outcomes. Additionally, aphasia shows a greater impact on survival and medical burden among young patients with AIS.

Rehabilitation interventions for improving balance following stroke: An overview of systematic reviews

Background

The aim of this study was to synthesize evidence from systematic reviews, to summarise the effects of rehabilitation interventions for improving balance in stroke survivors.

Methods

We conducted an overview of systematic reviews (SRs). We included Cochrane Systematic Reviews and non-Cochrane Systematic Reviews of randomized-controlled clinical trials and not-randomized clinical trials, in all types of stroke, comparing the effects of interventions, control interventions and no interventions on balance-related outcomes. We conducted a comprehensive search of electronic databases, from inception to December 2017. Data extracted included: number and type of participants, type of intervention, control intervention, method of assessing risk of bias of primary studies, balance outcome measures and results of statistical meta-analyses. Methodological quality of included reviews was assessed using AMSTAR 2. A narrative description of the characteristics of the SRs was provided and results of meta-analyses summarised with reference to their methodological quality.

Results

51 SRs (248 primary studies and 10,638 participants) met the inclusion criteria and were included in the overview. All participants were adults with stroke. A wide variety of different balance and postural control outcomes were included. 61% of SRs focussed on the effectiveness of physical therapy, 20% virtual reality, 6% electromechanical devices, 4% Tai-Chi, whole body vibration and circuit training intervention, and 2% cognitive rehabilitation. The methodology of 54% of SRs were judged to be of a “low or critically low” quality, 23% “moderate” quality and 22% “high” quality.

Conclusions

There are 51 SRs of evidence relating to the effectiveness of interventions to improve balance in people with stroke, but the majority of these are of poor methodological quality, limiting our ability to draw clear implications. Only 22% of these SRs were judged to be of high quality, highlighting the need to address important methodological issues within rehabilitation research.

Mirror therapy for improving lower limb motor function and mobility after stroke: A systematic review and meta-analysis

BACKGROUND

Mirror therapy has been proposed as an effective intervention for lower limb rehabilitation post stroke.

RESEARCH QUESTION

This systematic review with meta-analysis examined if lower limb mirror therapy improved the primary outcome measures of muscle tone and motor function and the secondary outcome measures balance characteristics, functional ambulation, walking velocity, passive range of motion (PROM) for ankle dorsiflexion and gait characteristics in patients with stroke compared to other interventions.

METHODS

Standardised mean differences (SMD) and mean differences (MD) were used to assess the effect of mirror therapy on lower limb functioning.

RESULTS

Nine studies were included in the review. Among the primary outcome measures there was evidence of a significant effect of mirror therapy on motor function compared with sham and non-sham interventions (SMD 0.54; 95% CI 0.24-0.93). Furthermore, among the secondary outcome measures there was evidence of a significant effect of mirror therapy for balance capacity (SMD -0.55; 95% CI -1.01 to -0.10), walking velocity (SMD 0.71; 95% CI 0.35-1.07), PROM for ankle dorsiflexion (SMD 1.20; 95% CI 0.71-1.69) and step length (SMD 0.56; 95% CI -0.00 to 1.12).

SIGNIFICANCE

The results indicate that using mirror therapy for the treatment of certain lower limb deficits in patients with stroke may have a positive effect. Although results are somewhat positive, overly favourable interpretation is cautioned due to methodological issues concerning included studies.

Intensive speech and language therapy in patients with chronic aphasia after stroke: a randomised, open-label, blinded-endpoint, controlled trial in a health-care setting

BACKGROUND

Treatment guidelines for aphasia recommend intensive speech and language therapy for chronic (≥6 months) aphasia after stroke, but large-scale, class 1 randomised controlled trials on treatment effectiveness are scarce. We aimed to examine whether 3 weeks of intensive speech and language therapy under routine clinical conditions improved verbal communication in daily-life situations in people with chronic aphasia after stroke.

METHODS

In this multicentre, parallel group, superiority, open-label, blinded-endpoint, randomised controlled trial, patients aged 70 years or younger with aphasia after stroke lasting for 6 months or more were recruited from 19 inpatient or outpatient rehabilitation centres in Germany. An external biostatistician used a computer-generated permuted block randomisation method, stratified by treatment centre, to randomly assign participants to either 3 weeks or more of intensive speech and language therapy (≥10 h per week) or 3 weeks deferral of intensive speech and language therapy. The primary endpoint was between-group difference in the change in verbal communication effectiveness in everyday life scenarios (Amsterdam-Nijmegen Everyday Language Test A-scale) from baseline to immediately after 3 weeks of treatment or treatment deferral. All analyses were done using the modified intention-to-treat population (those who received 1 day or more of intensive treatment or treatment deferral). This study is registered with ClinicalTrials.gov, number NCT01540383.

FINDINGS

We randomly assigned 158 patients between April 1, 2012, and May 31, 2014. The modified intention-to-treat population comprised 156 patients (78 per group). Verbal communication was significantly improved from baseline to after intensive speech and language treatment (mean difference 2·61 points [SD 4·94]; 95% CI 1·49 to 3·72), but not from baseline to after treatment deferral (-0·03 points [4·04]; -0·94 to 0·88; between-group difference Cohen's d 0·58; p=0·0004). Eight patients had adverse events during therapy or treatment deferral (one car accident [in the control group], two common cold [one patient per group], three gastrointestinal or cardiac symptoms [all intervention group], two recurrent stroke [one in intervention group before initiation of treatment, and one before group assignment had occurred]); all were unrelated to study participation.

INTERPRETATION

3 weeks of intensive speech and language therapy significantly enhanced verbal communication in people aged 70 years or younger with chronic aphasia after stroke, providing an effective evidence-based treatment approach in this population. Future studies should examine the minimum treatment intensity required for meaningful treatment effects, and determine whether treatment effects cumulate over repeated intervention periods.

FUNDING

German Federal Ministry of Education and Research and the German Society for Aphasia Research and Treatment.

Modeling of in hospital mortality determinants in myocardial infarction patients, with and without stroke: A national study in Iran

Background:

The data and determinants of mortality due to stroke in myocardial infarction (MI) patients are unknown. This study was conducted to evaluate the differences in risk factors for hospital mortality among MI patients with and without stroke history.

Materials and Methods:

This study was a retrospective, cohort study; 20,750 new patients with MI from April, 2012 to March, 2013 were followed up and their data were analyzed according to having or not having the stroke history. Stroke and MI were defined based on the World Health Organization's definition. The data were analyzed by logistic regression in STATA software.

Results:

Of the 20,750 studied patients, 4293 had stroke history. The prevalence of stroke in the studied population was derived 20.96% (confidence interval [CI] 95%: 20.13–21.24). Of the patients, 2537 (59.1%) had ST-elevation MI (STEMI). Mortality ratio in patients with and without stroke was obtained 18.8% and 10.3%, respectively. The prevalence of risk factors in MI patients with and without a stroke is various. The adjusted odds ratio of mortality in patients with stroke history was derived 7.02 (95% CI: 5.42–9) for chest pain resistant to treatment, 2.39 (95% CI: 1.97–2.9) for STEMI, 3.02 (95% CI: 2.5–3.64) for lack of thrombolytic therapy, 2.2 (95% CI: 1.66–2.91) for heart failure, and 2.17 (95% CI: 1.6–2.9) for ventricular tachycardia.

Conclusion:

With regards to the factors associated with mortality in this study, it is particularly necessary to control the mortality in MI patients with stroke history. More emphasis should be placed on the MI patients with the previous stroke over those without in the interventions developed for prevention and treatment, and for the prevention of avoidable mortalities.

The Course of Activities in Daily Living: Who Is at Risk for Decline after First Ever Stroke?

Background: Stroke is not only an acute disease, but for the majority of patients, it also becomes a chronic condition. There is a major concern about the long-term follow-up with respect to activities of daily living (ADL) in stroke survivors. Some patients seem to be at risk for decline after a first-ever stroke. The purpose of this study was to determine the course of ADL from 3 months after the first-ever stroke and onward and identify factors associated with decline in ADL. Methods: A systematic literature search of 3 electronic databases through June 2015 was conducted. Longitudinal studies evaluating changes in ADL from 3 months post stroke onward were included. Cohorts including recurrent strokes and transient ischemic attacks were excluded. Regarding the course of ADL, a meta-analysis was performed using random-effects model. A best evidence synthesis was performed to identify factors associated with decline in ADL. Results: Out of 10,473 publications, 28 unique studies were included. A small but significant improvement in ADL was found from 3 to 12 months post stroke (standardized mean difference (SMD) 0.17 (0.04-0.30)), which mainly seemed to occur between 3 and 6 months post stroke (SMD 0.15 (0.05-0.26)). From 1 to 3 years post stroke, no significant change was found. Five studies found a decline in ADL status over time in 12-40% of patients. Nine factors were associated with ADL decline. There is moderate evidence for being dependent in ADL and impaired motor function of the leg. Limited evidence was found associated with insurance status, living alone, age ≥80, inactive state and having impaired cognitive function, depression and fatigue with decline in ADL. Conclusion: Although on an average patients do not seem to decline in ADL for up to 3 years, there is considerable variation within the population. Some modifiable factors associated with decline in ADL were identified. However, more research is needed before patients at risk of deterioration in ADL can be identified.

30-Year Trends in Stroke Rates and Outcome in Auckland, New Zealand (1981-2012): A Multi-Ethnic Population-Based Series of Studies

Background

Insufficient data exist on population-based trends in morbidity and mortality to determine the success of prevention strategies and improvements in health care delivery in stroke. The aim of this study was to determine trends in incidence and outcome (1-year mortality, 28-day case-fatality) in relation to management and risk factors for stroke in the multi-ethnic population of Auckland, New Zealand (NZ) over 30-years.

Methods

Four stroke incidence population-based register studies were undertaken in adult residents (aged ≥15 years) of Auckland NZ in 1981–1982, 1991–1992, 2002–2003 and 2011–2012. All used standard World Health Organization (WHO) diagnostic criteria and multiple overlapping sources of case-ascertainment for hospitalised and non-hospitalised, fatal and non-fatal, new stroke events. Ethnicity was consistently self-identified into four major groups. Crude and age-adjusted (WHO world population standard) annual incidence and mortality with corresponding 95% confidence intervals (CI) were calculated per 100,000 people, assuming a Poisson distribution.

Results

5400 new stroke patients were registered in four 12 month recruitment phases over the 30-year study period; 79% were NZ/European, 6% Māori, 8% Pacific people, and 7% were of Asian or other origin. Overall stroke incidence and 1-year mortality decreased by 23% (95% CI 5%-31%) and 62% (95% CI 36%-86%), respectively, from 1981 to 2012. Whilst stroke incidence and mortality declined across all groups in NZ from 1991, Māori and Pacific groups had the slowest rate of decline and continue to experience stroke at a significantly younger age (mean ages 60 and 62 years, respectively) compared with NZ/Europeans (mean age 75 years). There was also a decline in 28-day stroke case fatality (overall by 14%, 95% CI 11%-17%) across all ethnic groups from 1981 to 2012. However, there were significant increases in the frequencies of pre-morbid hypertension, myocardial infarction, and diabetes mellitus, but a reduction in frequency of current smoking among stroke patients.

Conclusions

In this unique temporal series of studies spanning 30 years, stroke incidence, early case-fatality and 1-year mortality have declined, but ethnic disparities in risk and outcome for stroke persisted suggesting that primary stroke prevention remains crucial to reducing the burden of this disease.

User involvement in a Cochrane systematic review: using structured methods to enhance the clinical relevance, usefulness and usability of a systematic review update

BACKGROUND

This paper describes the structured methods used to involve patients, carers and health professionals in an update of a Cochrane systematic review relating to physiotherapy after stroke and explores the perceived impact of involvement.

METHODS

We sought funding and ethical approval for our user involvement. We recruited a stakeholder group comprising stroke survivors, carers, physiotherapists and educators and held three pre-planned meetings during the course of updating a Cochrane systematic review. Within these meetings, we used formal group consensus methods, based on nominal group techniques, to reach consensus decisions on key issues relating to the structure and methods of the review.

RESULTS

The stakeholder group comprised 13 people, including stroke survivors, carers and physiotherapists with a range of different experience, and either 12 or 13 participated in each meeting. At meeting 1, there was consensus that methods of categorising interventions that were used in the original Cochrane review were no longer appropriate or clinically relevant (11/13 participants disagreed or strongly disagreed with previous categories) and that international trials (which had not fitted into the original method of categorisation) ought to be included within the review (12/12 participants agreed or strongly agreed these should be included). At meeting 2, the group members reached consensus over 27 clearly defined treatment components, which were to be used to categorise interventions within the review (12/12 agreed or strongly agreed), and at meeting 3, they agreed on the key messages emerging from the completed review. All participants strongly agreed that the views of the group impacted on the review update, that the review benefited from the involvement of the stakeholder group, and that they believed other Cochrane reviews would benefit from the involvement of similar stakeholder groups.

CONCLUSIONS

We involved a stakeholder group in the update of a Cochrane systematic review, using clearly described structured methods to reach consensus decisions. The involvement of stakeholders impacted substantially on the review, with the inclusion of international studies, and changes to classification of treatments, comparisons and subgroup comparisons explored within the meta-analysis. We argue that the structured approach which we adopted has implications for other systematic reviews.

Physical rehabilitation approaches for the recovery of function and mobility following stroke

BACKGROUND

Various approaches to physical rehabilitation may be used after stroke, and considerable controversy and debate surround the effectiveness of relative approaches. Some physiotherapists base their treatments on a single approach; others use a mixture of components from several different approaches.

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 previous versions of this review, 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 individual treatment components, 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.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 12, 2012), MEDLINE (1966 to December 2012), EMBASE (1980 to December 2012), AMED (1985 to December 2012) and CINAHL (1982 to December 2012). We searched reference lists and contacted experts and researchers who have an interest in stroke rehabilitation.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke. Outcomes included measures of independence in activities of daily living (ADL), motor function, balance, gait velocity and length of stay. We included trials comparing physical rehabilitation approaches versus no treatment, usual care or attention control and those comparing different physical rehabilitation approaches.

DATA COLLECTION AND ANALYSIS

Two review authors independently categorised identified trials according to the selection criteria, documented their methodological quality and extracted the data.

MAIN RESULTS

We included a total of 96 studies (10,401 participants) in this review. More than half of the studies (50/96) were carried out in China. Generally the studies were heterogeneous, and many were poorly reported.Physical rehabilitation was found to have a beneficial effect, as compared with no treatment, on functional recovery after stroke (27 studies, 3423 participants; standardised mean difference (SMD) 0.78, 95% confidence interval (CI) 0.58 to 0.97, for Independence in ADL scales), and this effect was noted to persist beyond the length of the intervention period (nine studies, 540 participants; SMD 0.58, 95% CI 0.11 to 1.04). Subgroup analysis revealed a significant difference based on dose of intervention (P value < 0.0001, for independence in ADL), indicating that a dose of 30 to 60 minutes per day delivered five to seven days per week is effective. This evidence principally arises from studies carried out in China. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.003, for independence in ADL).We found physical rehabilitation to be more effective than usual care or attention control in improving motor function (12 studies, 887 participants; SMD 0.37, 95% CI 0.20 to 0.55), balance (five studies, 246 participants; SMD 0.31, 95% CI 0.05 to 0.56) and gait velocity (14 studies, 1126 participants; SMD 0.46, 95% CI 0.32 to 0.60). Subgroup analysis demonstrated a significant difference based on dose of intervention (P value 0.02 for motor function), indicating that a dose of 30 to 60 minutes delivered five to seven days a week provides significant benefit. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.05, for independence in ADL).No one physical rehabilitation approach was more (or less) effective than any other approach in improving independence in ADL (eight studies, 491 participants; test for subgroup differences: P value 0.71) or motor function (nine studies, 546 participants; test for subgroup differences: P value 0.41). These findings are supported by subgroup analyses carried out for comparisons of intervention versus no treatment or usual care, which identified no significant effects of different treatment components or categories of interventions.

AUTHORS' CONCLUSIONS

Physical rehabilitation, comprising a selection of components from different approaches, is effective for recovery of function and mobility after stroke. Evidence related to dose of physical therapy is limited by substantial heterogeneity and does not support robust conclusions. No one approach to physical rehabilitation is any more (or less) effective in promoting recovery of function and mobility after stroke. Therefore, evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin.

Physical rehabilitation approaches for the recovery of function and mobility following stroke

BACKGROUND

Various approaches to physical rehabilitation may be used after stroke, and considerable controversy and debate surround the effectiveness of relative approaches. Some physiotherapists base their treatments on a single approach; others use a mixture of components from several different approaches.

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 previous versions of this review, 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 individual treatment components, 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.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 12, 2012), MEDLINE (1966 to December 2012), EMBASE (1980 to December 2012), AMED (1985 to December 2012) and CINAHL (1982 to December 2012). We searched reference lists and contacted experts and researchers who have an interest in stroke rehabilitation.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke. Outcomes included measures of independence in activities of daily living (ADL), motor function, balance, gait velocity and length of stay. We included trials comparing physical rehabilitation approaches versus no treatment, usual care or attention control and those comparing different physical rehabilitation approaches.

DATA COLLECTION AND ANALYSIS

Two review authors independently categorised identified trials according to the selection criteria, documented their methodological quality and extracted the data.

MAIN RESULTS

We included a total of 96 studies (10,401 participants) in this review. More than half of the studies (50/96) were carried out in China. Generally the studies were heterogeneous, and many were poorly reported.Physical rehabilitation was found to have a beneficial effect, as compared with no treatment, on functional recovery after stroke (27 studies, 3423 participants; standardised mean difference (SMD) 0.78, 95% confidence interval (CI) 0.58 to 0.97, for Independence in ADL scales), and this effect was noted to persist beyond the length of the intervention period (nine studies, 540 participants; SMD 0.58, 95% CI 0.11 to 1.04). Subgroup analysis revealed a significant difference based on dose of intervention (P value < 0.0001, for independence in ADL), indicating that a dose of 30 to 60 minutes per day delivered five to seven days per week is effective. This evidence principally arises from studies carried out in China. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.003, for independence in ADL).We found physical rehabilitation to be more effective than usual care or attention control in improving motor function (12 studies, 887 participants; SMD 0.37, 95% CI 0.20 to 0.55), balance (five studies, 246 participants; SMD 0.31, 95% CI 0.05 to 0.56) and gait velocity (14 studies, 1126 participants; SMD 0.46, 95% CI 0.32 to 0.60). Subgroup analysis demonstrated a significant difference based on dose of intervention (P value 0.02 for motor function), indicating that a dose of 30 to 60 minutes delivered five to seven days a week provides significant benefit. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.05, for independence in ADL).No one physical rehabilitation approach was more (or less) effective than any other approach in improving independence in ADL (eight studies, 491 participants; test for subgroup differences: P value 0.71) or motor function (nine studies, 546 participants; test for subgroup differences: P value 0.41). These findings are supported by subgroup analyses carried out for comparisons of intervention versus no treatment or usual care, which identified no significant effects of different treatment components or categories of interventions.

AUTHORS' CONCLUSIONS

Physical rehabilitation, comprising a selection of components from different approaches, is effective for recovery of function and mobility after stroke. Evidence related to dose of physical therapy is limited by substantial heterogeneity and does not support robust conclusions. No one approach to physical rehabilitation is any more (or less) effective in promoting recovery of function and mobility after stroke. Therefore, evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin.