Rehabilitation Effort to Improve Upper Extremity Function in Post-Stroke Patients: A Meta-Analysis

Bobath therapy is inferior to task-specific training and not superior to other interventions in improving arm activity and arm strength outcomes after stroke: a systematic review

QUESTION

What is the effect of Bobath therapy on arm activity and arm strength compared with a dose-matched comparison intervention or no intervention after stroke?

DESIGN

Systematic review of randomised trials with meta-analysis.

PARTICIPANTS

Adults after stroke.

INTERVENTION

Bobath therapy compared with no intervention or other interventions delivered at the same dose as the Bobath therapy.

OUTCOME MEASURES

Arm activity outcomes and arm strength outcomes. Trial quality was assessed with the PEDro scale.

RESULTS

Thirteen trials were included; all compared Bobath with another intervention, which were categorised as: task-specific training (five trials), arm movements (five trials), robotics (two trials) and mental practice (one trial). The PEDro scale scores ranged from 5 to 8. Pooled data from five trials indicated that Bobath therapy was less effective than task-specific training for improving arm activities (SMD -1.07, 95% CI -1.59 to -0.55). Pooled data from five trials indicated that Bobath therapy was similar to or less effective than arm movements for improving arm activities (SMD -0.18, 95% CI -0.44 to 0.09). One trial indicated that Bobath therapy was less effective than robotics for improving arm activities and one trial indicated similar effects of Bobath therapy and mental practice on arm activities. For strength outcomes, pooled data from two trials indicated a large benefit of task-specific training over Bobath therapy (SMD -1.08); however, this estimate had substantial uncertainty (95% CI -3.17 to 1.01). The pooled data of three trials indicated that Bobath therapy was less effective than task-specific training for improving Fugl-Meyer scores (MD -7.84, 95% CI -12.99 to -2.69). The effects of Bobath therapy relative to other interventions on strength outcomes remained uncertain.

CONCLUSIONS

After stroke, Bobath therapy is less effective than task-specific training and robotics in improving arm activity and less effective than task-specific training on the Fugl-Meyer score.

REGISTRATION

PROSPERO CRD42021251630.

Getting a kinematic handle on reach-to-grasp: a meta-analysis

BACKGROUND AND OBJECTIVES

Reach-to-grasp is an essential everyday activity that is often impaired after stroke. The objectives of this review are: (1) identify differences in the kinematic characteristics of reach-to-grasp between individuals with and without stroke, and (2) determine the influence of object location on kinematics.

DATA SOURCES

MEDLINE, AMED, and Embase databases.

ELIGIBILITY CRITERIA

Studies investigating individuals with stroke and neurologically intact control participants completing reach-to-grasp (paretic upper limb) of an object assessed via kinematic assessment (motion analysis).

REVIEW METHODS

Following Cochrane Collaboration guidelines a meta-analysis comparing kinematic characteristics of reach-to-grasp between individuals with and without stroke. Potential risk of bias was assessed using the Down's and Black Tool. Data were synthesised by calculating the standardised mean difference (SMD) in kinematic characteristics between adults with and without stroke.

RESULTS

Twenty-nine studies met the review criteria, mainly of observational design; 460 individuals with stroke and 324 control participants. Kinematic differences in reach-to-grasp were identified in the central and ipsilateral workspace for example, individuals with stroke exhibited significantly lower peak velocity SMD -1.48 (95% CI -1.94, -1.02), and greater trunk displacement SMD 1.55 (95% CI 0.85, 2.25) than control participants. Included studies were assessed as demonstrating unclear or high potential risk-of-bias.

CONCLUSIONS

Differences in kinematic characteristics between individuals with and without stroke were identified which may be different reaching in the ipsilateral and central workspace. Suggesting, that object location may influence some kinematic characteristics and not others which may be pertinent when re-training reach-to-grasp.

PROSPERO

CRD42014009479.

Improved functional independence measure facilitates return to home after paralyzed upper-limb training: a case report

[Purpose] We report a case in which rehabilitation that targeted the paralyzed side’s upper limb in a hemiplegic stroke patient remarkably accelerated the patient’s ability to perform activities of daily living, improved her Functional Independence Measure score, and facilitated the patient’s return to home. [Subject and Methods] We provided rehabilitation training to a female patient who experienced a cerebral infarction at a nursing home for the elderly and was admitted to the Kaifukuki recovery phase rehabilitation ward in order to improve her activities of daily living and return home. An intensive rehabilitation program incorporating occupational therapy and physical training for upper-limb function on the affected side was instituted over 170 days. [Results] At presentation, the patient had functional disorders and load-induced pain in both lower limbs requiring her to walk with a fixed-type walker. After the intensive rehabilitation program, her activities of daily living improved and she was able to return home. [Conclusion] This case suggests that activities of daily living training and simultaneous active training of upper-limb function on the affected side in patients with functional disorders or lower-limb pain could effectively improve their Functional Independence Measure scores, promote functional recovery, and facilitate their return to home.

Evidence for Occupational Therapy Interventions: Effectiveness Research Indexed in the OTseeker Database

The aim of this study was to determine the overall quantity and quality of randomised controlled trials and the quantity of systematic reviews relevant to occupational therapy practice.

The content of OTseeker ( www.otseeker.com ) was surveyed in June 2006. There were 3401 randomised controlled trials and 939 systematic reviews in OTseeker (total = 4340), published mostly in non-occupational therapy journals. The diagnostic areas of stroke (n = 458) and back or neck conditions/injuries (n = 391), and the intervention categories of exercise (n = 1262) and consumer education (n = 1098), were the most frequently listed. Although the quantity of evidence available about the effectiveness of occupational therapy interventions is rapidly increasing, some areas require greater research effort. Occupational therapists also need to search more broadly than occupational therapy journals for research to support clinical decision making.

Treatment Interventions for the Paretic Upper Limb of Stroke Survivors: A Critical Review

Despite a threefold increase in treatment interventions studies during the past 10 years, “best practice” for the rehabilitation of the paretic upper limb is still unclear. This review aims to lessen uncertainty in the management of the poststroke upper limb. Two separate searches of the scientific literature from 1966-2001 yielded 333 articles. Three referees, using strict inclusion and exclusion criteria, selected 68 relevant references. Cohort studies, randomized control trials, and systematic reviews were critically appraised. Mean randomized control trial quality (n = 33) was 17.1/27 (SD = 5.2, 95% CI = 15.2–19.0, range = 6–26). Mean quality of cohort studies (n = 29) was 11.8/27 (SD = 3.8, 95% CI = 10.4–13.2, range = 4–19). Quantitative syntheses were done using theZ -statistic. This systematic review indicated that sensorimotor training; motor learning training that includes the use of imagery, electrical stimulation alone, or combined with biofeedback; and engaging the client in repetitive, novel tasks can be effective in reducing motor impairment after stroke. Furthermore, careful handling, electrical stimulation, movement with elevation, strapping, and the avoidance of overhead pulleys could effectively reduce or prevent pain in the paretic upper limb. Rehabilitation specialists can use this research synthesis to guide their selection of effective treatment techniques for persons with impairments after stroke.

The effect of a skilled reaching task on hippocampal plasticity after intracerebral hemorrhage in adult rats

[Purpose] The primary objective of this study was to assess the effects of a skilled reaching task on cognition, as indexed by the pattern of GAP-43 expression in the hippocampus, following intracerebral hemorrhage (ICH) in rats (when the hippocampus plays a critical role in spatial memory and learning). [Subjects and Methods] The model of ICH used in the present study involved intrastriatal injection of collagenase. Sixty male Sprague-Dawley rats (aged 12 weeks) were randomly assigned to either a control (n = 30; CON) or skilled reaching training group (n = 30; SRT). The SRT group were trained 5 days per week for 4 weeks following ICH. Animals were sacrificed 1, 2, or 4 weeks after ICH. Western blot analysis was used to evaluate GAP-43 expression. [Results] GAP-43 expression was increased in the SRT group, in accordance with greater elapsed time, but decreased in the CON group. At 1 week post injury, there were no significant differences between the CON and SRT groups. However, there were significant differences at both 2 and 4 weeks. [Conclusion] The present findings suggest that increased GAP-43 expression in the hippocampus following skilled reaching training may result in enhanced cognition and neural plasticity following ICH.

Systematic review and meta-analysis of constraint-induced movement therapy in the hemiparetic upper extremity more than six months post stroke

OBJECTIVE

To conduct a systematic review and meta-analysis of the available evidence on the effectiveness of constraint-induced movement therapy (CIMT) in the hemiparetic upper extremity (UE) among individuals who were more than 6 months post stroke.

METHODS

A literature search of multiple databases (PubMed, CINAHL, and EMBASE) was conducted to identify articles published in the English language up to and including July 2012. Studies were included for review if (1) ≥50% of the sample had sustained a stroke, (2) the research design was a randomized controlled trial (RCT), (3) the mean time since stroke was ≥6 months for both the treated and control groups, (4) the treatment group received CIMT, (5) the control group received a form of traditional rehabilitation, and (6) functional improvement was assessed both pre and posttreatment. Methodological quality was assessed using the PEDro tool with a score out of 10.

RESULTS

Sixteen RCTs (PEDro scores 4-8) met inclusion criteria and included a pooled sample size of 572 individuals with a mean age of 58.2 years (range, 30-87). The meta-analysis revealed a significant treatment effect on the amount of use and quality of movements subscales of the Motor Activity Log ( P < .001, for both), Fugl-Meyer Assessment ( P = .014), and Action Research Arm Test ( P = .001); however, there was no significant treatment effect demonstrated by the Wolf Motor Function Test ( P = .120) or FIM ( P = .070).

CONCLUSIONS

CIMT to improve UE function is an appropriate and beneficial therapy for individuals who have sustained a stroke more than 6 months previously.

Interventions for improving coordination of reach to grasp following stroke: a systematic review

BACKGROUND

Stroke is associated with disruption to efficient and accurate reach to grasp function. Information about treatments for upper limb coordination deficits and their effectiveness may contribute to improved recovery of upper limb function after stroke.

AIMS

To identify all existing interventions targeted at coordination of arm and hand segments for reach to grasp following stroke. To determine the effectiveness of current treatments for improving coordination of reach to grasp after stroke.

SEARCH STRATEGY

The search included The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); MEDLINE; EMBASE; CINAHL; AMED; ProQuest Dissertations and Theses (International) and ISI Proceedings (Conference) databases. A grey literature search included Mednar, Dissertation International, Conference Proceedings, National Institute of Health Clinical Trials and the National Institute of Clinical Studies. We also explored Physiotherapy Evidence Database, Chartered Society of Physiotherapy Research and REHABDATA therapy databases. Finally, the reference lists of identified articles were examined for additional studies. The search spanned from 1950 to April 2010 and was limited to English language papers only.

METHODS OF THE REVIEW

Studies were included with a specific design objective related to coordination of the hand and arm during reach to grasp and involving participants with a clinical diagnosis of stroke. The review was inclusive with regard to study design. To determine effectiveness of interventions we analysed studies with coordination measures that exist within impairment measurement scales or specific kinematic measures of coordination. The methodological quality of the studies was assessed by two independent authors using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Comparable Cohort/Case Control and the JBI Critical Appraisal Checklist for Experimental Studies together with additional questions from Downs and Black. Two review authors independently extracted data from the studies using standardised JBI-MAStARI data extraction forms. Pooling of results was not appropriate so the findings were summarised in tables and in narrative form.

RESULTS

One randomised controlled trial, two case-control studies and four experimental studies without controls were included in this review. The review has identified three categories of potential intervention for improving hand and arm coordination after stroke; functional therapy, biofeedback or electrical stimulation and robot or computerised training. In view of the limited availability of good quality evidence and lack of empirical data, this review does not draw a definitive conclusion for the second question regarding the effectiveness of interventions aimed at improving hand and arm coordination after stroke. Improvements in hand and arm coordination during reach to grasp were reported in four studies, whereas one study found no benefit. Two studies did not report specific effects of interventions for hand and arm coordination after stroke.

CONCLUSIONS

IMPLICATIONS FOR PRACTICE

There is currently insufficient evidence to provide strong recommendations about the effect of interventions for improving hand and arm coordination during reach to grasp after stroke.

IMPLICATIONS FOR RESEARCH

Randomised controlled trials of sufficient power with standardised outcome measures are needed to enable meta-analysis comparison in the future. Such studies should include both functional performance and detailed kinematic measures of hand and arm coordination.

Paretic upper extremity movement gains are retained 3 months after training with an electrical stimulation neuroprosthesis

OBJECTIVE

To determine retention of upper extremity (UE) motor changes 3 months after participation in a regimen in which subjects with moderate UE hemiparesis engaged in repetitive task-specific training using an electrical stimulation neuroprosthesis (ESN).

DESIGN

Prospective, blinded, cohort, pre-post study.

SETTING

Outpatient rehabilitation hospital.

PARTICIPANTS

Individuals (N=24) in the chronic stage of stroke exhibiting stable UE hemiparesis (11 men; mean age, 57.9±9.5y; age range, 39-75y; mean time since stroke at time of repetitive task-specific practice [RTP] using ESN intervention start, 36.7mo; range of onset, 7-162mo).

INTERVENTION

As part of a larger trial, subjects had been randomly assigned to receive an 8-week regimen comprised of RTP on valued activities using the ESN. This observational study assessed this single group's paretic UE motor levels immediately after, and 3 months after, the intervention.

MAIN OUTCOME MEASURES

The Fugl-Meyer (FM) assessment of sensorimotor impairment, the Action Research Arm Test (ARAT), the Arm Motor Ability Test (AMAT), and the Box and Block Test (BBT).

RESULTS

None of the scores significantly changed from the period directly after intervention to the test 3-months follow-up (FM: t=1.64; ARAT: t=2.17; AMAT: t=.76, .92, and 1.01 for the functional ability, quality of movement, and time scales, respectively; BBT: t=.36; adjusted t critical value to reject the null [t(crit)]=2.90, 2-tailed α=.008 to preserve experiment-wise error rate of .05).

CONCLUSIONS

Subjects exhibited no changes in the various functional tests, indicating that changes in paretic UE movement realized through RTP using ESN appear to be retained 3 months after the intervention has concluded. This was the first study to our knowledge to examine the longer-term effects of RTP using an ESN in any population.

Valid and reliable instruments for arm-hand assessment at ICF activity level in persons with hemiplegia: a systematic review

BACKGROUND

Loss of arm-hand performance due to a hemiparesis as a result of stroke or cerebral palsy (CP), leads to large problems in daily life of these patients. Assessment of arm-hand performance is important in both clinical practice and research. To gain more insight in e.g. effectiveness of common therapies for different patient populations with similar clinical characteristics, consensus regarding the choice and use of outcome measures is paramount. To guide this choice, an overview of available instruments is necessary. The aim of this systematic review is to identify, evaluate and categorize instruments, reported to be valid and reliable, assessing arm-hand performance at the ICF activity level in patients with stroke or cerebral palsy.

METHODS

A systematic literature search was performed to identify articles containing instruments assessing arm-hand skilled performance in patients with stroke or cerebral palsy. Instruments were identified and divided into the categories capacity, perceived performance and actual performance. A second search was performed to obtain information on their content and psychometrics.

RESULTS

Regarding capacity, perceived performance and actual performance, 18, 9 and 3 instruments were included respectively. Only 3 of all included instruments were used and tested in both patient populations. The content of the instruments differed widely regarding the ICF levels measured, assessment of the amount of use versus the quality of use, the inclusion of unimanual and/or bimanual tasks and the inclusion of basic and/or extended tasks.

CONCLUSIONS

Although many instruments assess capacity and perceived performance, a dearth exists of instruments assessing actual performance. In addition, instruments appropriate for more than one patient population are sparse. For actual performance, new instruments have to be developed, with specific focus on the usability in different patient populations and the assessment of quality of use as well as amount of use. Also, consensus about the choice and use of instruments within and across populations is needed.

Physical fitness training for stroke patients

BACKGROUND

Levels of physical fitness are low after stroke. It is unknown whether improving physical fitness after stroke reduces disability.

OBJECTIVES

To determine whether fitness training after stroke reduces death, dependence, and disability. The secondary aims were to determine the effects of training on physical fitness, mobility, physical function, quality of life, mood, and incidence of adverse events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched April 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, July 2010), MEDLINE (1966 to March 2010), EMBASE (1980 to March 2010), CINAHL (1982 to March 2010), SPORTDiscus (1949 to March 2010), and five additional databases (March 2010). We also searched ongoing trials registers, handsearched relevant journals and conference proceedings, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing either cardiorespiratory training or resistance training, or both, with no intervention, a non-exercise intervention, or usual care in stroke survivors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed quality, and extracted data. We analysed data using random-effects meta-analyses. Diverse outcome measures limited the intended analyses.

MAIN RESULTS

We included 32 trials, involving 1414 participants, which comprised cardiorespiratory (14 trials, 651 participants), resistance (seven trials, 246 participants), and mixed training interventions (11 trials, 517 participants). Five deaths were reported at the end of the intervention and nine at the end of follow-up. No dependence data were reported. Diverse outcome measures made data pooling difficult. The majority of the estimates of effect were not significant. Cardiorespiratory training involving walking improved maximum walking speed (mean difference (MD) 8.66 metres per minute, 95% confidence interval (CI) 2.98 to 14.34), preferred gait speed (MD 4.68 metres per minute, 95% CI 1.40 to 7.96) and walking capacity (MD 47.13 metres per six minutes, 95% CI 19.39 to 74.88) at the end of the intervention. These training effects were retained at the end of follow-up. Mixed training, involving walking, increased preferred walking speed (MD 2.93 metres per minute, 95% CI 0.02 to 5.84) and walking capacity (MD 30.59 metres per six minutes, 95% CI 8.90 to 52.28) but effects were smaller and there was heterogeneity amongst the trial results. There were insufficient data to assess the effects of resistance training. The variability in the quality of included trials hampered the reliability and generalizability of the observed results.

AUTHORS' CONCLUSIONS

The effects of training on death, dependence, and disability after stroke are unclear. There is sufficient evidence to incorporate cardiorespiratory training involving walking within post-stroke rehabilitation programmes to improve speed, tolerance, and independence during walking. Further well-designed trials are needed to determine the optimal exercise prescription and identify long-term benefits.

Physical fitness training for stroke patients

BACKGROUND

Physical fitness is low after stroke. It is unknown whether improving physical fitness after stroke reduces disability.

OBJECTIVES

To determine whether fitness training (cardiorespiratory or strength, or both) after stroke reduces death, dependence and disability. The secondary aims were to determine the effects of fitness training on physical fitness, mobility, physical function, health status and quality of life, mood and incidence of adverse events.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched March 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2007), MEDLINE (1966 to March 2007), EMBASE (1980 to March 2007), CINAHL (1982 to March 2007), and six additional databases to March 2007. We handsearched relevant journals and conference proceedings, and screened bibliographies. We searched trials registers and contacted experts in the field.

SELECTION CRITERIA

We included randomised controlled trials if the aim of the intervention was to improve muscle strength or cardiorespiratory fitness, or both, and if the control groups comprised either no intervention, usual care or a non-exercise intervention.

DATA COLLECTION AND ANALYSIS

Two review authors determined trial eligibility and quality. One review author extracted outcome data at end of intervention and follow-up scores, or as change from baseline scores. Diverse outcome measures limited the intended analysis.

MAIN RESULTS

We included 24 trials, involving 1147 participants, comprising cardiorespiratory (11 trials, 692 participants), strength (four trials, 158 participants) and mixed training interventions (nine trials, 360 participants). Death was infrequent at the end of the intervention (1/1147) and follow up (8/627). No dependence data were reported. Diverse disability measures made meta-analysis difficult; the majority of effect sizes were not significant. Cardiorespiratory training involving walking, improved maximum walking speed (mean difference (MD) 6.47 metres per minute, 95% confidence interval (CI) 2.37 to 10.57), walking endurance (MD 38.9 metres per six minutes, 95% CI 14.3 to 63.5), and reduced dependence during walking (Functional Ambulation Categories MD 0.72, 95% CI 0.46 to 0.98). Current data include few strength training trials, and lack non-exercise attention controls, long-term training and follow up.

AUTHORS' CONCLUSIONS

The effects of training on death, dependence and disability after stroke are unclear. There is sufficient evidence to incorporate cardiorespiratory training, involving walking, within post-stroke rehabilitation in order to improve speed, tolerance and independence during walking. Further trials are needed to determine the optimal exercise prescription after stroke and identify any long-term benefits.

Repetitive task training for improving functional ability after stroke

BACKGROUND

The active practice of task-specific motor activities is a component of current approaches to stroke rehabilitation.

OBJECTIVES

To determine if repetitive task training after stroke improves global, upper or lower limb function, and if treatment effects are dependent on the amount, type or timing of practice.

SEARCH STRATEGY

We searched the Cochrane Stroke Trials Register (October 2006), The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, SportDiscus, Science Citation Index, Index to Theses, ZETOC, PEDro, and OT Seeker (to September 2006), and OT search (to March 2006). We also searched for unpublished/non-English language trials, conference proceedings, combed reference lists, requested information on bulletin boards, and contacted trial authors.

SELECTION CRITERIA

Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal, and where the amount of practice could be quantified.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts, extracted data and appraised trials. Assessment of methodological quality was undertaken for allocation concealment, blinding, loss to follow up and equivalence of treatment. We contacted trial authors for additional information.

MAIN RESULTS

Fourteen trials with 17 intervention-control pairs and 659 participants were included.

PRIMARY OUTCOMES

results were statistically significant for walking distance (mean difference (MD) 54.6, 95% CI 17.5 to 91.7); walking speed (standardised mean difference (SMD) 0.29, 95% CI 0.04 to 0.53); sit-to-stand (standard effect estimate 0.35, 95% CI 0.13 to 0.56); and of borderline statistical significance for functional ambulation (SMD 0.25, 95% CI 0.00 to 0.51), and global motor function (SMD 0.32, 95% CI -0.01 to 0.66). There were no statistically significant differences for hand/arm function, or sitting balance/reach.

SECONDARY OUTCOMES

results were statistically significant for activities of daily living (SMD 0.29, 95% CI 0.07 to 0.51), but not for quality of life or impairment measures. There was no evidence of adverse effects. Follow-up measures were not significant for any outcome at six or twelve months. Treatment effects were not modified by intervention amount or timing, but were modified by intervention type for lower limbs.

AUTHORS' CONCLUSIONS

Repetitive task training resulted in modest improvement in lower limb function, but not upper limb function. Training may be sufficient to impact on daily living function. However, there is no evidence that improvements are sustained once training has ended. The review potentially investigates task specificity rather more than repetition. Further research should focus on the type and amount of training, and how to maintain functional gain.

Effectiveness of exercise therapy: a best-evidence summary of systematic reviews

The purpose of this project was to summarise the available evidence on the effectiveness of exercise therapy for patients with disorders of the musculoskeletal, nervous, respiratory, and cardiovascular systems. Systematic reviews were identified by means of a comprehensive search strategy in 11 bibliographic databases (08/2002), in combination with reference tracking. Reviews that included (i) at least one randomised controlled trial investigating the effectiveness of exercise therapy, (ii) clinically relevant outcome measures, and (iii) full text written in English, German or Dutch, were selected by two reviewers. Thirteen independent and blinded reviewers participated in the selection, quality assessment and data-extraction of the systematic reviews. Conclusions about the effectiveness of exercise therapy were based on the results presented in reasonable or good quality systematic reviews (quality score > or = 60 out of 100 points). A total of 104 systematic reviews were selected, 45 of which were of reasonable or good quality. Exercise therapy is effective for patients with knee osteoarthritis, sub-acute (6 to 12 weeks) and chronic (> or = 12 weeks) low back pain, cystic fibrosis, chronic obstructive pulmonary disease, and intermittent claudication. Furthermore, there are indications that exercise therapy is effective for patients with ankylosing spondylitis, hip osteoarthritis, Parkinson's disease, and for patients who have suffered a stroke. There is insufficient evidence to support or refute the effectiveness of exercise therapy for patients with neck pain, shoulder pain, repetitive strain injury, rheumatoid arthritis, asthma, and bronchiectasis. Exercise therapy is not effective for patients with acute low back pain. It is concluded that exercise therapy is effective for a wide range of chronic disorders.

Outcomes of the Bobath concept on upper limb recovery following stroke

OBJECTIVE

To determine the effectiveness of the Bobath concept at reducing upper limb impairments, activity limitations and participation restrictions after stroke.

METHODS

Electronic databases were searched to identify relevant trials published between 1966 and 2003. Two reviewers independently assessed articles for the following inclusion criteria: population of adults with upper limb disability after stroke; stated use of the Bobath concept aimed at improving upper limb disability in isolation from other approaches; outcomes reflecting changes in upper limb impairment, activity limitation or participation restriction.

RESULTS

Of the 688 articles initially identified, eight met the inclusion criteria. Five were randomized controlled trials, one used a single-group crossover design and two were single-case design studies. Five studies measured impairments including shoulder pain, tone, muscle strength and motor control. The Bobath concept was found to reduce shoulder pain better than cryotherapy, and to reduce tone compared to no intervention and compared to proprioceptive neuromuscular facilitation (PNF). However, no difference was detected for changes in tone between the Bobath concept and a functional approach. Differences did not reach significance for measures of muscle strength and motor control. Six studies measured activity limitations, none of these found the Bobath concept was superior to other therapy approaches. Two studies measured changes in participation restriction and both found equivocal results.

CONCLUSIONS

Comparisons of the Bobath concept with other approaches do not demonstrate superiority of one approach over the other at improving upper limb impairment, activity or participation. However, study limitations relating to methodological quality, the outcome measures used and contextual factors investigated limit the ability to draw conclusions. Future research should use sensitive upper limb measures, trained Bobath therapists and homogeneous samples to identify the influence of patient factors on the response to therapy approaches.