Physical Rehabilitation Approaches for the Recovery of Function and Mobility Following Stroke

Summary

A Cochrane review [Abstract] 1 included 96 studies with a total of 10 401 subjects. More than half of the studies (50/96) were carried out in China. In 38 studies, the time since stroke was 30 days or less and in 21 studies more than 3 months, the time was not stated in 28 studies. A total of 101 of the 122 active interventions were categorised as including treatment components from functional task training. Of the remaining 21 interventions, 17 included components from the neurophysiological category. The duration of intervention periods varied from under 28 days to over 6 months and was unclear in 21 studies. The frequency of intervention varied from more than once per day to less than once per week. The comparison groups got no treatment or usual care. The trials used a large number of heterogeneous outcome measures. Physical rehabilitation was found to have a beneficial effect on functional recovery after stroke (SMD 0.78, 95% CI 0.58 to 0.97, for Independence in ADL scales; 27 studies, n=3423), and this effect was noted to persist beyond the length of the intervention period (SMD 0.58, 95% CI 0.11 to 1.04; 9 studies, n=540). Subgroup analysis revealed a significant difference based on dose of intervention (p<0.0001, for independence in ADL), indicating that a dose of 30 to 60 minutes per day delivered 5 to 7 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=0.003, for independence in ADL). Physical rehabilitation was more effective than usual care or attention control in improving motor function (SMD 0.37, 95% CI 0.20 to 0.55; 12 studies, n=887), balance (SMD 0.31, 95% CI 0.05 to 0.56; 5 studies, n=246) and gait velocity (SMD 0.46, 95% CI 0.32 to 0.60; 14 studies, n=1126). Subgroup analysis demonstrated a significant difference based on dose of intervention (p= 0.02 for motor function), indicating that a dose of 30 to 60 minutes delivered 5 to 7 days a week provides significant benefit. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (p=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 (test for subgroup differences: p=0.71; 8 studies, n=491) or motor function (test for subgroup differences: p=0.41; 9 studies, n=546). 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.

Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment) and inconsistency (heterogeneity in patients, interventions and outcomes).