Key messages
For people who have had a stroke:
- Physical rehabilitation may improve daily activities, moving legs, balance, and walking, when compared to no physical rehabilitation. There may be greater benefits when more than 2.5 hours/week of physical rehabilitation is delivered.
- Extra physical rehabilitation, given in addition to 'usual' physical rehabilitation, may also improve outcomes. The greater the amount of extra physical rehabilitation, the greater the benefit may be.
- Physical rehabilitation focussed on functional task training (the active practice of real-life tasks with the aim of acquiring - or reacquiring - a movement skill) may improve daily activities and movement.
Why is it important to review the evidence on this topic?
Stroke can cause paralysis of some parts of the body and can create difficulties with physical functions. Over the years, various approaches to physical rehabilitation have been developed, based on ideas about how people recover after a stroke. Often, physiotherapists will choose one particular approach, based on their clinical experience and the rationale, but clear research evidence is lacking. This means that techniques used by individual physiotherapists may differ (e.g. one may provide strengthening exercises, while another may focus on passive movements). Historically, a number of named physical rehabilitation approaches (e.g. the ‘Bobath’ approach) have been used; together we call these neurophysiological approaches, as they were developed based on knowledge and theories relating to the function and recovery of the nervous system. It is important to help physiotherapists select the approach that will help their patients gain the best recovery.
Note: Physiotherapist/physiotherapy can be called physical or rehabilitation therapist/therapy, meaning the same. We use the term physical rehabilitation and describe the person providing physical rehabilitation as a therapist.
What did we want to find out?
We wanted to know:
- Are physical rehabilitation approaches effective in the recovery of function and mobility in people with stroke?
- Is one physical rehabilitation approach more effective than another approach?
What did we do?
We searched for relevant studies, called randomised controlled trials. We brought together studies in which people who had a stroke received physical rehabilitation with the goal of improving the ability to walk and carry out activities of daily living. We were interested in different approaches to physical rehabilitation (i.e. a programme of treatment based on a particular scientific rationale). These approaches might involve therapist-delivered, group, or remote treatment. Therapists may select specific treatments/exercises according to individual patient needs, or deliver standard exercises based on the stage of patient recovery. We excluded studies that only looked at 'single' treatments (e.g. electrical stimulation, robotic device) or were focused only on arm function.
What did we find?
We found 267 studies, which included 21,838 people with stroke. Studies were from 36 different countries, but half (133 studies) were carried out in China.
One hundred and five studies looked at whether physical rehabilitation was better than no physical rehabilitation. Most of these studies were carried out in hospital in-patient settings in China where physical rehabilitation was not part of routine care, but a few were carried out in outpatient settings after the patient had been discharged from routine physical rehabilitation. These studies showed that physical rehabilitation may improve a person's ability to carry out activities of daily living, move the legs, remain balanced, and walk, in comparison to no physical rehabilitation.
Fifty-six studies looked at the effect of giving extra, or additional, physical rehabilitation. Everyone in these studies received their usual physical rehabilitation, but one group of stroke survivors received some additional treatment based on a particular physical rehabilitation approach. These studies showed that additional physical rehabilitation may improve the ability to carry out activities of daily living, move the legs, remain balanced, and walk; the greater the amount of additional rehabilitation, the greater the possible benefit.
Ninety-two studies compared different physical rehabilitation approaches. There were many variations in the types and amount of physical rehabilitation, and the types of people (e.g. different lengths of time post-stroke). These studies showed that physical rehabilitation that focused on functional task training may improve the ability to carry out activities of daily living and move the legs (but not balance or walking). Neurophysiological approaches to physical rehabilitation may be less effective than other approaches at improving daily activities (but no different for other outcomes).
For all comparisons, there was very limited information about potential adverse events relating to physical rehabilitation.
Few studies took long-term follow-up measurements after the physical rehabilitation had stopped.
What are the limitations of the evidence?
There were large variations between participants, interventions, outcomes, and comparisons in the studies included in this review. There were also geographical and cultural differences that may influence the results. Generally, the reporting of the details of these studies was very poor. These issues mean that we have limited confidence in the results of our statistical analyses.
How up-to-date is this evidence?
The evidence is up-to-date to November 2022. It is unlikely that any studies published since November 2022 would alter our conclusions.
Physical rehabilitation, using a mix of different treatment components, likely improves recovery of function and mobility after stroke. Additional physical rehabilitation, delivered as an adjunct to 'usual' rehabilitation, may provide added benefits. Physical rehabilitation approaches that focus on functional task training may be useful. Neurophysiological approaches to physical rehabilitation may be no different from, or less effective than, other physical rehabilitation approaches.
Certainty in this evidence is limited due to substantial heterogeneity, with mainly small studies and important differences between study populations and interventions. We feel it is unlikely that any studies published since November 2022 would alter our conclusions. Given the size of this review, future updates warrant consensus discussion amongst stakeholders to ensure the most relevant questions are explored for optimal decision-making.
Various approaches to physical rehabilitation to improve function and mobility are used after stroke. There is considerable controversy around the relative effectiveness of approaches, and little known about optimal delivery and dose. Some physiotherapists base their treatments on a single approach; others use components from several different approaches.
Primary objective: To determine whether physical rehabilitation is effective for 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.
Secondary objective: To explore factors that may impact the effectiveness of physical rehabilitation approaches, including time after stroke, geographical location of study, intervention dose/duration, intervention provider, and treatment components.
Stakeholder involvement: Key aims were to clarify the focus of the review, inform decisions about subgroup analyses, and co-produce statements relating to key implications.
For this update, we searched the Cochrane Stroke Trials Register (last searched November 2022), CENTRAL (2022, Issue 10), MEDLINE (1966 to November 2022), Embase (1980 to November 2022), AMED (1985 to November 2022), CINAHL (1982 to November 2022), and the Chinese Biomedical Literature Database (to November 2022).
Inclusion 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.
Exclusion criteria: RCTs of upper limb function or single treatment components.
Primary outcomes: measures of independence in activities of daily living (IADL) and motor function.
Secondary outcomes: balance, gait velocity, and length of stay.
Two independent authors selected studies according to pre-defined eligibility criteria, extracted data, and assessed the risk of bias in the included studies. We used GRADE to assess the certainty of evidence.
In this review update, we included 267 studies (21,838 participants). Studies were conducted in 36 countries, with half (133/267) in China. Generally, studies were heterogeneous, and often poorly reported. We judged only 14 studies in meta-analyses as at low risk of bias for all domains and, on average, we considered 33% of studies in analyses of primary outcomes at high risk of bias.
Is physical rehabilitation more effective than no (or minimal) physical rehabilitation?
Compared to no physical rehabilitation, physical rehabilitation may improve IADL (standardised mean difference (SMD) 1.32, 95% confidence interval (CI) 1.08 to 1.56; 52 studies, 5403 participants; low-certainty evidence) and motor function (SMD 1.01, 95% CI 0.80 to 1.22; 50 studies, 5669 participants; low-certainty evidence). There was evidence of long-term benefits for these outcomes.
Physical rehabilitation may improve balance (MD 4.54, 95% CI 1.36 to 7.72; 9 studies, 452 participants; low-certainty evidence) and likely improves gait velocity (SMD 0.23, 95% CI 0.05 to 0.42; 18 studies, 1131 participants; moderate-certainty evidence), but with no evidence of long-term benefits.
Is physical rehabilitation more effective than attention control?
The evidence is very uncertain about the effects of physical rehabilitation, as compared to attention control, on IADL (SMD 0.91, 95% CI 0.06 to 1.75; 2 studies, 106 participants), motor function (SMD 0.13, 95% CI -0.13 to 0.38; 5 studies, 237 participants), and balance (MD 6.61, 95% CI -0.45 to 13.66; 4 studies, 240 participants).
Physical rehabilitation likely improves gait speed when compared to attention control (SMD 0.34, 95% CI 0.14 to 0.54; 7 studies, 405 participants; moderate-certainty evidence).
Does additional physical rehabilitation improve outcomes?
Additional physical rehabilitation may improve IADL (SMD 1.26, 95% CI 0.82 to 1.71; 21 studies, 1972 participants; low-certainty evidence) and motor function (SMD 0.69, 95% CI 0.46 to 0.92; 22 studies, 1965 participants; low-certainty evidence). Very few studies assessed these outcomes at long-term follow-up.
Additional physical rehabilitation may improve balance (MD 5.74, 95% CI 3.78 to 7.71; 15 studies, 795 participants; low-certainty evidence) and gait velocity (SMD 0.59, 95% CI 0.26 to 0.91; 19 studies, 1004 participants; low-certainty evidence). Very few studies assessed these outcomes at long-term follow-up.
Is any one approach to physical rehabilitation more effective than any other approach?
Compared to other approaches, those that focus on functional task training may improve IADL (SMD 0.58, 95% CI 0.29 to 0.87; 22 studies, 1535 participants; low-certainty evidence) and motor function (SMD 0.72, 95% CI 0.21 to 1.22; 20 studies, 1671 participants; very low-certainty evidence) but the evidence in the latter is very uncertain. The benefit was sustained long-term.
The evidence is very uncertain about the effect of functional task training on balance (MD 2.16, 95% CI -0.24 to 4.55) and gait velocity (SMD 0.28, 95% CI -0.01 to 0.56).
Compared to other approaches, neurophysiological approaches may be less effective than other approaches in improving IADL (SMD -0.34, 95% CI -0.63 to -0.06; 14 studies, 737 participants; low-certainty evidence), and there may be no difference in improving motor function (SMD -0.60, 95% CI -1.32 to 0.12; 13 studies, 663 participants; low-certainty evidence), balance (MD -0.60, 95% CI -5.90 to 6.03; 9 studies, 292 participants; low-certainty evidence), and gait velocity (SMD -0.17, 95% CI -0.62 to 0.27; 16 studies, 630 participants; very low-certainty evidence), but the evidence is very uncertain about the effect on gait velocity.
For all comparisons, the evidence is very uncertain about the effects of physical rehabilitation on adverse events and length of hospital stay.