Major Update of a Cochrane Review: Physical rehabilitation approaches for the recovery of function and mobility following stroke

Background 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.

Objectives 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.

Search methods For this update, we searched the Cochrane Stroke Group Trials Register (last searched November 2022), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 10, 2022), MEDLINE (1966to November 2022), Embase (1980 to November 2022), AMED (1985 to November 2022), CINAHL (1982 to November 2022), and Chinese Biomedical Literature Database (to November 2022).Selection criteria 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. Data collection and analysis Two independent reviewers categorised identified trials according to the selection criteria, documented methodological quality and extracted data. GRADE was used to assess the certainty of evidence.

Main results We included 267 studies (21,838 participants) in this review. Studies were conducted in 36 countries, with half(133/267) carried out in China. Generally studies were heterogeneous, and often poorly reported. Only 14 studies in meta-analyses were judged as low risk of bias (ROB) for all domains and, on average, 33% of studies in analyses of primary outcomes were considered high ROB.Is physical rehabilitation more effective than no (or minimal) physical rehabilitation? Primary outcomes: Physical rehabilitation may be more beneficial than no physical rehabilitation for IADL and motor function (ADL: 52 studies(participants, n=5403); standardised mean difference (SMD)1.32, 95%confidence interval (CI)[1.08, 1.56]; low certainty of evidence (GRADE). Motor function: 50 studies, 5669participants; SMD 1.01[0.80, 1.22]; low GRADE). There was evidence of long-term benefits for these outcomes. Secondary outcomes: Physical rehabilitation may be more beneficial than no treatment for balance (9 studies (n=452), MD 4.54[1.36, 7.72]; low GRADE) and gait velocity (18 studies (n=1131), SMD 0,23[0.05, 0.42], moderate GRADE), but with no evidence of long-term benefit. Is physical rehabilitation more effective than attention control? Primary outcomes: IADL and motor function: only 2 studies (106 participants) and 5 studies (237 participants) respectively were combined in analyses, limiting certainty in results (both very low GRADE).Secondary outcomes: Balance: evidence was very uncertain (only 4 studies (n=240); (very low GRADE). Gait velocity: physical rehabilitation was more likely to improve gait speed than attention control (7 studies(n=405), SMD 0.34[0.14, 0.54); moderate GRADE). Does additional physical rehabilitation improve outcomes? Primary outcomes: Additional physical rehabilitation may improve IADL (21 studies, (n=1972); SMD 1.26[0.82, 1.71]; low GRADE) and motor function (22 studies, (n=1965); SMD 0.69[0.46, 0.92], low GRADE). Very few studies assessed a long-term follow-up. Secondary outcomes: Additional physical rehabilitation may improve balance (15 studies (n=795), MD 5.74[3.78, 7.71]; low GRADE) and gait velocity (19 studies (n=1004), SMD 0.59[0.26, 0.91); low GRADE). Very few studies assessed a long-term follow-up. Is any one approach to physical rehabilitation more effective than any other approach to physical rehabilitation? Functional task training: Approaches focussed on functional task training may have a greater benefit than other approaches for IADL (22 studies, (n=1535 ; SMD 0.58[0.29, 0.87], low GRADE) and motor function (20 studies, (n=1671); SMD 0.72[0.21, 1.22]; very low GRADE), and the benefit was sustained long-term. The evidence was very uncertain for secondary outcomes of balance and gait velocity (both very low GRADE). Neurophysiological approaches: Neurophysiological approaches may be less effective than other approaches for IADL (14 studies, (n=737); SMD -0.34[-0.63, -0.06]; low GRADE), and there may be no difference for motor function (13 studies, (n=663); SMD -0.60, [-1.32, 0.12]; low GRADE), balance or gait velocity. For all comparisons, very few (<5) trials actively monitored adverse events. Evidence about length of hospital stay was very uncertain (only 2 trials ).

Authors' conclusions Physical rehabilitation, using a mix of different treatment components, is likely to improve recovery of function and mobility after stroke. Additional physical rehabilitation, delivered as an adjunct to "usual" rehabilitation, may provide added benefit. Physical rehabilitation which focusses on functional task training is likely to be most effective. Neurophysiological approaches to physical rehabilitation are not superior to, and may be 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.