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Meta-Analysis
. 2014 Apr 22;2014(4):CD001920.
doi: 10.1002/14651858.CD001920.pub3.

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

Alex Pollock  1 , Gillian Baer, Pauline Campbell, Pei Ling Choo, Anne Forster, Jacqui Morris, Valerie M Pomeroy, Peter Langhorne
Affiliations
Meta-Analysis

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

Alex Pollock et al. Cochrane Database Syst Rev. .

Update in

Abstract

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.

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Conflict of interest statement

Authors Alex Pollock and Gillian Baer carried out trials included in this review (Baer 2007; Pollock 1998).

Figures

1
1
The figure summarises the process undertaken by the stakeholder group, which met on three occasions (green circles). The nominal group technique was used to achieve all decisions. The blue circles represent the 'preparation phase,' which included drafting role descriptors for the SG; obtaining local University ethics and recruiting the SG and data extraction exercise of the sample of Chinese studies (n = 10) that had previously been identified in the 2007 version of this review. Purple circles represent the months dedicated to undertaking the systematic review.
2
2
Study flow diagram.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Intervention versus no treatment: immediate outcomes, Outcome 1: Independence in ADL scales
1.2
1.2. Analysis
Comparison 1: Intervention versus no treatment: immediate outcomes, Outcome 2: Motor function scales
1.3
1.3. Analysis
Comparison 1: Intervention versus no treatment: immediate outcomes, Outcome 3: Balance (Berg Balance Scale)
1.4
1.4. Analysis
Comparison 1: Intervention versus no treatment: immediate outcomes, Outcome 4: Gait velocity
1.5
1.5. Analysis
Comparison 1: Intervention versus no treatment: immediate outcomes, Outcome 5: Length of stay
2.1
2.1. Analysis
Comparison 2: Intervention versus usual care or attention control: immediate outcomes, Outcome 1: Independence in ADL scales
2.2
2.2. Analysis
Comparison 2: Intervention versus usual care or attention control: immediate outcomes, Outcome 2: Motor function scales
2.3
2.3. Analysis
Comparison 2: Intervention versus usual care or attention control: immediate outcomes, Outcome 3: Balance (Berg Balance Scale)
2.4
2.4. Analysis
Comparison 2: Intervention versus usual care or attention control: immediate outcomes, Outcome 4: Gait velocity
2.5
2.5. Analysis
Comparison 2: Intervention versus usual care or attention control: immediate outcomes, Outcome 5: Length of stay
3.1
3.1. Analysis
Comparison 3: One active intervention versus another active intervention: immediate outcomes, Outcome 1: Independence in ADL scales
3.2
3.2. Analysis
Comparison 3: One active intervention versus another active intervention: immediate outcomes, Outcome 2: Motor function scales
3.3
3.3. Analysis
Comparison 3: One active intervention versus another active intervention: immediate outcomes, Outcome 3: Balance (Berg Balance Scale)
3.4
3.4. Analysis
Comparison 3: One active intervention versus another active intervention: immediate outcomes, Outcome 4: Gait velocity
3.5
3.5. Analysis
Comparison 3: One active intervention versus another active intervention: immediate outcomes, Outcome 5: Length of stay
4.1
4.1. Analysis
Comparison 4: Intervention versus no treatment: persisting outcomes, Outcome 1: Independence in ADL scales
4.2
4.2. Analysis
Comparison 4: Intervention versus no treatment: persisting outcomes, Outcome 2: Motor function scales
4.3
4.3. Analysis
Comparison 4: Intervention versus no treatment: persisting outcomes, Outcome 3: Balance (Berg Balance Scale)
4.4
4.4. Analysis
Comparison 4: Intervention versus no treatment: persisting outcomes, Outcome 4: Gait velocity
5.1
5.1. Analysis
Comparison 5: Intervention versus usual care or attention control: persisting outcomes, Outcome 1: Independence in ADL scales
5.2
5.2. Analysis
Comparison 5: Intervention versus usual care or attention control: persisting outcomes, Outcome 2: Motor function scales
5.3
5.3. Analysis
Comparison 5: Intervention versus usual care or attention control: persisting outcomes, Outcome 3: Balance (Berg Balance Scale)
5.4
5.4. Analysis
Comparison 5: Intervention versus usual care or attention control: persisting outcomes, Outcome 4: Gait velocity
6.1
6.1. Analysis
Comparison 6: One active intervention versus another active intervention: persisting outcomes, Outcome 1: Independence in ADL scales
6.2
6.2. Analysis
Comparison 6: One active intervention versus another active intervention: persisting outcomes, Outcome 2: Motor function scales
6.3
6.3. Analysis
Comparison 6: One active intervention versus another active intervention: persisting outcomes, Outcome 3: Balance (Berg Balance Scale)
6.4
6.4. Analysis
Comparison 6: One active intervention versus another active intervention: persisting outcomes, Outcome 4: Gait velocity
7.1
7.1. Analysis
Comparison 7: Subgroups. Intervention versus no treatment: immediate outcome: independence in ADL, Outcome 1: Time after stroke
7.2
7.2. Analysis
Comparison 7: Subgroups. Intervention versus no treatment: immediate outcome: independence in ADL, Outcome 2: Study geographical location
7.3
7.3. Analysis
Comparison 7: Subgroups. Intervention versus no treatment: immediate outcome: independence in ADL, Outcome 3: Dose of intervention
7.4
7.4. Analysis
Comparison 7: Subgroups. Intervention versus no treatment: immediate outcome: independence in ADL, Outcome 4: Provider of intervention
7.5
7.5. Analysis
Comparison 7: Subgroups. Intervention versus no treatment: immediate outcome: independence in ADL, Outcome 5: Treatment components included
8.1
8.1. Analysis
Comparison 8: Subgroups. Intervention versus attention control or usual care: immediate outcome: independence in ADL, Outcome 1: Time after stroke
8.2
8.2. Analysis
Comparison 8: Subgroups. Intervention versus attention control or usual care: immediate outcome: independence in ADL, Outcome 2: Study geographical location
8.3
8.3. Analysis
Comparison 8: Subgroups. Intervention versus attention control or usual care: immediate outcome: independence in ADL, Outcome 3: Dose of intervention
8.4
8.4. Analysis
Comparison 8: Subgroups. Intervention versus attention control or usual care: immediate outcome: independence in ADL, Outcome 4: Provider of intervention
8.5
8.5. Analysis
Comparison 8: Subgroups. Intervention versus attention control or usual care: immediate outcome: independence in ADL, Outcome 5: Treatment components included
9.1
9.1. Analysis
Comparison 9: Subgroups. Intervention versus no treatment: immediate outcome: motor function, Outcome 1: Time after stroke
9.2
9.2. Analysis
Comparison 9: Subgroups. Intervention versus no treatment: immediate outcome: motor function, Outcome 2: Study geographical location
9.3
9.3. Analysis
Comparison 9: Subgroups. Intervention versus no treatment: immediate outcome: motor function, Outcome 3: Dose of intervention
9.4
9.4. Analysis
Comparison 9: Subgroups. Intervention versus no treatment: immediate outcome: motor function, Outcome 4: Provider of intervention
9.5
9.5. Analysis
Comparison 9: Subgroups. Intervention versus no treatment: immediate outcome: motor function, Outcome 5: Treatment components included
10.1
10.1. Analysis
Comparison 10: Subgroups. Intervention versus attention control or usual care: immediate outcome: motor function, Outcome 1: Time after stroke
10.2
10.2. Analysis
Comparison 10: Subgroups. Intervention versus attention control or usual care: immediate outcome: motor function, Outcome 2: Study geographical location
10.3
10.3. Analysis
Comparison 10: Subgroups. Intervention versus attention control or usual care: immediate outcome: motor function, Outcome 3: Dose of intervention
10.4
10.4. Analysis
Comparison 10: Subgroups. Intervention versus attention control or usual care: immediate outcome: motor function, Outcome 4: Provider of intervention
10.5
10.5. Analysis
Comparison 10: Subgroups. Intervention versus attention control or usual care: immediate outcome: motor function, Outcome 5: Treatment components included
11.1
11.1. Analysis
Comparison 11: Subgroups. One active intervention versus another active intervention: immediate outcomes: independence in ADL, Outcome 1: Functional task training components
11.2
11.2. Analysis
Comparison 11: Subgroups. One active intervention versus another active intervention: immediate outcomes: independence in ADL, Outcome 2: Neurophysiological components
11.3
11.3. Analysis
Comparison 11: Subgroups. One active intervention versus another active intervention: immediate outcomes: independence in ADL, Outcome 3: Musculoskeletal components
12.1
12.1. Analysis
Comparison 12: Subgroups. One active intervention versus another active intervention: immediate outcomes: motor function, Outcome 1: Functional task training components
12.2
12.2. Analysis
Comparison 12: Subgroups. One active intervention versus another active intervention: immediate outcomes: motor function, Outcome 2: Neurophysiological components
12.3
12.3. Analysis
Comparison 12: Subgroups. One active intervention versus another active intervention: immediate outcomes: motor function, Outcome 3: Musculoskeletal components
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Lincoln 2003 {unpublished data only}
    1. Lincoln N, Van Vliet P. A comparison of a UK approach to stroke rehabilitation with a movement science based approach. Personal communication 2000.
    1. Vliet PM, Lincoln NB, Foxall A. Comparison of Bobath based and movement science based treatment for stroke: a randomised controlled trial. Journal of Neurology Neurosurgery and Psychiatry 2005;76:503-8. - PMC - PubMed
Liu 2003 {published data only}
    1. Liu G, Zhang H. Early rehabilitation and prognosis of post-stroke hemiplegic patients. Zhongguo Linchuang Kangfu 2003;7(3):506.
McClellan 2004 {published data only}
    1. McClellan R, Ada L. A six-week, resource-efficient mobility program after discharge from rehabilitation improves standing in people affected by stroke: placebo-controlled, randomised trial. Australian Journal of Physiotherapy 2004;50:163-7. - PubMed
Mudge 2009 {published data only}
    1. Mudge S, Barber PA, Stott NS. Circuit-based rehabilitation improves gait endurance but not usual walking activity in chronic stroke: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation 2009;90(12):1989-96. - PubMed
Mudie 2002 {published data only}
    1. Mudie MH, Winzeler-Mercay U, Radwan S, Lee L. Training symmetry of weight distribution after stroke: a randomised controlled pilot study comparing task-related reach, Bobath and feedback training approaches. Clinical Rehabilitation 2002;16:582-92. - PubMed
Ni 1997 {published data only}
    1. Ni CM, Fu J, Liu CY. Influence of early rehabilitation on walking function of the patients with acute stroke. Zhongguo Linchuang Kangfu 1997;12(4):164-5.
Pan 2004 {published data only}
    1. Pan C-H, He J-Q, Pu S-X, Wan X-L, Gao C. Effects of early rehabilitation therapy on the motor function of limbs and activities of daily living in patients with hemiplegia after stroke. Zhongguo Linchuang Kangfu 2004;8(13):2404-5.
Pang 2003 {published data only}
    1. Pang G. Early rehabilitation care effect on activities of daily life of stroke patients. Zhongguo Linchuang Kangfu 2003;7(7):1230-1.
Pang 2006 {published data only}
    1. Pang AL, Ren H, Chang LH, Gong SX, Ma SP. Effects of cocktail treatment on motor function of patients with ischemic stroke. Zhongguo Linchuang Kangfu 2006;10(32):6-8.
Pollock 1998 {published and unpublished data}
    1. Pollock AS, Durward BR, Rowe PJ, Paul JP. The effect of independent practice of motor tasks by stroke patients: a pilot randomized controlled trial. Clinical Rehabilitation 2002;16:473-80. - PubMed
    1. Pollock AS. An Investigation into Independent Practice as an Addition to Physiotherapy Intervention for Patients with Recently Acquired Stroke [Dissertation]. Edinburgh: Queen Margaret College, 1998.
Qian 2004 {published data only}
    1. Qian K-L, Wang T. Effect of early rehabilitation therapy on short and long term functional assessment in hemiplegic patients after stroke. Zhongguo Linchuang Kangfu 2004;8(25):5210-1.
Qian 2005 {published data only}
    1. Qian KL, Wang T. Application of flexor reflex therapy in rehabilitation of lower extremity of hemiplegic patients after brain injury. Zhongguo Linchuang Kangfu 2005;9(5):24-5.
Richards 1993 {published and unpublished data}
    1. Malouin F, Potvin M, Prevost J, Richards CL, Wood-Dauphinee S. Use of intensive task-oriented gait training program in a series of patients with acute cerebrovascular accidents. Physical Therapy 1992;72(11):781-93. - PubMed
    1. Malouin F, Richards CL, Wood-Dauphinee S, Williams JI. A randomized controlled trial comparing early and intensive task-specific physical therapy to conventional therapy in acute stroke patients. Canadian Journal of Rehabilitation 1993;7:27-8.
    1. Richards CL, Malouin F, Wood-Dauphinee S, Williams JI, Bouchard JP, Brunet D. Task-specific physical therapy for optimization of gait recovery in acute stroke patients. Archives of Physical Medicine and Rehabilitation 1993;74:612-20. - PubMed
Salbach 2004 {published data only}
    1. Salbach NM, Mayo NE, Wood-Dauphinee S, Hanley JA, Richards CL, Cote R. A task-orientated intervention enhances walking distance and speed in the first year post stroke: a randomised controlled trial. Clinical Rehabilitation 2004;18:509-19. - PubMed
Shin 2011 {published data only}
    1. Shin WS, Lee SW, Lee YW, Choi SB, Song CH. Effects of combined exercise training on balance of hemiplegic stroke patients. Journal of Physical Therapy Science 2011;23(4):639-43.
Stephenson 2004 {published data only}
    1. Stephenson J, Maitland M, Beckstead J. Body weight support treadmill training compared with PNF training in persons with chronic stroke. Journal of Neurologic Physical Therapy 2004;28(4):186.
Tang 2009 {published data only}
    1. Tang W, Yang B. Influence of sensory function training on motor function of cerebral apoplexy patients complicated with hemiplegia. Zhongguo Huli Zazhì 2009;23(7C):1905-6.
Thaut 2007 {published data only}
    1. Thaut MH, Leins AK, Rice RR, Argstatter H, Kenyon GP, McIntosh GC, et al. Rhythmic auditory stimulation improves gait more than NDT/Bobath training in near-ambulatory patients early poststroke: a single-blind, randomized trial. Neurorehabilitation and Neural Repair 2007;21(5):455-9. - PubMed
Torres‐Arreola 2009 {published data only}
    1. Torres-Arreola L del P, Doubova Dubova SV, Hernandez SF, Torres-Valdez LE, Constantino-Casas NP, Garcia-Contreras F, et al. Effectiveness of two rehabilitation strategies provided by nurses for stroke patients in Mexico. Journal of Clinical Nursing 2009;18:2993-3002. - PubMed
Verheyden 2006 {published data only}
    1. Verheyden G, Vereeck L, Truijen S, De Weerdt W. Additional exercises improve trunk performance after stroke: an assessor-blinded randomized controlled trial. In: UK Stroke Forum Conference. 2007:31. - PubMed
    1. Verheyden G, Vereeck L, Truijen S, Nieuwboer A, De Weerdt W. Trunk rehabilitation after stroke: a pilot randomized controlled trial. Neurorehabilitation and Neural Repair 2006;20(1):118-9. - PubMed
    1. Verheyden G, Vereeck L, Truijen S, Troch M, Lafosse C, Saeys W, et al. Additional exercises improve trunk performance after stroke: a pilot randomized controlled trial. Neurorehabilitation and Neural Repair 2009;23(3):281-6. - PubMed
Verma 2011 {published data only}
    1. Verma R, Arya K, Garg RK, Singh T. Task-oriented circuit class training program with motor imagery for gait rehabilitation in poststroke patients: a randomized controlled trial. Topics in Stroke Rehabilitation 2011;18(1):620-32. - PubMed
Wade 1992 {published data only}
    1. Wade DT, Collen FM, Robb GF, Warlow CP. Physiotherapy intervention late after stroke and mobility. BMJ 1992;304:609-13. - PMC - PubMed
Wang 2004a {published data only}
    1. Wang Q-R, Gan Z-R, Lu H, Hu X, Liu H-L, Cai C-Q, et al. Effect of early exercise therapy on the recovery of motor function in patients with cerebral infarction and the changes of somatosensory evoked potentials. Zhongguo Linchuang Kangfu 2004;8(28):6023-5.
Wang 2004b {published data only}
    1. Wang WM. Treatment of limb spasticity in hemiplegic patients within 4 months after stroke: curative effect of neural facilitation combined with low frequency pulse current. Zhongguo Linchuang Kangfu 2004;8(25):5224-5.
Wang 2005 {published data only}
    1. Wang RY, Chen HI, Chen CY, Yang YR. Efficacy of Bobath versus orthopaedic approach on impairment and function at different motor recovery stages after stroke: a randomized controlled study. Clinical Rehabilitation 2005;19:155-64. - PubMed
Wang 2006 {published data only}
    1. Wang H, Wang T, Chen Q. The dynamic analysis of effects of 3-phase rehabilitation intervention on muscle tone and function in hemiplegia after stroke. Zhongguo Linchuang Kangfu 2006;21(9):807-10.
Wei 1998 {published data only}
    1. Wei G, Song L, Huang M et al. Effects of selective trunk activities training on the recovery of hemiplegic patients. Zhongguo Linchuang Kangfu 1998;13(3):108-10.
    1. Wei G, Song L, Huang M. Effects of selective trunk activities training on the recovery of hemiplegic patients (Abstract PO-RR-392-27). In: Proceedings of the World Confederation of Physical Therapy. Yokohama, Japan: Science Council of Japan and the Japanese Physical Therapy Association, May 23-28, 1999.
Wellmon 1997 {published and unpublished data}
    1. Wellmon R, Newton RA. An examination of changes in gait and standing symmetry associated with the practice of a weight shifting task. Neurology Report 1997;21(2):52-3.
Wu 2006 {published data only}
    1. Wu X, Ni C, Han R. Effect of early rehabilitation on spasticity, activities of daily living and motor function in patients with hemiplegia after stroke. Zhongguo Linchuang Kangfu 2006;21(6):494-6.
Xiao 2003 {published data only}
    1. Xiao W, Wang J, Luo Z, Xie R. The economic health evaluation to the early intensive rehabilitation on patients with stroke. Zhongguo Linchuang Kangfu 2003;7(3):372-3.
Xie 2003 {published data only}
    1. Xie S, Zhu M, Zhang X. Effect of early rehabilitation nursing on activities of daily living in patients with stroke. Zhongguo Linchuang Kangfu 2003;7(1):143.
Xie 2005 {published data only}
    1. Xie XH, Chen WH, Yang R, Wu WQ, Zhang W, Qi Q, et al. Effects of rehabilitation training on quality of life in stroke patients at different stages after the episode. Zhongguo Linchuang Kangfu 2005;9(32):47-9.
Xu 1999 {published data only}
    1. Xu L, Shong Q, Zuo H. Effects of rehabilitation treatment on the hemiplegic patients following stroke. Jiangxi Medical Journal 1999;34(3):149-50.
Xu 2003a {published data only}
    1. Xu Y, Liu S. Effects of early rehabilitation on patients with paralysis after cerebral infarction. Zhongguo Linchuang Kangfu 2003;7(1):127.
Xu 2003b {published data only}
    1. Xu H, Sun S, Wang M. The effect of early rehabilitation on hemiplegic limbs of patients with stroke. Zhongguo Linchuang Kangfu 2003;7(3):503.
Xu 2004 {published data only}
    1. Xu BH, Yu RQ, Yu W, Xie B, Huang YX. Effects of early rehabilitation on activities of daily living and complications in acute stroke patients. Beijing Da Xue Xue Bao 2004;36(1):75-8. - PubMed
Xue 2006 {published data only}
    1. Xue J, Bai L, Guo QR, Yang CR, Lu J. Efficacy of early intervention of motor relearning program on post-stroke hemiplegia: a randomized controlled observation. Neural Regeneration Research 2006;1(3):277-9.
Yan 2002 {published data only}
    1. Yan YL. Effects of early rehabilitation on lower extremity motor function in stroke hemiplegia. Zhongguo Linchuang Kangfu 2002;6(3):331-2.
Yelnik 2008 {published data only}
    1. Yelnik AP, Le Breton F, Colle FM, Bonan IV, Hugeron C, Egal V, et al. Rehabilitation of balance after stroke with multisensorial training: a single-blind randomized controlled study. Neurorehabilitation and Neural Repair 2008;22(5):468-76. - PubMed
Yin 2003a {published data only}
    1. Yin H, Tian Y. Early rehabilitation of hemiplegic extremities after stroke and effect observation of therapy with intermediate frequency. Zhongguo Linchuang Kangfu 2003;7(7):1198.
Zhang 1998 {published data only}
    1. Zhang X. Observation of the effects of early rehabilitation intervention for cerebral apoplexy and hemiplegia. Heilongjiang Nursing Journal 1998;4(11):1-2.
Zhang 2004 {published data only}
    1. Zhang T, Li LL, Bi S, Mei YW, Xie RM, Luo ZM, et al. Effects of three-stage rehabilitation treatment on acute cerebrovascular diseases: a prospective, randomized, controlled, multicenter study. Zhonghua Yi Xue Za Zhi 2004;84(23):1948-54. - PubMed
Zhao 2002 {published data only}
    1. Zhao F, Ji X. Early stage rehabilitation and nursing care in cerebral apoplexy patients with hemiparalysis. Zhongguo Huli Zazhì 2002;16(4):194-6.
Zhao 2003 {published data only}
    1. Zhao F, Wang L, Tian G, Zhou J, Han J. Early rehabilitation intervention promoting ability of daily living in acute stroke patients. Zhongguo Linchuang Kangfu 2003;7(5):851.
Zhu 2001 {published data only}
    1. Zhu Y-L, Hu Y-S, Yang P-J. Effects of three months' rehabilitation on motor function in hemiplegics after stroke. Chinese Journal of Rehabilitation Theory and Practice 2001;7(4):155-6.
Zhu 2004b {published data only}
    1. Zhu GX, Hu YS, Wu Y, Zhu YL, Han X, Sun LM, et al. Effects of standardized three-stage rehabilitation on recovery of neurological function in stroke patients with hemiplegia. Zhonghua Yi Xue Za Zhi 2004;84(23):1955-8. - PubMed
Zhu 2006 {published data only}
    1. Zhu J, Liao L, Chen S. Influence of rehabilitative nursing intervention on activities of daily living of senile cerebral apoplexy patients. Zhongguo Huli Zazhì 2006;20(4A):890-2.
Zhu 2007 haem {published data only}
    1. Zhu XJ, Wang T, Chen Q, Wang X, Hou H, Wang HX. The effects of standardised rehabilitation treatment on the outcome of activities of daily living in patients with hemiplegia after stroke. Chinese Journal of Cerebrovascular Diseases 2007;4(6):254-9.
Zhu 2007 isch {published data only}
    1. Zhu X, Wang T, Chen Q, Wang X, Hou H, Wang H. The effects of early rehabilitation on quality of life for elderly patients with stroke. Journal of Rehabilitation Medicine 2008;Suppl 46:118.
    1. Zhu XJ, Wang T, Chen Q, Wang X, Hou H, Wang HX. The effects of standardized rehabilitation treatment on the outcome of activities of daily living in patients with hemiplegia after stroke. Chinese Journal of Cerebrovascular Diseases 2007;4(6):254-9.
Zhuang 2012 {published data only}
    1. Zhuang LX, Xu SF, D'Amado CR, Jia C, He J, Han DX, et al. An effectiveness study comparing acupuncture, physiotherapy, and their combination in poststroke rehabilitation: a multicentered, randomized, controlled clinical trial. Alternative Therapies in Health and Medicine 2012;18(3):8-14. - PubMed

References to studies excluded from this review

Acalha 2010 {published data only}
    1. Acalha T, MG, Suzuki SO, Berg TL. Effects of the task oriented and auditory cues for chronic stroke patients. Revista Terapia Manual 2010;8(39):441-7.
Dean 2000a {unpublished data only}
    1. Dean CM, Malouin F, Richards CL. Locomotor task-related training for chronic stroke: multiple single case design. [Unpublished].
de Paula Oliveira 2007 {published data only}
    1. Paula Oliveira T, Voos M, Korim W, Piemonte M. Home-exercise program for stroke patients: improvement in functional performance. Physiotherapy 2007;93 Suppl 1:S563-4.
Dickstein 1986 {published data only}
    1. Dickstein R, Hocherman S, Pillar T, Shaham R. Stroke rehabilitation: three exercise therapy approaches. Physical Therapy 1986;66(8):1233-8. - PubMed
Eng 2003 {published data only}
    1. Eng JJ, Chu KS, Kim CM, Dawson AS, Carswell A, Hepburn K. A community-based group exercise program for persons with chronic stroke. Medicine and Science in Sports and Exercise 2003;35:1271-8. - PMC - PubMed
English 2003 {published data only}
    1. English C, Warden-Flood A, Stiller K, Hillier S. Is task-related circuit training an effective means of providing rehabilitation to acute stroke patients? Australian Journal of Physiotherapy 2003;49 Suppl 4:s9-s10.
Gong 2003 {published data only}
    1. Gong S, Zhang J, Yu K. Effect of early rehabilitation training on daily life activity of patients with hemiplegia after stroke. Zhongguo Linchuang Kangfu 2003;7(5):848-9.
Gregson 2003 {published data only}
    1. Gregson J. Exercise training early after stroke: a feasibility study. Current Controlled Trials, 2003. http://www.controlled-trials.com/.
Hesse 1998 {published data only}
    1. Hesse S, Jahnke MT, Schaffrin A, Lucke D, Reiter F, Konrad M. Immediate effects of therapeutic facilitation on the gait of hemiparetic patients as compared with walking with and without a cane. Electroencephalography and Clinical Neurophysiology 1998;109:515-22. - PubMed
Inaba 1973 {published data only}
    1. Inaba M, Edberg E, Montgomery J, Gillis MK. Effectiveness of functional training, active exercise, and resistive exercise for patients with hemiplegia. Physical Therapy 1973;53(1):28-35. - PubMed
Karaduman 2001 {published data only}
    1. Karaduman A, Armutlu K, Aksu A, Aras O, Arikan H. The comparison of different exercise-treatment methods in the rehabilitation of early stage hemiplegic patients. Neurorehabilitation and Neural Repair 2001;15(4):348.
Khanna 2003 {published data only}
    1. Khanna PB. A randomised controlled study of the immediate and long term benefits of conventional stroke rehabilitation with task related group therapy in chronic stroke patients. www.controlled-trials.com (accessed July 2005).
Kim 2001 {published data only}
    1. Kim CM, Eng JJ, MacIntyre DL, Dawson AS. Effects of isokinetic strength training on walking in persons with stroke: a double-blind controlled pilot study. Journal of Stroke and Cerebrovascular Diseases 2001;10:265-73. - PMC - PubMed
Krutulyte 2003 {published data only}
    1. Krutulyte G, Kimtys A, Krisciunas A. The effectiveness of physical therapy methods (Bobath and motor relearning program) in rehabilitation of stroke patients. Medicina 2003;39(9):889-95. - PubMed
Li 2004 {published data only}
    1. Li K, Dou Z-L, Zhu H-X, Zheng J-L, Lan Y. Effect of supported balance training on balance and activities of daily living in convalescent stroke patients. Zhongguo Linchuang Kangfu 2004;8(34):7620-1.
Lin 2004 {published data only}
    1. Lin JH, Hsieh CL, Lo SK, Chai HM, Liao LR. Preliminary study of the effect of low-intensity home-based physical therapy in chronic stroke patients. Kaohsiung Journal of Medical Science 2004;20(1):18-23. - PMC - PubMed
Liu 2008 {published data only}
    1. Liu L, Zhu L. Efficacy observation of modified comprehensive rehabilitation therapy in patients with moderate to severe hemiplegia in acute stage of stroke. Chinese Journal of Cerebrovascular Diseases 2008;5(3):117-20.
Meng 2005 {published data only}
    1. Meng ZX, Ni CM, Li JB, Han R. Effects of early rehabilitation on the functional outcomes of stroke patients estimated with functional comprehensive assessment. Chinese Journal of Clinical Rehabilitation 2005;9(5):1-3.
Ng 2005 {published data only}
    1. Ng SS. Effectiveness of an Innovative Home-Based Rehabilitation Program on Lower Limb Functions in Subjects with Chronic Stroke: A Randomized, Controlled Trial. Hong Kong Polytechnic University (People's Republic of China), 2005.
Nissan‐Lavi 2009 {published data only}
    1. Nissan-Lavi L, Carmeli E. Stroke patients in the community: comparison of the effect of physical therapy group training and walking training. Journal of the Israeli Physical Therapy Society (JIPTS) 2009;11(1):28.
Ozdemir 2001 {published data only}
    1. Ozdemir F, Birtane M, Tabatabaei R, Kokino S, Ekuklu G. Comparing stroke rehabilitation outcomes between acute inpatient and nonintense home settings. Archives of Physical Medicine and Rehabilitation 2001;82:1375-9. - PubMed
Pomeroy 2001a {published data only}
    1. Pomeroy VM. The immediate effects of neurofacilitatory physiotherapy on gait parameters early post-stroke. The National Research Register 2001;1:Publication ID: NO217063260.
Pyoria 2007 {published data only}
    1. Pyoria O, Talvitie U, Nyrkko H, Kautiainen H, Pohjolainen T, Kasper V. The effect of two physiotherapy approaches on physical and cognitive functions and independent coping at home in stroke rehabilitation. A preliminary follow-up study. Disability and Rehabilitation 2007;29(6):503-11. - PubMed
Qiu 2004 {published data only}
    1. Qui W-H, Hu X-Q, Zheng J-L, Li K, Lan Y, Chen X-M. Effect of balance function on limb function and activities of daily living in hemiplegic patients. Zhongguo Linchuang Kangfu 2004;8(31):6872-3.
Richards 2004 {published data only}
    1. Richards CL, Malouin F, Bravo G, Dumas F, Wood-Dauphinee S. The role of technology in task-oriented training in persons with subacute stroke: a randomised controlled trial. Neurorehabilitation and Neural Repair 2004;18:199-211. - PubMed
Salter 1991 {published data only}
    1. Salter J, Camp Y, Pierce LL, Mion LC. Rehabilitation nursing approaches to cerebrovascular accident: a comparison of two approaches. Rehabilitation Nursing 1991;16(2):62-6. - PubMed
Stern 1970 {published data only}
    1. Stern PH, McDowell F, Miller JM, Robinson M. Effects of facilitation exercise techniques in stroke rehabilitation. Archives of Physical Medicine and Rehabilitation 1970;51:526-31. - PubMed
Stuart 2008 {published data only}
    1. Macko RF, Benvenuti F, Stanhope S, Macellari V, Taviani, A, Nesi B, et al. Adaptive physical activity improves mobility function and quality of life in chronic hemiparesis. Journal of Rehabilitation Research and Development 2008;45(2):323-8. - PubMed
    1. Stuart M, Benvenuti F, Macko R, Taviani A, Segenni L, Mayer F, et al. Community-based adaptive physical activity program for chronic stroke: feasibility, safety, and efficacy of the Empoli model. Neurorehabilitation and Neural Repair 2009;23(7):726-34. - PMC - PubMed
    1. Stuart M, Chard S, Benvenuti F, Steinwachs S. Community exercise: a vital component to healthy aging. Healthcare Papers 2009;10(1):23-8. - PubMed
    1. Stuart M, Chard S, Roettger S. Exercise for chronic stroke survivors: a policy perspective. Journal of Rehabilitation Research and Development 2008;45(2):329-35. - PubMed
    1. Stuart M. Adaptive physical activity for chronic stroke (APA-Stroke). ClinicalTrials.gov 2008.
Thielman 2004 {published data only}
    1. Thielman GT, Dean CD, Gentile AM. Rehabilitation of reaching after stroke: task-relating training versus progressive resistive exercise. Archives of Physical Medicine and Rehabilitation 2004;85:1613-8. - PubMed
Wagenaar 1990 {published data only}
    1. Wagenaar RC, Meijer OG, Wieringen PCW, Kuik DJ, Hazenberg GJ, Lindeboom J, et al. The functional recovery of stroke: a comparison between neuro-developmental treatment and the Brunnström method. Scandinavian Journal of Rehabilitation Medicine 1990;22:1-8. - PubMed
Wang 2005b {published data only}
    1. Wang A, Wang Y, Hu P. Influence of comprehensive nursing intervention on extremities function in patients with cerebrovascular accidents. Chinese Nursing Research 2005;19(1A):37-39.
Wolny 2003 {published data only}
    1. Wolny T, Saulicz E, Gnat R, Bacik B. The effectiveness of PNF method in gait reeducation in hemiplegic patients - a preliminary study. In: Proceedings of the 14th International Congress of the World Confederation for Physical Therapy. Barcelona, Spain, 2003:Abst. RR-PO-0326.
Wood 1994 {published data only}
    1. Wood-Dauphinee S. The impact of task-oriented physical therapy on locomotion recovery of stroke patients. [Unpublished].
Xu 2008 {published data only}
    1. Xu Y. The effect of early intensive exercise on patients with hemiplegia. Journal of Rehabilitation Medicine 2008;Suppl 46:75.
Yin 2003b {published data only}
    1. Yin S. The recovery comparison of comprehensive rehabilitation and simple pharmacotherapy on the patients after stroke during the period of sequela. Chinese Journal of Clinical Rehabilitation 2003;7(1):140.
Yu 2008 {published data only}
    1. Yu J, Hu Y, Wu Y, Chen W, Cui X, Lu W, et al. An analysis about the effects of standardized community-based rehabilitation (CBR) therapy on ADL for patients after stroke in China. Journal of Rehabilitation Medicine 2008;Suppl 46:110.
Zhong 2006 {published data only}
    1. Zhong M, Mo H, Liu H. Evidence-based nursing on early rehabilitation of cerebral infarction patients with hemiplegia. Chinese Nursing Research 2006;20(2B):393-5.
Zhou 2003 {published data only}
    1. Zhou J, Wang J. The effect of earlier functional training improving ability of living self care of patients with stroke. Zhongguo Linchuang Kangfu 2003;7(3):508.
Zhu 2004a {published data only}
    1. Zhu Y-L, Hu Y-S, Wu Y, Xu Y-M. Possibility of functional recovery with early rehabilitation training during the first 3 months in hemiplegic patients with stroke. Zhongguo Linchuang Kangfu 2004;8(1):18-9.

References to studies awaiting assessment

Giraux 2008 {published data only}
    1. Giraux P. Impact of prolonged physical therapy on gait performance of chronic phase stroke patients (HEMIMARCHE). ClinicalTrials.gov 2008.
Li 2000 {published data only}
    1. Li H, Jia Z, Song L. Early rehabilitation effect on stroke hemiplegia. Chinese Journal of Physical Medicine 1998;20:1-2.
    1. Li H. Long term effect of early rehabilitation on stroke hemiplegic patients. Chinese Journal of Physical Medicine and Rehabilitation 2000;22(1):15-7.
Matsumoto 2010 {published data only}
    1. Matsumoto S. The effect of trunk facilitation in post-stroke patients. UMIN Clinical Trials Registry (UMIN-CTR), 2010. http://www.umin.ac.jp/ctr/.
Richardson 2011 {published data only}
    1. Richardson J, Fleck R, Hladysh G, McBay C, MacKay E, Thorlakson R, et al. Fit for function: a community wellness program for persons with stroke. Stroke 2011;42(11):e596.
Sanchez‐Sanchez 2011 {published data only}
    1. Sanchez-Sanchez ML, Igual-Camacho C, Villaplana-Alcazar M, Rubio-Moreno MC, Viosca-Herrero E. Gait recovery after stroke: a physiotherapy protocol based on clinical and functional criteria. Cerebrovascular Diseases 2011;31 Suppl 2:202.
Wang 2005a {published data only}
    1. Wang W. Effect of systematic rehabilitative training on motor function and activity of daily life in post stroke hemiplegic patients. Chinese Journal of Clinical Rehabilitation 2005;9(21):14-5.
Wang 2012 {published data only}
    1. Wang W, Ru X, Dai H, Wu S, Jiang B. A new model of rehabilitation study at community level for stroke survivors in five urban populations in China. Neuroepidemiology 2012;39(3-4):191.
Yau 2010 {published data only}
    1. Yau WWM, Wong WL. The feasibility and efficacy of an augmented exercise program for acute stroke patients. International Journal of Stroke 2010;5:346-7.
Zhang 2008 {published data only}
    1. Zhang J, Wu S, Huang Y, Long Y, Chen T, Feng L, et al. The effects of standardized three stages rehabilitation program in promoting active function in stroke patients with hemiplegia. Journal of Rehabilitation Medicine 2008;Suppl 46:111 (Abst PP002-060).

References to ongoing studies

Cross 2009 {published data only}
    1. Cross J. FeST1vAIS. Functional strength training to improve walking and upper limb function in people at least 1 year after stroke. UK Clinical Research Network Portfolio Database, 2009. http://public.ukcrn.org.uk/search/:last accessed 27th June 2013.
    1. Cross J. Functional strength training to improve walking and upper limb function in people at least one year after stroke: a phase II trial. Current Controlled Trials, 2009. http://www.controlled-trials.com/:last accessed 27th June 2013.
    1. Mares K, Cross J, Clark A, Barton GR, Poland F, O'Driscoll ML, et al. The FeSTivaLS trial protocol: a randomized evaluation of the efficacy of functional strength training on enhancing walking and upper limb function later post stroke. International Journal of Stroke 2013;5:374-82. - PubMed
Kumaran 2010 {published data only}
    1. Kumaran S. Effectiveness and feasibility of a task and context based exercise program in stroke patients: a randomized controlled trial. Clinical Trials Registry - India (CTRI), 2010. http://www.ctri.in:last accessed 19th June 2013.

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