Limited evidence of physical therapy on balance after stroke: A systematic review and meta-analysis

Abstract

Background: Stroke results in balance disorders and these directly affect autonomy and quality of life. The purpose of this systematic review and meta-analysis was to determine the efficacy of physical therapy (PT) on balance and postural control after stroke.

Methods: We included all randomized controlled trials assessing the efficacy of PT on balance and postural control in adult patients after stroke without language restriction. Medline, Embase/Scopus, Cochrane Central Register of Controlled Trials, PEDro, Pascal, and Francis databases were searched until January 2019. Primary outcomes were balance (Berg Balance scale and Postural Assessment Scale for Stroke) and postural control with postural deviation or stability measurement in sitting or standing static evaluation. A pair of independent reviewers selected studies, extracted data, and assessed risk of bias. Meta-analyses with subgroups (categories of PT, time post-stroke, and lesion location) and meta-regression (duration of PT) were conducted.

Results: A total of 145 studies (n = 5912) were selected from the 13,123 records identified. For balance, evidence was found in favor of the efficacy of functional task-training alone (standardized mean difference 0.39, 95% confidence interval [0.09; 0.68], heterogeneity I2 = 63%) or associated with musculoskeletal intervention and/or cardiopulmonary intervention (0.37, [0.19; 0.55], I2 = 48%), electrostimulation (0.91, [0.49; 1.34], I2 = 52%) immediately after intervention, compared to sham treatment or usual care (ST/UC). For postural deviation eyes open, assistive devices were more effective than no treatment (-0.21, [-0.37; -0.05], I2 = 0%) immediately after intervention; for postural stability eyes open, functional task-training and sensory interventions were more effective than ST/UC (0.97, [0.35; 1.59], I2 = 65% and 0.80, [0.46; 1.13], I2 = 37% respectively) immediately after intervention.

Conclusions: Functional task-training associated with musculoskeletal intervention and/or cardiopulmonary intervention and sensory interventions seem to be immediately effective in improving balance and postural stability, respectively. The heterogeneity of PT and the weak methodological quality of studies limited the interpretation and the confidence in findings.

Fig 1. Flow-chart.

Fig 2. Forest plot of PT versus NT.

Outcome: Balance, post-intervention effects. Risk of bias: A, Random sequence generation; B, Allocation concealment; C, Blinding of outcome assessment; D, Incomplete outcome data; E, Blinding of participants and therapists; F, Selective reporting; G, Other bias. Risk of bias: green color corresponds to low risk, yellow color unclear risk, and red color high risk. Abbreviations: CI, Confidence interval; SD, Standard deviation; SMD, Standardized mean difference.

Fig 3. Forest plot of PT versus NT.

Outcome: Balance, persisting effects. Risk of bias: A, Random sequence generation; B, Allocation concealment; C, Blinding of outcome assessment; D, Incomplete outcome data; E, Blinding of participants and therapists; F, Selective reporting; G, Other bias. Risk of bias: green color corresponds to low risk, yellow color unclear risk, and red color high risk. Abbreviations: CI, Confidence interval; SD, Standard deviation; SMD, Standardized mean difference.

Fig 4. Forest plot of PT versus ST/UC.

Outcome: Balance, post-intervention effects. Risk of bias: A, Random sequence generation; B, Allocation concealment; C, Blinding of outcome assessment; D, Incomplete outcome data; E, Blinding of participants and therapists; F, Selective reporting; G, Other bias. Risk of bias: green color corresponds to low risk, yellow color unclear risk, and red color high risk. Abbreviations: CI, Confidence interval; SD, Standard deviation; SMD, Standardized mean difference.

Fig 5. Forest plot of PT versus ST/UC.

Outcome: Balance, persisting effects. Risk of bias: A, Random sequence generation; B, Allocation concealment; C, Blinding of outcome assessment; D, Incomplete outcome data; E, Blinding of participants and therapists; F, Selective reporting; G, Other bias. Risk of bias: green color corresponds to low risk, yellow color unclear risk, and red color high risk. Abbreviations: CI, Confidence interval; SD, Standard deviation; SMD, Standardized mean difference.

Fig 6. Forest plot of PT versus NT and versus ST/UC.

Outcome: Mediolateral postural deviation EO. Risk of bias: A, Random sequence generation; B, Allocation concealment; C, Blinding of outcome assessment; D, Incomplete outcome data; E, Blinding of participants and therapists; F, Selective reporting; G, Other bias. Risk of bias: green color corresponds to low risk, yellow color unclear risk, and red color high risk. Abbreviations: CI, Confidence interval; SD, Standard deviation; SMD, Standardized mean difference.

Fig 7. Forest plot of PT versus NT.

Outcome: Postural stability EO. Risk of bias: A, Random sequence generation; B, Allocation concealment; C, Blinding of outcome assessment; D, Incomplete outcome data; E, Blinding of participants and therapists; F, Selective reporting; G, Other bias. Risk of bias: green color corresponds to low risk, yellow color unclear risk, and red color high risk. Abbreviations: CI, Confidence interval; SD, Standard deviation; SMD, Standardized mean difference.

Fig 8. Forest plot of PT versus ST/UC.

Outcome: Postural stability EO. Risk of bias: A, Random sequence generation; B, Allocation concealment; C, Blinding of outcome assessment; D, Incomplete outcome data; E, Blinding of participants and therapists; F, Selective reporting; G, Other bias. Risk of bias: green color corresponds to low risk, yellow color unclear risk, and red color high risk. Abbreviations: CI, Confidence interval; SD, Standard deviation; SMD, Standardized mean difference.