The evidence is that therapy after stroke is a complete fucking failure; only 10% get to full recovery from it. But you're using the tyranny of low expectations to declare success from failure. You ask one question of your patients: Are you 100% recovered? Y/N? That will give you the correct answer to your evidence question.
What Is the Evidence for Physical Therapy Poststroke? A Systematic Review and Meta-Analysis
Janne Marieke Veerbeek 1,
Erwin van Wegen1,
Roland van Peppen2,
Philip Jan van der Wees3,
Erik Hendriks4,
Marc Rietberg1,
Gert Kwakkel 1,5*
1 Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, The Netherlands,
2 Department of Physiotherapy, University of Applied Sciences Utrecht, Utrecht, The Netherlands,
3 Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud UniversityNijmegen Medical Center, Nijmegen, The Netherlands,
4 Department of Epidemiology, Maastricht University, Maastricht, The Netherlands,
5 Department of Neurorehabilitation, Reade Center for Rehabilitation and Rheumatology, Amsterdam, The Netherlands
1 Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, The Netherlands,
2 Department of Physiotherapy, University of Applied Sciences Utrecht, Utrecht, The Netherlands,
3 Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud UniversityNijmegen Medical Center, Nijmegen, The Netherlands,
4 Department of Epidemiology, Maastricht University, Maastricht, The Netherlands,
5 Department of Neurorehabilitation, Reade Center for Rehabilitation and Rheumatology, Amsterdam, The Netherlands
Abstract
Background:Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of thissystematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.
Methods and Findings:
Randomized controlled trials (RCTs) regarding PT in stroke rehabilitation were retrieved through a systematic search. Outcomes were classified according to the ICF. RCTs with a low risk of bias were quantitatively analyzed.Differences between phases poststroke were explored in subgroup analyses. A best evidence synthesis was performed forneurological treatment approaches. The search yielded 467 RCTs (N=25373; median PEDro score 6 [IQR 5–7]), identifying 53interventions. No adverse events were reported. Strong evidence was found for significant positive effects of 13interventions related to gait, 11 interventions related to arm-hand activities, 1 intervention for ADL, and 3 interventions forphysical fitness. Summary Effect Sizes (SESs) ranged from 0.17 (95%CI 0.03–0.70; I2=0%) for therapeutic positioning of theparetic arm to 2.47 (95%CI 0.84–4.11; I2=77%) for training of sitting balance. There is strong evidence that a higher dose of practice is better, with SESs ranging from 0.21 (95%CI 0.02–0.39; I2=6%) for motor function of the paretic arm to 0.61(95%CI 0.41–0.82; I2=41%) for muscle strength of the paretic leg. Subgroup analyses yielded significant differences with respect to timing post stroke for 10 interventions. Neurological treatment approaches to training of body functions and activities showed equal or unfavorable effects when compared to other training interventions. Main limitations of the present review are not using individual patient data for meta-analyses and absence of correction for multiple testing.
Conclusions:
There is strong evidence for PT interventions favoring intensive high repetitive task-oriented and task-specific training in all phases post stroke. Effects are mostly restricted to the actually trained functions and activities. Suggestions for prioritizing PT stroke research are given.
Citation:
Veerbeek JM, van Wegen E, van Peppen R, van der Wees PJ, Hendriks E, et al. (2014) What Is the Evidence for Physical Therapy Poststroke? A SystematicReview and Meta-Analysis. PLoS ONE 9(2): e87987. doi:10.1371/journal.pone.0087987
Editor:
Terence J. Quinn, University of Glasgow, United Kingdom
Received
October 29, 2013;
Accepted
December 30, 2013;
Published
February 4, 2014
Copyright:
2014 Veerbeek et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding:
This research project was supported by the Royal Dutch Society for Physical Therapy (KNGF grant no. 8091.1; http://www.fysionet.nl/). The funders hadno role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests:
The authors have declared that no competing interests exist.* E-mail: g.kwakkel@vumc.nl
Methods and Findings:
Randomized controlled trials (RCTs) regarding PT in stroke rehabilitation were retrieved through a systematic search. Outcomes were classified according to the ICF. RCTs with a low risk of bias were quantitatively analyzed.Differences between phases poststroke were explored in subgroup analyses. A best evidence synthesis was performed forneurological treatment approaches. The search yielded 467 RCTs (N=25373; median PEDro score 6 [IQR 5–7]), identifying 53interventions. No adverse events were reported. Strong evidence was found for significant positive effects of 13interventions related to gait, 11 interventions related to arm-hand activities, 1 intervention for ADL, and 3 interventions forphysical fitness. Summary Effect Sizes (SESs) ranged from 0.17 (95%CI 0.03–0.70; I2=0%) for therapeutic positioning of theparetic arm to 2.47 (95%CI 0.84–4.11; I2=77%) for training of sitting balance. There is strong evidence that a higher dose of practice is better, with SESs ranging from 0.21 (95%CI 0.02–0.39; I2=6%) for motor function of the paretic arm to 0.61(95%CI 0.41–0.82; I2=41%) for muscle strength of the paretic leg. Subgroup analyses yielded significant differences with respect to timing post stroke for 10 interventions. Neurological treatment approaches to training of body functions and activities showed equal or unfavorable effects when compared to other training interventions. Main limitations of the present review are not using individual patient data for meta-analyses and absence of correction for multiple testing.
Conclusions:
There is strong evidence for PT interventions favoring intensive high repetitive task-oriented and task-specific training in all phases post stroke. Effects are mostly restricted to the actually trained functions and activities. Suggestions for prioritizing PT stroke research are given.
Citation:
Veerbeek JM, van Wegen E, van Peppen R, van der Wees PJ, Hendriks E, et al. (2014) What Is the Evidence for Physical Therapy Poststroke? A SystematicReview and Meta-Analysis. PLoS ONE 9(2): e87987. doi:10.1371/journal.pone.0087987
Editor:
Terence J. Quinn, University of Glasgow, United Kingdom
Received
October 29, 2013;
Accepted
December 30, 2013;
Published
February 4, 2014
Copyright:
2014 Veerbeek et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding:
This research project was supported by the Royal Dutch Society for Physical Therapy (KNGF grant no. 8091.1; http://www.fysionet.nl/). The funders hadno role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests:
The authors have declared that no competing interests exist.* E-mail: g.kwakkel@vumc.nl
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