What Is the Evidence for Physical Therapy Poststroke? A Systematic Review and Meta-Analysis

The evidence is appalling that stroke therapy only gets 10% to full recovery. THAT BY ANY DEFINITION IS COMPLETE AND TOTAL FAILURE! Only by using the tyranny of low expectations can  the stroke medical world  claim any modicum of success. I'd fire everyone involved in stroke for not even attempting to get to 100% recovery. All this biomarkers and predicting failure to recover is totally fucking useless to get survivors recovered.

YOU need to get involved, you can't leave this up to stroke medical 'professionals', they came up with the inadequate Helsingborg declarations.

Helsingborg 1996

Helsingborg 2006

What Is the Evidence for Physical Therapy Poststroke? A Systematic Review and Meta-Analysis

 
What Is the Evidence for Physical Therapy Poststroke? ASystematic Review and Meta-Analysis
Janne Marieke Veerbeek
1
, Erwin van Wegen
1
, Roland van Peppen
2
, Philip Jan van der Wees
3
,Erik Hendriks
4
, Marc Rietberg
1
, 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

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 asystematic 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 withrespect to timing poststroke for 10 interventions. Neurological treatment approaches to training of body functions andactivities showed equal or unfavorable effects when compared to other training interventions. Main limitations of thepresent 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

Introduction

Prospective studies have estimated that about 795.000 people in the USA suffer a first or recurrent stroke each year [1]. The prevalence of chronic stroke in the USA is estimated at about 7million [1], with about 80% of patients with stroke being over the age of 65. The prevalence of stroke is likely to increase in the future due to the aging population. Even though acute stroke care (Quit talking about 'care', just tell us recovery and results.)has improved, for example by large-scale application of recombinant tissue plasminogen activator (rTPA) [1,2] and organized interdisciplinary inpatient stroke care [3], and although mortality rates have been decreasing [1], a large number of patients still remain disabled regardless of the time that has elapsed post stroke.Only 12% of the patients with stroke are independent in basic activities of daily living (ADL) at the end of the first week [4]. In the long term, 25–74% of patients have to rely on human assistance for basic ADLs like feeding, self-care, and mobility [5].Interdisciplinary complex rehabilitation interventions [6,7] are assumed to represent the mainstay of post stroke care [8]. One of the key disciplines in interdisciplinary stroke rehabilitation is physical therapy which is primarily aimed at restoring and maintaining ADLs, usually starting within the first days and often continuing into the chronic phase post stroke [8]. While the interdisciplinary character of stroke rehabilitation is paramount,the availability of specific, up-to-date, and professional evidence-based guidelines for the physical therapy profession is crucial for making adequate evidence-based clinical decisions [9–11]. The recommendations in the first Dutch evidence-based ‘Clinical Practice Guideline for physical therapy in patients with stroke were based on meta-analyses of 123 randomized controlled trials(RCTs) and date back to 2004 [12]. In view of the tremendous growth in the number of RCTs in this field, it is now necessary to re-establish the ‘‘state of the art’’ concerning the evidence for physical therapy interventions in stroke rehabilitation. This aim is in line with the 2006 Helsingborg Declaration on European Stroke Strategies(Which I consider a total failure for not even trying for 100% recovery), which states that stroke rehabilitation should be based on evidence as much as possible [13,14]. The first aim of the present systematic review was to update our previous meta-analyses of complex stroke rehabilitation interventions in the domain of physical therapy, based on RCTs with a low risk of bias (i.e. a moderate to good methodological quality) with no restrictions to the comparator. Primary outcomes, measured post intervention, were defined at the levels of body functions and/or activities and participation of the International Classification of Functioning, disability and health model (ICF) [15]. The second aim was to explore whether the timing of interventions post stroke moderated the main effects.

 

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