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Effects of physical therapy modalities for motor function, functional recovery, and post-stroke complications in patients with severe stroke: a systematic review update

Systematic Reviews volume 13, Article number: 270 (2024) Cite this article

Abstract

Background

Physical therapy interventions play a crucial role in the daily care of patients recovering from severe stroke. However, the efficacy of these interventions and associated modalities, including duration, intensity, and frequency, have not been fully elucidated. In 2020, a systematic review reported the beneficial effects of physical therapy for patients with severe stroke but did not assess therapeutic modalities. We aim to update the current evidence on the effects of physical therapy interventions and their modalities in relation to the recovery phase in people with severe stroke in a hospital or inpatient rehabilitation facility.

Methods

We searched CENTRAL, MEDLINE, Web of Science, and three other relevant databases between December 2018 and March 2021 and updated the search between April 2021 and March 2023. ClinicalTrials.gov and ICTRP for searching trial registries helped to identify ongoing RCTs since 2023. We included individual and cluster randomized controlled trials in the English and German languages that compared physical therapy interventions to similar or other interventions, usual care, or no intervention in a hospital or rehabilitation inpatient setting. We screened the studies from this recent review for eligibility criteria, especially according to the setting. Critical appraisal was performed according to the Cochrane risk-of-bias tool 2.0. The data were synthesized narratively.

Results

The update identified 15 new studies, cumulating in a total of 30 studies (n = 2545 participants) meeting the eligibility criteria. These studies reported 54 outcomes and 20 physical therapy interventions. Two studies included participants during the hyperacute phase, 4 during the acute phase,18 during the early subacute phase, and 3 in the late subacute phase. Three studies started in the chronic phase. Summarised evidence has revealed an uncertain effect of physical therapy on patient outcomes (with moderate to low-quality evidence). Most studies showed a high risk of bias and did not reach the optimal sample size. Little was stated about the standard care and their therapy modalities.

Discussion

There is conflicting evidence for the effectiveness of physical therapy interventions in patients with severe stroke. There is a need for additional high-quality studies that also systematically report therapeutic modalities from a multidimensional perspective in motor stroke recovery. Due to the high risk of bias and the generally small sample size of the included studies, the generalizability of the findings to large and heterogeneous volumes of outcome data is limited.

Systematic review registration

PROSPERO CRD42021244285.

Peer Review reports

Introduction

Stroke is the second leading cause of death and the third leading cause of death and disability worldwide according to the Global Burden of Diseases Study Group [1]. An increase in stroke deaths and disability-adjusted life years (DALYs) will accompany future population growth and increased life expectancy in many countries [2, 3]. Simultaneously, stroke care has been optimized through specialized acute facilities (e.g., stroke units), and the advancement of recanalization therapies (i.e., thrombectomies and thrombolysis) has shown positive effects [4].

In 2017, the Stroke Recovery and Rehabilitation Roundtable Taskforce agreed on a standard definition of stroke phases [5]. This decision is based on current knowledge and understanding of the biological repair processes of the brain [6,7,8]. In animal models, a time dependency of recovery has already been observed [6]. It is hypothesized that the biological repair process begins early after the stroke and then slowly subsides. A similar course has also been observed in humans [6, 9].

However, this concept of stroke phases does not imply that functional recovery occurs linearly; rather, it is meant to ensure better comparability between research data sets. The proportion recovery rule (PRR) follows the hypothetical assumption that within the first 3–6 months, patients can improve on average by 70% (± 15%), and thus, the extent of recovery is highly predictable, regardless of the dose of therapy provided [10,11,12]. Some patients do not follow this rule, especially those who show severe deficits at baseline [13]. Recent approaches indicate that most people with stroke tend to experience a combination of constant recovery and proportional-to-spared function [14]. It was found that there are two different patterns of recovery for patients with stroke and different severities of initial motor impairment [15]. Severely and non-severely impaired patients exhibit individual recovery trajectories [15].

Reports on patients with severe stroke indicate that even after intensive and prolonged therapy, some patients may show little to no improvement [16]. According to a systematic review, people with severe stroke often progress more slowly and with less functional improvement during inpatient rehabilitation than people with mild impairment [17]. This could be due to the combination of significant sensory-motor and cognitive impairments induced by severe stroke [18]. Stroke severity is an important determinant of the length of hospital stay and is one of the most important indices for measuring the use of hospital care [19]. Several predictors of stroke recovery have been analyzed thus far, but therapy modalities, including duration, frequency, and intensity, have not been considered.

An important factor in understanding study outcomes can be the therapeutic modality of an intervention [20]. In the literature, there is a lack of definitions and heterogeneous use of the dose of intervention. In 2021, the group around Hayward [21] proposed a framework for dose articulation in stroke recovery: duration can measure the length of intervention in days, sessions per day, and session length with active or inactive episodes; an episode can be defined by the length of a task, its difficulty, and its intensity. For this reason, among others, studies have been conducted to examine the influence of duration and intensity of therapy and have shown positive treatment effects for a longer therapy duration. For example, depending on the author, the therapy time varied between upper extremity interventions post-stroke of 10 h/week, as measured by the Motor Activity Log (MAL) [22], and 30 h/week, as measured by the Fugl-Meyer-Assessment Upper Limb (FMA-UL) [23]. Little information is available about studies of people with severe stroke and associated therapy modalities, such as duration and episodes.

McGlinchey et al. (2020) [24] reported the beneficial effects of rehabilitation interventions for severely affected patients with stroke according to their stroke recovery phase and outcome measures according to the International Classification of Functioning, Disability and Health (ICF). His review did not address therapy modalities and included all kinds of settings. This review builds on and expands upon McGlinchey’s systematic review [24] by additionally evaluating the duration and episodes of interventions in people after a severe stroke in a hospital or inpatient rehabilitative setting.

Methods

This systematic review was conducted following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions, version 6.3 [25] and was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement 2020 [26]. The protocol was registered prospectively at the Prospective Register of Systematic Reviews platform (CRD42021244285). There were no deviations from the protocol.

Eligibility criteria

Studies were included when.

  1. (1)

    they were a randomized or non-randomized controlled trials. A randomized controlled trial can be an individually randomized trial (RCT), a cluster randomized controlled trial (cRCT) randomized crossover trial, or a multicenter randomized study. A non-randomized controlled trial can be mono- or multicentric, with a prospective study design. RCTs are considered the gold standard for demonstrating efficacy.

  2. (2)

    Study participants were aged ≥ 18 years and diagnosed with severe stroke (ischemic or hemorrhagic). For the purpose of this review, severe stroke was defined as Functional Independence Measure (FIM) score < 54 or early FIM < 40 or National Institute of Health Stroke Scale (NIHSS) ≤ 16 or modified Rankin Scale (mRS) ≤ 4 or Barthel Index (BI) ≤ 35 or Fugl-Meyer-Assessment (FMA) ≤ 55 or Functional Ambulatory Categories (FAC) ≤ 2 [27,28,29,30,31,32].

  3. (3)

    The placement of the intervention was within a hospital or inpatient rehabilitation facility.

  4. (4)

    Any kind of physical rehabilitation intervention was applied with the intention of managing physical problems following a medical or surgical condition.

  5. (5)

    A comparison intervention was reported, including any other type of physical rehabilitation or usual care.

  6. (6)

    At least one of the following outcomes was reported:

  7. (7)

    Functional recovery was defined as a partial or complete return to normal or proper physiologic activity of an organ or body part following disease or trauma and was assessed using a recognized outcome measure of functional ability or activities of daily living (ADLs) [33].

  8. (8)

    Motor function was defined as any activity of muscles due to stimulation by a motor neuron, movement, or activation and was assessed using a recognized measure of motor function [34].

  9. (9)

    Post-stroke complications, adverse events, and medical or neurological problems necessitate a physician’s order and require monitoring by medical staff [35, 36].

  10. (10)

    The study was published in English or German to ensure feasibility.

Studies were excluded if.

  1. (1)

    patients suffered a mild to moderate stroke.

  2. (2)

    Pharmacological, surgical, or complementary (e.g., acupuncture or non-invasive brain stimulation) interventions were used.

  3. (3)

    Interventions were delivered in an outpatient setting (e.g., home or ambulatory).

Search strategy and selection criteria

Since the review builds up on the systematic review of McGlinchey et al. [24] a search was conducted for studies published between January 1987 and November 2018), and the search strategy was based on their report. For this reason, we have not consulted any other experts. Electronic searches were also conducted in the Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINHAL), Physiotherapy Evidence Database (PEDro), Web of Science, Database of Research in Stroke (DORIS) and the Cochrane Central Register of Controlled Trials (CENTRAL) from December 2018 to March 2021 and an update from April 2021 to March 2023. The search strategy included identifying the terms related to severe stroke, physical therapy modalities, stroke rehabilitation, motor recovery, and motor function. Information specialists were consulted. An example of the search strategy can be found in Supplementary material S1. The search was restricted to human studies. The International Trials Registry Platform (ICTRP) and ClinicalTrials.gov helped to identify ongoing trials from January 2019 to March 2021 and were updated from April 2022 to March 2023. To identify further studies, reference lists were searched, and a forward citation search was carried out on the Web of Science, Google Scholar, and Scopus.

Data collection and analysis

Study selection

All eligible studies were uploaded to a reference management program. After duplicate removal, the remaining studies were uploaded to Rayyan [37]. Using the prespecified criteria for eligibility, two authors (KR, BSM) independently screened the studies for inclusion based on their titles and abstracts. Two independent reviewers (KR, MK) screened the full texts of the studies identified as eligible for inclusion during title and abstract screening. The reasons for the excluded studies are listed in a table (Supplementary material S2). Reports from the same study population were linked to ensure that data from the same population were only included once in the review and analysis. Discrepancies were discussed and resolved by consensus with a third reviewer (SuS).

Data extraction and management

Two review authors (KR, TB) independently extracted the data from all the included studies. A prespecified data extraction form was developed based on the Cochrane Handbook for Systematic Review of Interventions (version 6.3), the CONSORT statement for reporting randomized trials and extensions, and the Template for Intervention Description and Replication (TiDieR) [25, 38, 39]. The data extraction form was pilot-tested during two online face-to-face training sessions. The review by McGlinchey et al. [24] did not report the therapeutic modalities; therefore, we screened all the studies according to the setting, stroke severity cut-off points, and interventions. The following information was extracted: aim and focus of the studies, study design, details about the intervention according to the TiDieR Checklist [39], number and characteristics of participants, time post-stroke (converted in days), outcomes, and outcome measures. The individuals in each study were assigned to the following post-stroke recovery phases: hyperacute (≤ 24 h post-stroke), acute (> 24 h but ≤ 7 days post-stroke), early subacute (> 7 days but ≤ 3 months (≤ 90 days) post-stroke) and late subacute (> 3 months but ≤ 6 months (≤ 180 days) post-stroke) [4]. Funding sources for the studies were collected in tabular form (Supplementary material S3).

Risk of bias

Two authors (BS, KR) independently rated the risk of bias using the Cochrane Risk of Bias 2 (RoB2) tool for individually randomized, parallel-group trials [40] and recommended according to the “SHORT VERSION (CRIBSHEET)” [41]. An overall judgment of a high risk of bias was given when the study was judged to be at high risk of bias in one domain or if there was some concern for multiple, in this review, two domains. Any differences in opinion were discussed between the two authors and were recorded in writing. There was no need to consult a third reviewer. McGlinchey [24] stated in his review that a high quality meant a low risk of bias, a moderate quality a serious risk and a low to very low quality of evidence was based on a high risk of bias.

Reporting on intervention and dose

Extraction according to the TiDieR checklist [39] of the goal of the interventions included who and what was provided, whether it was tailored or modified, how well it was planned, and whether there was economic information available. Item eight of the TiDieR instrument evaluates the number of times the intervention was delivered and the duration, intensity, or dose during which the intervention was delivered. In addition, further dose dimensions such as session density and episodes were extracted [42].

Data analysis and synthesis

Demographics and study results are reported as medians (IQRs), minimum to maximum ranges, or numbers of studies (percentages) as appropriate. Due to the heterogeneity of outcome measures, recovery phases, therapy modality outcomes, and the high proportion of studies where concerns regarding bias were present, pooled analyses were not performed. The extracted data are summarised in tables as narrative descriptions of the intervention and therapy modalities by recovery phase. If various outcomes were reported, the means and standard deviations, including participant characteristics and test results, were combined into one group using the free accessible Statistics Toolkit (STATTOOLS, Palisade, Ithaca, NY) [43]. This procedure of combining means (SDs) complies with the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions (version 6.3) [25]. To judge the quality of evidence narratively, the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used [44, 45].

Results

Study selection

Out of 3216 identified records, 564 full-title articles were screened. The search was conducted between the 11th and 23rd of April 2021 and the 1st and 10th of April 2023. This review included 30 studies, 15 of which were also included in McGlinchey’s analysis [46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69]. However, 13 studies included by McGlinchey were excluded in this current review due to an incorrect setting, intervention, or different cut-offs for the severity of stroke. Two reports [47, 48] were subanalyses from the AVERT study [49], and two [50, 51] were follow-up studies to Kwakkel et al. (1999 [52]). No further results were found through searching reference lists or forward citations in the Web of Science, Google Scholar, or Scopus databases. Figure 1 shows the results of the screening procedure.

Fig. 1
figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 study selection flow diagram

Full size image

Study characteristics

Study characteristics, including the interventions used, are provided in Table 1. All the studies were published between 1999 [52, 53] and 2023 [54] and were mostly conducted in Italy [55,56,57,58], Korea [46, 59,60,61,62,63,64], and China [54, 65,66,67,68,69]. A total of 2545 participants were included across all the RCTs (range: n = 20 [70] to n = 294 [49]). The overall study duration ranged between one [71] and 20 weeks [52].

Table 1 Result
Full size table

Participant characteristics

The participants’ characteristics are summarised in Table 2. Thirty studies reported on 2545 randomized patients with an average age of 67.25 years (SD ± 13.50). Two studies [49, 57] included participants in the hyperacute phase, four studies [52, 67, 71, 79] in the acute phase, 18 studies [53,54,55,56, 58, 60, 61, 64, 66, 68,69,70, 72,73,74,75,76,77,78] in the early subacute phase and three studies in the late subacute phase [59, 63, 65]. Three studies started in the chronic phase [46, 62, 70].

Table 2 Study demographics
Full size table

Risk of bias

The results of the risk of bias assessment are shown in Figure 2. The individually randomised, parallel-group studies[46, 55, 60, 62, 63, 65, 66, 69, 71, 80], showed an overall high risk of bias. All ten studies raised some concerns or were rated as having a high risk of bias in the domains of deviation from intended interventions [46, 62, 65, 69, 80], randomisation process [62, 71] or missing or retrospective study registration [55]. According to the quality assessments of McGlinchey’s 15 studies, one had a low risk of bias [49], four studies had a serious risk [50,51,52, 72, 76, 79], and ten had a high risk of bias [53, 56,57,58, 61, 67, 68, 70, 73, 78].

Fig. 2
figure 2

Risk of bias of individual domains for the updated studies. Randomisation process Deviations from the intended interventions Missing outcome data Measurement of the outcome Selection of the reported result

Full size image

Types of interventions

The included studies used various types of interventions. Studies have used active rehabilitation interventions without technical support or devices, such as mirror therapy [60, 62, 69], additional upper or lower limb therapy [52], very early mobilization [49, 57], and interventions with specialized therapists in the Bobath or Carr and Shepard approaches [67, 68, 71]. Robotic-assisted body weight supported (BWS) treadmill gait training [61, 70, 76, 77], underwater gait training [46], BWS-supported overground gait training [55, 75], BWS-supported treadmill [58], or gait training and leg cycle ergometry [79] were used.

Three studies used electrical stimulation, such as functional electrical stimulation (FES) [66] and neuromuscular electrical stimulation (NMES) [65, 66]. Supportive devices for verticalization, such as a standing frame [73, 74] or robotic verticalization with the help of an Erigo [56], were used in 2 studies. One study involved digital practice with virtual reality [59], an elastic sling for the upper extremity [63], strength training [54], a whole-body tilt apparatus for postural training [64], differently qualified therapists [53], and thermal stimulation [78] as interventions. An overview of the interventions can be found in Table 1.

Types of comparators

Interventions were compared to standard care [49, 57, 61, 66], delivered by physiotherapists (PTs) [53, 55, 56, 66, 70, 71, 74, 76,77,78,79], occupational therapists (OTs) [52, 60, 62, 78] or speech-language therapists (SLTs) [76, 79], as well as by nursing staff [57]. Only one study [67] used routine medication as a control intervention.

Standard care was often not described in detail. Information on the control intervention was incomplete in five studies [59, 60, 66, 71, 73] and was missing in two studies [24, 55].

Therapy modalities

The study duration ranged from  7 days [71] to 20 weeks [50,51,52]. Therapy sessions were offered twice a day [55, 67, 72], daily [71], and most often five times per week [50,51,52,53, 58, 60, 61, 65, 66, 68, 70, 73, 76, 78, 81]. Session length differs per day from 10 min [79] to 120 min [57] up to statements that refer to the time spent in therapy alone [46, 55, 58, 68, 70, 72, 73, 76, 78]. The intensity of the interventions and what the control group performed in terms of content were inconsistently reported. An overview can be found in Table 2.

Reporting on quality of evidence and dose

The 30 studies used 54 outcome measures. Those outcome measures were categorized by the ICF into body function (n = 26), activity (n = 23), and participation (n = 5). Supplementary material S4 provides an overview. Details on the GRADE criteria are reported in Supplementary material S5.

Functional impairment in global early mobilization without electrical supportive devices within 24 h

Two studies [49, 57] compared early mobilization within 24 h to usual care referred to the outcome of independence. The quality of evidence was judged to be moderate due to concerns about inconsistency and imprecision. Inconsistency and imprecision in the results and their direction had been found and the threshold of 400 participants was not reached.

Basic ADLs for neurodevelopmental interventions without electrical supportive devices

Neurodevelopmental interventions without electrical supportive devices compared to usual care for basic ADLs in severe stroke patients. The quality was judged with low quality of evidence due to concerns of inconsistency and imprecision [53, 71]. Wide confidence intervals (CG CI 95% 46.41 (37.77–55.04)); IG CI 95% (67 (58.99–75.94)) and appreciable benefits, and no difference between groups were found. Further on there were different directions of effects.

Basic ADL in interventions with NMES

Two studies [65, 72] compared NMES to standardized upper limb therapy and sham NMES in basic ADL. The quality of evidence was judged to be low due to inconsistency and imprecision. Different control groups and varying ages in the population may affect the consistency. The required threshold of participants was not reached with 172 participants.

Extended ADLs in interventions with verticalization support

Interventions with verticalization support compared to usual care in extended ADLs were found in two studies [73, 74]. The quality of evidence was judged to be low due to imprecisions and limitations in the design and implementation of the available studies. The threshold of 400 participants is not reached and the results are imprecise. Both studies showed no significant between-group differences when using a standing frame as verticalization support.

Balance skills in neurodevelopmental interventions

The Berg Balance Scale (BBS) was used to assess balance skills in two RCTs [68, 71] using neurodevelopmental interventions compared to usual care and a conventional Bobath approach. The quality of evidence was judged to be very low due to imprecisions, inconsistency of the results, and a high risk of bias in both studies due to serious methodological limitations. The optimal information size (OIS) was not reached and differences in population had been detected.

Walking capacity in robotic-assisted gait training

Three studies [61, 75, 76] assessed walking capacity using the FAC comparing robotic-assisted gait training (RAGT) to conventional therapy and overground gait training. The quality of evidence was judged to be low. We had serious concerns about the inconsistency of the results based on the different reporting and directions of the effects. Regarding the OIS and the given effect sizes, we had serious concerns regarding imprecision.

Motor function in robotic-assisted gait training

Three studies [61, 75, 76] compared RAGT to conventional therapy and overground gait training for assessing motor function in the lower limb with the Fugl-Mayer-Assessment of the lower extremity (FMA-LE). The quality of evidence was judged to be low due to concerns about inconsistency and imprecision. Serious concerns were raised regarding the OIS and the missing effect sizes as well as different directions of effect and slight differences in the intervention and control groups.

Dexterity in highly intensive active interventions (without electric support)

Two studies investigating highly intensive active interventions compared to restriction and usual care for the dexterity of participants with severe stroke, measured using the Action Research Arm Test (ARAT), were judged low-quality evidence. This is due to some concerns about the risk of bias and the number of participants and the authors’ overall assessment, inconsistency in the results and their direction had been detected as well as not researching the threshold of 400 participants and imprecise results [52, 53].

The following outcomes were each examined in one study, and therefore no reliable conclusions can be drawn regarding their effects: spasticity in a staged rehabilitation intervention [67], neglect in digital training with virtual reality [59], and bimanual mirror therapy [62], cognitive function in robotic verticalization [81], sensorimotor function in thermal stimulation [69], walking capacity in BWS overground gait training [55], walking capacity in BWS overground gait training [70], spatiotemporal gait parameters in underwater gait training [46], walking speed in RAGT [77], balance in four-channel FES [66] and in strength training off the non-hemiplegic lower extremity [54], upper extremity function in multijoint mirror therapy [60], independence in daily and social activities in leg cycle ergometer [79], functional mobility in the use of an Oswestry standing [73], muscle strength while using an elastic dynamic sling [63] and pusher syndrome in whole-body tilt apparatus [82].

Discussion

The goal of this systematic review was to summarise the most recent research on physical therapy interventions and their dosage requirements for patients with severe stroke who are treated in hospitals or inpatient rehabilitation facilities. Thirty studies [46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79] were included, with 54 outcomes and various types of interventions. Despite being an update of a recent systematic review, the overall evidence remains insufficient. However, the evidence is not robust enough to determine the effect of physical therapy interventions for patients with severe stroke. Due to limitations in the design, inconsistencies in results, and subjective interpretations, much of the evidence has been rated as low quality. There were not enough individual studies to obtain trustworthy evidence for the outcomes considered.

Robotic gait interventions

The review included six studies using robotic, BWS, treadmill, or overground training to undertake a form of gait training, such as robotic-assisted body weight supported (BWS) treadmill gait training and underwater gait training [46, 47, 57, 60, 66, 67]. Unexpectedly, there was poor-quality evidence for all gait therapy outcomes. A systematic review of the current guidelines showed that robotic gait interventions are now recommended [83]. Eight out of 11 guidelines included supporting RAGT, which was shown to improve walking speed, step length, and balance. Previously, in a meta-regression study, Moucheboeuf et al. (2020, [84]) showed no correlation between stroke severity and age, time since stroke, rehabilitation intensity, or treatment success. Stroke severity was measured using the FAC. In contrast, other studies have shown that the severity of paresis influences the ability to predict the recovery of walking ability [85]. However, severity was measured by the presence of hemiparesis or hemiplegia. The Cochrane Review on treadmill training and BWS for walking after stroke [86] rated walking speed with moderate evidence quality, while our rating was low. They included 26 studies, compared to 2 in our review, and found that patients able to walk at the start improved more than those who could not. These findings align with our results, despite differing stroke severity levels in the studies. The differences in outcomes may caused by the different search approaches used. The current Cochrane Review on Electromechanical-assisted training for walking after stroke [87] still highlights recent findings. In contrast to our findings, they showed high-quality evidence that the use of electromechanical devices increased the likelihood of walking independently at the end of the intervention phase for survivors of stroke. Studies with a focus on patients with severe stroke were included instead of being intervention-specific. Nevertheless, the authors of the guideline review recommend the use of the RAGT for people who would not otherwise perform gait training [83]. However, RAGT should not be used in place of conventional therapy [83].

Usual care

It is possible to hypothesize that the intervention or control group can be as effective only as the underlying standard therapies are if standard therapy (usual care) is used. In most of the studies included the interventions were carried out in addition to standard care. According to the TiDieR checklist, many of the studies lack a description of their interventions. Regardless of the term “standard therapy”, “standard care”, etc., refer to the standard of care at the local institution. Usual care and control groups are still insufficiently reported in intervention studies. For example, an intervention study may be based on very good usual care, and intervention in the study, however poor, may achieve good results. The reverse may also be true. A recent systematic review [88] reignited the discussion on control intervention groups and highlighted the importance of the therapies on which study interventions are based. Although usual care may be referred to by various terms, e.g., rehabilitative therapy [57], standard intervention [71], or conventional therapy [61], precise details regarding the frequency, intensity, and methods of patient treatment are rarely recorded. Using tools like the TidieR checklist [39], facilitate accurate therapy descriptions [89, 90], but this issue exists beyond neurorehabilitation [91]. It is important to remember that each nation's standard of treatment is shaped by its healthcare system. In Germany, outpatient stroke therapy can involve specialized methods like Bobath or proprioceptive neuromuscular facilitation  (PNF), which allow for higher payments [92]. Although Bobath is not guideline-recommended, it is widely used in the UK, with 67% of clinicians employing it for people with stroke [93]. Its use is evident in our findings [53, 61, 68]. Studies on the effectiveness of the Bobath vary from ineffective [92] to inconclusive [94] to effective [95]. Clinicians seek evidence-based, practical research that reflects real-world rehabilitation [96], underscoring the need for more transparent reporting in future studies, particularly regarding comparison interventions.

Therapy dimensions

The frequency and dosage of therapeutic interventions like Bobath or RAGT are often unclear. For example, there is no consensus on the number, duration, timing, or appropriate patient profile for RAGT [83]. A Cochrane review indicates that treadmill gait training may be more beneficial in the first three months post-stroke than in the chronic phase, but the precise dosage remains uncertain [86]. The review also found no significant increase in walking speed for dependent stroke survivors at treatment onset (95% CI [− 0.06 to 0.03]; P = 0.52) [86]. A Cochrane review indicated that increased therapy duration generally improves outcomes, particularly for lower extremity functional impairments and ADLs [97].

One study approached this issue by varying the intervention start time [49]. However, the functional mobility outcome of early mobilization after stroke showed moderate evidence that early activation had no advantage over the control group. These interventions both took place in the acute phase after stroke. In a large multicentre study, 75% of all patients were mobilized within 18 h [49], but earlier mobilization was linked to higher mortality when the mRS score was evaluated (adjusted odds ratio (OR) 0.73, 95% CI [0.59 to 0.90]; p = 0.004). A recent systematic review supports starting mobilization 24 h post-stroke [98]. Although there was some evidence that patients with severe stroke and intracerebral hemorrhage would have worse outcomes with very early mobilization, these differences were not statistically significant (p > 0.05). Other RCTs [99, 100] with patients with mild to moderate strokes also indicated that more intervention did not necessarily lead to better outcomes (daily amount per person IG: 31 min (16.5–50.5 min); CG: 10 min (0–18 min)). These findings suggest that early mobilization within 24 h may be disadvantageous, and factors like intensity and duration, which depend on recovery phases, also affect outcomes [97]. Dromerick et al. [101] demonstrated positive effects in the subacute phase post-stroke, with a treatment window of two and three months and a daily intensity of 2 h. Of the included studies, only three [50,51,52, 61, 76] provided more therapy, and one [66] met Dromerick et al. [101] 600 min/week threshold. A systematic review reported a 240% increase in usual rehabilitation aimed at reducing ADL limitations [102], though it did not account for stroke severity. The interventions in weekly duration and total therapy amount are shown in Table 2.

Limitations

A limitation of this review was restricting the language to German and English. To address this, we searched multiple databases using a broad strategy to identify RCTs for severe stroke treatment. Our strict assessment of the high risk of bias using the RoB 2 tool ensured consistency but may have contributed to heterogeneous evaluations among different authors.

Our given cut-off score for stroke severity may have excluded studies using different measures to define severe stroke [18, 103]. However, broad inclusion criteria resulted in a diverse range of studies with populations that were difficult to compare. The BI and mBI were most commonly used (twelve times in all studies) to define stroke severity. The heterogeneity in defining severe stroke may change with the adoption of Stroke Recovery and Rehabilitation Roundtable Taskforce recommendations [5], which suggest using the NIHSS score. Yet, no studies before 2018 reported this assessment. This could lead to the large heterogeneity of the included studies. Other reasons for this heterogeneity were also a high rated risk of bias, generally small sample size of included studies, and large and heterogeneous volume of outcome data. We did not include outpatient or home-based settings because we wanted to focus on the early health care of patients with severe stroke.

Future research

Future research should: (a) address, how to assess stroke severity [5] and especially during baseline assessments [5]; (b) consider detailed reporting of interventions and control intervention as well as usual care [104, 105] including the amount of dosage according to the reporting guidelines and (c) studies should include follow-ups to assess long-term outcomes.

The interventions identified in this review are present in clinical practice, but certainty of their effectiveness is lacking for daily application. (d) A structured recording [42], would help accurately describe both the intervention and standard care, improving study comparability, certainty, and theory–practice transfer.

Investigating whether optimal, timely, and targeted therapy can reduce long-term costs is essential.

Conclusion

This systematic review revealed mostly low- and moderate-quality evidence related to physical therapy interventions for patients with severe stroke. Although this is an update of an existing systematic review, there is still insufficient and little evidence to support the effectiveness of physical therapies in an inpatient setting. Compared to those of patients who had mild or moderate stroke, the results of the interventions in these studies had varying quality of evidence.

The included interventions reflected daily clinical practice. Until now, this certainty of evidence has been hindered by heterogeneous study populations and control groups that are difficult to compare. This has prevented us from drawing any practical conclusions. More research is needed. Certainty can be gained when there are more comparable interventions through a better description of the interventions, through a comparable control group, and through a clear description of the severity of stroke that has been studied. Better transparency will allow for better comparability between studies and their respective outcomes. The analysis of the therapy dimension of an intervention can be a key component in explaining study outcomes for patients. Here, in particular, it is interesting to take a closer look at which intervention is effective for which degree of severity of stroke and time post-stroke so that it does not turn into a watering can principle.

There is a need for additional high-quality studies in the early to late subacute phase that systematically articulate intervention doses from a multidimensional perspective in motor stroke recovery. This requires the implementation of the recommendation of stroke recovery and rehabilitation roundtables for the use of the NIHSS score as an assessment of stroke severity [5, 106].

Abbreviations

ADL:

Activities of daily living

ARAT:

Action Research Arm Test

BBS:

Berg Balance Scale

BI:

Barthel Index

BWS:

Body weight support

CENTRAL:

Cochrane Central Register of Controlled Trials

CI:

Confidence interval

CINHAL:

Cumulative Index to Nursing and Allied Health Literature

cRCT:

Cluster randomized controlled trial

DALYs:

Disability-adjusted life years

DORIS:

Web of Science, Database of Research in Stroke

EMBASE:

Excerpta Medica Database

FAC:

Functional Ambulatory Categories

FES:

Functional electrical stimulation

FIM:

Functional Independence Measure

FMA:

Fugl-Meyer-Assessment

FMA-UL:

Fugl-Meyer-Assessment Upper Limb

FMA-LE:

Fugl-Meyer-Assessment Lower Extremity

GRADE:

Grading of Recommendations, Assessment, Development and Evaluation

ICF:

International Classification of Functioning, Disability and Health

ICTRP:

International Trials Registry Platform

IQR:

Interquartile range

MAL:

Motor Activity Log

MAS:

Modified Ashworth Scale

MEDLINE:

Medical Literature Analysis and Retrieval System Online

mRS:

Modified Rankin Scale

NIHSS:

National Institute of Health Stroke Scale

NMES:

Neuromuscular electrical stimulation therapy

OIS:

Optimal information size

OR:

Odds ratio

OT:

Occupational therapist

PEDro:

Physiotherapy Evidence Database

PNF:

Proprioceptive neuromuscular facilitation

PRR:

Proportion recovery rule

PT:

Physiotherapist

RAGT:

Robotic-assisted gait therapy

RCT:

Randomised controlled trial

RMA:

Rivermead Motor Assessment

RoB2:

Risk of Bias Tool 2

SLT:

Speech-language therapist

TiDieR:

Template for Intervention Description and Replication

UK:

United Kingdom

References

  1. Krishnamurthi RV, Ikeda T, Feigin VL. Global, regional and country-specific burden of ischaemic stroke, intracerebral haemorrhage and subarachnoid haemorrhage: a systematic analysis of the global burden of disease study 2017. Neuroepidemiology. 2020;54(Suppl. 2):171–9.

    Article  PubMed  Google Scholar 

  2. Feigin VL, Nichols E, Alam T, Bannick MS, Beghi E, Blake N, et al. Global, regional, and national burden of neurological disorders, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology. 2019May;18(5):459–80.

    Article  Google Scholar 

  3. Feigin VL, Stark BA, Johnson CO, Roth GA, Bisignano C, Abady GG, et al. Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet Neurology. 2021Oct;20(10):795–820.

    Article  CAS  Google Scholar 

  4. Grefkes C, Fink GR. Recovery from stroke: current concepts and future perspectives. Neurol Res Pract. 2020Dec;2(1):17.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Bernhardt J, Hayward KS, Kwakkel G, Ward NS, Wolf SL, Borschmann K, et al. Agreed definitions and a shared vision for new standards in stroke recovery research: The Stroke Recovery and Rehabilitation Roundtable taskforce. Int J Stroke. 2017Jul;12(5):444–50.

    Article  PubMed  Google Scholar 

  6. Buma F, Kwakkel G, Ramsey N. Understanding upper limb recovery after stroke. Restor Neurol Neurosci. 2013;31(6):707–22.

    PubMed  Google Scholar 

  7. Grefkes C, Ward NS. Cortical reorganization after stroke: how much and how functional? Neuroscientist. 2014Feb;20(1):56–70.

    Article  PubMed  Google Scholar 

  8. Krakauer JW, Carmichael ST, Corbett D, Wittenberg GF. Getting neurorehabilitation right: what can be learned from animal models? Neurorehabil Neural Repair. 2012Oct;26(8):923–31.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Carmichael ST. Cellular and molecular mechanisms of neural repair after stroke: making waves. Ann Neurol. 2006May;59(5):735–42.

    Article  CAS  PubMed  Google Scholar 

  10. Krakauer J, Marshall R. The proportional recovery rule for stroke revisited: the proportional recovery rule for stroke revisited. Ann Neurol. 2015Dec;78(6):845–7.

    Article  CAS  PubMed  Google Scholar 

  11. Prabhakaran S, Zarahn E, Riley C, Speizer A, Chong JY, Lazar RM, et al. Inter-individual variability in the capacity for motor recovery after ischemic stroke. Neurorehabil Neural Repair. 2008Jan;22(1):64–71.

    Article  PubMed  Google Scholar 

  12. Stinear CM. Prediction of motor recovery after stroke: advances in biomarkers. The Lancet Neurology. 2017Oct;16(10):826–36.

    Article  PubMed  Google Scholar 

  13. van der Vliet R, Ribbers GM, Vandermeeren Y, Frens MA, Selles RW. BDNF Val66Met but not transcranial direct current stimulation affects motor learning after stroke. Brain Stimul. 2017Oct;10(5):882–92.

    Article  PubMed  Google Scholar 

  14. Bonkhoff AK, Hope T, Bzdok D, Guggisberg AG, Hawe RL, Dukelow SP, et al. Bringing proportional recovery into proportion: Bayesian modelling of post-stroke motor impairment. Brain. 2020Jul 1;143(7):2189–206.

    Article  PubMed  Google Scholar 

  15. Bonkhoff AK, Hope T, Bzdok D, Guggisberg AG, Hawe RL, Dukelow SP, et al. Recovery after stroke: the severely impaired are a distinct group. J Neurol Neurosurg Psychiatry. 2021 Dec 22;jnnp-2021–327211.

  16. Nakayma H, Jørgensen HS, Raaschou HO, Olsen TS. Compensation in recovery of upper extremity function after stroke: The Copenhagen Stroke Study. Arch Phys Med Rehabil. 1994Aug;75(8):852–7.

    Article  Google Scholar 

  17. Pereira S, Ross Graham J, Shahabaz A, Salter K, Foley N, Meyer M, et al. Rehabilitation of individuals with severe stroke: synthesis of best evidence and challenges in implementation. Top Stroke Rehabil. 2012Mar;19(2):122–31.

    Article  PubMed  Google Scholar 

  18. Teasell R, Pereira S, Cotoi A. Evidence-based review ofstroke rehabilitation [Internet]. The Rehabilitation of Severe Stroke. 2021. Available from: http://www.ebrsr.com/evidence-review/22-rehabilitation-severe-stroke

  19. García-Rudolph A, Cegarra B, Opisso E, Tormos JM, Bernabeu M, Saurí J. Predicting length of stay in patients admitted to stroke rehabilitation with severe and moderate levels of functional impairments. Medicine. 2020Oct 23;99(43): e22423.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Lang CE, Lohse KR, Birkenmeier RL. Dose and timing in neurorehabilitation: prescribing motor therapy after stroke. Curr Opin Neurol. 2015Dec;28(6):549–55.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Hayward KS, Churilov L, Dalton EJ, Brodtmann A, Campbell BCV, Copland D, et al. Advancing stroke recovery through improved articulation of nonpharmacological intervention dose. Stroke. 2021Feb;52(2):761–9.

    Article  PubMed  Google Scholar 

  22. Winstein C, Kim B, Kim S, Martinez C, Schweighofer N. Dosage matters: a phase iib randomized controlled trial of motor therapy in the chronic phase after stroke. Stroke. 2019Jul;50(7):1831–7.

    Article  PubMed  Google Scholar 

  23. Ward NS, Brander F, Kelly K. Intensive upper limb neurorehabilitation in chronic stroke: outcomes from the Queen Square programme. J Neurol Neurosurg Psychiatry. 2019May;90(5):498–506.

    Article  PubMed  Google Scholar 

  24. McGlinchey MP, James J, McKevitt C, Douiri A, Sackley C. The effect of rehabilitation interventions on physical function and immobility-related complications in severe stroke: a systematic review. BMJ Open. 2020Feb;10(2): e033642.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022) [Internet]. Cochrane; 2022. Available from: www.training.cochrane.org/handbook

  26. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021Mar;29: n71.

    Article  Google Scholar 

  27. Quinn T, Harrison, McArthur. Assessment scales in stroke: clinimetric and clinical considerations. CIA. 2013 Feb;201.

  28. Ancheta J, Husband M, Law D, Reding M. Initial functional independence measure score and interval post stroke help assess outcome, length of hospitalization, and quality of care. Neurorehabil Neural Repair. 2000Jun;14(2):127–34.

    Article  CAS  PubMed  Google Scholar 

  29. Holloway G, Prognosis R. and decision making in severe stroke. JAMA. 2005Aug 10;294(6):725.

    Article  CAS  PubMed  Google Scholar 

  30. Rollnik JD, Janosch U. Current trends in the length of stay in neurological early rehabilitation. Deutsches Ärzteblatt international. 2010 Apr 23; Available from: https://www.aerzteblatt.de/https://doiorg.publicaciones.saludcastillayleon.es/10.3238/arztebl.2010.0286[cited 2022 Mar 13]

  31. Duncan PW, Goldstein LB, Horner RD, Landsman PB, Samsa GP, Matchar DB. Similar motor recovery of upper and lower extremities after stroke. Stroke. 1994Jun;25(6):1181–8.

    Article  CAS  PubMed  Google Scholar 

  32. Mehrholz J, Wagner K, Rutte K, Meiβner D, Pohl M. Predictive validity and responsiveness of the functional ambulation category in hemiparetic patients after stroke. Arch Phys Med Rehabil. 2007Oct;88(10):1314–9.

    Article  PubMed  Google Scholar 

  33. Ko SB, Yoon BW. Mechanisms of functional recovery after stroke. In: Naritomi H, Krieger DW, editors. Frontiers of Neurology and Neuroscience. Basel: S. KARGER AG; 2013. p. 1–8. Available from: https://www.karger.com/Article/FullText/346405. [cited 2022 Mar 13].

  34. Hatem SM, Saussez G, della Faille M, Prist V, Zhang X, Dispa D, et al. Rehabilitation of motor function after stroke: a multiple systematic review focused on techniques to stimulate upper extremity recovery. Front Hum Neurosci. 2016 Sep 13;10. Available from: http://journal.frontiersin.org/Article/https://doiorg.publicaciones.saludcastillayleon.es/10.3389/fnhum.2016.00442/abstract. [cited 2022 Mar 13].

  35. Chen CM, Hsu HC, Chang CH, Lin CH, Chen KH, Hsieh WC, et al. Age-based prediction of incidence of complications during inpatient stroke rehabilitation: a retrospective longitudinal cohort study. BMC Geriatr. 2014Dec;14(1):41.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Dromerick A, Reding M. Medical and neurological complications during inpatient stroke rehabilitation. Stroke. 1994Feb;25(2):358–61.

    Article  CAS  PubMed  Google Scholar 

  37. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016Dec;5(1):210.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Schulz KF, Altman DG, Moher D, CONSORT Group. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. BMC Med. 2010 Mar 24;8:18.

  39. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014 Mar 7;348(mar07 3):g1687–g1687.

  40. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019Aug;28: l4898.

    Article  Google Scholar 

  41. Revised Cochrane risk-of-bias-tool for randomized controlled trails (RoB 2) – SHORT VERSION (CRIBSHEET). Available from: https://drive.google.com/file/d/1Q4Fk3HCuBRwIDWTGZa5oH11OdR4Gbhdo/view

  42. Dalton EJ, Churilov L, Lannin NA, Corbett D, Campbell BCV, Hayward KS. Multidimensional phase I dose ranging trials for stroke recovery interventions: key challenges and how to address them. Neurorehabil Neural Repair. 2021Aug;35(8):663–79.

    Article  PubMed  Google Scholar 

  43. Chang A, Sahota D. Statistics Toolkit (StatsToDo). Available from: https://www.statstodo.com/CombineMeansSDs.php. [cited 2021 May 22].

  44. Murad MH, Mustafa RA, Schünemann HJ, Sultan S, Santesso N. Rating the certainty in evidence in the absence of a single estimate of effect. Evid Based Med. 2017Jun;22(3):85–7.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Schünemann H, Brożek J, Guyatt G, Oxman A, editors. GRADE handbook for grading quality of evidence and strength of recommendations. GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group, 2013. Available from: guidelinedevelopment.org/handbook. [cited 2022 Apr 30].

  46. Kim NH, Park HY, Son JK, Moon Y, Lee JH, Cha YJ. Comparison of underwater gait training and overground gait training for improving the walking and balancing ability of patients with severe hemiplegic stroke: a randomized controlled pilot trial. Gait Posture. 2020Jul;80:124–9.

    Article  PubMed  Google Scholar 

  47. Bernhardt J, Borschmann K, Collier JM, Thrift AG, Langhorne P, Middleton S, et al. Fatal and nonfatal events within 14 days after early, intensive mobilization poststroke. Neurology. 2021Feb 23;96(8):e1156–66.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. Cain S, Churilov L, Collier J, Carvalho L, Borschmann K, Moodie M, et al. Factors associated with paid employment 12 months after stroke in A Very Early Rehabilitation Trial (AVERT). Ann Phys Rehabil Med. 2022;65(3): 101565.

    Article  PubMed  Google Scholar 

  49. AVERT Trial Collaboration group. Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. The Lancet. 2015Jul;386(9988):46–55.

    Article  Google Scholar 

  50. Kwakkel G, Wagenaar RC. Effect of duration of upper- and lower-extremity rehabilitation sessions and walking speed on recovery of interlimb coordination in hemiplegic gait. Phys Ther. 2002May;82(5):432–48.

    Article  PubMed  Google Scholar 

  51. Kwakkel G, Kollen BJ, Wagenaar RC. Long term effects of intensity of upper and lower limb training after stroke: a randomised trial. J Neurol Neurosurg Psychiatry. 2002Apr;72(4):473–9.

    CAS  PubMed  PubMed Central  Google Scholar 

  52. Kwakkel G, Wagenaar RC, Twisk JW, Lankhorst GJ, Koetsier JC. Intensity of leg and arm training after primary middle-cerebral-artery stroke: a randomised trial. The Lancet. 1999Jul;354(9174):191–6.

    Article  CAS  Google Scholar 

  53. Lincoln NB, Parry RH, Vass CD. Randomized, controlled trial to evaluate increased intensity of physiotherapy treatment of arm function after stroke. Stroke. 1999Mar;30(3):573–9.

    Article  CAS  PubMed  Google Scholar 

  54. Shao C, Wang Y, Gou H, Xiao H, Chen T. Strength training of the nonhemiplegic side promotes motor function recovery in patients with stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2023;104(2):188–94.

    Article  PubMed  Google Scholar 

  55. Brunelli S, Iosa M, Fusco F, Pirri C, Di Giunta C, Foti C, et al. Early body weight-supported overground walking training in patients with stroke in subacute phase compared to conventional physiotherapy: a randomized controlled pilot study. International journal of rehabilitation research Internationale Zeitschrift fur Rehabilitationsforschung Revue internationale de recherches de readaptation. 2019;42(4):309–15.

    Article  PubMed  Google Scholar 

  56. Calabrò RS, Naro A, Russo M, Leo A, Balletta T, Saccá I, et al. Do post-stroke patients benefit from robotic verticalization? A pilot-study focusing on a novel neurophysiological approach. RNN. 2015Oct 5;33(5):671–81.

    Article  Google Scholar 

  57. Di Lauro A, Pellegrino L, Savastano G, Ferraro C, Fusco M, Balzarano F, et al. A randomized trial on the efficacy of intensive rehabilitation in the acute phase of ischemic stroke. J Neurol. 2003Oct 1;250(10):1206–8.

    Article  PubMed  Google Scholar 

  58. Franceschini M, Carda S, Agosti M, Antenucci R, Malgrati D, Cisari C. Walking After Stroke: What Does Treadmill Training With Body Weight Support Add to Overground Gait Training in Patients Early After Stroke?: A Single-Blind, Randomized. Controlled Trial Stroke. 2009Sep;40(9):3079–85.

    PubMed  Google Scholar 

  59. Choi HS, Shin WS, Bang DH. Application of digital practice to improve head movement, visual perception and activities of daily living for subacute stroke patients with unilateral spatial neglect: Preliminary results of a single-blinded, randomized controlled trial. Medicine. 2021Feb 12;100(6): e24637.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Lee SH, Prak JS, Choi JB, Yoo WG. Improving upper extremity motor function in stroke patients using a complex task with multi-joint-based mirror therapy: a randomized controlled trial. Neurology Asia. 2020;25(3):245–51.

    Google Scholar 

  61. Chang WH, Kim MS, Huh JP, Lee PKW, Kim YH. Effects of robot-assisted gait training on cardiopulmonary fitness in subacute stroke patients: a randomized controlled study. Neurorehabil Neural Repair. 2012May;26(4):318–24.

    Article  PubMed  Google Scholar 

  62. Sim T, Kwon J. Comparing the effectiveness of bimanual and unimanual mirror therapy in unilateral neglect after stroke: a pilot study. NeuroRehabilitation. 2022;50(1):133–41.

    Article  PubMed  Google Scholar 

  63. Kim M, Lee S, Park E, Choi M, Kim J, Sohn M, et al. Elastic dynamic sling on subluxation of hemiplegic shoulder in patients with subacute stroke: a multicenter randomized controlled trial. International journal of environmental research and public health. 2022;19(16). Available from: https://www.cochranelibrary.com/central/doi/https://doiorg.publicaciones.saludcastillayleon.es/10.1002/central/CN-02456101/full

  64. An CM, Ko MH, Kim D hyun, Kim GW. Effect of postural training using a whole-body tilt apparatus in subacute stroke patients with lateropulsion: a single-blinded randomized controlled trial. Annals of Physical and Rehabilitation Medicine. 2021 Mar;64(2):101393.

  65. Guo G yan, Kang Y gang. Effectiveness of neuromuscular electrical stimulation therapy in patients with urinary incontinence after stroke: a randomized sham controlled trial. Medicine. 2018 Dec;97(52):e13702.

  66. Zheng X, Chen D, Yan T, Jin D, Zhuang Z, Tan Z, et al. A randomized clinical trial of a functional electrical stimulation mimic to gait promotes motor recovery and brain remodeling in acute stroke. Behav Neurol. 2018Dec;18(2018):1–10.

    Google Scholar 

  67. Bai Y long, Hu Y shan, Wu Y, Zhu Y lian, Zhang B, Jiang C yu, et al. Long-term three-stage rehabilitation intervention alleviates spasticity of the elbows, fingers, and plantar flexors and improves activities of daily living in ischemic stroke patients: a randomized, controlled trial. NeuroReport. 2014 Sep 10;25(13):998–1005.

  68. Tang Q, Tan L, Li B, Huang X, Ouyang C, Zhan H, et al. Early sitting, standing, and walking in conjunction with contemporary bobath approach for stroke patients with severe motor deficit. Top Stroke Rehabil. 2014Mar;21(2):120–7.

    Article  PubMed  Google Scholar 

  69. Cui W, Huang L, Tian Y, Luo H, Chen S, Yang Y, et al. Effect and mechanism of mirror therapy on lower limb rehabilitation after ischemic stroke: a fMRI study. NeuroRehabilitation. 2022;51(1):65–77.

    Article  PubMed  Google Scholar 

  70. Rodrigues TA, Goroso DG, Westgate PM, Carrico C, Batistella LR, Sawaki L. Slow versus fast robot-assisted locomotor training after severe stroke: a randomized controlled trial. Am J Phys Med Rehabil. 2017Oct;96(10):S165–70.

    Article  PubMed  Google Scholar 

  71. Rahayu UB, Wibowo S, Setyopranoto I, Hibatullah RM. Effectiveness of physiotherapy interventions in brain plasticity, balance and functional ability in stroke survivors: a randomized controlled trial. NRE. 2020Dec 22;47(4):463–70.

    Article  Google Scholar 

  72. Rosewilliam S, Malhotra S, Roffe C, Jones P, Pandyan AD. Can surface neuromuscular electrical stimulation of the wrist and hand combined with routine therapy facilitate recovery of arm function in patients with stroke? Arch Phys Med Rehabil. 2012Oct;93(10):1715-1721.e1.

    Article  PubMed  Google Scholar 

  73. Bagley P, Hudson M, Forster A, Smith J, Young J. A randomized trial evaluation of the Oswestry Standing Frame for patients after stroke. Clin Rehabil. 2005Jun;19(4):354–64.

    Article  PubMed  Google Scholar 

  74. Logan A; Freeman J; Kent B; Pooler J; Creanor S; Enki D; Vickery J; Barton A; Marsden J. Functional standing frame programme early after severe sub-acute stroke (SPIRES): a randomised controlled feasibility trial. Pilot and Feasibility Studies 2022 Mar 3;8(50):Epub. 2022;

  75. Louie DR, Mortenson WB, Durocher M, Schneeberg A, Teasell R, Yao J, et al. Efficacy of an exoskeleton-based physical therapy program for non-ambulatory patients during subacute stroke rehabilitation: a randomized controlled trial. J Neuroeng Rehabil. 2021;18(1):149.

    Article  PubMed  PubMed Central  Google Scholar 

  76. Ochi M, Wada F, Saeki S, Hachisuka K. Gait training in subacute non-ambulatory stroke patients using a full weight-bearing gait-assistance robot: a prospective, randomized, open, blinded-endpoint trial. J Neurol Sci. 2015Jun;353(1–2):130–6.

    Article  PubMed  Google Scholar 

  77. Thimabut N, Yotnuengnit P, Charoenlimprasert J, Sillapachai T, Hirano S, Saitoh E, et al. Effects of the robot-assisted gait training device plus physiotherapy in improving ambulatory functions in patients with subacute stroke with hemiplegia: an assessor-blinded, randomized controlled trial. Arch Phys Med Rehabil. 2022;103(5):843–50.

    Article  PubMed  Google Scholar 

  78. Chen JC, Lin CH, Wei YC, Hsiao J, Liang CC. Facilitation of motor and balance recovery by thermal intervention for the paretic lower limb of acute stroke: a single-blind randomized clinical trial. Clin Rehabil. 2011Sep;25(9):823–32.

    Article  PubMed  Google Scholar 

  79. Katz-Leurer M, Carmeli E, Shochina M. The effect of early aerobic training on independence six months post stroke. Clin Rehabil. 2003Nov;17(7):735–41.

    Article  PubMed  Google Scholar 

  80. Choi HS, Shin WS, Bang DH. Application of digital practice to improve head movement, visual perception and activities of daily living for subacute stroke patients with unilateral spatial neglect: Preliminary results of a single-blinded, randomized controlled trial. Medicine (Baltimore). 2021Feb 12;100(6): e24637.

    Article  PubMed  Google Scholar 

  81. Calabro RS, Accorinti M, Porcari B, Carioti L, Ciatto L, Billeri L, et al. Does hand robotic rehabilitation improve motor function by rebalancing interhemispheric connectivity after chronic stroke? Encouraging data from a randomised-clinical-trial. Clin Neurophysiol. 2019May;130(5):767–80.

    Article  PubMed  Google Scholar 

  82. An CM, Ko MH, Kim DH, Kim GW. Effect of postural training using a whole-body tilt apparatus in subacute stroke patients with lateropulsion: a single-blinded randomized controlled trial. Ann Phys Rehabil Med. 2021;64(2): 101393.

    Article  PubMed  Google Scholar 

  83. on behalf of Italian Consensus Conference on Robotics in Neurorehabilitation (CICERONE), Calabrò RS, Sorrentino G, Cassio A, Mazzoli D, Andrenelli E, et al. Robotic-assisted gait rehabilitation following stroke: a systematic review of current guidelines and practical clinical recommendations. Eur J Phys Rehabil Med [Internet]. 2021 Jul;57(3). Available from: https://www.minervamedica.it/index2.php?show=R33Y2021N03A0460. [cited 2022 Aug 24].

  84. Moucheboeuf G, Griffier R, Gasq D, Glize B, Bouyer L, Dehail P, et al. Effects of robotic gait training after stroke: a meta-analysis. Ann Phys Rehabil Med. 2020Nov;63(6):518–34.

    Article  PubMed  Google Scholar 

  85. Matsunaga A, Kurokawa Y, Kanda T, Sakai F. Prediction of locomotion function at one month after stroke. J Phys Ther Sci. 1997;9(2):93–7.

    Article  Google Scholar 

  86. Mehrholz J, Thomas S, Elsner B. Treadmill training and body weight support for walking after stroke. Cochrane Stroke Group, editor. Cochrane Database of Systematic Reviews. 2017 Aug 17.;2017(8). Available from: http://doi.wiley.com/https://doiorg.publicaciones.saludcastillayleon.es/10.1002/14651858.CD002840.pub4. [cited 2022 Aug 24].

  87. Mehrholz J, Thomas S, Kugler J, Pohl M, Elsner B. Electromechanical‐assisted training for walking after stroke. Cochrane Database of Systematic Reviews [Internet]. 2020;(10). Available from: https://doiorg.publicaciones.saludcastillayleon.es/10.1002/14651858.CD006185.pub5

  88. Arienti C, Buraschi R, Pollet J, Lazzarini SG, Cordani C, Negrini S, et al. A systematic review opens the black box of ‘usual care’ in stroke rehabilitation control groups and finds a black hole. Eur J Phys Rehabil Med [Internet]. 2022 Jul;58(4). Available from: https://www.minervamedica.it/index2.php?show=R33Y2022N04A0520. [cited 2022 Aug 28].

  89. Nicholls SG, Zwarenstein M, Taljaard M. The importance of describing as well as defining usual care. Am J Bioeth. 2020Jan 2;20(1):56–8.

    Article  PubMed  Google Scholar 

  90. Macklin R, Natanson C. Misrepresenting, “usual care” in research: an ethical and scientific error. Am J Bioeth. 2020Jan 2;20(1):31–9.

    Article  PubMed  PubMed Central  Google Scholar 

  91. Young HM, Miyamoto S, Tang-Feldman Y, Dharmar M, Balsbaugh T, Greenwood D. Defining usual care in clinical trials. Res Gerontol Nurs. 2020May;13(3):125–9.

    Article  PubMed  Google Scholar 

  92. Pt SH, Pt PGP, Dutta A, Pt AK. Comparison of effectiveness of trunk PNF versus NDT on trunk stability in stroke patients: life sciences-physiotherapy. Int J Life Sci Pharm Res. 2022Jul;1:L78-92.

    Google Scholar 

  93. Lennon S. Physiotherapy practice in stroke rehabilitation: a survey. Disabil Rehabil. 2003Jan;25(9):455–61.

    Article  PubMed  Google Scholar 

  94. Pathak A, Gyanpuri V, Dev P, Dhiman N. The Bobath Concept (NDT) as rehabilitation in stroke patients: a systematic review. J Family Med Prim Care. 2021;10(11):3983.

    Article  PubMed  PubMed Central  Google Scholar 

  95. Yazıcı G, Güçlü Gündüz A, Batur Çağlayan HZ, Özkul Ç, Volkan Yazıcı M, Nazlıel B. Investigation of early term neurodevelopmental treatment-bobath approach results in patients with stroke. Türk Beyin Damar Hast Derg. 2021;27(1):27–33.

  96. Cott CA, Graham JV, Brunton K. When will the evidence catch up with clinical practice? Physiother Can. 2011Jul;63(3):387–90.

    Article  PubMed  PubMed Central  Google Scholar 

  97. Clark B, Whitall J, Kwakkel G, Mehrholz J, Ewings S, Burridge J. The effect of time spent in rehabilitation on activity limitation and impairment after stroke. Cochrane Stroke Group, editor. Cochrane Database of Systematic Reviews. 2021 Oct 25;2021(10). Available from: http://doi.wiley.com/https://doiorg.publicaciones.saludcastillayleon.es/10.1002/14651858.CD012612.pub2. [cited 2022 Aug 31].

  98. Rethnam V, Langhorne P, Churilov L, Hayward KS, Herisson F, Poletto SR, et al. Early mobilisation post-stroke: a systematic review and meta-analysis of individual participant data. Disabil Rehabil. 2022Apr 10;44(8):1156–63.

    Article  PubMed  Google Scholar 

  99. Sundseth A, Thommessen B, Rønning OM. Outcome after mobilization within 24 hours of acute stroke: a randomized controlled trial. Stroke. 2012Sep;43(9):2389–94.

    Article  PubMed  Google Scholar 

  100. Yelnik AP, Quintaine V, Andriantsifanetra C, Wannepain M, Reiner P, Marnef H, et al. AMOBES (Active Mobility Very Early After Stroke): a randomized controlled trial. Stroke. 2017Feb;48(2):400–5.

    Article  PubMed  Google Scholar 

  101. Dromerick AW, Geed S, Barth J, Brady K, Giannetti ML, Mitchell A, et al. Critical Period After Stroke Study (CPASS): a phase II clinical trial testing an optimal time for motor recovery after stroke in humans. Proc Natl Acad Sci USA. 2021Sep 28;118(39): e2026676118.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  102. Schneider EJ, Lannin NA, Ada L, Schmidt J. Increasing the amount of usual rehabilitation improves activity after stroke: a systematic review. J Physiother. 2016Oct;62(4):182–7.

    Article  PubMed  Google Scholar 

  103. Sulter G, Steen C, Jacques De Keyser. Use of the Barthel Index and Modified Rankin Scale in Acute Stroke Trials. Stroke. 1999 Aug;30(8):1538–41.

  104. Negrini S, Armijo-Olivo S, Patrini M, Frontera WR, Heinemann AW, Machalicek W, et al. The randomized controlled trials rehabilitation checklist: methodology of development of a reporting guideline specific to rehabilitation. Am J Phys Med Rehabil. 2020Mar;99(3):210–5.

    Article  PubMed  Google Scholar 

  105. Negrini S, Arienti C, Kiekens C. Usual care: the big but unmanaged problem of rehabilitation evidence. The Lancet. 2020Feb;395(10221):337.

    Article  Google Scholar 

  106. Kwakkel G, Meskers CG, Ward NS. Time for the next stage of stroke recovery trials. Lancet Neurol. 2020;19(8):636–7.

    Article  PubMed  Google Scholar 

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Acknowledgements

The authors have nothing to acknowledge.

We would like to extend our sincere thanks to Kerstin Luedtke for the critical revision and supporting thoughts.

Funding

Open Access funding enabled and organized by Projekt DEAL. We acknowledge financial support from Land Schleswig–Holstein within the funding program Open Access Publikationsfonds. This research received no further funding.

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Authors and Affiliations

  1. Department of Physiotherapy, Pain and Exercise Research Luebeck (P.E.R.L.), Institute of Health Sciences, Universität zu Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany

    Katrin Roesner

  2. International Graduate Academy (InGrA), Institute of Health and Nursing Sciences, Medical Faculty of Martin Luther University Halle-Wittenberg, University Medicine Halle, Magdeburger Straße 8, 06112 Halle (Saale), Germany

    Katrin Roesner

  3. Department of Therapy Science I, Brandenburg University of Technology Cottbus–Senftenberg, Universitätsplatz 1, 01968 Senftenberg, Germany

    Bettina Scheffler

  4. Schön Klinik Hamburg Eilbek, Dehnhaide 120, 22081 Hamburg, Germany

    Martina Kaehler

  5. Executive Department for Nursing Competencies, Wilhelmsburger Krankenhaus Hamburg Großsand, Groß-Sand 3, 21107 Hamburg, Germany

    Bianca Schmidt-Maciejewski

  6. Department of Occupational Therapy, Institute of Health Sciences, Universität zu Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany

    Tabea Boettger

  7. Ernst-Abbe-Hochschule Jena-University of Applied Science, Carl-Zeiß-Promenade 2, 07745 Jena, Germany

    Susanne Saal

  8. Institute of Health and Nursing Science, Medical Faculty of Martin Luther University Halle-Wittenberg, University Medicine Halle, Magdeburger Straße 8, 06112 Halle (Saale), Germany

    Susanne Saal

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  1. Katrin Roesner
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  2. Bettina Scheffler
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  3. Martina Kaehler
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  4. Bianca Schmidt-Maciejewski
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  5. Tabea Boettger
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  6. Susanne Saal
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Contributions

KR and SuS conceived the idea for the systematic review. KR conceptualized the research strategy for this systematic review and wrote the draft of the manuscript. BS, TB, MK, BSM, and SuS contributed to the critical revision of the manuscript. All the authors read and approved the final manuscript.

Corresponding author

Correspondence to Katrin Roesner.

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Supplementary Information

13643_2024_2676_MOESM1_ESM.docx

Supplementary material 1: S1. Search strategy example. S2. Reasons for excluded studies. S3. Funding sources of the included studies. S4. Outcomes according to ICF domains, S5. Grade Judgement

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Roesner, K., Scheffler, B., Kaehler, M. et al. Effects of physical therapy modalities for motor function, functional recovery, and post-stroke complications in patients with severe stroke: a systematic review update. Syst Rev 13, 270 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13643-024-02676-0

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Keywords

Systematic Reviews

ISSN: 2046-4053