pollock 07 phys treatment

Clinical Rehabilitation 2007; 21: 395410

Physiotherapy treatment approaches for therecovery of postural control and lower limbfunction following stroke: a systematic reviewAlex Pollock Stroke Therapy Evaluation Programme, Academic Section of Geriatric Medicine, Glasgow Royal Infirmary,Glasgow, Gillian Baer Department of Physiotherapy, Queen Margaret University College, Edinburgh, Peter LanghorneAcademic Section of Geriatric Medicine, Glasgow Royal Infirmary, Glasgow and Valerie Pomeroy Rehabilitation andAgeing, Geriatric Medicine, St Georges University of London, London, UK

Received 30th September 2006; accepted 6th October 2006.

Objectives: To determine whether there is a difference in global dependency andfunctional independence in patients with stroke associated with differentapproaches to physiotherapy treatment.Data sources: We searched the Cochrane Stroke Group Trials Register (lastsearched May 2005), Cochrane Central Register of Controlled Trials (CENTRAL)(Cochrane Library Issue 2, 2005), MEDLINE (1966 to May 2005), EMBASE (1980to May 2005) and CINAHL (1982 to May 2005). We contacted experts andresearchers with an interest in stroke rehabilitation.Review methods: Inclusion criteria were: (a) randomized or quasi-randomized controlled trials; (b) adults with a clinical diagnosis of stroke; (c) physiotherapytreatment approaches aimed at promoting postural control and lower limb func-tion; (d) measures of disability, motor impairment or participation. Two independentreviewers categorized identified trials according to the inclusion/exclusion criteria,documented the methodological quality and extracted the data.Results: Twenty trials (1087 patients) were included in the review. Comparisonsincluded: neurophysiological approach versus other approach; motor learningapproach versus other approach; mixed approach versus other approach for theoutcomes of global dependency and functional independence. A mixed approachwas significantly more effective than no treatment control at improving functionalindependence (standardized mean difference (SMD) 0.94, 95% confidence interval(CI) 0.08 to 1.80). There were no significant differences found for any othercomparisons.Conclusions: Physiotherapy intervention, using a mix of components from differentapproaches is more effective than no treatment control in attaining functionalindependence following stroke. There is insufficient evidence to conclude that anyone physiotherapy approach is more effective in promoting recovery of disabilitythan any other approach.

Address for correspondence: Alex Pollock, Stroke TherapyEvaluation Programme, Academic Section of Geriatric Medicine,Room 34, Level 3, University Block, Queen Elizabeth Building, 10Alexandra Parade, Glasgow Royal Infirmary University NHS Trust,Glasgow G31 2ER, UK. e-mail: [email protected] 2007 SAGE Publications 10.1177/0269215507073438

396 A Pollock et al.

Background

There are several different approaches to physiothera-py treatment following stroke. Prior to the 1940s theseprimarily consisted of corrective exercises based onorthopaedic principles related to the contraction andrelaxation of muscles, with the emphasis placed onregaining function by compensating with the unaf-fected limbs.1,2 In the 1950s and 1960s techniquesbased on available neurophysiological knowledgewere developed, including the methods of Bobath,3,4Brunnstrm,5 Rood6 and the ProprioceptiveNeuromuscular Facilitation (PNF) approach.7,8 In the1980s the potential importance of neuropsychologyand motor learning was highlighted9,10 and the motorlearning, or relearning, approach was proposed.11This approach suggested that active practice of con-text-specific motor tasks with appropriate feedbackwould promote learning and motor recovery.1117

The practical application of these approachesresults in substantial differences in patient treatment.Approaches based on neurophysiological principleshave traditionally primarily involved the physiothera-pist moving the patient through patterns of movement,with the therapist acting as problem solver and deci-sion maker and the patient being a relatively passiverecipient.18 In direct contrast, the motor learningapproaches emphasize the importance of activeinvolvement by the patient,11 while orthopaedicapproaches emphasize muscle strengthening tech-niques and compensation with the non-paretic side. Atpresent, the Bobath Approach, based on neurophysio-logical principles, remains probably the most widelyused approach in Sweden,19 Australia20 and theUK.2123

Physiotherapists often seek evidence relating toglobal approaches to treatment of stroke patients,rather than evidence in support of individual treat-ments. The evaluation of this research evidence isoften difficult due to poor description and documenta-tion of the approaches investigated. Often the treat-ment approach is vaguely described as conventionalor traditional (e.g. refs 2430) and few other detailsare available. Although questionnaire-based studiesdo demonstrate that physiotherapists often have apreference for a particular approach, there is present-ly no convincing evidence to support any specificphysiotherapy treatment approach.21,31

This report details key findings from a CochraneSystematic Review.32 Readers are referred to the full

Cochrane Review for additional details. The objectivewas to determine if there is a difference in the recov-ery from disability in patients with stroke if physio-therapy treatment is based on any one of orthopaedicor neurophysiological or motor learning principles, oron a mixture of these treatment principles.

Methods

Types of studiesControlled trials were included if participants were

randomly or quasi-randomly assigned to one of two ormore treatment groups. Trials with or without blind-ing of participants, physiotherapists and assessorswere included.

Types of participantsTrials were included if participants were adults

(over 18 years) with a clinical diagnosis of stroke.33Participants with diagnosis of either ischaemic strokeor haemorrhagic stroke were included (confirmationof the clinical diagnosis using imaging was notcompulsory).

Types of interventionsPhysiotherapy treatment approaches that were

aimed at promoting the recovery of postural control(balance during the maintenance of a posture, restora-tion of a posture or movement between postures) andlower limb function (including gait) were included.Interventions that had a more generalized stated aim,such as improving functional ability, were alsoincluded. Treatment approaches that were primarilyaimed at promoting recovery of upper limb movementor function were excluded. Studies of specific inter-ventions, such as electrical stimulation, biofeedbackand treadmill training, were excluded.

Types of outcome measuresPrimary outcomes were defined as measures of dis-

ability. Relevant measures of disability were prestatedas (1) global dependency scales or (2) functional inde-pendence in mobility. (A number of secondary out-comes were also included; these are detailed in theCochrane Review.32)

Physiotherapy treatment approaches for stroke 397

Search strategyFull details of the search strategy, including the full

bibliographic search history for electronic databases,are provided within the Cochrane Review.32

The searching was based on the strategy developedby the Cochrane Stroke Group and was done usingintervention-based search strategies developed in con-sultation with the Cochrane Stroke Group TrialsSearch Co-ordinator. Searching included: CochraneStroke Group Trials Register (May 2005); CochraneCentral Register of Controlled Trials (CENTRAL)(Cochrane Library Issue 2, 2005); MEDLINE (1966to May 2005); EMBASE (1980 to May 2005);CINAHL (1982 to May 2005). Experts and authorswere contacted and asked if they knew of any addi-tional, unpublished or on-going trials, and the refer-ence lists of all trials found using the above searchmethods were searched.

Search resultsThe electronic searching resulted in 8408 potentially

relevant trials. One reviewer (AP) eliminated obvious-ly irrelevant studies based on titles and, where avail-able, abstracts. This eliminated 8161 studies, leaving247 potentially relevant trials. Examination of thereference lists of these potential trials, and communi-cation with known experts and colleagues, added afurther 18 studies, making a total of 265 potentiallyrelevant trials.

Two independent reviewers (AP, GB) read theabstracts for these 265 studies. Of these, 184 (69%)were classified as relevant or possibly relevant.

Titles, introduction and methods sections of the184 possible trials were independently scrutinized bytwo reviewers (AP, GB). Based on a detailed writtendescription (which was based on the available litera-ture, and which had been discussed between allreviewers to ensure consensus) of the classification ofphysiotherapy approaches based on motor learning,neurophysiological or orthopaedic principles (seeCochrane Review32 for details) reviewers independ-ently classified the interventions administered in eachtrial. Any disagreements were resolved through dis-cussion involving a third reviewer (PL), and furtherinformation was obtained from trialists where neces-sary (and possible).

This review process led to the identification of 20relevant trials to be included in this review: Dean andShepherd,34 Dean et al.,35 Duncan et al.,36 Duncan

et al.,37 Gelber et al.,38 Green et al.,39 Hesse et al.,40Howe et al.,41 Langhammer and Stranghelle,42Lincoln,43 McClellan and Ada,44 Mudie et al.,45Ozdemir et al.,46 Pollock,47 Richards et al.,48 Salbachet al.,49 Stern et al.,24 Wade et al.,50 Wang et al.51 andWellmon and Newton.52

Brief descriptions of the included studies can befound in Table 1; detailed descriptions are publishedin the Cochrane Review.32

Methodological quality and data extractionTwo independent reviewers (AP, GB) judged the

methodological quality of studies and extracted data,with any disagreements resolved through discussioninvolving a third reviewer. Trial authors were contactedfor clarification where necessary.

The following quality criteria were documented:randomization (allocation concealment); baselinecomparison of groups; blindness of recipients andproviders of care to treatment group/study aims;blindness of outcome assessor; possibility of contam-ination/co-intervention by therapists providing inter-vention; completeness of follow-up; other potentialconfounders.

Data extraction documented (where possible): trialsetting (e.g. hospital, community); details of partici-pants (e.g. age, gender, side of hemiplegia, strokeclassification, comorbid conditions, premorbid dis-ability); inclusion and exclusion criteria; all assessedoutcomes.

Details of the methodological quality and dataextraction from individual trials are fully presentedwithin the Cochrane Review.32

Data analysis was carried out using CochraneRevMan software. Standardized mean differences(SMD) and 95% confidence intervals (CI) were calcu-lated, using a random effects model, for all outcomesanalysed.

Results

The 20 included trials randomized 1087 patients.Three of these studies (78 patients) have no dataincluded in any of the review analyses: we wereunable to obtain the data from the first phase of thestudy by Hesse et al.40 (n 22); and Wellmon andNewton52 (n 21) and Howe et al.41 (n 35) reported

398 A Pollock et al.Ta

ble

1S

umm

ary

of c

hara

cter

istic

s of

incl

uded

stu

dies

Tria

lD

esig

nA

lloca

tion

Num

ber

of

Incl

usio

n O

utco

me

Trea

tmen

t O

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me:

O

utco

me:

N

otes

conc

ealm

ent

part

icip

ants

cr

iteria

: Tim

e as

sess

or

grou

psgl

obal

fu

nctio

nal

rand

omiz

edsi

nce

stro

kebl

inde

d to

de

pend

ency

inde

pend

ence

grou

p al

loca

tion?

Dea

n 19

9734

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lock

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1

year

Yes

Mot

or

(non

e)(n

one)

Sec

onda

ry

rand

omiz

atio

n)le

arni

ng

outc

omes

P

lace

boin

clud

ed in

C

ochr

ane

revi

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ean

2000

35R

CT

(mat

ched

Ade

quat

e12

3

mon

ths

Yes

Mot

or

(non

e)(n

one)

Sec

onda

ry

pairs

le

arni

ng

outc

omes

ra

ndom

ized

)P

lace

boin

clud

ed in

C

ochr

ane

revi

ewD

unca

n R

CT

(met

hod

Ade

quat

e20

309

0 da

ysU

ncle

arM

ixed

B

arth

el

Fugl

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er

1998

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ran

dom

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olIn

dex

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or s

core

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not

Law

ton

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ed)

Inst

rum

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can

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lock

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Ade

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day

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ixed

(n

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nctio

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Physiotherapy treatment approaches for stroke 399in

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lock

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(blo

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dequ

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28

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roph

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logi

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Bar

thel

(n

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side

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C

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grou

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thes

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acco

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are

to p

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(Bob

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com

para

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cate

gory

)in

ter

ms

oftim

ing

and

inte

nsity

Sal

bach

R

CT

Ade

quat

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1

year

Yes

Mot

or

(non

e)(n

one)

Sec

onda

ry20

0449

(str

atifi

ed

lear

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outc

omes

bloc

ked

(mob

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)in

clud

ed in

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Pla

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ochr

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zatio

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cont

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revi

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ratifi

ed

(mot

or

acco

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le

arni

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3 le

vels

of

uppe

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alki

ng

limb)

defic

it)S

tern

Q

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-ran

do-

Inad

equa

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Not

sta

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Unc

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hopa

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(non

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nctio

nal

1970

24m

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tria

l M

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st

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(50

patie

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hopa

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(ada

pted

wer

e

Neu

roph

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cal)

from

rat

ing

orig

inal

ly

scal

e)

Tab

le 1

cont

inue

d

Tria

lD

esig

nA

lloca

tion

Num

ber

of

Incl

usio

n O

utco

me

Trea

tmen

t O

utco

me:

O

utco

me:

N

otes

conc

ealm

ent

part

icip

ants

cr

iteria

: Tim

e as

sess

or

grou

psgl

obal

fu

nctio

nal

rand

omiz

edsi

nce

stro

kebl

inde

d to

de

pend

ency

inde

pend

ence

grou

p al

loca

tion?

Physiotherapy treatment approaches for stroke 401re

crui

ted

and

rand

omiz

ed.

Add

ition

al 1

2pa

tient

s th

ense

lect

ivel

y as

sign

ed t

o ev

en o

ut

diff

eren

ces

in im

port

ant

char

acte

r-is

tics

)W

ade

RC

T (b

lock

edA

dequ

ate

94

1 ye

arYe

sM

ixed

B

arth

el

Riv

erm

ead

Com

men

ts

1992

50ra

ndom

i-(p

robl

em

Inde

x M

obili

ty

from

pee

r za

tion)

.so

lvin

g,

Fren

chay

Ass

essm

ent

revi

ewer

s co

mm

unity

Act

iviti

es

for

the

phys

ioth

er-

Inde

x up

date

dap

y)

Not

tingh

am

vers

ion

led

No

trea

tmen

tE

AD

L sc

ale

to t

he

incl

usio

n of

this

tria

lW

ang

RC

T (s

trat

ified

Ade

quat

e44

Not

sta

ted

Yes

Neu

roph

ysio

logi

cal

(non

e)M

otor

D

ata

from

20

0551

into

pat

ient

s(B

obat

h)

Ass

essm

ent

patie

nts

with

O

rtho

paed

icS

cale

Str

oke

with

sp

astic

ity

Ass

essm

ent

spas

ticity

(B

runn

stro

m

Impa

irmen

t en

tere

d st

age

2 or

3)

Set

unde

r W

ang

and

pat

ient

s20

05, a

nd

with

rel

ativ

eda

ta f

rom

re

cove

ry

patie

nts

with

(B

runn

stro

m

rela

tive

stag

e 4

or 5

))re

cove

ry

ente

red

unde

r W

ang

2005

aW

ellm

onR

CT

Ade

quat

e21

15

0 da

ysN

oM

otor

(n

one)

(non

e)N

o ou

tcom

es19

9752

(met

hod

of

lear

ning

incl

uded

inra

ndom

izat

ion

Con

trol

an

alys

isno

t st

ated

)(n

o tr

eatm

ent)


no outcomes which were included in the analysis. Afurther three studies (123 patients)34,35,49 did notreport a measure of disability, although they didinclude secondary measures that are analysed in theCochrane review.32 These six studies are not includedin the analysis, results or discussion of this paper.

The remaining 14 trials were analysed within thecomparisons of (1) neurophysiological versus other, (2)motor learning versus other, (3) mixed versus others.

Neurophysiological (Bobath) versus otherComparisons of neurophysiological approaches

with other approaches were reported in seven studies,with one of these studies45 comparing a neurophysio-logical approach to both another approach (motorlearning) and to a control group. The neurophysiolog-ical approach used for all seven studies was describedas Bobath. Time of follow-up was four weeks forLincoln43 and Wang et al.51, six weeks for Pollock47and Richards et al.,48 three months for Langhammerand Stranghelle,42 two weeks after the end of the inter-vention for Mudie et al.45 and at the time of dischargefor Gelber et al.38

The analyses are displayed in the figures and arebriefly described below.

Global dependency (Figure 1)The Barthel Index was reported by six of the

trials.42,43,45 (2 comparisons),47,48 No trials compared theneurophysiological approach with the orthopaedicapproach for global dependency. There were nosignificant differences between neurophysiologicalapproach and motor learning approach (SMD 0.12,95% CI 0.56 to 0.33), mixed approach (SMD 0.13,95% CI 0.87 to 0.61) or no treatment/placebo(SMD 0.71, 95%, CI 0.79 to 0.36), indicating thatthere are no significant differences between neuro-physiological and other approaches for globaldependency.

Functional independence (Figure 2)Five trials reported measures of functional inde-

pendence Gelber et al.38: Functional IndependenceMeasure (FIM); Langhammer and Stranghelle42 andWang et al.51: Motor Assessment Scale (MAS);Lincoln43 and Richards et al.48: Fugl-Meyer motorassessment lower limb score. No trials compared theneurophysiologial approach with no treatment/placebo for functional independence. There were nosignificant differences between neurophysiologicalapproach and orthopaedic approach (SMD 0.02,95% CI 0.55 to 0.59), motor learning approach

Figure 1 Neurophysiological versus other approaches; global dependency scale.


(SMD 0.08, 95% CI 0.60 to 0.75) or mixedapproach (SMD 0.12, 95% CI 1.16 to 0.91), indi-cating that there are no significant differencesbetween neurophysiological and other approaches forfunctional independence.

Motor learning (Carr and Shepherd) versus otherComparisons of motor learning approaches with

other approaches were reported in seven studies. Themotor learning approach used for all seven studieswas described as, or referenced to, Carr andShepherd. Time of follow-up was two weeks forDean and Shepherd,34 four weeks for Lincoln,43 sixweeks for McClellan and Ada,44 two months for Deanet al.35 and Salbach et al.49 and three months forLanghammer and Stranghelle.42

The analyses are displayed in the figures and arebriefly described below.

Global dependency (Figure 3)Langhammer and Stranghelle,42 Lincoln,43 and

Mudie et al.45 reported the Barthel Index. No trials com-pared the motor learning approach with the orthopaedicapproach or mixed approach for global dependency.There were no significant differences between themotor learning approach and neurophysiological

approach (SMD 0.12, 95% CI 0.33 to 0.56) or notreatment/placebo (SMD 0.24, 95% CI 1.26 to0.78), indicating that there are no significant differ-ences between motor learning and other approaches forglobal dependency.

Functional independence (Figure 4)Langhammer and Stranghelle,42 Lincoln,43 and

McClellan and Ada44 reported the Motor AssessmentScale. No trials compared the motor learningapproach with the orthopaedic approach or mixedapproach for functional independence. There were nosignificant differences between the motor learningapproach and neurophysiological approach (SMD0.08, 95% CI 0.75 to 0.60) or no treatment/placebo(SMD 0.34, 95% CI 1.21 to 0.53), indicating thatthere are no significant differences between motorlearning and other approaches for functionalindependence.

Mixed versus otherEight studies reported comparisons using a mixed

approach. Time of follow-up was six weeks forPollock47 and Richards et al.,48 12 weeks for Duncanet al.,36,37 Green et al.39 and Wade et al.50 and at thetime of discharge from rehabilitation for Stern et al.24

Figure 2 Neurophysiological versus other approaches; functional independence scale.


and Ozdemir et al.46 There is considerable hetero-geneity in these data. Stern et al.24 and Ozdemiret al.46 are both quasi-randomized trials and sensitivityanalyses were therefore planned to explore the effectof including these studies. As Stern et al.24 was theonly trial comparing a mixed approach with anorthopaedic approach, it is not combined with anyother trials, and sensitivity analysis was therefore notnecessary.

The analyses displayed in the figures and are brieflydescribed below:

Global dependency (Figure 5)Six of the nine studies included measures of global

dependency. The Kenny Institute of RehabilitationScale was used by Stern et al.,24 and the Barthel Indexby Pollock,47 Richards et al.,48 Duncan et al.,36 Greenet al.39 and Wade et al.50 No trials compared the mixed

Figure 3 Motor learning versus other approaches; global dependency scale.

Figure 4 Motor learning versus other approaches; functional independence scale.


approach with the motor learning approach for globaldependency. There were no significant differencesbetween mixed approach and neurophysiologicalapproach (SMD 0.13, 95% CI 0.61 to 0.87),orthopaedic approach (SMD 0.08, 95% CI 0.42 to0.58) or no treatment/placebo (SMD 0.05, 95%

CI 0.28 to 0.19), indicating that there are no signifi-cant differences between mixed and other approaches.

Functional independence (Figure 6)The Fugl-Meyer motor assessment lower limb

score was used by Richards et al.,48 Duncan et al.36,37;

Figure 5 Mixed versus other approaches; global dependency scale.

Figure 6 Mixed versus other approaches; functional independence scale.


the Rivermead Mobility Index was used by Greenet al.39 and Wade et al.50 and the FunctionalIndependence Measure was used by Ozdemir et al. 46A mixed approach was significantly more favourablethan a no treatment control (SMD 0.94, 95% CI 0.08to 1.80)(data from Duncan et al.,36,37 Green et al.,39Ozdemir et al.46 and Wade et al.50). If Ozdemiret al.,46 which uses quasi-randomization is removedfrom the analysis the result ceases to shows a signifi-cant effect, although there is a trend towards signifi-cance (SMD 0.28, 95% CI 0.03 to 0.58). No trialscompared the mixed approach with the motor learningor orthopaedic approach for functional independence.There was no significant difference between themixed approach and neurophysiological approach(SMD 0.12, 95% CI 0.91 to 1.16).

Discussion

This review was carried out with the specific aim ofinvestigating the efficacy of different treatmentapproaches, based on a historical perspective. This wasin direct response to a consultation exercise carried outin Scotland which aimed to identify the burning ques-tions of Scottish stroke rehabilitation workers, andwhich identified different treatment approaches to beamongst the most burning questions of physiothera-pists.53 Hence this review was driven by an identifiedclinical question, rather than originating from a scien-tific and logical standpoint. While the results of thisreview may lead to the conclusion that no one physio-therapy treatment approach appears to be more advan-tageous to the promotion of recovery of lower limbfunction or postural control, the difficulties encoun-tered in the methodology of the review highlight theabsence of a scientific rationale for basing physiother-apy interventions on named approaches.

A statistically significant result was found in thecomparison of a mixed approach with a no treatmentcontrol, for the recovery of functional independence.Data from five trials (427 participants) demonstratedthat a mixed approach was significantly morefavourable than no treatment control in the recoveryof functional independence (SMD 0.94, 95% CI 0.08to 1.80). One of the five trials did have a number ofmethodological limitations.46 Ozdemir et al.,46 whichreported a much more significant result, did not userandom allocation to groups and did not have a blinded

outcome assessor: these methodological limitationscould have allowed the introduction of bias into thedata collected. With Ozdemir et al.46 removed fromthe analysis the result ceases to be significant,although there is a trend towards significance (SMD0.28, 95% CI 0.03 to 0.58).

The data analysed in this review provide evidencethat a mixed physiotherapy intervention is signifi-cantly favourable to no treatment intervention in therecovery of functional independence following stroke.This significant effect arguably demonstrates thatany physiotherapy is better than none.

Limitations

Identification of relevant trialsThe identification of all relevant trials was

confounded by a number of factors:

Inconsistent and poorly defined terminology:Electronic searching was difficult as the names andcontent associated with different physiotherapytreatment approaches are poorly documented,often have several derivations, and have variedover time.

Lack of detail within abstract: Lack of informa-tion on study methodology, subjects and interven-tions potentially increases the chance of excludinga relevant trial. However the method of includingall possible trials should have prevented this.

Material published in journals not included inelectronic databases and unpublished material:While substantial effort was made to identifyunpublished material and material in journals notcited on the included databases, relevant trials mayhave not been identified.

Non-English trials awaiting assessment: Twenty-six non-English (23 Chinese) trials are currentlyawaiting translation and formal assessment. Withso many studies awaiting assessment, and thepotential that they may be relevant to the currentlyincluded comparison groups, there is a possibilitythat inclusion of these trials will alter the conclu-sions made in this review.

Quality of included trialsMany of the included trials had methodological

limitations, which may have led to the introduction of


selection bias. Two key methodological factors whichreduced the quality of many of the included trialswere the method of randomization and blinding:

Randomization: Three of the identified studiesdid not state the method of randomization36,38,52;one study divided patients into matched pairs andthen randomly allocated the pairs35; one study usedquasi-random assignment based on order of entryinto the study46; and the method of randomizationof a fifth24 was identified to be potentially unreli-able. Questions about the quality of randomizationmust challenge the robustness of the study design,and hence the results of this review.

Blinding and contamination: In the majority ofstudies it was unclear whether or not the patientswere blinded to the study group and aims. Thenature of rehabilitation interventions and the ethi-cal requirement to obtain informed consent oftenmakes it difficult, if not impossible, to blindpatients. If the aims and objectives of the studywere apparent to the subjects this could confoundthe study results. The treating therapist(s) was notblinded in any of the trials. This was to be expectedas a treating therapist has to be familiar with theintervention that they are administering. Therapistswho strongly favoured one approach over anothercould introduce performance bias. In several of thestudies the same therapist(s) administered treat-ment to patients in both study groups: this poten-tially introduces considerable contaminationbetween groups. Pollock47 reported some reluc-tance of patients to participate in the treatmentintervention confounding variables such as thesemay be attributed to the beliefs of patients andtherapists, and are examples of effects of lack ofblinding of patients and therapists. Only 13 of the20 included trials stated that they used a blindedassessor. The lack of blinding of assessor potentiallyintroduces considerable bias into the study results.This is particularly important in studies in whichtherapists often have strong beliefs in support of aparticular approach.

Heterogeneity of included trialsIn addition to the limitations of the study method-

ology, the studies included in the review had consid-erable heterogeneity within the interventions, outcomesmeasures and patient samples.

Documentation of interventionsClear, concise documentation of complex physical

interventions is exceptionally difficult to achieve.All of the included studies either gave a briefdescription of the techniques used, or referenced atext in which techniques are described in moredetail. Where possible, authors were contacted andasked to supply any further material that was avail-able (e.g. the more detailed information used by thetreating therapists). However, although there hasbeen an attempt to describe all the administeredinterventions, the available documentation is ofteninsufficient to allow confident and accurate repeti-tion of the applied treatment approach. The prob-lems of documentation are confounded by the factthat the treatments applied are ultimately the deci-sion of a single physiotherapist, based on an indi-vidual assessment of a unique patients movementdisorders.

Furthermore, the common basis of the differentphysiotherapy approaches are that they are holistic.All body parts and movements can be assessed andtreated based on the selected approach; however aphysiotherapist may select to concentrate on thetreatment of one particular body part or movementduring a treatment session. Subsequently the treat-ments given to individual patients by individual ther-apists may vary enormously. This review attemptedto limit this variation slightly by excluding trials thathad only given interventions to the upper limb.Nevertheless, although patients receiving treatmentbased on a particular approach should receivean intervention that conforms to the stated philoso-phy/theory of the approach, it is conceivable thatthere were few similarities between the physicalinterventions given to patients in the same treatmentgroup.

The argument that a physiotherapy approach isbased on an individual assessment of a uniquepatients movement disorders has been used by sometherapists/researchers to perpetuate limited documen-tation and standardization. However recent studieshave demonstrated that clear concise documentationof a treatment intervention does not necessarily meanthe removal of the therapists ability to select a treat-ment based on an individual patients problems. Forexample, Wang et al.,51 within a detailed documenta-tion of the intervention, highlights that the treatmentsare individualised, constantly modified according tosubject response.


Classification of treatment approachesThe classification of the treatment approaches used inthis review can potentially be criticized for combininga number of different physiotherapy approaches undervery broad classifications (i.e. neurophysiological,motor learning, orthopaedic). Subgroup analysis ofthe individual named approaches within each classifi-cation was planned. However, as all of the neuro-physiological approaches were described asBobath, and all of the motor learning approachesare referenced to Carr and Shepherd, this reviewcannot by default be criticized for combining avariety of approaches under one classification head-ing, as this has not occurred.

The Bobath concept: This review includes eighttrials which stated that they were evaluating aBobath approach to stroke therapy. It is importantto note that there is considerable debate surround-ing the content of physiotherapy interventionsbased on the Bobath concept. This debate largelyarises from the fact that the content of the Bobathapproach has changed over time, there are limitedupdated published descriptions, and that there is avariation in the content of current therapy.1921,5456It is beyond the scope of this review to determinewhether the interventions described as Bobathhad any practical or theoretical differences.

Motor learning and mixed approaches:Reviewers found most difficulty in distinguishingbetween a mixed approach (not a mixture of twodifferent approaches, such as Stern et al.24 mixingorthopaedic and neurophysiological approaches,but an unclassified mix) and a motor learningapproach. The mixed, intensive and focusedapproach investigated by Richards et al.48 and theproblem-solving approach investigated by Greenet al.39 and Wade et al.50 had stated philosophiesvery similar to that of motor learning approaches.However the described techniques, and the sup-porting references, led the reviewers to classifythese interventions as mixed. This highlights akey problem with the classification of the motorlearning approach. While a motor relearning pro-gramme has been described by Carr andShepherd,11,14 these authors primarily advocate anapproach based on related research in relevantareas such as medical science, neuroscience, exer-cise physiology and biomechanics. Such an

approach is arguably one of research-based practice,rather than being based on one specific philosophy.

We suggest that if physiotherapists are to practiseevidence-based stroke rehabilitation their culture, atti-tudes and beliefs will have to shift away from the useof compartmentalized approaches to judging the sci-entific and research base for each individual treatmenttechnique. This review supports this approachbecause it suggests that a mixed approach is moreeffective than no treatment and it fails to demonstrateany superiority for any single approach relating to therecovery of disability following stroke. Future ran-domized controlled trials and systematic reviewsshould concentrate on investigating clearly definedand described techniques and task-specific treatments,and not on compartmentalized approaches.

Clinical messages

No one physiotherapy approach has beenshown to be more advantageous to the promo-tion of recovery of disability following stroke.

Physiotherapy which uses a mix of compo-nents from different approaches may be moreeffective than no treatment or placebo controlin the recovery of functional independencefollowing stroke.

AcknowledgementsThe Stroke Therapy Evaluation Programme is

funded by The Big Lottery Fund, and has previouslybeen funded by Chest Heart and Stroke Scotland andThe Health Foundation.

Competing interestsNone.

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