Key messages

For people who have had a stroke:

- Physical rehabilitation may improve daily activities, moving legs, balance, and walking, when compared to no physical rehabilitation. There may be greater benefits when more than 2.5 hours/week of physical rehabilitation is delivered.

- Extra physical rehabilitation, given in addition to 'usual' physical rehabilitation, may also improve outcomes. The greater the amount of extra physical rehabilitation, the greater the benefit may be.

- Physical rehabilitation focussed on functional task training (the active practice of real-life tasks with the aim of acquiring - or reacquiring - a movement skill) may improve daily activities and movement.

Why is it important to review the evidence on this topic?

Stroke can cause paralysis of some parts of the body and can create difficulties with physical functions. Over the years, various approaches to physical rehabilitation have been developed, based on ideas about how people recover after a stroke. Often, physiotherapists will choose one particular approach, based on their clinical experience and the rationale, but clear research evidence is lacking. This means that techniques used by individual physiotherapists may differ (e.g. one may provide strengthening exercises, while another may focus on passive movements). Historically, a number of named physical rehabilitation approaches (e.g. the ‘Bobath’ approach) have been used; together we call these neurophysiological approaches, as they were developed based on knowledge and theories relating to the function and recovery of the nervous system. It is important to help physiotherapists select the approach that will help their patients gain the best recovery.

Note: Physiotherapist/physiotherapy can be called physical or rehabilitation therapist/therapy, meaning the same. We use the term physical rehabilitation and describe the person providing physical rehabilitation as a therapist.

What did we want to find out?

We wanted to know:

- Are physical rehabilitation approaches effective in the recovery of function and mobility in people with stroke?

- Is one physical rehabilitation approach more effective than another approach?

What did we do?

We searched for relevant studies, called randomised controlled trials. We brought together studies in which people who had a stroke received physical rehabilitation with the goal of improving the ability to walk and carry out activities of daily living. We were interested in different approaches to physical rehabilitation (i.e. a programme of treatment based on a particular scientific rationale). These approaches might involve therapist-delivered, group, or remote treatment. Therapists may select specific treatments/exercises according to individual patient needs, or deliver standard exercises based on the stage of patient recovery. We excluded studies that only looked at 'single' treatments (e.g. electrical stimulation, robotic device) or were focused only on arm function.

What did we find?

We found 267 studies, which included 21,838 people with stroke. Studies were from 36 different countries, but half (133 studies) were carried out in China.

One hundred and five studies looked at whether physical rehabilitation was better than no physical rehabilitation. Most of these studies were carried out in hospital in-patient settings in China where physical rehabilitation was not part of routine care, but a few were carried out in outpatient settings after the patient had been discharged from routine physical rehabilitation. These studies showed that physical rehabilitation may improve a person's ability to carry out activities of daily living, move the legs, remain balanced, and walk, in comparison to no physical rehabilitation.

Fifty-six studies looked at the effect of giving extra, or additional, physical rehabilitation. Everyone in these studies received their usual physical rehabilitation, but one group of stroke survivors received some additional treatment based on a particular physical rehabilitation approach. These studies showed that additional physical rehabilitation may improve the ability to carry out activities of daily living, move the legs, remain balanced, and walk; the greater the amount of additional rehabilitation, the greater the possible benefit.

Ninety-two studies compared different physical rehabilitation approaches. There were many variations in the types and amount of physical rehabilitation, and the types of people (e.g. different lengths of time post-stroke). These studies showed that physical rehabilitation that focused on functional task training may improve the ability to carry out activities of daily living and move the legs (but not balance or walking). Neurophysiological approaches to physical rehabilitation may be less effective than other approaches at improving daily activities (but no different for other outcomes).

For all comparisons, there was very limited information about potential adverse events relating to physical rehabilitation.

Few studies took long-term follow-up measurements after the physical rehabilitation had stopped.

What are the limitations of the evidence?

There were large variations between participants, interventions, outcomes, and comparisons in the studies included in this review. There were also geographical and cultural differences that may influence the results. Generally, the reporting of the details of these studies was very poor. These issues mean that we have limited confidence in the results of our statistical analyses.

How up-to-date is this evidence?

The evidence is up-to-date to November 2022. It is unlikely that any studies published since November 2022 would alter our conclusions.