Physiotherapy treatment approaches for the recovery of

postural control and lower limb function following stroke

(Review)

Pollock A, Baer G, Pomeroy VM, Langhorne P

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2009, Issue 1
http://www.thecochranelibrary.com

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Analysis 1.1. Comparison 1 Neurophysiological versus other approaches, Outcome 1 Global Dependency Scale. . . 38
Analysis 1.2. Comparison 1 Neurophysiological versus other approaches, Outcome 2 Functional Independence Scale. 39
Analysis 1.3. Comparison 1 Neurophysiological versus other approaches, Outcome 3 Balance (Berg Balance Scale). . 40
Analysis 1.5. Comparison 1 Neurophysiological versus other approaches, Outcome 5 Gait velocity. . . . . . . 41
Analysis 1.6. Comparison 1 Neurophysiological versus other approaches, Outcome 6 Length of stay. . . . . . . 42
Analysis 2.1. Comparison 2 Motor learning versus other approaches, Outcome 1 Global Dependency Scale. . . . 43
Analysis 2.2. Comparison 2 Motor learning versus other approaches, Outcome 2 Functional Independence Scale. . 44
Analysis 2.3. Comparison 2 Motor learning versus other approaches, Outcome 3 Balance (Berg Balance Scale). . . 45
Analysis 2.5. Comparison 2 Motor learning versus other approaches, Outcome 5 Gait Velocity. . . . . . . . . 46
Analysis 3.1. Comparison 3 Mixed versus other approaches, Outcome 1 Global Dependency Scale. . . . . . . 47
Analysis 3.2. Comparison 3 Mixed versus other approaches, Outcome 2 Functional Independence Scale. . . . . 48
Analysis 3.3. Comparison 3 Mixed versus other approaches, Outcome 3 Balance (Berg Balance Scale). . . . . . 49
Analysis 3.4. Comparison 3 Mixed versus other approaches, Outcome 4 Muscle strength. . . . . . . . . . . 50
Analysis 3.5. Comparison 3 Mixed versus other approaches, Outcome 5 Gait velocity. . . . . . . . . . . . 51
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) i
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]

Physiotherapy treatment approaches for the recovery of

postural control and lower limb function following stroke

Alex Pollock1 , Gill Baer2 , Valerie M Pomeroy3 , Peter Langhorne4

1 Nursing,Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK. 2 Physiotherapy
Department, School of Health Sciences, Queen Margaret University College, Edinburgh, UK. 3 Faculty of Health, University of East
Anglia, Norwich, UK. 4 Academic Section of Geriatric Medicine, University of Glasgow, Glasgow, UK

Contact address: Alex Pollock, Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University,
Buchanan House, Cowcaddens Road, Glasgow, G4 0BA, UK. alex.pollock@gcal.ac.uk.

Editorial group: Cochrane Stroke Group.

Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009.
Review content assessed as up-to-date: 18 January 2006.

Citation: Pollock A, Baer G, Pomeroy VM, Langhorne P. Physiotherapy treatment approaches for the recovery of postural con-
trol and lower limb function following stroke. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001920. DOI:
10.1002/14651858.CD001920.pub2.

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

Background

There are a number of different approaches to physiotherapy treatment following stroke that, broadly speaking, are based on neuro-
physiological, motor learning and orthopaedic principles. Some physiotherapists base their treatment on a single approach, while others
use a mixture of components from a number of different approaches.

Objectives

To determine if there is a difference in the recovery of postural control and lower limb function in patients with stroke if physiotherapy
treatment is based on orthopaedic or neurophysiological or motor learning principles, or on a mixture of these treatment principles.

Search methods

We searched the Cochrane Stroke Group Trials Register (last searched May 2005), the Cochrane Central Register of Controlled Trials
(CENTRAL) (The Cochrane Library Issue 2, 2005), MEDLINE (1966 to May 2005), EMBASE (1980 to May 2005) and CINAHL
(1982 to May 2005). We contacted experts and researchers with an interest in stroke rehabilitation.

Selection criteria

Randomised or quasi-randomised controlled trials of physiotherapy treatment approaches aimed at promoting the recovery of postural
control and lower limb function in adult participants with a clinical diagnosis of stroke. Outcomes included measures of disability,
motor impairment or participation.

Data collection and analysis

Two review authors independently categorised the identified trials according to the inclusion and exclusion criteria, documented their
methodological quality, and extracted the data.
Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 1
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Main results

Twenty-one trials were included in the review, five of which were included in two comparisons. Eight trials compared a neurophysiological
approach with another approach; eight compared a motor learning approach with another approach; and eight compared a mixed
approach with another approach. A mixed approach was significantly more effective than no treatment or placebo control for improving
functional independence (standardised mean difference (SMD) 0.94, 95% confidence intervals (CI) 0.08 to 1.80). There was no
significant evidence that any single approach had a better outcome than any other single approach or no treatment control.

Authors’ conclusions

There is evidence that physiotherapy intervention, using a mix of components from different approaches, is significantly more effective
than no treatment or placebo control in the recovery of functional independence following stroke. There is insufficient evidence to
conclude that any one physiotherapy approach is more effective in promoting recovery of lower limb function or postural control
following stroke than any other approach. We recommend that future research should concentrate on investigating the effectiveness of
clearly described individual techniques and task-specific treatments, regardless of their historical or philosophical origin.

PLAIN LANGUAGE SUMMARY

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

Physiotherapy, using a mix of components from different treatment approaches, appears best for promoting functional independence
following stroke; no single physiotherapy approach is clearly best for promoting recovery after stroke. A stroke interrupts the blood flow
to the brain, often leading to damage to some brain functions. This can cause paralysis of some parts of the body or other difficulties
with various physical functions. Physiotherapy is an important part of rehabilitation for people who have had a stroke. A number of
physiotherapy approaches have been developed based on different ideas about how people recover after a stroke. This review of 21 trials
found there is no evidence that any one approach was clearly better than another for improving leg strength, balance, walking speed or
the ability to perform everyday tasks. However, physiotherapy using a mixture of components from the different approaches was better
than no treatment or placebo treatment for improving aspects of function following a stroke.

BACKGROUND The practical application of these approaches results in substantial

There are a number of different approaches to physiotherapy treat- differences in patient treatment. Approaches based on neurophys-
ment following stroke. Prior to the 1940s these primarily con- iological principles primarily involve the physiotherapist moving
sisted of corrective exercises based on orthopaedic principles re- the patient through patterns of movement, with the therapist act-
lated to the contraction and relaxation of muscles, with empha- ing as problem solver and decision maker and the patient being
sis placed on regaining function by compensating with the unaf- a relatively passive recipient (Lennon 1996). In direct contrast,
fected limbs (Ashburn 1995; Partridge 1996). In the 1950s and motor learning stresses the importance of active involvement by
1960s techniques based on available neurophysiological knowl- the patient (Carr 1982), while orthopaedic approaches emphasise
edge were developed, including the methods of Bobath (Bobath muscle strengthening techniques and compensation with the non-
1990; Davies 1985), Brunnström (Brunnström 1970), Rood (Goff paretic side.
1969) and the proprioceptive neuromuscular facilitation approach
(Knott 1968; Voss 1985). In the 1980s the potential importance of Since the 1980s the need to base neurological physiotherapy on
neuropsychology and motor learning was highlighted (Anderson scientific research in relevant areas such as medical science, neu-
1986; Turnbull 1982) and the motor learning, or re-learning, roscience, exercise physiology and biomechanics, and to test the
approach was proposed (Carr 1982). This suggests that active outcomes in order to develop evidence-based physiotherapy, has
practice of context-specific motor tasks with appropriate feedback been increasingly emphasised. However, anecdotal evidence and
would promote learning and motor recovery (Carr 1980; Carr the results of questionnaire-based studies suggest that, tradition-
1982; Carr 1987a; Carr 1987b; Carr 1989; Carr 1990; Carr 1998). ally, many physiotherapists continue to base their clinical practice
Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 2
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
around a treatment approach. Currently, the Bobath approach,
based on neurophysiological principles, remains the most widely
used method in Sweden (Nilsson 1992), Australia (Carr 1994a)
and the United Kingdom (Davidson 2000; Lennon 2001; Sackley
1996). As a consequence, physiotherapists often seek evidence re-
lating to global approaches to the treatment of stroke patients,
rather than evidence in support of individual treatments. The eval-
uation of this research evidence is often difficult owing to poor de-
scription and documentation of the approaches investigated. Of-
ten the treatment approach is vaguely described as conventional
or traditional (Basmajian 1987; Brunham 1992; Dickstein 1986;
Logigian 1983; Lord 1986; Stern 1970; Sunderland 1992) and few
other details are available. Although questionnaire-based studies
do demonstrate that physiotherapists often have their own pref-
erences, there is presently no convincing evidence to support any
specific physiotherapy treatment approach (Ernst 1990; Sackley
1996).
OBJECTIVES
To determine if there is a difference in the recovery of postural
control and lower limb function in patients with stroke if phys-
iotherapy treatment is based on any one orthopaedic or neuro-
physiological or motor learning principle, or on a mixture of these
treatment principles.
Hypotheses to be tested
(1) Physiotherapy treatment based on neurophysiological princi-
ples results in better recovery of postural control and lower limb
function than treatment based on motor learning principles, or-
thopaedic principles or a mixture of treatment principles in pa-
tients with stroke.
(2) Physiotherapy treatment based on motor learning principles
results in better recovery of postural control and lower limb func-
tion than treatment based on orthopaedic principles, or on a mix-
ture of treatment principles in patients with stroke.
METHODS
Criteria for considering studies for this review
Types of studies
We included controlled trials if the participants were randomly or
quasi-randomly assigned to one of two or more treatment groups.
Random assignment will give each participant entering the trial
Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
the same, predetermined, chance of receiving each of the possible
treatments (for example, by using sequentially numbered opaque
sealed envelopes or computer generated random numbers). Quasi-
random assignment must prospectively allocate participants to re-
ceive treatment in a manner that may produce balanced groups,
but which is not strictly random and is potentially open to bias
(such as allocated alternately or according to the day of the week
or bed availability). We included trials with or without blinding of
participants, physiotherapists and assessors. For the next update
of this review we have decided to exclude studies that use quasi-
random assignment.
Types of participants
We included trials enrolling adult participants (aged over 18 years)
with a clinical diagnosis of stroke (World Health Organization def-
inition, Hatano 1976), which could be either ischaemic or haem-
orrhagic in origin (confirmation of the clinical diagnosis using
imaging was not compulsory).
Types of interventions
We included physiotherapy treatment approaches that were aimed
at promoting the recovery of postural control (balance during the
maintenance of a posture, restoration of a posture or movement
between postures) and lower limb function (including gait), and
also interventions that had a more generalised stated aim, such as
improving functional ability. We excluded treatment approaches
that were primarily aimed at promoting recovery of upper limb
movement or function.
Types of outcome measures
We defined primary outcomes as measures of disability, and
prestated relevant measures of disability as:
(1) global dependency scales; or
(2) functional independence in mobility.
We defined secondary outcomes as measures of motor impairment,
classifying them as measures of:
(1) postural control and balance;
(2) voluntary movements (including movement associated with
gait);
(3) tone/spasticity;
(4) range of movement; or
(5) strength.
We also identified participation (handicap or quality of life) as an
outcome of relevance to this review.
The review authors documented and extracted descriptions and
data from any outcomes falling into these categories. Based on the
prestated categories of relevant outcomes and the availability of
data from specific measures in the included trials, they discussed
and reached consensus on which outcome measures should be
included in the analysis.
3
Search methods for identification of studies
See: ’Specialized register’ section in Cochrane Stroke Group
We searched the Cochrane Stroke Group Trials Register, which
was last searched by the Review Group Co-ordinator in May 2005.
In addition, we searched the Cochrane Central Register of Con-
trolled Trials (CENTRAL) (The Cochrane Library Issue 2, 2005),
MEDLINE (1966 to May 2005), EMBASE (1980 to May 2005)
and CINAHL (1982 to May 2005). To avoid unnecessary dupli-
cation, we developed intervention-based search strategies for elec-
tronic databases in consultation with the Cochrane Stroke Group
Trials Search Co-ordinator. To identify additional studies compar-
ing different physiotherapy treatment approaches for stroke, we
employed a strategy, using controlled vocabulary (MeSH) and free
text terms, to search MEDLINE and modified it to suit the other
bibliographic databases (Appendix 1).
For the original version of this review, we contacted relevant ex-
perts from the Physiotherapy Researchers Register, held by the
Chartered Society of Physiotherapy, and asked them if they knew
of any additional, unpublished or ongoing trials of treatment ap-
proaches for stroke. We also placed a request on the PHYSIO
email discussion list asking the list members (who originate from
approximately 35 countries) if they knew of any unpublished or
ongoing trials of treatment approaches for stroke. We identified
no relevant additional, unpublished or ongoing trials through ex-
perts from the Physiotherapy Researchers Register and received no
relevant responses from the PHYSIO email discussion list.
We handsearched the reference lists of all trials found using the
above search methods.
In future updates of this review we will consider expanding the
search strategy to include AMED (Allied and Complementary
Medicine Database), the Physiotherapy Evidence Database (PE-
Dro), the REHABDATA Database and ongoing trials and research
registers (such as the National Research Register).
Data collection and analysis
Identification of relevant trials
One review author (AP) read the titles of the identified references
and eliminated obviously irrelevant studies. The abstracts for the
remaining studies were obtained and then, based on the inclusion
criteria (types of studies, types of participants, aims of interven-
tions, outcome measures), two review authors (AP, GB) indepen-
dently ranked these as relevant, irrelevant or unsure. We excluded
any trials ranked as irrelevant by all review authors, but included
all other trials at this stage.
Using the titles and abstracts, two review authors (AP, GB) in-
dependently categorised the identified trials as trials of different
(global) physiotherapy approaches or of specific treatment com-
ponents. Any disagreements were resolved through discussion be-
tween three review authors (AP, GB, PL). We included all trials that
Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
were assessed to investigate different (global) physiotherapy treat-
ment approaches, and excluded all trials of specific treatment com-
ponents. Specific treatment components included biofeedback,
functional electrical stimulation, treadmill walking, acupuncture,
ankle-foot orthoses, continuous passive movements and transcu-
taneous electrical nerve stimulation. Some of these specific treat-
ment components have been the subject of other Cochrane re-
views (Moseley 2001; Pomeroy 2006).
Two review authors (AP,GB) independently scrutinised the titles,
introductions and methods sections of the included trials. Based
on a detailed written description of the classification of physio-
therapy approaches based on motor learning, neurophysiological
or orthopaedic principles (Table 1) (which was derived from the
available literature, and had been discussed among all the review
authors to ensure consensus), the review authors independently
classified the interventions administered in each trial. Any dis-
agreements were resolved through discussion and we obtained fur-
ther information from trialists where necessary (and possible).
Documentation of methodological quality
Two review authors independently documented the methodolog-
ical quality of the studies, recording the following quality crite-
ria: randomisation (allocation concealment); baseline comparison
of groups; blinding of recipients and providers of care to treat-
ment group/study aims; blinding of outcome assessor; possibil-
ity of contamination/co-intervention by the therapists providing
the intervention; completeness of follow up; and other potential
confounders. The review authors resolved any disagreements by
discussion. Study authors were contacted for clarification where
necessary.
Data extraction
Two review authors independently performed the data extraction
and we contacted study authors to request missing data where
possible. The data extracted were (where possible): trial setting
(e.g. hospital, community); details of participants (e.g. age, gen-
der, side of hemiplegia, stroke classification, comorbid conditions,
premorbid disability); inclusion and exclusion criteria; and all as-
sessed outcomes. The review authors resolved any disagreements
by discussion. Study authors were contacted for clarification where
necessary.
Comparisons to be made
Prestated comparisons to be made were:
• neurophysiological versus motor learning;
• neurophysiological versus orthopaedic;
• neurophysiological versus mixed;
• motor learning versus orthopaedic;
• motor learning versus mixed.
4
We combined these comparisons into the following categories:
• neurophysiological versus other (motor learning,
orthopaedic, mixed or placebo/control);
• motor learning versus other (neurophysiological,
orthopaedic, mixed or placebo/control);
• mixed versus other (neurophysiological, motor learning,
orthopaedic or placebo/control).
Comparisons of sub-classifications of the same
treatment approach
At the time of the original 1999 version of this review, no explicit
criteria had been written regarding trials that compared subclas-
sifications of the same treatment approach (that is neurophysi-
ological versus neurophysiological, motor learning versus motor
learning, orthopaedic versus orthopaedic); we therefore included
these trials. Two such trials were included (Inaba 1973; Wagenaar
1990). For this version of the review, discussion amongst the au-
thors led to the decision that any trials comparing subclassifica-
tion of the same treatment approach should be excluded because
these comparisons were not directly answering the review ques-
tion and therefore were not adding any relevant data to the review.
Therefore, Inaba 1973 (n = 77), which compared three different
types of orthopaedic approach, and Wagenaar 1990 (n = 7), which
compared neurophysiological approaches based on neurodevelop-
mental treatment (NDT) and Brunnström, are excluded from this
version of the review.
All outcome measures analysed were presented as continuous data.
We calculated standardised mean differences (SMD) and 95%
confidence intervals (CI), using a random-effects model, for all
outcomes analysed.
There were insufficient data to carry out subgroup analysis on an
intention-to-treat basis, or to carry out the preplanned sensitivity
analyses to examine the effects on the results of blinding of out-
come assessor, inclusion criteria (infarct or haemorrhagic stroke;
confirmation of clinical diagnosis), or the effects of drop outs (in-
cluding trials with participants who stopped participating during
therapy and for whom no further data were available). The lack
of data also prevented subgroup analyses being carried out to in-
vestigate possible differences between participants of various ages,
the side of the lesion, lesion type, and the effects of different sub-
classifications of treatment approach.
Quasi-random assignment
The selection criteria for this review stated that studies using
quasi-random assignment would be included. However, discus-
sion amongst the review authors led to the decision that, in fu-
ture updates of this review, studies with quasi-random assignment
should be excluded. In this version of the review, studies with
quasi-random assignment are included and sensitivity analyses are
carried out to determine the effect of including or removing the
quasi-random trials.
Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
RESULTS
Description of studies
See: Characteristics of included studies; Characteristics of excluded
studies; Characteristics of ongoing studies.
Identification of relevant trials
Search results
The electronic searching resulted in 8408 potentially relevant tri-
als. One review author (AP) eliminated obviously irrelevant stud-
ies based on titles and, where available, abstracts. A total of 8161
studies were eliminated, leaving 247 potentially relevant trials. Ex-
amination of the reference lists of these trials, and communication
with known experts and colleagues, added a further 18 studies,
making a total of 265 potentially relevant trials.
Two review authors (AP, GB) independently read the abstracts for
these 265 studies. Thirty (11%) were classified as relevant, and 154
(58%) as possibly relevant. This provided a total of 184 abstracts,
papers or theses.
Two review authors (AP, GB) independently classified these 184
studies into the previously identified categories.
• Trials of different physiotherapy treatment approaches (21
studies).
• Trials of specific components of physiotherapy treatment:
(1) biofeedback (37 studies); (2) functional electrical stimulation
(10 studies); (3) other specific treatment components (24
studies). In addition: 10 studies were found to relate to other
physiotherapy issues (such as intensity or duration of treatment);
26 were found not to be physiotherapy-related interventions; 20
were not randomised controlled or controlled studies; four did
not include stroke participants; three were upper limb studies;
two studies never took place and funding was still being sought
for one. A further 26 studies could not be classified because they
were not written in English and insufficient translation
information was available: 23 were Chinese, one Turkish, one
Lithuanian and one Polish.
At this stage we included the 21 studies categorised as trials of
different physiotherapy treatment approaches, 26 were included
as ’studies awaiting assessment’, and one as an ’ongoing study’; the
remaining 136 were excluded.
Comments from peer-reviewers led to the reassessment of one trial
(Wade 1992), which had been excluded from the original version
of this review. Based on the full text of this published study (rather
than the abstract only) we have included this trial in this updated
version of the review.
5
Studies with methodological limitations
Two of the included trials used quasi-random assignment (Stern
1970; Ozdemir 2001). The methodology of Stern 1970 (n = 62)
was highlighted as possibly inadequate: this study randomised 50
participants and then selected and assigned an additional 12 par-
ticipants in order to ’even out differences in important characteris-
tics’. Discussion between the review authors (AP, GB, PL) reached
the consensus that this study should be included, although the
possible inadequacies in randomisation should be noted. Ozdemir
2001 (n = 60) used alternate allocation according to order of entry
to the study.
Hesse 1998 used repeated-measures methods; however, as patients
were randomly assigned to the first phase of this study, it was
assessed that the first phase should be included as a controlled trial.
Included trials
Hence, 20 relevant trials are included in this review (Dean 1997;
Dean 2000; Duncan 1998; Duncan 2003; Gelber 1995; Green
2002; Hesse 1998; Howe 2005; Langhammer 2000; Lincoln
2003; McClellan 2004; Mudie 2002; Ozdemir 2001; Pollock
1998; Richards 1993; Salbach 2004; Stern 1970; Wade 1992;
Wang 2005a; Wellmon 1997).
These included trials randomised 1087 participants. Three of these
studies (78 participants) have no data included in the analyses: we
were unable to obtain the data from the first phase of the study by
Hesse 1998 (n = 22); and Wellmon 1997 (n = 21) and Howe 2005
(n = 35) reported no outcomes that were included in the analysis.
Wang 2005a stratified participants into those with spasticity
(Brunnström stages 2 or 3) and those with relative recovery
(Brunnström stages 4 or 5). We were unable to obtain combined
data for these groups of patients and this study is therefore entered
into the analyses as two studies: Wang 2005a (patients with spas-
ticity) and Wang 2005b (patients with relative recovery). These
two studies have not been included in the analyses, results or dis-
cussion.
Descriptions of the included studies can be found in
Characteristics of included studies, and in the Additional tables:
Table 2 (methodological quality of included studies), Table 3 (sum-
mary of study setting), and Table 4 (details of study participants).
Classification of treatment approaches
Based on the written descriptions of treatment approaches, two
review authors (AP, GB) independently classified the approaches
investigated in the 20 included trials (41 treatment approaches).
They independently agreed on the classification of 40 of the 41
approaches, from 19 of the 20 studies. For the study by Richards
1993 the review authors independently agreed on the classifica-
tion of one of the two investigated approaches. After discussion
between the review authors, a further paper referred to by Richards
1993 was obtained (Malouin 1992): this provided further details
Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
of the interventions and the review authors agreed on the classi-
fication of a mixed approach. Both the review authors indepen-
dently queried the classification of the treatment intervention in-
vestigated by Howe 2005. This intervention was primarily refer-
enced to Davies (a neurophysiological approach), but there were
secondary references to motor learning-based interventions. In the
introduction to the paper, Howe 2005 referenced the first edition
of this review, supporting the argument that research should con-
centrate on ’clearly defined and described techniques regardless of
their theoretical origin’. In discussion, it was agreed between the
review authors that the intervention studied by Howe 2005 was a
mixed approach; this was confirmed by the study author.
Details of the classification and subclassifications of the treatment
approaches, the described philosophy or theory of the interven-
tions, the described techniques, supporting references stated by
the study authors, and the amount of treatment given in the in-
cluded studies, are provided in Table 5.
Study setting
The setting for the recruitment of participants and for the admin-
istration of the intervention is summarised in Table 3.
Outcome measures for analysis
The included trials used a large number of heterogeneous outcome
measures. The many diverse outcome measures recorded in the
included studies made it impossible to analyse all the documented
data. Based on the prestated categories of relevant outcomes and
the availability of data from specific measures in the included trials,
the review authors decided to concentrate data analysis on global
dependency, functional independence, balance, muscle strength,
gait velocity and length of rehabilitation stay.
Outcome measures were recorded at a number of different time
points during and after the intervention period. For the analyses
in the review, data were recorded from the outcome measures re-
ported at the end of the treatment period, or at the time point
nearest to the end of treatment period. If the intervention com-
prised a change in treatment throughout the whole of a patient’s
rehabilitation period, then data were recorded from the outcome
measures noted at the time of discharge from rehabilitation, or at
the time point nearest to discharge. The time point at which data
has been extracted for analysis is clearly documented and stated
for each trial.
Comparisons
Trials were categorised into comparisons of: (1) neurophysiolog-
ical versus other (eight trials); (2) motor learning versus other
(eight trials); and (3) mixed versus other (nine trials). (Note that
Langhammer 2000; Lincoln 2003; Mudie 2002; Pollock 1998;
and Richards 1993 each fall within at least two of these compar-
isons.) The data available from Wang 2005a were stratified into
6
patients with spasticity and patients with relative recovery, and
have been entered as Wang 2005a and Wang 2005b respectively.
The comparisons included the following subgroups.
Comparison 01: Neurophysiological versus other approaches:
• neurophysiological versus orthopaedic (Gelber 1995; Wang
2005a);
• neurophysiological versus motor learning (Langhammer
2000; Lincoln 2003; Mudie 2002);
• neurophysiological versus mixed (this included: (a)
neurophysiological versus motor learning plus
neurophysiological (Pollock 1998); and (b) neurophysiological
versus ’intensive and focused’ (Richards 1993));
• neurophysiological versus control/placebo (Mudie 2002;
Hesse 1998) (no data available for Hesse 1998).
For all eight of these trials the neurophysiological approach was
described or referenced as ’Bobath’.
Comparison 02: Motor learning versus other approaches:
• motor learning versus neurophysiological (Langhammer
2000; Lincoln 2003; Mudie 2002);
• motor learning versus orthopaedic (no trials);
• motor learning versus mixed (no trials);
• motor learning versus control/placebo (Dean 1997; Dean
2000; McClellan 2004; Mudie 2002; Salbach 2004; Wellmon
1997) (no data available for Wellmon 1997).
For all eight of these trials the motor learning approach was refer-
enced directly or indirectly to ’Carr and Shepherd’.
Comparison 03: Mixed versus other approaches:
• mixed versus neurophysiological (mixed interventions
included: (a) neurophysiological plus additional mixed (Howe
2005); (b) motor learning plus neurophysiological (Pollock
1998); and (c) ’intensive and focused’ (Richards 1993)) (no data
available for Howe 2005);
• mixed versus motor learning (no trials);
• mixed (orthopaedic plus neurophysiological) versus
orthopaedic (Stern 1970);
• mixed versus control/placebo (Duncan 1998; Duncan
2003; Green 2002; Ozdemir 2001; Wade 1992).
Risk of bias in included studies
Details of the methodological quality of the studies are provided
in Table 2, in Characteristics of included studies, and in the above
study descriptions.
Effects of interventions
The results are described under the comparisons carried out: (01)
neurophysiological versus other approaches; (02) motor learning
versus other approaches; and (03) mixed versus other approaches,
for each of the explored outcomes (Global Dependency Scale,
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Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Functional Independence Scale, balance, muscle strength, gait ve-
locity, length of stay). Within the tables and analyses there are sub-
stantial gaps arising from the small number of trials and the diverse
outcomes recorded. (In some cases the number of participants for
whom data were available was less than the number completing a
trial. This was due to missing data and occurred especially for gait
velocity because participants completing a trial were not necessar-
ily able to walk.)
Comparison 01: Neurophysiological (Bobath) versus
other approaches
Comparisons of neurophysiological with other approaches were
reported in seven studies, with one (Mudie 2002) comparing a
neurophysiological approach with another approach (motor learn-
ing) and to a control group. Time of follow up was four weeks for
Lincoln 2003 and Wang 2005a, six weeks for Pollock 1998 and
Richards 1993, three months for Langhammer 2000, two weeks
after the end of the intervention for Mudie 2002, and at the time of
discharge for Gelber 1995. No significant differences were found
between neurophysiological or other approaches for recovery of
disability or impairment. These analyses are briefly described be-
low.
Comparison 01.01: Global Dependency Scale
The Barthel Index was reported by six of the trials (Langhammer
2000; Lincoln 2003; Mudie 2002 (two comparisons); Pollock
1998; Richards 1993). No trials compared the neurophysiological
approach with the orthopaedic approach for global dependency.
There were no significant differences between the neurophysiolog-
ical and motor learning approaches (SMD -0.12, 95% CI -0.56
to 0.33), a 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 that there are no significant differences between neuro-
physiological and other approaches for global dependency.
Comparison 01.02: Functional Independence Scale
Six trials reported measures of functional independence: Gelber
1995 - Functional Independence Measure; Langhammer 2000
and Wang 2005a - Motor Assessment Scale; and Lincoln 2003,
Richards 1993 and Wei 1999 - Fugl-Meyer motor assessment
lower limb score. No trials compared the neurophysiological ap-
proach with no treatment/placebo for functional independence.
There were no significant differences between neurophysiological
and orthopaedic approaches (SMD -0.02, 95% CI -0.55 to 0.59),
motor learning approach (SMD 0.08, 95% CI -0.60 to 0.75) or
mixed approach (SMD -0.12, 95% CI -1.16 to 0.91), indicating
that there are no significant differences between neurophysiologi-
cal and other approaches for functional independence.
7
Comparison 01.03: Balance (Berg Balance scale)
Two trials (Richards 1993; Wang 2005a) in this group of com-
parisons reported the Berg Balance Scale. No trials compared the
neurophysiological approach with the motor learning approach or
with no treatment/placebo for balance. There were no significant
differences between the neurophysiological and orthopaedic ap-
proaches (SMD -0.16, 95% CI -0.77 to 0.45) or mixed approach
(SMD 0.37, 95% CI -0.68, 1.41) for the Berg Balance Scale, in-
dicating that there are no significant differences between neuro-
physiological and other approaches for balance.
Comparison 01.04: Muscle strength
No data were available.
Comparison 01.05: Gait velocity
Gait velocity was recorded by Gelber 1995, Lincoln 2003 and
Richards 1993. The comparison of neurophysiological and or-
thopaedic approaches (Gelber 1995) favoured neurophysiological
treatment (SMD 1.85, 95% CI 0.40 to 3.29); however, the in-
ability of some patients to walk resulted in Gelber 1995 missing
data for 9 (out of 15) patients in the neurophysiological group
and for 6 (out of 12) patients in the orthopaedic group. Entering
zero values for these participants results in no significant effect of
the neurophysiological intervention (SMD 0.61, 95% CI -0.18 to
1.38). No trials compared the neurophysiological approach with
no treatment/placebo for gait velocity. There were no significant
differences between the neurophysiological approach and the mo-
tor learning approach (SMD 0.12, 95% CI -0.28 to 0.51) or a
mixed approach (SMD -0.44, 95% CI -1.55 to 0.67).
Comparison 01.06: Length of stay
Length of stay was reported by Gelber 1995 and Langhammer
2000. The comparison of neurophysiological and motor learning
approaches (Langhammer 2000) favoured motor learning (SMD
0.93, 95% CI 0.36 to 1.50). No trials compared the neurophysio-
logical approach with a mixed approach or no treatment for length
of stay. There were no significant differences between the neuro-
physiological and orthopaedic approaches (SMD 0.20, 95% CI -
0.56 to 0.96).
Comparison 02: Motor learning (Carr and Shepherd)
versus other approaches
Comparisons of motor learning approaches with other approaches
were reported in seven studies. Time of follow up was two weeks for
Dean 1997, four weeks for Lincoln 2003, six weeks for McClellan
2004, two months for Dean 2000 and Salbach 2004, and three
months for Langhammer 2000.
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Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Comparison 02.01: Global Dependency Scale
Langhammer 2000, Lincoln 2003 and Mudie 2002 reported re-
sults of using the Barthel Index. No trials compared the mo-
tor learning approach with the orthopaedic approach or mixed
approach for global dependency. There were no significant dif-
ferences between the motor learning and neurophysiological ap-
proaches (SMD 0.12, 95% CI -0.33 to 0.56) or no treatment/
placebo (SMD -0.24, 95% CI -1.26 to 0.78), indicating that there
are no significant differences between motor learning and other
approaches for global dependency.
Comparison 02.02: Functional Independence Scale
Langhammer 2000, Lincoln 2003 and McClellan 2004 reported
results of the Motor Assessment Scale. No trials compared the
motor learning approach with the orthopaedic approach or mixed
approach for functional independence. There were no significant
differences between the motor learning and neurophysiological
approaches (SMD -0.08, 95% CI -0.75 to 0.60) or no treatment/
placebo (SMD -0.34, 95% CI -1.21 to 0.53), indicating that there
are no significant differences between motor learning and other
approaches for functional independence.
Comparison 02.03: Balance (Berg Balance Scale)
Salbach 2004 reported results from the Berg Balance Scale. The
SMD indicated that there were no significant differences between
motor learning and placebo treatments (SMD 0.25, 95% CI -0.17
to 0.66).
Comparison 02.04: Muscle strength
No data were available.
Comparison 02.05: Gait velocity
Gait velocity was recorded by Dean 1997, Dean 2000, Salbach
2004 and Lincoln 2003. No trials compared the motor learning
approach with the orthopaedic approach or mixed approach for
gait velocity. There were no significant differences between the
motor learning and neurophysiological approaches (SMD -0.11,
95% CI -0.51 to 0.28) or no treatment/placebo (SMD 0.31, 95%
CI -0.06 to 0.67), although there is evidence of a (non-significant)
trend in favour of the motor learning approach compared with a
no treatment control.
Comparison 02.06: Length of stay
No data were available.
8
Comparison 03: Mixed versus other approaches
Eight studies reported comparisons using a mixed approach. Times
of follow up were six weeks for Pollock 1998 and Richards 1993,
12 weeks for Duncan 1998, Duncan 2003, Green 2002 and Wade
1992, and at the time of discharge from rehabilitation for Stern
1970 and Ozdemir 2001. There is considerable heterogeneity in
these data. Stern 1970 and Ozdemir 2001are both quasi-ran-
domised trials and sensitivity analyses were therefore planned to
explore the effect of including these studies. As Stern 1970 is the
only trial comparing a mixed approach with an orthopaedic ap-
proach, it is not combined with any other trials, and sensitivity
analysis is therefore not necessary.
Comparison 03.01: Global Dependency Scale
Six of nine studies included measures of global dependency. The
Kenny Institute of Rehabilitation Scale was used by Stern 1970,
and the Barthel Index by Pollock 1998, Richards 1993, Duncan
1998, Green 2002 and Wade 1992. No trials compared a mixed
approach with the motor learning approach for global dependency.
There were no significant differences between a mixed approach
and a neurophysiological approach (SMD 0.13, 95% CI -0.61
to 0.87), an orthopaedic approach (SMD 0.08, 95% CI -0.42
to 0.58) or no treatment/placebo (SMD -0.05, 95% CI -0.28 to
0.19), indicating that there are no significant differences between
mixed and other approaches.
Comparison 03.02: Functional Independence Scale
The Fugl-Meyer motor assessment lower limb score was used by
Richards 1993, Duncan 1998, and Duncan 2003; the Rivermead
Mobility Index by Green 2002 and Wade 1992, and the Functional
Independence Measure by Ozdemir 2001. A mixed approach was
significantly more favourable than a no treatment control (SMD
0.94, 95% CI 0.08 to 1.80) (data from Duncan 1998, Duncan
2003, Green 2002, Ozdemir 2001and Wade 1992). If Ozdemir
2001, which used quasi-randomisation, is removed from the anal-
ysis the result ceases to show a significant effect, although there is
a trend towards significance (SMD 0.28, 95% CI -0.03 to 0.58).
No trials compared the mixed approach with the motor learning
or orthopaedic approach for functional independence. There was
no significant difference between the mixed and neurophysiolog-
ical approaches (SMD 0.12, 95% CI -0.91 to 1.16).
Comparison 03.03 Balance (Berg Balance Scale)
Three trials in this group of comparisons (Duncan 1998; Duncan
2003; Richards 1993) reported the Berg Balance Scale. None com-
pared the mixed approach with the orthopaedic approach or mo-
tor learning approach for the Berg Balance Scale. There were no
significant differences between the mixed approach and the neuro-
physiological approach (SMD -0.37, 95% CI -0.41 to 0.68) or no
Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
treatment/placebo (SMD 0.28, 95% CI -0.10 to 0.65), although
there is evidence of a (non-significant) trend in favour of the mixed
approach compared with a no treatment control.
Comparison 03.04: Muscle strength
Muscle strength was recorded by Stern 1970 and Duncan 2003.
No trials compared the mixed approach with the neurophysiologi-
cal approach or motor learning approach for muscle strength. The
comparison of mixed and orthopaedic approaches (Stern 1970)
favoured orthopaedic treatment (SMD -0.53, 95% CI -1.04 to
-0.03). The comparison of mixed with no treatment showed a
(non-significant) trend in favour of a mixed approach (SMD 0.33,
95% CI -0.08 to 0.74).
Comparison 03.05: Gait velocity
Gait velocity was recorded by Duncan 1998, Duncan 2003, Green
2002 and Wade 1992, and demonstrated that a mixed approach
was no more favourable than a no treatment control (SMD 0.20,
95% CI -0.07 to 0.46).
Comparison 03.06: Length of stay
No data were available.
DISCUSSION
This review was carried out with the specific aim of investigating
the efficacy of different treatment approaches, based on a historical
perspective. This was in direct response to a consultation exercise
carried out in Scotland that aimed to identify the ’burning ques-
tions’ of Scottish stroke rehabilitation workers, and which identi-
fied ’different treatment approaches’ to be amongst the most im-
portant questions posed by physiotherapists (Legg 2000). Hence
this review was driven by an identified clinical question, rather
than originating from a scientific and logical standpoint. Although
the results of this review may lead to the conclusion that no one
physiotherapy treatment approach appears to be more advanta-
geous to the promotion of recovery of lower limb function or pos-
tural control, the difficulties encountered in the method of the re-
view must highlight the absence of a scientific rationale for basing
physiotherapy interventions on named ’approaches’.
A statistically significant result was found in the comparison of a
mixed approach with a no treatment or placebo control for the re-
covery of functional independence. Data from five trials (427 par-
ticipants) demonstrated that a mixed approach was significantly
more favourable than no treatment or a placebo control in the
recovery of functional independence (SMD 0.94, 95% CI 0.08
9
to 1.80). One of the five trials did have a number of method-
ological limitations (Ozdemir 2001). Ozdemir 2001, which re-
ported a much more significant result, did not use random alloca-
tion to groups and did not have a blinded outcome assessor: these
methodological limitations could have allowed the introduction
of bias into the data collected. With Ozdemir 2001 removed from
the analysis the result ceases to be significant, although there is a
trend towards significance (SMD 0.39, 95% CI 0.15 to 0.63).
The data analysed in this review provide evidence that a ’mixed’
physiotherapy intervention is significantly favourable to no treat-
ment or placebo intervention in the recovery of functional inde-
pendence following stroke. This significant effect arguably demon-
strates that any physiotherapy is better than none.
A further statistically significant result was found in the compar-
ison of a mixed approach with an orthopaedic approach for the
recovery of muscle strength. Data from only one trial (Stern 1970,
62 participants) demonstrated a significant effect in favour of the
orthopaedic approach (SMD -0.53, 95% CI -1.04 to -0.03). How-
ever, this was a quasi-randomised trial with a number of method-
ological limitations, and generalised conclusions should not be
drawn from this result (see Table 2).
There is no evidence of any other differences in the effectiveness
of varied physiotherapy ’approaches’ (neurophysiological, motor
learning or orthopaedic) in the recovery of disability or impairment
(postural control or lower limb) after a stroke.
The lack of difference for outcomes between various physiotherapy
treatment approaches must be considered in the light of limitations
and factors. Each of these points will be expanded on and discussed
in turn.
Identification of relevant trials
The identification of all relevant trials was confounded by a num-
ber of factors.
• Inconsistent and poorly defined terminology: electronic
searching was difficult because the names given to different
physiotherapy treatment approaches are poorly documented,
often have several derivations, and have varied over time.
• Lack of detail within abstracts: lack of information on study
methods, participants and interventions potentially increases the
chance of excluding a relevant trial. However, the method of
including all possible trials should have prevented this.
• Material published in journals not included in electronic
databases, and unpublished material: while substantial effort was
made to identify unpublished material and material in journals
not cited on the databases searched, relevant trials may not have
been identified.
In the 2005 update of this review a large number (26) of non-
English (23 Chinese) trials were identified. These studies are cur-
rently awaiting translation and formal assessment. With so many
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Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
studies still to be assessed, and the potential that they may be
relevant to the currently included comparison groups, there is a
possibility that inclusion of these trials will alter the conclusions
made in this review. However, the application of the inclusion and
exclusion criteria to these trials will be complicated. The authors
did not want to introduce error and hence decided to gain further
knowledge prior to the assessment of these trials. The criteria for
selection and classification of trials included in this review were
written based on western concepts of physiotherapy and knowl-
edge of western physiotherapy approaches. The information cur-
rently available from the majority of the Chinese trials awaiting
assessment suggests that it is unlikely that the interventions stud-
ied in these trials will fit into the western categorisations and clas-
sifications of physiotherapy treatment approaches developed for
this review. Prior to the next update of this review, the authors
intend to seek advice and write additional inclusion and exclusion
criteria to deal with the non-western approaches to physiotherapy
for stroke. Anyone with experience and knowledge of Chinese or
other eastern approaches to physiotherapy for stroke is urged to
contact the review authors to assist with the definition of new
criteria. (Wang 2005a has been included although this study was
carried out in Taiwan; Wang 2005a has based the studied phys-
iotherapy interventions on the western classification system pub-
lished in the first version of this review and has provided a sub-
stantial description of the interventions, and, on discussion, the
authors of this review felt confident that the interventions could
be appropriately categorised and included.)
Anyone who is aware of additional trials that are appropriate to
this review is now urged to send details to the Cochrane Stroke
Group, to ensure that they are included when this review is next
updated.
Quality of included trials
Many of the included trials had methodological limitations, which
may have led to the introduction of selection bias. Two key
methodological factors that reduced the quality of many of the
included trials were the methods of randomisation and blinding.
• Randomisation: three of the identified studies did not state
the method of randomisation (Duncan 1998; Gelber 1995;
Wellmon 1997); one divided patients into matched pairs and
then randomly allocated the pairs (Dean 2000); one used quasi-
random assignment based on order of entry into the study
(Ozdemir 2001); and the method of randomisation of a fifth
(Stern 1970) was identified to be potentially unreliable.
Questions about the quality of randomisation must challenge the
robustness of study design, and hence the results of this review. It
is the intention of the review authors to exclude studies using
’quasi’ methods of randomisation from any future updates of this
review.
• Blinding and contamination: in the majority of studies it
was unclear whether or not the patients were blinded to the
10
study group and aims. The nature of rehabilitation interventions
and the ethical requirement to obtain informed consent often
makes it difficult, if not impossible, to blind patients. If the aims
and objectives of the study were apparent to the participants this
could confound the study results. The treating therapist was not
blinded in any of the trials. This was to be expected because
treating therapists have to be familiar with the intervention they
are administering. Therapists who strongly favoured one
approach over another could introduce performance bias. In
several of the studies the same therapist administered treatment
to patients in both study groups; this potentially introduces
considerable contamination between groups. Pollock 1998
reported some reluctance of patients to participate in the
treatment intervention; confounding variables such as these may
be attributed to the ’beliefs’ of patients and therapists, and are
examples of the effects of lack of blinding of patients and
therapists. Only 13 of the 21 included trials stated that they used
a blinded assessor. The lack of blinding of assessors potentially
introduces considerable bias into the study results. This is
particularly important in studies in which therapists often have
strong beliefs in support of a particular approach.
Heterogeneity of included trials
In addition to limitations of the study methods, the trials included
in the review had considerable heterogeneity. Three key areas of
heterogeneity were: interventions, outcome measures and patient
samples.
• Interventions: the analysis compared neurophysiological,
motor learning and mixed approaches with other approaches,
with subcategories classifying the other approaches into
neurophysiological, motor learning, orthopaedic, mixed and
control/placebo. From a clinical viewpoint, combining
subclassifications of a treatment approach, for example
combining treatments based on the theories of Brunnström and
Bobath under the umbrella of neurophysiological approaches,
may be dubious. Where there is more than one trial in a
subcategory, these combinations could be argued to be
inappropriate, owing to differences in the approaches of these
trials. From a clinical standpoint it could be argued that it is
inappropriate to combine these subcategories (e.g. combining
trials of motor learning, orthopaedic and mixed approaches to
compare these with trials of neurophysiological approaches).
However, ’Do neurophysiological approaches promote better
recovery than all or any other approaches?’ is arguably a valid
scientific and clinical question.
• Outcome measures: the included studies reported
heterogeneous measures of disability and impairment (see
’Description of studies’). Although many of the outcomes
recorded were tested for validity and reliability, this was not the
case for all outcomes; those for which the validity and reliability
had not been tested must be interpreted with caution. The
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legitimacy of combining, often very different, outcome measures
in order to carry out the comparisons must be challenged.
• Patient samples: the patient populations in the different
included studies were heterogeneous. They varied from limited
populations (for example pure motor strokes only) to those
inclusive of all stroke patients. The validity of combining results
from such heterogeneous samples is debatable.
Interventions included in the review
The nature of the systematic review question and the included
trials introduced a number of limitations to this review. These will
be discussed under the headings: documentation of interventions;
and classification of treatment approaches.
Documentation of interventions
Clear, concise documentation of complex physical interventions is
exceptionally difficult to achieve. The written information regard-
ing the interventions administered in the included trials is sum-
marised in Table 5. All of the included studies either gave a brief
description of the techniques used or referenced a text in which
the techniques are described in more detail. Where possible, we
contacted authors and asked them to supply any further material
that was available (e.g. the more detailed information used by the
treating therapists). However, although there has been an attempt
to describe all the administered interventions, the available doc-
umentation is often insufficient to allow confident and accurate
repetition of the applied treatment approach.
Problems with the documentation of interventions are generally
not the fault of the researchers: they are due to the fundamental
problem of recording methods of physical handling skills and tech-
niques, and the nature of the often intimate relationship between
patient and physiotherapist. Documentation of this process would
generally be complex and ’wordy’, and therefore often not possible
to present within research papers with limitations on length. These
problems are confounded by the fact that the treatments applied
are ultimately the decision of a single physiotherapist, based on an
individual assessment of a unique patient’s movement disorders.
Furthermore, the common basis of the different physiotherapy
approaches are that they are holistic. All body parts and move-
ments can be assessed and treated based on the selected approach;
however, a physiotherapist may select to concentrate on the treat-
ment of one particular body part or movement during a treatment
session. Subsequently the treatments given to specific patients by
individual therapists may vary enormously. This review attempted
to limit this variation slightly by excluding trials that had given
interventions only to the upper limb. Nevertheless, although pa-
tients receiving treatment based on a particular approach should
receive an intervention that conforms with the stated philosophy
or theory of the approach, it is conceivable that there were few
11
similarities between the physical interventions given to patients in
the same treatment group.
Despite the obvious difficulties in the documentation and consis-
tency of interventions, there does appear to be a recent improve-
ment in the quality of reporting the specific nature of the interven-
tions used in studies. The documentation and description of in-
terventions, and the use of standardised treatment protocols, does
seem to have improved substantially in the last few years. For ex-
ample, Ozdemir 2001, Green 2002, Mudie 2002, Duncan 2003,
McClellan 2004, Salbach 2004 and Wang 2005a have arguably
all provided substantial documentation relating to the nature of
the interventions. The categories of approaches published in this
review have also influenced study design, with Wang 2005a inves-
tigating an orthopaedic approach referenced to this review. The
availability of the categories and details of interventions used in
other studies, as reported in this review, will hopefully continue to
promote improved standardisation and documentation of physio-
therapy interventions.
The argument that a physiotherapy approach is based on an in-
dividual assessment of a unique patient’s movement disorders has
been used by some therapists and researchers to perpetuate limited
documentation and standardisation. However, recent studies have
demonstrated that clear concise documentation of a treatment in-
tervention does not necessarily mean the removal of the therapist’s
ability to select a treatment based on an individual patient’s prob-
lems. For example, Wang 2005a, within a detailed description of
the intervention, highlights that the treatments are ’individualised,
constantly modified according to subject response’.
Two of the studies are over 28 years old, and some of the oth-
ers over 10 years old. The clinical relevance of these older stud-
ies must be challenged because there is anecdotal evidence that
demonstrates that the practices within the named approaches have
changed considerably over time.
Classification of treatment approaches
The review authors had anticipated difficulties with gaining con-
sensus in the classification of the treatment approaches (as either
neurophysiological, motor learning or orthopaedic) investigated
in the individual trials. However, few problems were encountered.
Although clear, concise documentation of the interventions is dif-
ficult, the majority of trials: (1) named an approach (principally
the trials that investigated named neurophysiological approaches
such as Bobath); (2) provided supporting references that were un-
ambiguous in the approach they described (such as Bobath 1970;
Bobath 1990; Carr 1987b); or (3) provided a description of tech-
niques that were clearly from a particular approach (descriptions
were most commonly used to classify the trials investigating or-
thopaedic approaches).
The classification of the treatment approaches used in this review
can potentially be criticised for combining a number of different
physiotherapy approaches under very broad classifications (that
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is neurophysiological, motor learning, orthopaedic). Sub-group
analysis of the individual named approaches within each classifi-
cation was planned. However, as all of the neurophysiological ap-
proaches were described as Bobath, and all of the motor learning
approaches are referenced to Carr and Shepherd, this review can-
not, by default, be criticised for combining a variety of approaches
under one classification heading, as this has not occurred. Future
updates of this review will incorporate subgroup analyses of the
separate groups of Bobath, and Carr and Shepherd interventions
within the neurophysiological and motor learning comparisons if
appropriate.
The Bobath concept
This review includes eight trials that stated they were evaluating
a Bobath approach to stroke therapy. It is important to note that
there is much debate surrounding the content of physiotherapy
interventions based on the Bobath concept. This debate largely
arises from the fact that the content of the Bobath approach has
changed over time, there are limited updated published descrip-
tions, and there is variation in the content of current therapy (Carr
1994a; DeJong 2004; Nilsson 1992; Pomeroy 2001b; Sackley
1996; Turner 1995). It is beyond the scope of this review to deter-
mine whether the interventions described as Bobath had any prac-
tical or theoretical differences, although the philosophy or theory
and techniques of the approaches used in each trial are described
in Table 5.
Mixed approaches
Most difficulty was experienced in distinguishing between a mixed
approach (not a mixture of two different approaches, such as Stern
1970 mixing orthopaedic and neurophysiological approaches, but
an unclassified mix) and a motor learning approach. The mixed,
intensive and focused approach investigated by Richards 1993
and the problem-solving approach investigated by Green 2002
and Wade 1992, had stated philosophies very similar to those of
motor learning approaches. However, the described techniques
and the supporting references led the reviewers to classify these
interventions as mixed. This highlights a key problem with the
classification of the motor learning approach. Although a motor
relearning programme has been described by Carr and Shepherd
(Carr 1982; Carr 1987b), these authors primarily advocate an
approach based on related research in relevant areas such as medical
science, neuroscience, exercise physiology and biomechanics. Such
an approach is arguably one of research-based practice, rather than
being based on one specific philosophy.
A limitation of combining all mixed approaches is that this cat-
egory potentially amalgamates any number of possible combina-
tions of other approaches and techniques. The approaches and
techniques used in each trial are described in Table 5. This review
now provides limited evidence that physiotherapy using a mix of
12
components from different approaches is more beneficial than no
treatment or placebo control. It is therefore important that the
individual components of treatments used within the mixed ap-
proaches are investigated in future trials and systematic reviews.
However, the available evidence from combining all the mixed ap-
proaches does provide some support for the argument that physio-
therapists should select treatments regardless from which approach
they derive.
Non-western physiotherapy approaches
The classification of treatment approaches used in this review are
based entirely on western philosophies and cultures of treatment.
However, during the updating of this review, it became apparent
that this western classification of approaches was possibly inade-
quate. Several of the Chinese studies that are currently awaiting
assessment appear to have investigated the effectiveness of an ap-
proach often referred to as early physiotherapy. Based on limited
information from English abstracts, this generally seems to refer
to a number of treatment techniques, administered using a stan-
dardised protocol, applied during the acute inpatient phase (often
the first three months) following stroke. Again, based on limited
information, this approach seems to be compared with no physio-
therapy treatment. Determining the nature of the physiotherapy
approaches used in other countries such as China and deducing
whether they can be fitted into our current western categories, or
whether these constitute another different approach, is going to
be fundamental to the integrity of this review.
Individual treatment components
The difficulties described above in relation to the classification
of treatment approaches highlight the debate about whether or
not it is appropriate or clinically relevant to classify approaches
using a historical or philosophical perspective. Pomeroy 2005 ar-
gues that ’it is not sufficient to refer to named approaches’, and
that the diversities in approaches over time between therapists and
within different geographical settings has led to the concentration
of research on the development and evaluation of novel thera-
pies. These novel therapies (such as constraint-induced therapy,
treadmill retraining, robotic training) and a number of specific
treatment components (such as biofeedback, imagery, electrical
stimulation) have the advantage that they can be clearly defined,
and therefore more easily documented and researched. We sug-
gest that, if physiotherapists are to practice evidence-based stroke
rehabilitation their own culture, attitudes and beliefs will have to
shift away from the use of compartmentalised approaches to judg-
ing the scientific and research base for each treatment technique.
Future randomised controlled trials and systematic reviews should
concentrate on investigating clearly defined and described tech-
niques and task-specific treatments, regardless of their historical
or philosophical origin.
Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
This review leads us to the conclusion that no one physiother-
apy approach has been shown to be more advantageous to the
promotion of recovery of lower limb function or postural con-
trol. The available evidence is therefore insufficient to provide a
definitive answer to the ’burning’ question of which treatment
approach physiotherapists should use. However, this review does
provide evidence that physiotherapy using a mix of components
from different approaches is more beneficial than no treatment or
placebo control for the recovery of functional independence af-
ter stroke. This evidence provides a sound scientific rationale for
physiotherapists to use a selection of treatments, regardless of their
philosophical or theoretical origin.
AUTHORS’ CONCLUSIONS
Implications for practice
There is limited evidence that physiotherapy intervention using a
mix of components from different approaches is significantly more
effective than no treatment or placebo in the recovery of functional
independence following stroke. There is insufficient evidence to
conclude that any one physiotherapy approach is more effective
in promoting recovery of lower limb function or postural control
after stroke than any other approach.
Implications for research
There is now limited evidence that physiotherapy using a mix
of components from different approaches is more beneficial than
no treatment or placebo; researchers should add to this body of
evidence, determining which components contribute toward the
beneficial effect. There is a need for high quality randomised tri-
als and systematic reviews to determine the efficacy of clearly de-
scribed individual techniques and task-specific treatments, regard-
less of their historical or philosophical origin.
ACKNOWLEDGEMENTS
• Chest Heart and Stroke Scotland, for funding the STEP
project, which made the first version of this review possible.
• The Big Lottery Fund for current funding of the STEP
project.
• Brenda Thomas, Cochrane Stroke Group Trials Search Co-
ordinator, for her help in writing the search strategy, running the
searches and obtaining some of the trials.
• Lynsey Smyth, STEP, for help with obtaining trials and
tracking down references and authors.
13
 • The trialists who responded to emails and provided various
additional details about their studies: Cath Dean, John Green,
Stefan Hesse, Susan Hillier, Tracey Howe, Ayse Karaduman,
Nadina Lincoln, Nancy Mayo, Carol Richards, Nancy Salbach,
Judith Salter, Joni Stoker-Yates, Paulette van Vliet, Bob
Wellmon, Guo-rong Wei and Sharon Wood-Dauphinee.
• Dr You Hong who translated sections of Chinese trials.
• Janet Carr and Roberta Shepherd, who sent us detailed
comments on the published protocol.
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CD001920. DOI: 10.1002/14651858.CD001920]
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∗
Indicates the major publication for the study
19
CHARACTERISTICS OF STUDIES

Characteristics of included studies [ordered by study ID]

Dean 1997

Methods RCT
Blocked randomisation (’subjects drew a card from a box that was originally filled with 10 control and 10
experimental cards’)

Participants n = 20
Diagnosed with stroke more than 1 year previously
Discharged from rehabilitation
Able to understand instructions
Able to give informed consent
No orthopaedic problems that could interfere with ability to perform seated reaching tasks
Able to sit unsupported for 20 minutes

Interventions (1) Motor learning (n = 10)

(2) Placebo (n = 10)

Outcomes Measures of postural control and balance: ground reaction force during reaching; EMG during reaching;
maximum distance reached; ground reaction force during rising to stand
Measures of voluntary movement: timed 10 m walk
Other measures: time to complete cognitive task

Notes

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Dean 2000

Methods RCT
After baseline measurement participants were grouped into matched pairs according to their average gait
speed
Participants in each pair were randomly assigned to experimental or control group, using an independent
person to draw cards from boxes

Participants n = 12
First stroke
More than 3 months post stroke
Discharged from rehabilitation
Able to attend rehabilitation centre 3 times a week for4 weeks
Able to walk 10 m independently

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 20
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Dean 2000 (Continued)

Interventions (1) Motor learning (n = 6)

(2) Placebo (n = 6)

Outcomes Measures of voluntary movement: timed 10 m walk; 6-minute walk test; step test; timed up-and-go test;
laboratory gait assessment
Other measures: strength and dexterity of the upper limb

Notes

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Duncan 1998

Methods RCT
Method of randomisation not stated

Participants n = 20 (22 recruited; 20 randomised)

30 to 90 days post stroke
Fugl-Meyer score of 40 to 90
Orpington prognostic score 2 to 52
Ambulatory with supervision or assistive device, or both
Living at home (less than 50 miles from Kansas)
No medical condition that would limit participation
Mini Mental State score greater than 18
Able to follow 3-step command

Interventions (1) Mixed (n = 10)

(2) Control (n = 10)

Outcomes Measures of global dependency: Barthel Index; Lawton Instrumental ADL

Measures of functional independence: Fugl-Meyer motor score
Measures of postural control and balance: Berg Balance Scale
Measures of voluntary movement: timed 10 m walk; 6-minute walk test
Other measures: Orpington Prognostic Scale; Medical Outcomes Study 36 Health Status Measure; Jebsen
test of hand function

Notes

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 21
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Duncan 2003

Methods RCT
Blocked randomisation (block size 6), random number generator and sealed envelopes

Participants n = 100
Stroke within 30 to 150 days
Able to walk 25 m independently
Mild to moderate stroke deficits
MMSE greater than 16

Interventions (1) Mixed (n = 50)

(2) Control (n = 50)

Outcomes Measures of functional Independence: Fugl-Meyer (LL)

Measures of postural control and balance: Berg Balance Score
Measures of voluntary movement: gait velocity
Measures of muscle strength: ankle and knee strength

Notes

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Gelber 1995

Methods RCT
Method of randomisation not stated

Participants n = 27
Pure motor hemiparetic ischaemic stroke
Less than 1 month post stroke
No cognitive, language, visual, sensory or bilateral deficits
No history of stroke
No premorbid use of walking stick

Interventions (1) Neurophysiological (NDT) (n = 15)

(2) Orthopaedic (traditional functional retraining) (n = 12)

Outcomes Measures of functional independence: FIM

Measures of voluntary movement: parameters of gait
Other measures: length of stay and inpatient hospital costs; Box and Block test; 9-hole peg test

Notes

Risk of bias

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 22
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Gelber 1995 (Continued)

Item Authors’ judgement Description

Allocation concealment? Unclear B - Unclear

Green 2002

Methods RCT
Blocked randomisation (numbered, sealed, opaque envelopes prepared from random number tables.
Assignment by independent person)

Participants n = 170
Aged over 50 years
Stroke more than 1 year previously
Persisting mobility problems
Excluded if non-stroke mobility problem; dementia; severe co-morbidity; bed bound; physiotherapy in
previous 6 months

Interventions (1) Mixed: community physiotherapy using a problem-solving approach (n = 85)

(2) Control: no intervention (n = 85)

Outcomes Measures of global dependency: Barthel Index

Measures of functional independence: Rivermead Mobility Index, Frenchay Activities Index
Measures of voluntary movement: gait speed
Other measures: Hospital Anxiety and Depression scale; Depression, General Health Questionnaire 28;
number of patients who had falls

Notes

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Hesse 1998

Methods Single-subject design, with random order of allocation to 3 interventions

Participants n = 22
’Chronic’ stroke
Spastic gait pattern
No sensory impairment, obvious neglect syndrome, other neurological or orthopaedic deficits, or severe
disturbances of cognition or communication

Interventions (1) Bobath

(2) Control (no intervention)

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 23
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Hesse 1998 (Continued)

Outcomes Measures of voluntary movement: gait velocity

Notes Study used 3 interventions:

(1) walking;
(2) walking + stick;
(3) walking + Bobath facilitation
Only (1) and (3) are relevant to this review. Data have been sought for the first phase of this repeated
measure design, but have not yet been supplied by the study author

Risk of bias

Item Authors’ judgement Description

Allocation concealment? No C - Inadequate

Howe 2005

Methods RCT
’Group allocation was via randomized permutated blocks’, by telephone

Participants n = 35
Aged over 18 years
Acute vascular stroke
Previously independently mobile indoors and in personal ADL
Excluded if other neurological pathology, drugs or conditions affecting balance, impaired consciousness,
dementia, unable to tolerate therapy, ’pusher’ syndrome, severe perceptual problems

Interventions (1) Mixed (neurophysiological + motor learning)

(2) Neurophysiological

Outcomes Measures of postural control and balance: lateral reach test, weight distribution in standing, sit-to-stand

Notes No outcomes included in analysis; all outcomes were specific to goal of lateral weight transference

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 24
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Langhammer 2000

Methods RCT
Double-blind randomisation (stratified according to sex and side of lesion) and sealed coding

Participants n = 61
First stroke
Verified clinically and by CT scan
No subarachnoid bleeding
No tumours
No severe medical conditions
Not more than 4 points on each MAS section

Interventions (1) Neurophysiological (Bobath) (n = 28)

(2) Motor learning (n = 33)

Outcomes Measures of global dependency: Barthel Index

Measures of functional independence: MAS; Sodring Motor Evaluation
Measures of subjective outcome: Nottingham Health Profile
Other measures: length of stay, use of assistive devices, discharge destination

Notes

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Lincoln 2003

Methods RCT
Computer-generated random sequence of numbers in opaque sealed envelopes open sequentially by
researcher
Blocked randomisation

Participants n = 120
Stroke less than 2 weeks previously
Excluded if unconscious on admission; unable to toilet self prior to stroke; unable to tolerate more than
30 minutes of physical tasks; living more than 25 km from hospital or if no informed consent given

Interventions (1) Neurophysiological (Bobath) (n = 60)

(2) Motor learning (n = 60)

Outcomes Measures of global dependency: Barthel Index; EADL

Measures of functional independence: Motor Assessment Scale; Rivermead Motor Assessment
Measures of voluntary movement: 10 m walk test
Measures of tone/spasticity: Modified Ashworth Scale
Other measures: 9-hole peg test; Nottingham Sensory Assessment; length of stay

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 25
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Lincoln 2003 (Continued)

Notes

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

McClellan 2004

Methods RCT
Numbered, sealed, opaque envelopes

Participants n = 26
Stroke less than 18 months previously
Aged over 45 years
Living in community
Score more than 0 and less than 6 on item 5 of MAS, and less than 6 on item 7 and 8 of MAS

Interventions (1) Motor learning (n = 15)

(2) Placebo control (motor learning, upper limb) (n = 11)

Outcomes Measures of functional independence: MAS (item 5).

Measures of balance and postural control: Functional Reach Test

Notes

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Mudie 2002

Methods RCT
Random number tables; random numbers assigned alternately to group; random number drawn by
independent person and patient assigned to appropriate group

Participants n = 40
Recent stroke
Asymmetrical in sitting
Capacity for re-learning
Excluded if pain; existing co-morbidities; previous balance training

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 26
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Mudie 2002 (Continued)

Interventions (1) Feedback only (n = 10)

(2) Motor learning (task related training) (n = 10)
(3) Neurophysiological (Bobath) (n = 10)
(4) Control (no treatment) (n=10)

Outcomes Measures of global dependency: Barthel Index

Measures of postural control and balance: symmetry in sitting, weight distribution in sitting

Notes Intervention for group (1) based on components from motor learning theory, but as this intervention is
feedback only (and trials of feedback only have been excluded from this review) the data from this group
will not be used

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Ozdemir 2001

Methods Quasi-random controlled trial

Alternate allocation according to order of entry to study

Participants n = 60
Inpatients with stroke diagnosed between 1996 and 1999
Excluded if aged over 80 years; unconscious; medically unstable; complications inhibiting rehabilitation
(e.g. pressure sores, contractions); history of TIAs

Interventions (1) Mixed (orthopaedic + neurophysiological) (n = 30)

(2) Control (n = 30)

Outcomes Measures of functional independence: FIM

Measures of voluntary movement: Brunnström Motor Evaluation Scale
Measures of tone/spasticity: Ashworth Scale.
Other measures: MMSE

Notes The intensity of the interventions varied , with the mixed group receiving treatment from a therapist 5
days per week, and the control group receiving treatment from their family 7 days per week
The approach taught to the family could be classified as an orthopaedic approach

Risk of bias

Item Authors’ judgement Description

Allocation concealment? No C - Inadequate

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 27
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Pollock 1998

Methods RCT
Blocked randomisation, with 2 control (neurophysiology): 1 intervention (mixed); sealed opaque en-
velopes numbered and opened sequentially

Participants n = 28
Diagnosis of stroke less than 6 weeks previously
Attending regular physiotherapy sessions
Able to achieve 1 minute of independent sitting balance
Unable to achieve 10 independent steps
No known disabilities, pathology, or neurological deficit that affected mobility, prior to the current hospital
admission
Able to understand the nature of the study and give informed consent

Interventions (1) Neurophysiological (Bobath) (n = 19)

(2) Mixed (neurophysiological + motor learning) (n = 9)

Outcomes Measures of global dependency: Barthel Index

Measures of postural control and balance: symmetry during sitting, standing, rising to stand, sitting down;
weight transference during reaching

Notes Patients who were discharged from hospital prior to the end of the study period (6 weeks) were not
followed up, resulting in considerable numbers of drop-outs from the study

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Richards 1993

Methods RCT
Sealed envelopes, opened remotely by telephone request
Blocked randomisation, stratified according to prognostic category, with randomly varying block size

Participants n = 27
Middle cerebral artery infarct, confirmed by CT scan
Living less than 50 km from Quebec
Between 40 and 80 years old
0 to 7 days since onset of stroke
No other neurological problems
No major medical problems that would interfere with rehabilitation
Not independent in ambulation
Not unconscious at onset

Interventions (1) Early - mixed (n = 10)

(2) Early - neurophysiological (Bobath) (n = 8)
(3) Conventional - neurophysiological (Bobath) (n = 9).

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 28
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Richards 1993 (Continued)

Outcomes Measures of global dependency: Barthel Index

Measures of functional independence: Fugl-Meyer Motor Assessment
Measures of postural control and balance: Berg Balance Scale
Measures of voluntary movement: temporal gait parameters
Other measures: Canadian Stroke Scale

Notes Analysis based on comparison of neurophysiological (early) with mixed (early), as these 2 groups are
comparable in terms of timing and intensity
The results of the conventional - neurophysiological group are not included

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Salbach 2004

Methods RCT
Stratified blocked randomisation, stratified according to 3 levels of walking deficit
Computer generated numbers in sealed opaque envelopes, managed by person not involved in study

Participants n= 91
Clinical diagnosis of stroke
Less than 1 year post stroke
Residual walking deficit, but able to walk 10 m (with or without aid or supervision)
Discharged from physical rehabilitation
Living in community

Interventions (1) Motor learning (mobility) (n = 44)

(2) Placebo control (motor learning, upper limb) (n = 47)

Outcomes Measures of postural control and balance: Berg Balance Scale

Measures of voluntary movement: gait speed

Notes

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 29
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Stern 1970

Methods Quasi-randomised trial

50 patients were originally recruited and randomised
An additional 12 patients were then selectively assigned to the treatment groups ’to even out differences
in important characteristics’
The selection and assignment of these additional 12 patients provides a potential source of selection bias

Participants n = 62
First stroke
No other conditions affecting functional or motor ability
No acute illness during rehabilitation
Length of stay more than 10 days

Interventions (1) Orthopaedic (n = 31)

(2) Mixed (orthopaedic + neurophysiological) (n = 31)

Outcomes Measures of functional independence: functional status (adapted from rating scale)

Notes

Risk of bias

Item Authors’ judgement Description

Allocation concealment? No C - Inadequate

Wade 1992

Methods RCT
Permuted blocks of 10, using random number tables

Participants n = 94
First stroke, more than 1 year previously
Mobility problems (fall within last 3 months, used a walking aid, limited mobility or slow gait speed)

Interventions (1) Mixed (problem solving, community physiotherapy)

(2) No treatment

Outcomes Measures of global dependency: Barthel Index, Frenchay Activities Index, Nottingham EADL scale
Measures of functional independence: Rivermead Mobility Assessment
Measures of voluntary movement: gait speed

Notes Crossover design: patients in control group received treatment after three-month assessment
This study was initially excluded from this review as the review authors assessed, based on the abstract,
that this study explored timing of intervention
Comments from peer reviewers for the updated version led to the inclusion of this trial

Risk of bias

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 30
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Wade 1992 (Continued)

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Wang 2005a

Methods RCT
Stratified into ’patients with spasticity’ (Brunnström stage 2 or 3) and ’patients with relative recovery’
(Brunnström stage 4 or 5)
Sealed envelopes, independent person

Participants n = 44
Hemiparesis secondary to CVA
LE Brunnström motor recovery 2 to 5
Able to communicate and co-operate

Interventions (1) Neurophysiological (Bobath)

(2) Orthopaedic

Outcomes Measures of functional independence: MAS, Stroke Assessment Impairment Set

Measures of postural control and balance: Berg Balance Scale
Measures of spasticity/tone: Stroke Assessment Impairment Set (SAIS, tone)

Notes Data from ’patients with spasticity’ entered under Wang 2005a, and data from ’patients with relative
recovery’ entered under Wang 2005b

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Wang 2005b

Methods See Wang 2005a

Participants See Wang 2005a

Interventions See Wang 2005a

Outcomes See Wang 2005a

Notes See Wang 2005a

Risk of bias

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 31
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Wang 2005b (Continued)

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Wellmon 1997

Methods RCT
Method of randomisation not stated

Participants n = 21
Disorder of unilateral movement in lower limb
CVA less than 150 days previously
Able to stand unsupported for more than 30 seconds
Able to walk more than 7 m
Able to understand visual/verbal commands
Medically stable enough for 20 minutes of treatment
More than 0 degrees passive ankle dorsiflexion
No hip, knee, ankle, foot pain

Interventions (1) Motor learning

(2) Control (no treatment)

Outcomes Measures of postural control and balance: standing symmetry; step length symmetry; single stance sym-
metry

Notes No outcomes included in analysis

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

ADL: activities of daily living

CT: computed tomography
CVA: cerebrovascular accident
EADL: extended activities of daily living
EMG: electromyograph
FIM: Functional Independence Measure
LE: lower extremity
LL: lower limb
m: metre
MAS: Motor Assessment Scale
MMSE: Mini Mental State Examination
n: number of participants
NDT: neurodevelopmental treatment

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 32
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
RCT: randomised controlled trial
TIA: transient ischaemic attack

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Dean 2000a Repeated case study (n = 3); confirmed by correspondence with the author

Dickstein 1986 Cohort-design, not RCT: quasi-randomisation of patients (based on administrative procedures) to 1 of 13 physio-
therapists; however, each physiotherapist provided treatment interventions in a predetermined (not randomised)
order (first 5 patients received treatment A, next 5 patients treatment B, next 5 patients treatment C); this study
was therefore assessed to be a cohort design rather than a randomised trial

Eng 2003 Repeated measures design; not RCT

English 2003 Alternating allocation, not RCT: ’Patients admitted into a stroke unit during particular time periods were allocated
to either arm of the trial, e.g. weeks 1 to 6 to treatment group, weeks 7 to 12 to usual care and so on’

Inaba 1973 Compared 3 orthopaedic approaches; excluded from this version of the review; quasi-randomisation

Kim 2001 Specific strength training intervention (i.e. component, not approach)

Pomeroy 2001a This study was never carried out (confirmed by correspondence with author)

Richards 2004 Compares 2 different intensities of a mixed approach

Salter 1991 Collected data retrospectively from patient charts; had not used preplanned data collection

Thielman 2004 Treatment intervention and outcomes concentrated on upper limb

Wagenaar 1990 Compared 2 neurophysiological approaches; excluded from this version of the review; quasi-randomisation

Wood 1994 Study never carried out (confirmed by communication with author)

n: number of participants
RCT: randomised controlled trial

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 33
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Characteristics of ongoing studies [ordered by study ID]

Khanna 2003

Trial name or title A randomised control study of the immediate and long-term benefits of conventional stroke rehabilitation
with task-related group therapy in chronic stroke patients

Methods

Participants Stroke patients

Interventions Task-related training versus conventional stroke rehabilitation

Outcomes

Starting date April 2002

Contact information www.controlled-trials.com

Notes

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 34
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DATA AND ANALYSES

Comparison 1. Neurophysiological versus other approaches

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Global Dependency Scale 5 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
1.1 Neurophysiological versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
orthopaedic
1.2 Neurophysiological versus 3 171 Std. Mean Difference (IV, Random, 95% CI) -0.12 [-0.56, 0.32]
motor learning
1.3 Neurophysiological versus 2 31 Std. Mean Difference (IV, Random, 95% CI) -0.13 [-0.87, 0.61]
mixed
1.4 Neurophysiological versus 1 15 Std. Mean Difference (IV, Random, 95% CI) -0.71 [-1.79, 0.36]
no treatment/placebo
2 Functional Independence Scale 6 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
2.1 Neurophysiological versus 3 69 Std. Mean Difference (IV, Random, 95% CI) 0.02 [-0.55, 0.59]
orthopaedic
2.2 Neurophysiological versus 2 152 Std. Mean Difference (IV, Random, 95% CI) 0.08 [-0.60, 0.75]
motor learning
2.3 Neurophysiological versus 1 15 Std. Mean Difference (IV, Random, 95% CI) -0.12 [-1.16, 0.91]
mixed
2.4 Neurophysiological versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
no treatment/placebo
3 Balance (Berg Balance Scale) 3 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
3.1 Neurophysiological versus 2 42 Std. Mean Difference (IV, Random, 95% CI) -0.16 [-0.77, 0.45]
orthopaedic
3.2 Neurophysiological versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
motor learning
3.3 Neurophysiological versus 1 15 Std. Mean Difference (IV, Random, 95% CI) 0.37 [-0.68, 1.41]
mixed
3.4 Neurophysiological versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
no treatment/placebo
5 Gait velocity 3 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
5.1 Neurophysiological versus 1 12 Std. Mean Difference (IV, Random, 95% CI) 1.85 [0.40, 3.29]
orthopaedic
5.2 Neurophysiological versus 1 99 Std. Mean Difference (IV, Random, 95% CI) 0.12 [-0.28, 0.51]
motor learning
5.3 Neurophysiological versus 1 14 Std. Mean Difference (IV, Random, 95% CI) -0.44 [-1.55, 0.67]
mixed
5.4 Neurophysiological versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
no treatment/placebo
6 Length of stay 2 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
6.1 Neurophysiological versus 1 27 Std. Mean Difference (IV, Random, 95% CI) 0.20 [-0.56, 0.96]
orthopaedic
6.2 Neurophysiological versus 1 53 Std. Mean Difference (IV, Random, 95% CI) 0.93 [0.36, 1.50]
motor learning
Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 35
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 6.3 Neurophysiological versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
mixed
6.4 Neurophysiological versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
no treatment/control

Comparison 2. Motor learning versus other approaches

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Global Dependency Scale 3 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
1.1 Motor learning versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
orthopaedic
1.2 Motor learning versus 3 171 Std. Mean Difference (IV, Random, 95% CI) 0.12 [-0.32, 0.56]
neurophysiological
1.3 Motor learning versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
mixed
1.4 Motor learning versus no 1 16 Std. Mean Difference (IV, Random, 95% CI) -0.24 [-1.26, 0.78]
treatment/placebo
2 Functional Independence Scale 3 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
2.1 Motor learning versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
orthopaedic
2.2 Motor learning versus 2 152 Std. Mean Difference (IV, Random, 95% CI) -0.08 [-0.75, 0.60]
neurophysiological
2.3 Motor learning versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
mixed
2.4 Motor learning versus no 1 21 Std. Mean Difference (IV, Random, 95% CI) -0.34 [-1.21, 0.53]
treatment/placebo
3 Balance (Berg Balance Scale) 1 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
3.1 Motor learning versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
orthopaedic
3.2 Motor learning versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
neurophysiological
3.3 Motor learning versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
mixed
3.4 Motor learning versus no 1 91 Std. Mean Difference (IV, Random, 95% CI) 0.25 [-0.17, 0.66]
treatment/placebo
5 Gait Velocity 4 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
5.1 Motor learning versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
orthopaedic
5.2 Motor learning versus 1 99 Std. Mean Difference (IV, Random, 95% CI) -0.11 [-0.51, 0.28]
neurophysiological
5.3 Motor learning versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
mixed
5.4 Motor learning versus no 3 117 Std. Mean Difference (IV, Random, 95% CI) 0.31 [-0.06, 0.67]
treatment/placebo

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 36
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Comparison 3. Mixed versus other approaches

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Global Dependency Scale 6 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
1.1 Mixed versus 2 31 Std. Mean Difference (IV, Random, 95% CI) 0.13 [-0.61, 0.87]
neurophysiological
1.2 Mixed versus motor 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
learning
1.3 Mixed versus orthopaedic 1 62 Std. Mean Difference (IV, Random, 95% CI) 0.08 [-0.42, 0.58]
1.4 Mixed versus no 3 270 Std. Mean Difference (IV, Random, 95% CI) -0.05 [-0.28, 0.19]
treatment/placebo
2 Functional Independence Scale 6 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
2.1 Mixed versus 1 15 Std. Mean Difference (IV, Random, 95% CI) 0.12 [-0.91, 1.16]
neurophysiological
2.2 Mixed versus motor 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
learning
2.3 Mixed versus orthopaedic 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
2.4 Mixed versus no 5 422 Std. Mean Difference (IV, Random, 95% CI) 0.94 [0.08, 1.80]
treatment/placebo
3 Balance (Berg Balance Scale) 3 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
3.1 Mixed versus 1 15 Std. Mean Difference (IV, Random, 95% CI) -0.37 [-1.41, 0.68]
neurophysiological
3.2 Mixed versus motor 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
learning
3.3 Mixed versus orthopaedic 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
3.4 Mixed versus no 2 112 Std. Mean Difference (IV, Random, 95% CI) 0.28 [-0.10, 0.65]
treatment/placebo
4 Muscle strength 2 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
4.1 Mixed versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
neurophysiological
4.2 Mixed versus motor 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
learning
4.3 Mixed versus orthopaedic 1 62 Std. Mean Difference (IV, Random, 95% CI) -0.53 [-1.04, -0.03]
4.4 Mixed versus no 1 92 Std. Mean Difference (IV, Random, 95% CI) 0.33 [-0.08, 0.74]
treatment/placebo
5 Gait velocity 4 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
5.1 Mixed versus 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
neurophysiological
5.2 Mixed versus motor 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
learning
5.3 Mixed versus orthopaedic 0 0 Std. Mean Difference (IV, Random, 95% CI) Not estimable
5.4 Mixed versus no 4 350 Std. Mean Difference (IV, Random, 95% CI) 0.20 [-0.07, 0.46]
treatment/placebo

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Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 1.1. Comparison 1 Neurophysiological versus other approaches, Outcome 1 Global Dependency
Scale.
Review: Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

Comparison: 1 Neurophysiological versus other approaches

Outcome: 1 Global Dependency Scale

Std. Std.
Mean Mean
Study or subgroup Neurophysiological Other Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Neurophysiological versus orthopaedic

Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
2 Neurophysiological versus motor learning
Langhammer 2000 24 72 (34) 29 83 (25) 30.7 % -0.37 [ -0.91, 0.18 ]

Lincoln 2003 52 15 (4.3) 47 14 (5.7) 58.4 % 0.20 [ -0.20, 0.59 ]

Mudie 2002 9 68.9 (21.5) 10 79.5 (22.11) 10.9 % -0.46 [ -1.38, 0.45 ]

Subtotal (95% CI) 85 86 100.0 % -0.12 [ -0.56, 0.32 ]

Heterogeneity: Tau2 = 0.07; Chi2 = 3.60, df = 2 (P = 0.16); I2 =45%
Test for overall effect: Z = 0.53 (P = 0.60)
3 Neurophysiological versus mixed
Pollock 1998 11 9.64 (3.96) 5 10 (1.22) 48.9 % -0.10 [ -1.16, 0.96 ]

Richards 1993 6 23.3 (16.6) 9 25.8 (14.8) 51.1 % -0.15 [ -1.19, 0.88 ]

Subtotal (95% CI) 17 14 100.0 % -0.13 [ -0.87, 0.61 ]

Heterogeneity: Tau2 = 0.0; Chi2 = 0.00, df = 1 (P = 0.95); I2 =0.0%
Test for overall effect: Z = 0.33 (P = 0.74)
4 Neurophysiological versus no treatment/placebo
Mudie 2002 9 68.9 (21.5) 6 85 (20.73) 100.0 % -0.71 [ -1.79, 0.36 ]

Subtotal (95% CI) 9 6 100.0 % -0.71 [ -1.79, 0.36 ]

Heterogeneity: not applicable
Test for overall effect: Z = 1.30 (P = 0.19)

-4 -2 0 2 4
Favours other Favours neurophys

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 38
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 Analysis 1.2. Comparison 1 Neurophysiological versus other approaches, Outcome 2 Functional
Independence Scale.

Review: Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

Comparison: 1 Neurophysiological versus other approaches

Outcome: 2 Functional Independence Scale

Std. Std.
Mean Mean
Study or subgroup Neurophysiological Other Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Neurophysiological versus orthopaedic

Gelber 1995 15 101.2 (14.2) 12 105.3 (15.9) 38.0 % -0.27 [ -1.03, 0.50 ]

Wang 2005a 10 18.82 (5.84) 11 15.33 (4.59) 30.4 % 0.64 [ -0.24, 1.52 ]

Wang 2005b 10 24 (4.87) 11 25.54 (7.05) 31.6 % -0.24 [ -1.10, 0.62 ]

Subtotal (95% CI) 35 34 100.0 % 0.02 [ -0.55, 0.59 ]

Heterogeneity: Tau2 = 0.07; Chi2 = 2.80, df = 2 (P = 0.25); I2 =29%
Test for overall effect: Z = 0.07 (P = 0.95)
2 Neurophysiological versus motor learning
Langhammer 2000 24 33 (15) 29 37 (12) 42.0 % -0.29 [ -0.84, 0.25 ]

Lincoln 2003 52 7 (5) 47 5 (5) 58.0 % 0.40 [ 0.00, 0.80 ]

Subtotal (95% CI) 76 76 100.0 % 0.08 [ -0.60, 0.75 ]

Heterogeneity: Tau2 = 0.18; Chi2 = 4.02, df = 1 (P = 0.04); I2 =75%
Test for overall effect: Z = 0.23 (P = 0.82)
3 Neurophysiological versus mixed
Richards 1993 6 22.7 (9.2) 9 23.7 (6.7) 100.0 % -0.12 [ -1.16, 0.91 ]

Subtotal (95% CI) 6 9 100.0 % -0.12 [ -1.16, 0.91 ]

Heterogeneity: not applicable
Test for overall effect: Z = 0.23 (P = 0.82)
4 Neurophysiological versus no treatment/placebo
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable

-4 -2 0 2 4
Favours other Favours neurophys

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 39
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 1.3. Comparison 1 Neurophysiological versus other approaches, Outcome 3 Balance (Berg Balance
Scale).

Review: Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

Comparison: 1 Neurophysiological versus other approaches

Outcome: 3 Balance (Berg Balance Scale)

Std. Std.
Mean Mean
Study or subgroup Neurophysiological Other Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Neurophysiological versus orthopaedic

Wang 2005a 10 20.55 (12.2) 11 20.42 (4.64) 50.4 % 0.01 [ -0.84, 0.87 ]

Wang 2005b 10 35.18 (16.15) 11 40.31 (12.89) 49.6 % -0.34 [ -1.20, 0.52 ]

Subtotal (95% CI) 20 22 100.0 % -0.16 [ -0.77, 0.45 ]

Heterogeneity: Tau2 = 0.0; Chi2 = 0.32, df = 1 (P = 0.57); I2 =0.0%
Test for overall effect: Z = 0.52 (P = 0.60)
2 Neurophysiological versus motor learning
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
3 Neurophysiological versus mixed
Richards 1993 6 40 (16.1) 9 33.2 (18.2) 100.0 % 0.37 [ -0.68, 1.41 ]

Subtotal (95% CI) 6 9 100.0 % 0.37 [ -0.68, 1.41 ]

Heterogeneity: not applicable
Test for overall effect: Z = 0.69 (P = 0.49)
4 Neurophysiological versus no treatment/placebo
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable

-4 -2 0 2 4
Favours other Favours neurophys

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 40
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 1.5. Comparison 1 Neurophysiological versus other approaches, Outcome 5 Gait velocity.

Review: Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

Comparison: 1 Neurophysiological versus other approaches

Outcome: 5 Gait velocity

Std. Std.
Mean Mean
Study or subgroup Neurophysiological Other Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Neurophysiological versus orthopaedic

Gelber 1995 6 0.52 (0.2) 6 0.21 (0.09) 100.0 % 1.85 [ 0.40, 3.29 ]

Subtotal (95% CI) 6 6 100.0 % 1.85 [ 0.40, 3.29 ]

Heterogeneity: not applicable
Test for overall effect: Z = 2.50 (P = 0.012)
2 Neurophysiological versus motor learning
Lincoln 2003 52 0.69 (0.45) 47 0.64 (0.39) 100.0 % 0.12 [ -0.28, 0.51 ]

Subtotal (95% CI) 52 47 100.0 % 0.12 [ -0.28, 0.51 ]

Heterogeneity: not applicable
Test for overall effect: Z = 0.58 (P = 0.56)
3 Neurophysiological versus mixed
Richards 1993 5 0.23 (0.09) 9 0.31 (0.2) 100.0 % -0.44 [ -1.55, 0.67 ]

Subtotal (95% CI) 5 9 100.0 % -0.44 [ -1.55, 0.67 ]

Heterogeneity: not applicable
Test for overall effect: Z = 0.77 (P = 0.44)
4 Neurophysiological versus no treatment/placebo
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable

-4 -2 0 2 4
Favours other Favours neurophys

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Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 1.6. Comparison 1 Neurophysiological versus other approaches, Outcome 6 Length of stay.

Review: Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

Comparison: 1 Neurophysiological versus other approaches

Outcome: 6 Length of stay

Std. Std.
Mean Mean
Study or subgroup Neurophysiological Other Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Neurophysiological versus orthopaedic

Gelber 1995 15 27.3 (8.2) 12 25.2 (12.6) 100.0 % 0.20 [ -0.56, 0.96 ]

Subtotal (95% CI) 15 12 100.0 % 0.20 [ -0.56, 0.96 ]

Heterogeneity: not applicable
Test for overall effect: Z = 0.51 (P = 0.61)
2 Neurophysiological versus motor learning
Langhammer 2000 24 34 (17) 29 21 (10.5) 100.0 % 0.93 [ 0.36, 1.50 ]

Subtotal (95% CI) 24 29 100.0 % 0.93 [ 0.36, 1.50 ]

Heterogeneity: not applicable
Test for overall effect: Z = 3.18 (P = 0.0015)
3 Neurophysiological versus mixed
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
4 Neurophysiological versus no treatment/control
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable

-4 -2 0 2 4
Favours neurophys Favours other

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 42
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 2.1. Comparison 2 Motor learning versus other approaches, Outcome 1 Global Dependency Scale.

Review: Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

Comparison: 2 Motor learning versus other approaches

Outcome: 1 Global Dependency Scale

Std. Std.
Mean Mean
Study or subgroup Motor Learning Other Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Motor learning versus orthopaedic

Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
2 Motor learning versus neurophysiological
Langhammer 2000 29 83 (25) 24 72 (34) 33.9 % 0.37 [ -0.18, 0.91 ]

Lincoln 2003 47 14 (5.7) 52 15 (4.3) 51.2 % -0.20 [ -0.59, 0.20 ]

Mudie 2002 10 79.5 (22.11) 9 68.9 (21.5) 14.8 % 0.46 [ -0.45, 1.38 ]

Subtotal (95% CI) 86 85 100.0 % 0.12 [ -0.32, 0.56 ]

Heterogeneity: Tau2 = 0.07; Chi2 = 3.60, df = 2 (P = 0.16); I2 =45%
Test for overall effect: Z = 0.53 (P = 0.60)
3 Motor learning versus mixed
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
4 Motor learning versus no treatment/placebo
Mudie 2002 10 79.5 (22.11) 6 85 (20.73) 100.0 % -0.24 [ -1.26, 0.78 ]

Subtotal (95% CI) 10 6 100.0 % -0.24 [ -1.26, 0.78 ]

Heterogeneity: not applicable
Test for overall effect: Z = 0.46 (P = 0.64)

-4 -2 0 2 4
Favours other Favours motor learn

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 43
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 2.2. Comparison 2 Motor learning versus other approaches, Outcome 2 Functional Independence
Scale.
Review: Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

Comparison: 2 Motor learning versus other approaches

Outcome: 2 Functional Independence Scale

Std. Std.
Mean Mean
Study or subgroup Motor learning Other Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Motor learning versus orthopaedic

Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
2 Motor learning versus neurophysiological
Langhammer 2000 29 37 (12) 24 33 (15) 44.1 % 0.29 [ -0.25, 0.84 ]

Lincoln 2003 47 5 (5) 52 7 (5) 55.9 % -0.40 [ -0.80, 0.00 ]

Subtotal (95% CI) 76 76 100.0 % -0.08 [ -0.75, 0.60 ]

Heterogeneity: Tau2 = 0.18; Chi2 = 4.02, df = 1 (P = 0.04); I2 =75%
Test for overall effect: Z = 0.23 (P = 0.82)
3 Motor learning versus mixed
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
4 Motor learning versus no treatment/placebo
McClellan 2004 12 4.3 (1.2) 9 4.7 (1) 100.0 % -0.34 [ -1.21, 0.53 ]

Subtotal (95% CI) 12 9 100.0 % -0.34 [ -1.21, 0.53 ]

Heterogeneity: not applicable
Test for overall effect: Z = 0.77 (P = 0.44)

-4 -2 0 2 4
Favours other Favours motor learn

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 44
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 2.3. Comparison 2 Motor learning versus other approaches, Outcome 3 Balance (Berg Balance
Scale).

Review: Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

Comparison: 2 Motor learning versus other approaches

Outcome: 3 Balance (Berg Balance Scale)

Std. Std.
Mean Mean
Study or subgroup Motor Learning Other Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Motor learning versus orthopaedic

Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
2 Motor learning versus neurophysiological
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
3 Motor learning versus mixed
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
4 Motor learning versus no treatment/placebo
Salbach 2004 44 44 (11) 47 41 (13) 100.0 % 0.25 [ -0.17, 0.66 ]

Subtotal (95% CI) 44 47 100.0 % 0.25 [ -0.17, 0.66 ]

Heterogeneity: not applicable
Test for overall effect: Z = 1.17 (P = 0.24)

-10 -5 0 5 10
Favours other Favours ML

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Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 2.5. Comparison 2 Motor learning versus other approaches, Outcome 5 Gait Velocity.

Review: Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

Comparison: 2 Motor learning versus other approaches

Outcome: 5 Gait Velocity

Std. Std.
Mean Mean
Study or subgroup Motor Learning Other Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Motor learning versus orthopaedic

Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
2 Motor learning versus neurophysiological
Lincoln 2003 47 0.64 (0.39) 52 0.69 (0.47) 100.0 % -0.11 [ -0.51, 0.28 ]

Subtotal (95% CI) 47 52 100.0 % -0.11 [ -0.51, 0.28 ]

Heterogeneity: not applicable
Test for overall effect: Z = 0.57 (P = 0.57)
3 Motor learning versus mixed
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
4 Motor learning versus no treatment/placebo
Dean 1997 10 3.38 (1.86) 8 2.94 (3.39) 15.4 % 0.16 [ -0.77, 1.09 ]

Dean 2000 4 84 (46.7) 4 81.5 (47.2) 6.9 % 0.05 [ -1.34, 1.43 ]

Salbach 2004 44 0.78 (0.4) 47 0.64 (0.37) 77.7 % 0.36 [ -0.05, 0.78 ]

Subtotal (95% CI) 58 59 100.0 % 0.31 [ -0.06, 0.67 ]

Heterogeneity: Tau2 = 0.0; Chi2 = 0.30, df = 2 (P = 0.86); I2 =0.0%
Test for overall effect: Z = 1.65 (P = 0.099)

-4 -2 0 2 4
Favours other Favours motor learn

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 46
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 3.1. Comparison 3 Mixed versus other approaches, Outcome 1 Global Dependency Scale.

Review: Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

Comparison: 3 Mixed versus other approaches

Outcome: 1 Global Dependency Scale

Std. Std.
Mean Mean
Study or subgroup Mixed Other Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Mixed versus neurophysiological

Pollock 1998 5 10 (1.22) 11 9.64 (3.96) 48.9 % 0.10 [ -0.96, 1.16 ]

Richards 1993 9 25.8 (14.8) 6 23.3 (16.6) 51.1 % 0.15 [ -0.88, 1.19 ]

Subtotal (95% CI) 14 17 100.0 % 0.13 [ -0.61, 0.87 ]

Heterogeneity: Tau2 = 0.0; Chi2 = 0.00, df = 1 (P = 0.95); I2 =0.0%
Test for overall effect: Z = 0.33 (P = 0.74)
2 Mixed versus motor learning
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
3 Mixed versus orthopaedic
Stern 1970 31 19.5 (6) 31 19 (6) 100.0 % 0.08 [ -0.42, 0.58 ]

Subtotal (95% CI) 31 31 100.0 % 0.08 [ -0.42, 0.58 ]

Heterogeneity: not applicable
Test for overall effect: Z = 0.32 (P = 0.75)
4 Mixed versus no treatment/placebo
Duncan 1998 10 96 (5.16) 10 95.56 (5.27) 7.4 % 0.08 [ -0.80, 0.96 ]

Green 2002 81 18 (2.1) 80 18 (2.1) 59.8 % 0.0 [ -0.31, 0.31 ]

Wade 1992 48 16.2 (3.1) 41 16.7 (3.2) 32.8 % -0.16 [ -0.58, 0.26 ]

Subtotal (95% CI) 139 131 100.0 % -0.05 [ -0.28, 0.19 ]

Heterogeneity: Tau2 = 0.0; Chi2 = 0.44, df = 2 (P = 0.80); I2 =0.0%
Test for overall effect: Z = 0.37 (P = 0.71)

-10 -5 0 5 10
Favours other Favours mixed

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Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 3.2. Comparison 3 Mixed versus other approaches, Outcome 2 Functional Independence Scale.

Review: Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

Comparison: 3 Mixed versus other approaches

Outcome: 2 Functional Independence Scale

Std. Std.
Mean Mean
Study or subgroup Mixed Other Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Mixed versus neurophysiological

Richards 1993 9 23.7 (6.7) 6 22.7 (9.2) 100.0 % 0.12 [ -0.91, 1.16 ]

Subtotal (95% CI) 9 6 100.0 % 0.12 [ -0.91, 1.16 ]

Heterogeneity: not applicable
Test for overall effect: Z = 0.23 (P = 0.82)
2 Mixed versus motor learning
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
3 Mixed versus orthopaedic
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
4 Mixed versus no treatment/placebo
Duncan 1998 10 26.1 (2.51) 10 22.6 (4.7) 17.5 % 0.89 [ -0.04, 1.82 ]

Duncan 2003 44 26.84 (3.7) 48 25.46 (3.5) 21.2 % 0.38 [ -0.03, 0.79 ]

Green 2002 81 11 (2.9) 80 10 (2.9) 21.7 % 0.34 [ 0.03, 0.65 ]

Ozdemir 2001 30 100.84 (14.19) 30 51.5 (13.38) 18.3 % 3.53 [ 2.70, 4.36 ]

Wade 1992 48 12.2 (4.3) 41 12.7 (4.2) 21.2 % -0.12 [ -0.53, 0.30 ]

Subtotal (95% CI) 213 209 100.0 % 0.94 [ 0.08, 1.80 ]

Heterogeneity: Tau2 = 0.87; Chi2 = 61.87, df = 4 (P<0.00001); I2 =94%
Test for overall effect: Z = 2.14 (P = 0.033)

-4 -2 0 2 4
Favours other Favours mixed

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 48
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 3.3. Comparison 3 Mixed versus other approaches, Outcome 3 Balance (Berg Balance Scale).

Review: Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

Comparison: 3 Mixed versus other approaches

Outcome: 3 Balance (Berg Balance Scale)

Std. Std.
Mean Mean
Study or subgroup Mixed Other Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Mixed versus neurophysiological

Richards 1993 9 33.2 (18.2) 6 40 (16.1) 100.0 % -0.37 [ -1.41, 0.68 ]

Subtotal (95% CI) 9 6 100.0 % -0.37 [ -1.41, 0.68 ]

Heterogeneity: not applicable
Test for overall effect: Z = 0.69 (P = 0.49)
2 Mixed versus motor learning
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
3 Mixed versus orthopaedic
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
4 Mixed versus no treatment/placebo
Duncan 1998 10 46.9 (3.63) 10 45.8 (5.39) 17.9 % 0.23 [ -0.65, 1.11 ]

Duncan 2003 44 47.16 (7.2) 48 44.8 (9) 82.1 % 0.29 [ -0.13, 0.70 ]

Subtotal (95% CI) 54 58 100.0 % 0.28 [ -0.10, 0.65 ]

Heterogeneity: Tau2 = 0.0; Chi2 = 0.01, df = 1 (P = 0.91); I2 =0.0%
Test for overall effect: Z = 1.45 (P = 0.15)

-4 -2 0 2 4
Favours other Favours mixed

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 49
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 3.4. Comparison 3 Mixed versus other approaches, Outcome 4 Muscle strength.

Review: Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

Comparison: 3 Mixed versus other approaches

Outcome: 4 Muscle strength

Std. Std.
Mean Mean
Study or subgroup Mixed Other Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Mixed versus neurophysiological

Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
2 Mixed versus motor learning
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
3 Mixed versus orthopaedic
Stern 1970 31 40.9 (15) 31 49 (15) 100.0 % -0.53 [ -1.04, -0.03 ]

Subtotal (95% CI) 31 31 100.0 % -0.53 [ -1.04, -0.03 ]

Heterogeneity: not applicable
Test for overall effect: Z = 2.06 (P = 0.039)
4 Mixed versus no treatment/placebo
Duncan 2003 44 67.11 (27.4) 48 58.92 (22) 100.0 % 0.33 [ -0.08, 0.74 ]

Subtotal (95% CI) 44 48 100.0 % 0.33 [ -0.08, 0.74 ]

Heterogeneity: not applicable
Test for overall effect: Z = 1.56 (P = 0.12)

-4 -2 0 2 4
Favours other Favours mixed

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 50
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 3.5. Comparison 3 Mixed versus other approaches, Outcome 5 Gait velocity.

Review: Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

Comparison: 3 Mixed versus other approaches

Outcome: 5 Gait velocity

Std. Std.
Mean Mean
Study or subgroup Mixed Other Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Mixed versus neurophysiological

Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
2 Mixed versus motor learning
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
3 Mixed versus orthopaedic
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
4 Mixed versus no treatment/placebo
Duncan 1998 10 0.58 (0.31) 10 0.57 (0.34) 8.1 % 0.03 [ -0.85, 0.91 ]

Duncan 2003 44 0.88 (0.3) 48 0.71 (0.3) 27.2 % 0.56 [ 0.14, 0.98 ]

Green 2002 78 25.5 (12.6) 77 24.9 (13.8) 38.7 % 0.05 [ -0.27, 0.36 ]

Wade 1992 44 0.24 (0.38) 39 0.21 (0.26) 26.0 % 0.09 [ -0.34, 0.52 ]

Subtotal (95% CI) 176 174 100.0 % 0.20 [ -0.07, 0.46 ]

Heterogeneity: Tau2 = 0.02; Chi2 = 4.20, df = 3 (P = 0.24); I2 =28%
Test for overall effect: Z = 1.47 (P = 0.14)

-4 -2 0 2 4
Favours other Favours mixed

ADDITIONAL TABLES
Table 1. Criteria for classification of neurophysiological and motor learning approaches

Name of approach Philosophy/theory Treatment principles Descriptive terms Supporting references

Rood Concerned with ’the in- Activate/facilitate move- Ontogenetic sequences Goff 1969; Rood 1954;
teraction of somatic, au- ment and postural re- Developmental Stockmeyer 1967
(neurophysiological) tonomic, and psychic sponses of patient in sequences
factors, and their role in same automatic way as Postural stability

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 51
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Table 1. Criteria for classification of neurophysiological and motor learning approaches
regulations of motor be-
haviour’.
Motor and sensory func-
tions inseparable
Focuses on the develop-
mental sequence of re-
covery and the use of pe-
ripheral input to facili-
tate movement
Propriocep- Active muscle contrac-
tive neuromuscular facil- tions intended to stimu-
itation (PNF) or Knott late afferent propriocep-
and Voss tive discharges into the
CNS increased excita-
(neurophysiological) tion and recruitment of
additional motor units
Assumes that central and
peripheral stimu-
lation are enhanced and
facilitated in order to
maximise the motor re-
sponses required
Cortex controls patterns
of movement not singu-
lar muscular actions
Neces-
sary to return to normal
developmental sequence
for recovery
Brunnström Uses primitive reflexes to
initiate movement and
(neurophysiological) encourages use of mass
patterns in early stages of
recovery
Aims to encourage re-
turn of voluntary move-
ment through use of re-
flex activity and sensory
stimulation
Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
they occur in the normal Normal patterns of
Sequenc- movement
ing of movement from Joint and cutaneous re-
basic to complex (supine ceptors
lying; rolling; prone ly- Golgi tendon organs
ing; kneeling; standing; Abnormal tone
walking)
Sensory stim-
ulation (brushing, ic-
ing, tapping, pounding,
stroking, slow stretch,
joint compression) to
stimulate movement at
automatic level
Diagonal and spiral pat- Patterns of movement Kabat 1953; Voss 1967
terns of active and pas- Stretch and postural re-
sive movement flexes
Quick stretch at end of Manual pressure
range to promote con- Isometric and isotonic
traction following relax- contraction
ation in antagonists Approximation of joint
Maximal resistance is surfaces
given by therapist to fa- Afferent input
cilitate maximal activity
in the range of the re-
quired movement.
Voluntary contraction of
the targeted muscle(s)
Manual contact and
therapist’s tone of voice
to encourage purposeful
movement
Isometric and iso-
tonic contractions, trac-
tion and approximation
of joint surfaces to stim-
ulate postural reflexes
Use tasks that patient can Normal development Brunnström 1956;
master or almost master. Sensory cues Brunnström 1961;
Sensory Synergies Brunnström 1970; Perry
stimulation: from tonic Primitive reflexes 1967; Sawner 1992
neck or labyrinthine re- Tonic neck reflexes
flexes, or from stroking, Associated reactions
tapping muscles Movement patterns
Mass patterns
Tactile, proprioceptive,
visual, auditory stimuli
52
Table 1. Criteria for classification of neurophysiological and motor learning approaches
Assumes recovery pro-
gresses from subcortical
to cortical control of
muscle function
Stages of recovery: flac-
cidity; elicit major syn-
ergies at reflex level; es-
tablish voluntary control
of synergies; break away
from flexor and exten-
sor synergies by mixing
components from antag-
onist synergies; more dif-
ficult movement combi-
nations mastered; indi-
vidual joint movements
become possible; volun-
tary movement is elicited
Bobath or Aim to control afferent
neurodevelopmental ap- input and facilitate nor-
proach (NDT) mal postural reactions
Aim to give patients
(neurophysiological) the experience of nor-
mal movement and affer-
ent input while inhibit-
ing abnormal movement
and afferent input
To improve quality of
movement on affected
side, so that the 2 sides
work together harmo-
niously
Assump-
tion that increased tone
and increased reflex ac-
tivity will emerge as a re-
sult of lack of inhibition
from a damaged pos-
tural reflex mechanism.
Movement will be ab-
normal if comes from a
background of abnormal
tone
Tone can be influenced
by altering position or
movement of proximal
joints of the body
Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
Facilitation of normal Normal movement Bobath 1959; Bobath
movement by a thera- Abnormal postural reflex 1966; Bobath 1970;
pist, using direct han- activity/tone Bobath 1978; Bobath
dling of the body at Postural control 1990; Davies 1985;
key points such as head Key points Davies 1990; Mayston
and spine, shoulders and Reflex inhibitory pat- 2000
pelvic girdle and, distally, terns
feet and hands
Volitional movement by
patient is requested only
against a background of
automatic postural activ-
ity
NB. Techniques of treat-
ment have changed over
time; more recently they
have become more active
and functionally orien-
tated
However, there is a lack
of published material
describing the current
treatment principles of
the Bobath approach
More recently (October
2000) it has been em-
phasised that the con-
cepts of the Bobath ap-
53
Table 1. Criteria for classification of neurophysiological and motor learning approaches
Johnstone To control spasticity by
inhibiting abnormal pat-
(neurophysiological) terns and using position-
ing to influence tone
Assumes that damaged
postural reflex mecha-
nism can be controlled
through positioning and
splinting
Based on hierarchical
model that assumes re-
covery is from proximal
to distal
Aim to achieve cen-
tral stability, with gross
motor performance, be-
fore progressing to more
skilled movements
Inflatable air splints: ap-
ply even, deep pressure
to address sensory dys-
function
Carr and Shepherd or Assumes that neurolog-
motor learning or motor ically impaired people
relearning or movement learn in the same way as
science healthy people.
Assumes that motor con-
(motor learning) trol of posture and move-
ment are interrelated and
that appropriate sensory
input will help modulate
the motor response to a
task
Patient is an active
learner
Uses biomechanical
analysis of movement
Training should be con-
text-specific
Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
proach ’integrate with
the main ideas of mo-
tor learning theory’, and
that advocated key treat-
ment principles include
active participation,
practice and meaningful
goals (Mayston 2000)
Use of inflatable splints Muscle tone Johnstone 1980;
Emphasis on correct po- Air/pressure splints Johnstone 1989
sition and use of splints Positioning
Early stages: patient in Reflex inhibition
side lying, with splint on Tonic neck reflex
affected arm Anti-gravity patterns
Treatment progresses
through hierarchy of ac-
tivities, progressing from
rolling through to crawl-
ing
Family involvement en-
couraged
(1) Analysis of task Motor control Carr 1980; Carr 1982;
(2) Practice of missing Motor relearning Carr 1987a; Carr 1987b;
components Feedback Carr 1990; Carr 1998
(3) Practice of task Practice
(4) Transference of train- Problem solving
ing Training
Biomechanical analysis
with movements com-
pared to the normal
Instruction, explanation
and feedback are essen-
tial parts of training
Training involves prac-
tice with guidance from
therapist: guidance may
be manual (but is used
54
Table 1. Criteria for classification of neurophysiological and motor learning approaches (Continued)

Essential for motor for support or demon-

learning: elimination of stration, not for provid-
unnecessary muscle ac- ing sensory input)
tivity; feedback; practice Identifiable and specific
Focus is on cognitive goals
learning Appropriate
environment

Conductive education or Aims to teach pa- Educational Education Bower 1993; Cotton
Peto tient strategies for deal- principles and repetition Rhythmical intention 1983; Kinsman 1988
ing with disabilities in used as a method of rote Intention
(motor learning) order to encourage them learning Integrated system
to learn to live with or Highly structured day Group work
overcome disabilities Group work Conductor
Integrated approach em- Task analysis Independence
phasising continuity and Repe-
consistency tition and reinforcement
Assumes that feelings of task through rhyth-
of failure can produce mical intention or verbal
a dysfunctional attitude, chanting
which can prevent reha- Activities
bilitation broken down into com-
Teaches strategies for ponents or steps
coping with disability Patient encouraged to
Active movements start guide movements bilat-
with an intention and erally
end with the goal
Conductor assists pa-
tient to achieve move-
ment control through
task analysis and rhyth-
mical intention or verbal
reinforcement
Emphasis on learn-
ing rather than receiving
treatments

Affolter Interaction between in- NB. This ap- Perception Affolter 1980
dividual and environ- proach started from the- Assimilation
(motor learning) ment fundamental part ory, rather than from Anticipation
of learning clinical practice Complex human perfor-
Perception seen as hav- Starting at an elementary mance
ing an essential role in level, there will be no an-
the cycle of learning ticipation
Incoming information is The patient starts to ini-
compared with past ex- tiate more steps
perience (’assimilation’), There is increased antic-
which leads to anticipa- ipation of the steps to be
tory behaviour taken
Assimilation and antici-

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 55
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 1. Criteria for classification of neurophysiological and motor learning approaches (Continued)

pation seen as basic for As experience increases,

planning and for perfor- the patient will start to
mance of complex move- search for missing ob-
ments jects
Feedback is important to The patient is able plan
learning process more than 1 stage ahead
and can perform new se-
quences if functional sig-
nals are familiar
Not only can the patient
think ahead but is able to
check all the steps of the
task in advance

Sensory integration or Functional Sensory feedback Sensory and perceptual Ayres 1972
Ayres limitations compounded Repetition impairment
by sensory and percep- Behavioural goals
(motor learning) tual impairment Feedback
Sensory feedback and Repetition
repetition seen as impor- Adaptive response
tant principles of motor
learning

Table 2. Methodological quality of included studies

Study Patient Therapist Assessor Drop outs/ CT/MRI for Contamina- Other
blinded? blinded? blinded? follow up diagnosis tion confounders

Dean 1997 Yes No Yes, for some 19/20 Not stated 1 ther- The outcome
assessments completed in- apist (princi- measures for
tervention and pal investiga- which
final tor) car- there was no
assessment ried out all the blinded asses-
Drop-outs ac- treatments sor
counted for The were recorded
use of only 1 by computer
therapist pro- However, the
vides a poten- assessor could
tial source have encour-
of contamina- aged some pa-
tion between tients more
groups, or the than others
introduc-
tion of perfor-
mance bias

Dean 2000 Yes No Yes, for all ex- 9/12 com- Not stated The The study in-
Patients were cept one pleted training same therapist cluded only

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 56
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Methodological quality of included studies (Continued)

blind to the assessment (6- and pre- and conducted the participants
aims minute walk post-training training ses- who were able
of the study/ test) assessments sions for both to travel to the
their group al- 8/ groups, rehabil-
location 12 completed and was re- itation centre,
The study au- follow up (2 sponsible for and prepared
thors subjec- month) assess- progression of to meet the
tively ment treatment etc; costs of this
report that all Drop-outs ac- this may po- The results of
patients were counted for tentially con- this study can
motivated and taminate the only therefore
felt that the groups be applied to
program was equally moti-
beneficial vated partici-
pants
Although the
par-
ticipants were
paired accord-
ing to average
gait speed, it is
not clear how
this matching
was per-
formed; if the
person doing
the matching
was not blind
to the other
characteris-
tics of the par-
ticipants there
is the poten-
tial for selec-
tion bias

Duncan 1998 No No Unclear No drop-outs No There was Patients in the

some possibil- control group
ity of contam- received ’usual
ination be- care’
tween groups, All control
but action was group patients
taken to avoid received phys-
this, with the iotherapy and
therapists see- 7/10 re-
ing ceived occupa-
only the inter- tional therapy
vention group The

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 57
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Methodological quality of included studies (Continued)

exercises given
to the control
group patients
appear to have
similarities to
the interven-
tion group
Some of the
control group
had more con-
tact with ther-
apists than the
intervention
group

Duncan 2003 No, but un- No Yes 92/100 com- Not stated Patients in the
aware of study pleted inter- intervention
hypothe- vention and 3- group received
ses or primary month follow more contact
outcome mea- up. Drop-outs with therapists
sures accounted for than patients
in the control
group, provid-
ing a potential
source of per-
formance bias
However,
54% of the
control group
did receive re-
habilitation
from physio-
therapists and
occupational
therapists dur-
ing the study
period
This ’usual
care’ may have
made the con-
trol
and treatment
groups similar
in the rehabili-
tation they re-
ceived, poten-

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 58
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Methodological quality of included studies (Continued)

tially reducing
the effect of
the interven-
tion

Gelber 1995 Unclear No No 27/27 Not stated The same The nurs-
completed in- therapists pro- ing staff rein-
tervention vided treat- forced
16/27 at fol- ment to pa- any practice of
low-up assess- tients in both tech-
ments (23/27 the treatment niques that pa-
for Functional groups, creat- tients were to
Independence ing a possibil- carry out out-
Measure, car- ity side of their
ried out by of contamina- treatment ses-
telephone) tion between sions: this dif-
Drop-outs ac- the groups fer-
counted for ence in nurs-
ing care may
potentially
introduce per-
formance bias

Green 2002 Unclear No Yes 161/170 com- Not stated

pleted
intervention
151/170 at 6-
month assess-
ment
Drop-outs ac-
counted for

Hesse 1998 No No Unclear Unclear Not stated It is unclear The inter-

what the con- vention inves-
trol group did tigated is very
during dependent on
their ’session’ - the skill of in-
this may just dividual thera-
have involved pists
walking with
no assistance,
or the patients
may have re-
ceived verbal
prompts

Howe 2005 No No Yes 33/35 Not stated There is a pos- Patients could
completed in- si- have passed on
tervention bility that the information

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 59
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Methodological quality of included studies (Continued)

31/ standard phys- about their ad-

35 had 8-week iother- ditional treat-
follow up apy and other ment to both
Drop-outs ac- usual care pro- the therapists
counted for cedures could providing
have changed standard care
as a direct and to other
or indirect re- patients in the
sult of the ad- study
ditional study
intervention

Langhammer Unclear No Yes 29/33 in mo- Yes The same It

2000 tor learn- therapists pro- is possible that
ing group, and vided treat- the treatment
24/28 in ment to pa- following hos-
Bobath group tients in both pital discharge
completed in- the treatment may not have
tervention groups, creat- been adminis-
Drop-outs ac- ing a possibil- tered accord-
counted for ity ing to the ran-
of contamina- domi-
tion between sation process,
the groups potentially in-
troducing per-
formance bias
to the post-
discharge re-
sults

Lincoln 2003 No No Yes 52/ Not stated Some possibil- Both

60 in Bobath ity of contam- groups had re-
group and 47/ ination be- ceived treat-
60 in motor tween groups ment based on
learning group as physiother- the Bobath ap-
remained at 1 apists provid- proach prior
month; 43/60 ing the motor to randomisa-
and 42/60 learning inter- tion
completed as- ven- The
sessments re- tion were pre- Bobath treat-
spectively at 3 viously using ment was pro-
months; and Bobath ther- vided by phys-
45/60 and 42/ apy and may io-
60 respectively therefore have therapists who
at 6 months reverted to us- had previously
Drop- ing some Bo- used it, while
outs were ac- bath the motor
counted for techniques learning treat-

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 60
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Methodological quality of included studies (Continued)

Also ment was pro-

some possibil- vided by phys-
ity of contam- iotherapists
ination due to previously in-
patients being experienced in
inpatients on motor learn-
the same unit: ing and were
the authors given training
state ’some as- prior to the in-
pects of terventions
the treatments
could not be
implemented
because both
treatments
were oc-
curring on the
same rehabil-
itation wards
and there was
a risk of treat-
ment contam-
ination’

McClellan Yes, blinded to No Yes 23/26 Not stated Compliance

2004 study aims completed in- with the home
tervention exer-
21/26 assessed cise regime is a
at 6 weeks potential con-
Drop-outs ac- founding vari-
counted for able
This was mea-
sured and, on
av-
erage, patients
recorded that
they
practiced 75%
of the times
they were in-
structed to do
so

Mudie 2002 Unclear No, although Yes 33/ 40 Not stated Ther- The ’standard’
blind to data completed in- apists provid- treatment pro-
tervention ing ’standard’ vided after the
Drop-outs ac- therapy, given end of the in-
counted for in addition tervention pe-
to study inter- riod was

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 61
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Table 2. Methodological quality of included studies (Continued)

vention, could not monitored

have contam- and could
inated groups have involved
with the treat- substantial
ment they Bobath
provided weight-distri-
It is stated that bution train-
’co-operation ing
of both occu- Unskilled
pational thera- research assis-
pists and phys- tants (occupa-
iotherapists tional therapy
was sought to students and
ensure that the assistants) col-
con- lected
trol group re- outcome data
ceived no spe- which
cific weight- may have re-
distribution sulted in er-
training dur- rors
ing the study It is un-
period to the clear whether
first follow up’ the Barthel In-
dex was col-
lected by
researchers or
obtained from
patient
records

Ozdemir No No No Not stated if Not stated It does not No assessment

there were any state if it was of the amount
drop-outs the same or of time spent
different ther- treating the
apists who saw patients
the patients in by the families
the 2 treat- was recorded;
ment groups or of the abil-
There could ity and un-
be contamina- derstanding of
tion between the families to
groups if they continue the
were treatment
treated by the There was an
same therapist unblinded
outcome
assessor

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Table 2. Methodological quality of included studies (Continued)

Pollock 1998 No No No 11/19 control No The con- Attendance

group and 5/ trol group re- at the practice
9 intervention ceived no ad- sessions was
group com- ditional treat- voluntary, and
pleted final as- ment, and the varied consid-
sessment treatment er-
Drop-outs ac- group received ably between
counted for the interven- patients
tion
away from the The ’culture of
ward and the the ward and
control group rehabilitation
patients; it is was identified
therefore un- to be based on
likely that Bobath princi-
there was any ples, and prac-
contamina- tice was found
tion between to
the groups conflict with
these; this may
have af-
fected the mo-
tivation of pa-
tients in the
practice group

Richards 1993 Unclear No Yes 23/27 Yes The same 2

completed in- therapists pro-
tervention vided treat-
Drop-outs not ment to both
accounted for the treatment
Patients with groups, creat-
miss- ing a possibil-
ing data were ity
dropped from of contamina-
analysis tion between
the groups

Salbach 2004 No No Yes 84/91 Not stated Unblinding of

completed in- the outcome
tervention evaluators oc-
Drop-outs ac- curred for 18
counted for of 42 mobility
and 16 of 43
upper extrem-
ity evaluations

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 63
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Table 2. Methodological quality of included studies (Continued)

Stern 1970 Unclear No Unclear No drop-outs No The authors The method

identify a pos- of ’balancing’
sible source of out the groups
contam- by includ-
ination result- ing 12 addi-
ing from the tional patients
use of physio- is a potential
therapists who confounder
strongly
favoured the
neurophysio-
logical
approach: ’On
occasion resis-
tance was en-
countered
on the part of
some physical
therapists who
were strongly
biased in favor
of these (neu-
rophysiologi-
cal) exercises’
This could
provide a
source of per-
formance bias

Wade 1992 No, not possi- No, not possi- Yes 89/94 Not stated Initially re-
ble ble completed in- cruitment was
tervention and from final fol-
had 3-month low up from
follow up Oxford Com-
Drop-outs ac- munity Stroke
counted for Project, but
All patients in- not
cluded in anal- enough partic-
y- ipants were re-
sis unless they cruited
died or had Addi-
not reached tional patients
last follow-up were recruited
point by contact-
For some out- ing a rehabil-
comes (e. itation centre,
g. gait speed) asking GPs, a
num-

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 64
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Methodological quality of included studies (Continued)

bers are less radio appeal,

because not all con-
could perform tacting com-
the test munity work-
ers, and self re-
ferral
The patients
recruited from
the
Oxford Com-
munity Stroke
Project were
less disabled
than those re-
cruited in
other ways
However. the
2 groups were
similar at ran-
domisation

Wang 2005 No No Yes No drop-outs Not stated The partic- Different

ipants were all thera-
inpatients and pists did apply
presum- the 2 interven-
ably able to see tions (4 ther-
the treatment apists in total)
given to pa- , so different
tients in the aspects related
other treat- to their per-
ment group, sonal delivery
which is a po- of the inter-
tential source vention could
of contamina- be a potential
tion confounder
However, it is
not clear
whether 2
therapists each
applied 1 in-
tervention or
whether all 4
therapists ap-
plied both in-
terventions

Wellmon No No No No drop-outs No The amount

1997 of
treatment was

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 65
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Table 2. Methodological quality of included studies (Continued)

very limited (4
sessions over 2
days); this
may have been
insufficient to
effect a change

Table 3. Summary of study setting

Study At recruitment For intervention Country

Dean 1997 Own homes (recruited via stroke Own homes Australia
clubs)

Dean 2000 Own homes (recruited from reha- Rehabilitation centre (outpatients) Canada
bilitation research group database)

Duncan 1998 Previously inpatients, now dis- Own homes USA

charged?

Duncan 2003 Patients’ own homes Patients’ own homes USA

Gelber 1995 Acute inpatient ward Inpatient and outpatient rehabilita- USA
tion centres

Green 2002 Recruited from hospital and com- Outpatient rehabilitation centre; England
munity stroke registers patients’ own homes

Hesse 1998 Not stated Outpatients/gait laboratory Germany

Howe 2005 Rehabilitation unit (inpatients) Rehabilitation unit (inpatients) England

Langhammer 2000 Acute inpatient ward Acute inpatient ward; rehabilita- Norway
tion units; outpatients; own homes

Lincoln 2003 Rehabilitation unit (inpatients) Rehabilitation unit (inpatients); England

outpatients

McClellan 2004 Recruited on discharge from phys- Outpatients/patients’ own homes Australia
iotherapy services

Mudie 2002 Rehabilitation unit (inpatients) Rehabilitation unit (inpatients) Australia

Ozdemir 2001 Recruited via rehabilitation unit? Mixed group treated in rehabil- Turkey
itation unit; orthopaedic group
treated in own homes

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 66
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Table 3. Summary of study setting (Continued)

Pollock 1998 Stroke unit Stroke unit Scotland

Richards 1993 Acute inpatient ward Acute inpatient ward Canada

Salbach 2004 Patients’ own homes (community) Outpatients/patients’ own homes Canada
(self-practice)

Stern 1970 Rehabilitation unit (inpatients) Rehabilitation unit (inpatients) USA

Wade 1992 Community (own homes and resi- Community (own homes and resi- England
dential homes) dential homes)

Wang 2005 Rehabilitation unit (inpatients) Rehabilitation unit (inpatients) Taiwan

Wellmon 1997 Rehabilitation unit (inpatients) Rehabilitation unit (inpatients) USA

Table 4. Details of study participants

Study Study No. of parti- Sex - male/ Side - Age Time since Type of No.
group cipants female LCVA/ onset stroke finished in-
RCVA tervention

Dean 1997 Motor 10 7/3 5/5 Mean = 68.2 Mean = 6.7 10

learning y y
SD = 8.2 y SD = 5.8 y

Placebo 10 7/3 6/4 Mean = 66.9 Mean = 5.9 9

y y
SD = 8.2 y SD = 2.9 y

Dean 2000 Motor 6 3/3 3/3 Mean = 66.2 Mean = 2.3 5

learning y y
SD = 7.7 y SD = 0.7 y

Placebo 6 4/2 4/2 Mean = 62.3 Mean = 1.3 4

y y
SD = 6.6 y SD = 0.9 y

Duncan Mixed 10 4/6 Mean = 67.3 Mean = 66 Ischaemic = 10

1998 y days 10
SD = 9.6 y

Control 10 4/5 + 1 Mean = 67.8 Mean = 56 Ischaemic = 10

brainstem y days 8
SD = 7.2 y Haemor-
rhagic = 2

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 67
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Table 4. Details of study participants (Continued)

Duncan Mixed 50 (44 com- 23/21 18/22; 4 bi- Mean = 68.5 Mean = 77.5 Ischaemic = 44
2003 pleted inter- lateral y days 39
vention) SD = 9 y SD = 28.7
days

Control 50 (48 com- 27/21 22/22; 4 bi- Mean = 70.2 Mean = 73.5 Ischaemic = 48
pleted inter- lateral y days 44
vention) SD = 11.4 y SD = 27.1
days

Gelber 1995 Neurophysi- 15 9/6 8/7 Mean = 73.7 Mean = 11.3 Pure motor 15
ological y days ischaemic =
(NDT) SEM = 2.0 y SEM = 1.1 15
days

Or- 12 4/8 5/7 Mean = 69.8 Mean = 13.8 Pure motor 12

thopaedic y days ischaemic =
(TFR) SEM = 2.9 y SEM = 2.7 12
days

Green 2002 Mixed 85 49/36 56/26 + 3 81

’other’

Control (no 85 46/39 44/40 + 1 80

treatment) ’other’

Hesse 1998 Neurophysi- Total 16

ological Data for
first phase of
study
sought, but
not yet re-
ceived

Control Total 16
Data for
first phase of
study
sought, but
not yet re-
ceived

Howe 2005 Mixed 17 (15 at 4- 9/8 8/9 Mean = 71.5 Mean = 26.5 2 TACS / 15
week follow y days 7 PACS / 4
up) SD = 10.9 y SD = 15.7 LACS / 1
days POCS / 3
other

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 68
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Table 4. Details of study participants (Continued)

Control 18 (18 at 4- 9/9 7/11 Mean = 70.7 Mean = 23.1 3 TACS / 18

(neurophys- week follow y days 6 PACS / 4
iological) up) SD = 17.5 y SD = 17.5 LACS / 3
days POCS / 2
other

Langham- Neurophysi- 28 16/12 17/11 Whole 24

mer 2000 ological group
(Bobath) Mean = 78 y
SD = 9 y
Range 49 to
95 y

Motor 33 20/13 17/16 See above 29

learning

Lincoln Neurophysi- 60 27/33 30/29; 1 bi- Mean = 73.3 9 TACS / At 1 month -

2003 ological lateral y 29 PACS / 52
(Bobath) SD = 10.4 y 14 LACS /
4 POCS / 4
unsure

Motor 60 33/27 31/27; 2 bi- Mean = 75.0 8 TACS / At 1 month -

Learning lateral y 32 PACS / 47
SD = 9.1 y 11 LACS /
6 POCS / 3
unsure

McClellan Motor 15 10/3 8/5 Mean = 69 y Median = 6. 13

2004 learning (at end of in- (at end of in- SD = 13 y 5 mo
tervention) tervention) IQR = 5.5
mo

Placebo (up- 11 2/8 3/6; 1 bilat- Mean = 72 y Median = 4. 10

per limb (at end of in- eral SD = 9 y 5 mo
control) tervention) (at end of in- IQR = 3.0
tervention) mo

Mudie 2002 Motor 10 21/19 for to- 22/18 for to- Mean = 72.4 Range 2 to MCA 10
learning tal of 40 re- tal of 40 re- y 6 weeks (for infarct = 22
cruited cruited SD = 9.01 y total of 40 Haemor-
Range 47 to recruits) rhage = 11
86 y Lacunar in-
(for total of farct = 4
40 recruits) Cerebellar
infarct = 3
(for total of
40 recruits)

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 69
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Table 4. Details of study participants (Continued)

Neurophysi- 10 21/19 for to- 22 / 18 for Mean = 72.4 Range = 2 to MCA 9

ological tal of 40 re- total of 40 y 6 weeks (for infarct = 22
cruited recruited SD = 9.01 y total of 40 Haemor-
Range = 47 recruits) rhage = 11
to 86 y Lacunar in-
(for total of farct = 4
40 recruits) Cerebellar
infarct = 3
(for total of
40 recruits)

Control (no 10 21/19 for to- 22/18 for to- Mean = 72.4 Range 2 to MCA 6
treatment) tal of 40 re- tal of 40 re- y 6 weeks (for infarct = 22
cruited cruited SD = 9.01 y total of 40 Haemor-
Range 47 to recruits) rhage = 11
86 y Lacunar in-
(for total of farct = 4
40 recruits) Cerebellar
infarct = 3
(for total of
40 recruits)

Ozdemir Mixed 30 21/9 13/17 Mean = 59.1 Mean = 41 Haemor- 30

2001 y days rhagic = 13
SD = 5.9 y Range 10 to Thrombotic
Range 49 to 82 days =8
79 y Lacunar = 4
Embolic = 5

Control 30 19/11 14/16 Mean = 61.8 Mean = 36 Haemor- 30

y days rhagic = 7
SD = 9.2 y Range 15 to Thrombotic
Range 43 to 75 days = 16
84 y Lacunar = 4
Embolic = 3

Pollock Neurophysi- 19 12/7 10/9 Mean = 68.4 6 TACS / 11

1998 ological y 3 PACS /
(Bobath) SD = 13.4 y 5 LACS /
2 POCS/ 3
PICH

Mixed 9 0 /9 7/2 Mean = 73.1 2 TACS / 5

(Neuro- y 3 PACS / 4
physiolog- SD = 10.3 y LACS / 0
ical + motor POCS / 0
learning) PICH

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Table 4. Details of study participants (Continued)

Richards Mixed 10 5/5 2/8 Mean = 69.6 Mean = 8.3 Cana- 9

1993 (early) y days dian Stroke
SD = 7.4 y SD = 1.4 Score (maxi-
days mum score =
15)
Mean = 5.3
SD = 1.4

Neurophysi- 8 2/6 6/2 Mean = 67.3 Mean = 8.8 Cana- 6

ological y days dian Stroke
(early) SD = 11.2 y SD = 1.5 Score (maxi-
days mum score =
15)
Mean = 5.2
SD = 1.7

Neurophysi- 9 6/3 3/6 Mean = 70.3 Mean = 13.0 Cana- 8

o- y days dian Stroke
logical (con- SD = 7.3 y SD = 2.8 Score (maxi-
ventional) days mum score =
15)
Mean = 6.0
SD = 1.8

Salbach Motor 44 26/18 27/17 Mean = 71 y Mean = 239 Mild gait 41

2004 learning SD = 12 y days deficit = 19
SD = 83 Moderate =
days 17
Severe = 8

Placebo (up- 47 30/17 24/22; 1 bi- Mean = 73 y Mean = 217 Mild gait 43
per limb lateral SD = 8 y days deficit = 17
control) SD = 73 Moderate =
days 20
Severe = 10

Stern 1970 Or- 31 19/12 14/17 Mean = 64.4 Median = 33 31

thopaedic y days
Range 46 to Range 8
84 y days to 5 y

Mixed (or- 31 19/12 14/17 Mean = 63.5 Median = 29 31

thopaedic + y days
neurophysi- Range 38 to Range
ological) 77 y 13 days to 2.
25 y

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 71
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Table 4. Details of study participants (Continued)

Wade 1992 Mixed 49 27/22 25/19 Mean = 72.3 Mean = 53. 48

5 brainstem y 1mo
SD = 9.7 y SD = 29.5
mo

Control (no 45 20/25 21/21 Mean = 72.0 Mean = 59.6 41

treatment) 3 brainstem y mo
SD = 10.6 y SD = 35.3
mo

Wang 2005 Neurophysi- 21 14/7 11/10 Patients Patients Haemor- 21

ological with spastic- with spastic- rhagic = 7
ity ity Ischaemic =
Mean = 53.9 Mean = 21.9 14
y days SD = 7.
SD = 11.8 y 4 days

Patients Patients
with relative with relative
recovery recovery
Mean = 62.4 Mean 21.6
y days
SD = 11.6 y SD = 9.3
days

Or- 23 14/9 9/14 Patients Patients Haemor- 23

thopaedic with spastic- with spastic- rhagic = 7
ity ity Ischaemic =
Mean = 59.3 Mean = 20.7 14
y days SD = 5.
SD = 12.2 y 9 days

Patients Patients
with relative with relative
recovery recovery
Mean = 63.8 Mean = 19.6
y days SD = 7.
SD = 13.1 y 9 days

Wellmon Motor 12 12
1997 learning

Control (no 9 9
treatment)

LCVA: left cerebrovascular accident

IQR: interquartile range
LACS: lacunar stroke
MCA: middle cerebral artery

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 72
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
mo: months
PACS: partial anterior circulation stroke
POCS: posterior circulation stroke
PICH: primary intracerebral haemorrhage
RCVA: right cerebrovascular accident
SD: standard deviation
SEM: standard error of the mean
TACS: total anterior circulation stroke
y: years

Table 5. Classification of treatment approaches

Study Treatment Subclassifica- Philosophy/ Techniques Supporting ref- Amount of

approach tion theory erences treatment

Dean 1997 Motor learning None Task-related Stan- Carr 1987b 10 sessions over
training dardised training 2 weeks, average
programme de- 30 minutes
signed to
improve sitting
balance, through
reach-
ing with the un-
affected hand

Placebo None Sham reaching Cognitive- Not applicable 10 sessions over

tasks manipula- 2 weeks, average
tive tasks, involv- 30 minutes
ing reaching the
unaffected hand
over very small
distances

Dean 2000 Motor learning None ’Ex- Standardised cir- Carr 1982; Carr 1 hour program,
ercise classes can cuit programme 1987a; Carr 3 days/week for 4
be used to imple- designed 1987b; weeks
ment the philos- to strengthen the Carr 1990; Carr
ophy of rehabil- muscles in the af- 1998 (+ numer-
itation described fected leg in a ous references for
and updated by functionally rel- individual com-
Carr and Shep- evant way and ponents of exer-
herd’ provide for prac- cise programme;
tice of locomo- each of the 10
tor-related tasks exercises carried
out in the pro-
gram were based
on referenced
work)

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Table 5. Classification of treatment approaches (Continued)

Placebo None Upper limb Standardised cir- Not applicable 1 hour program,
training cuit programme 3 days/week for 4
designed weeks
to improve func-
tion of the upper
limb

Duncan 1998 Mixed None Home-based Assistive and re- Voss 1985 Ap-
programme aim- sistive exercises; proximately 1.5
ing to improve pro- hours, 3 times/
’strength, prioceptive neu- week for 8 weeks
balance and en- romuscular facil- + instructed
durance and to itation (PNF) to continue pro-
encourage more ; ‘Theraband’ ex- gramme on own
use of the af- ercises; balance for further 4
fected extremity’ exercises; func- weeks
tional activities
for the affected
upper extremity;
progressive walk-
ing programme;
progressive bicy-
cle ergometer ex-
ercise
’The study inves-
tigator and co-
investigator ob-
served at least
1 therapy session
for each subject
to ensure stan-
dard application
of interventions’
The treat-
ments followed a
detailed written
protocol for in-
tervention

Control None Usual care Usual care: ’the Not applicable Av-
ther- erage number of
apy programmes visits for physio-
received by the therapy and oc-
con- cupational ther-
trol group varied apy patients was
in intensity, fre- 39, average dura-
quency and du- tion 44 minutes
ration’
3

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 74
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Table 5. Classification of treatment approaches (Continued)

patients received
physiotherapy; 7
had physiother-
apy and occupa-
tional therapy
Types of exercise
interven-
tions given were
balance training
(60%), progres-
sive resistive ex-
ercises (40%)
, bimanual activ-
ities (50%) and
facilitative exer-
cises (30%)

Duncan 2003 Mixed None Exer- Tech- 36 sessions of 90

cise programme niques included minutes over 12
at home, super- ROM (range of to 14 weeks
vised by physio- movement) exer-
therapist or oc- cises, PNF (pro-
cupational thera- prioceptive neu-
pist, romuscular facil-
aimed at improv- itation), task-
ing strength, bal- specific training
ance, endurance, Structured pro-
upper limb use tocols for the ex-
Included ercise tasks, cri-
a variety of tech- teria for progres-
niques from dif- sion, and guide-
ferent theoretical lines for reintro-
’approaches’ ducing therapy
after intercurrent
illness

Control No treatment Usual care (no Visited by re-

therapy, other searcher every 2
than speech ther- weeks
apy)

Gelber 1995 Neurophysio- NDT (neurode- ’Inhibi- Tone inhibition; Bobath 1970; These treatment
logical velopmental tion of abnormal weight bear- Guarna 1988 approaches were
treatment) muscle tone and ing activities; en- used by both the
initiation of nor- courage to use af- physiothera-
mal (good qual- fected side; avoid pists and occupa-
ity) motor move- resistance tional therapists
ments with pro- exercises and use who treated the
gression through of abnormal re- pa-

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 75
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Table 5. Classification of treatment approaches (Continued)

developmental flexes and mass tients, and were

sequences prior movements used throughout
to advancing to Therapists had the patients’ time
functional activi- all received train- as both an in-
ties’ ing and evalua- patients and out-
tion in the use of patients Patients
the approaches, continued to re-
and were given ceived inpatient
’strict guidelines’ or outpatient oc-
for treatment cupational ther-
apy and/or phys-
iotherapy if as-
sessed to have
need
All interventions
administered ac-
cording to allo-
cated treatment
group
The nursing staff
reinforced
any practice of
techniques that
patients were to
carry out out-
side their treat-
ment sessions

Orthopaedic TFR ’Practicing func- Passive range of Dickstein 1986; As above

(tradi- tional tasks as movement; pro- Price 1994;
tional functional early as possible gressive resistive Wescott 1967
retraining) even in the pres- exercises; assis-
ence of spasticity tive devices and
or abnormal pos- bracing; allow
tures’ use of unaffected
side to perform
functional tasks
Therapists had
all received train-
ing and evalua-
tion in the use of
the approaches,
and were given
’strict guidelines’
for treatment

Green 2002 Mixed Commu- ’Phys- Physiotherapy Min-

nity physiother- iotherapy treat- interventions in- imum 3 contacts
apy using ment was done cluded: ’gait re- per patient over
a ’problem solv- by an established

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Table 5. Classification of treatment approaches (Continued)

ing’ approach commu- education, exer- maximum of 13

nity physiother- cise therapy, bal- weeks
apy service (13 ance re-educa-
staff ) as part of tion, counselling
their usual work’ and advice, neu-
Commu- rological mobili-
nity physiothera- sations,
pists assessed us- functional exer-
ing a ’prob- cises, posture re-
lem solving ap- education, other
proach’ and ad- interventions’
ministered inter-
ventions accord-
ing to the prob-
lem identified

Control No treatment

Hesse 1998 Neurophysio- Bobath Walk- Intervention Bobath 1970; 1 treatment ’ses-
logical ing with Bobath performed by 5 Davies 1985 sion’
facilitation certified Bobath
therapists
’Princi-
ples of gait facili-
tation (after hav-
ing applied stan-
dard tone inhib-
ing manoeuvres
for the lower ex-
tremi-
ties) followed the
NDT (neurode-
velopmental
treatment) tech-
nique’
Manual tech-
niques for gait fa-
cilitation are de-
scribed in some
detail

Control No treatment Walking with no 1 treatment ’ses-

assistance sion’

Howe 2005 Mixed Neurophys- ’The interven- Exercises aimed Carr 1987a; Carr 12 additional
iological (usual tion, based at improving lat- 1998; Davies therapy sessions -
care) + motor on the work of eral weight trans- 1990 total of 6 addi-
learning Davies, may lack ference in sitting Com- tional hours over
a strong theoret- and standing munication with 4 weeks
ical basis ...’ Delivered the author con-

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Table 5. Classification of treatment approaches (Continued)

by trained phys- firms the classifi-

iotherapy assis- cation of this as a
tants ’mixed’ approach
Incorporated el-
ements of motor
learning, includ-
ing
repetition (prac-
tice) of self-initi-
ated goal-ori-
entated activities
with, where ap-
propriate, man-
ual guidance and
verbal
encouragement
(feedback)
Specific tech-
niques are de-
tailed with an
appendix to the
published paper

Control Neurophys- ’Physiotherapists Not stated

iological (usual re-
care) ported that usual
care was loosely
based on ’neuro-
physiological’
principles, how-
ever, their choice
of specific physi-
cal interventions
during each ses-
sion was deter-
mined on an in-
divid-
ual basis based
on the symp-
tomatic presen-
tation of the pa-
tient at the time’

Langhammer Neurophysio- Bobath A ’theoretical Not described Bobath 1990 5 days/

2000 logical framework week, for a mini-
in a reflex-hierar- mum of 40 min-
chical theory’ utes, while an in-
Physiotherapists patient. Follow-
attended work- ing discharge, at-

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Table 5. Classification of treatment approaches (Continued)

shops and dis- tempts were

cussed the treat- made to ensure
ment that physiother-
approaches, and apy continued
were provided based on the as-
with a man- signed approach,
ual, based on the and physiothera-
supporting texts, pists involved in
which described the treat-
the key philoso- ment were able
phy of the ap- to discuss treat-
proaches ments with hos-
pital physiother-
apists and
project leaders

Motor learning MRP ’Based in sys- Not described Carr 1987b As above
(motor relearn- tem theory, and
ing programme) is basically task-
oriented’
Physiotherapists
attended work-
shops and dis-
cussed the treat-
ment
approaches, and
were provided
with a man-
ual, based on the
supporting texts,
which described
the key philoso-
phy of the ap-
proaches

Lincoln 2003 Neurophysio- Bobath ’Treatment Not described Bobath 1990; ’Treatment con-
logical delivered by dif- The Bo- Davies 1985; tinued for as long
ferent groups of bath-based treat- Davies 1990 as was needed’ .
physio- ment was deliv- .. approach con-
therapists using ered by the unit’s tinued as outpa-
prepared written existing phys- tient if necessary
guidelines, con- iotherapists who Amount
sisting of theo- had used this ap- matched to ’typ-
retical concepts proach routinely ical amount’
for practice and prior to the start given by existing
main clinical ob- of the study ward physiother-
jectives, based on Prepared written apists
their own knowl- guidelines were Median 23 min-
edge and expe- available

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Table 5. Classification of treatment approaches (Continued)

rience and their utes per weekday

interpretation of More time was
the literature’ spent with
both physiother-
apist and physio-
therapy assistant
together for this
treatment group
Stated that oc-
cupational ther-
apists also used
this approach

Motor learning Movement As above Not described Carr 1987a; Carr ’Treatment con-
science The motor 1987b; tinued for as long
learning treat- Carr 1989; Carr as was needed’..
ment was deliv- 1994b . approach con-
ered by 2 phys- tinued as outpa-
iotherapists who tient if necessary
pre- Amount
viously had ’in- matched to ’typ-
sufficient experi- ical amount’
ence of the treat- given by existing
ment’ but who ward physiother-
were given train- apists
ing Median 23 min-
Prepared written utes per weekday
guidelines were More time was
available spent with phys-
iotherapy assis-
tant alone in this
treatment group
Stated that oc-
cupational ther-
apists also used
this approach

McClellan 2004 Motor learning Mo- ’Inter- Berg 1989; Carr In-
tor learning (mo- vention was stan- 1987b structed to prac-
bility in standing dardised by pre- tice twice per day
and walking) scribing the first with videotape
five exercises that Telephoned after
the subject could 1 week
perform success- Returned for ex-
fully from a list ercise review at
of 23 predeter- end of week 2
mined exercises and 4 Record of
The practice kept for
exercises were ar-

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Table 5. Classification of treatment approaches (Continued)

ranged loosely 6 weeks

hierarchi-
cally, based on
their challenge to
balance ... exer-
cises were pro-
gressed systemat-
ically ...’

Placebo control Motor learning Similar to above, Carr 1987b As above

(upper limb) but aimed at im-
prov-
ing functional of
the affected up-
per limb

Mudie 2002 Motor learning Task-related None stated Sitting Wu 1996 30 minutes per
training Reaching to en- day, ?5 days per
courage weight- week
shift Received trial in-
tervention in ad-
dition to ’stan-
dard’ treatment

Neurophysio- Bobath None stated Treatment pro- Davies 1985 30 minutes per
logical tocol based on day, ?5 days per
Bobath practices week
(devised by Bo- Received trial in-
bath trained staff tervention in ad-
physiothera- dition to ’stan-
pists) dard’ treatment
Protocol focused
on increasing
trunk and pelvic
range of move-
ment, normalis-
ing muscle tone,
maintaining ap-
propriate bal-
ance responses
Series of postures
and postural ma-
noeuvres involv-
ing weight shift,
pelvic tilt-
ing, trunk move-
ments; verbally
and manually fa-

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 81
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Table 5. Classification of treatment approaches (Continued)

cilitated by ther-
apists

Control No treatment Received ’stan-

dard’ treatment

Ozdemir 2001 Mixed Orthopaedic None stated In- Davies 1985 2 hours per day,
+ Neurophysio- tense multidisci- 5 days per week
logical plinary rehabili-
tation services as
inpatients:
ROM (range of
movement), pas-
sive stretching,
muscle strength-
ening, mobilisa-
tion + neuro-
muscular facili-
tation (Davies)
Ice, hot packs,
TENS (transcu-
taneous electri-
cal nerve stimu-
lation) as neces-
sary

Control Family-led ther- None stated Rehabilitation in 2 hours per day,

apy their own 7 days per week
homes: (by family)
family members Reha-
shown bed posi- bilitation physi-
tioning and ex- cian + physio-
ercises, no neu- therapist vis-
romuscular facil- ited for 2 hours
itation once per week to
The tech- give instructions
niques taught to to family
the family
are based on the
’orthopaedic’ ap-
proach

Pollock 1998 Neurophysio- Bobath Routine care Based on assess- Bobath 1990 Usual care, nor-
logical ment by treat- mally once per
ing physiothera- day, 5 days per
pist: routine care week

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 82
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Table 5. Classification of treatment approaches (Continued)

Mixed Bobath + motor Independent Supervised Carr 1987b Addition of 1

learning practice of con- practice of seated hour per day, 5
text-specific task reaching tasks days per week for
4 weeks, in addi-
tion to usual care

Richards 1993 Neurophysio- Bobath None stated Not described Com- ’Intensive’
logical munication with
the author con-
firms this inter-
vention as ’neu-
rodevelopmental
or Bobath’

Mixed Intensive and fo- ’Goal was to Tilt table; limb None ’Intensive’
cused promote gait re- load monitor; re-
learning through sistive exercises,
locomotor activ- with isokinetic
ities that were exercises; tread-
adapted to the mill training
individual level
of motor recov-
ery’

Salbach 2004 Motor learning Motor learning Task-orientated ’Standard- Dean 2000 (’in- 18 sessions,
(mobility) training of walk- ised programme, tervention given 3 times per
ing supervised by a inspired by’). week for 6 weeks
physical or oc- Recom-
cupational thera- mended that pa-
pist, of 10 walk- tients carry over
ing-related tasks walking compo-
designed nent of the pro-
to strengthen the gramme to home
lower extremities
and enhance
walking balance,
speed and dis-
tance in a pro-
gressive manner’

Placebo control Motor learning Functional 18 sessions,

(upper limb) upper extremity given 3 times per
tasks, done in sit- week for 6 weeks
ting Recom-
mended that pa-
tients carry over
walking compo-
nent of the pro-
gramme to home

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Table 5. Classification of treatment approaches (Continued)

Stern 1970 Mixed (Or- Orthopaedic ’Based on neuro- Pro- Brunnström 40 minutes in
thopaedic + neu- + neuromuscular physiological prioceptive neu- 1965; Knott addition to or-
rophysiological) re-education and/or develop- romuscular facil- 1968 thopaedic inter-
mental theories’ itation (PNF) as vention
described by ’Treat-
Knott and Voss ment schedules
Tech- were strictly con-
niques described trolled and given
by Brunnström. daily on week-
Assisted or days for the du-
resisted exercise ration of hospi-
where required talisation’
Maximal effort
for 10 repetitions

Orthopaedic None None stated; this Heat/cold; None 20 minutes heat/

was the ’tradi- passive range of cold; 15 minutes
tional’ approach motion; bracing; passive range of
at the time of this gait training motion; 40 min-
study utes gait training
’Treat-
ment schedules
were strictly con-
trolled and given
daily on week-
days for the du-
ration of hospi-
talisation’

Wade 1992 Mixed Commu- ’Problem solv- Re-education of None Mean number of
nity physiother- ing’ approach abnormal com- visits = 4 (stan-
apy using ’Patients were as- ponents of gait dard deviation 2.
a ’Problem-solv- sessed, with par- Practice walking 5)
ing’ approach ticular reference inside and out- Range 1 to 11
to their mobility, side visits
and problem ar- For standing bal-
eas were identi- ance: exercises to Time (including
fied stimulate re- travel and ad-
Realistic, achiev- actions, obstacle min-
able goals were courses, practice istration): range
discussed with on uneven sur- 1 hour 10 min-
the patient and faces utes to 3 hours
carers and then Re-education of 10 minutes
the physiothera- sitting to stand-
pist intervened if ing
required’ Equipment: re-
moval,
provision, main-

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Table 5. Classification of treatment approaches (Continued)

tenance, adjust-
ment
Activities of
daily living: ad-
vice, referral to
community oc-
cupational thera-
pist
Demonstrate pa-
tient’s ability to
patient/carer
Graduated exer-
cise program

Control No treatment None

Wang 2005 Neurophysio- Bobath ’Based on Bo- ’Approach used Bobath 1990; 40 minutes, 5
logical bath philosophy’ strictly adhered Davies 1985 sessions per week
to the principles for 20 sessions
described in de-
tail in the Bobath
and Davis texts’
Treat-
ment was ’indi-
vidualised, con-
stantly modified
according to sub-
ject response’
Tech-
niques included
facilitating nor-
mal movement
patterns and re-
training normal
alignment
through appro-
priate sensory
and propriocep-
tive input, direct
manual facilita-
tion, key point
control,
verbal and visual
feedback

Orthopaedic None As described in Passive, assistive, Pollock 2003 40 minutes, 5

this review active and pro- sessions per week
gressive resistive for 20 sessions
exercise

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Table 5. Classification of treatment approaches (Continued)

Multiple repeti-
tions of practice
of functional ac-
tivities: rolling,
sitting up, trans-
fer and gait
Gait training us-
ing parallel bars

Wellmon 1997 Motor learning None Repetitive prac- Repetitive prac- Addition of 20
tice of context- tice of stepping minutes, twice a
specific task task day for 2 days

Patients
had received rou-
tine phys-
iotherapy, based
on motor learn-
ing principles,
although no rou-
tine physiother-
apy was given on
the 2 days of the
intervention

Control No treatment Patients

had received rou-
tine phys-
iotherapy, based
on motor learn-
ing principles,
although no rou-
tine physiother-
apy was given on
the 2 days of the
intervention

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APPENDICES

Appendix 1. MEDLINE search strategy

1 exp cerebrovascular disorders/
2 stroke$.tw.
3 cerebrovascular$.tw.
4 (cerebral or cerebellar or brainstem or vertebrobasilar).tw.
5 (infarct$ or isch?emi$ or thrombo$ or emboli$).tw.
6 4 and 5
7 (cerebral or brain or subarachnoid).tw.
8 (haemorrhage or hemorrhage or haematoma or hematoma or bleeding).tw.
9 7 and 8
10 exp hemiplegia/ or “hemiplegi$”.mp.
11 1 or 2 or 3 or 6 or 9 or 10
12 physical therapy/
13 exercise therapy/
14 rehabilitation/
15 occupational therapy/
16 exercise/
17 electric stimulation therapy/
18 “biofeedback (psychology)”/
19 feedback/
20 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19
21 (physiotherapy or physical therapy or exercise therapy or rehabilitation).tw.
22 (neurorehabilitation or feedback or biofeedback).tw.
23 (motor adj5 (train$ or re?train$ or learn$ or re?learn$)).tw.
24 neuromuscular facilitation.tw.
25 (movement adj5 (therap$ or science)).tw.
26 (neurodevelopmental or neurophysiologic$ or orthop?edic).tw.
27 (therap$ or treatment$ or rehabilitation or principle$ or approach$).tw.
28 26 and 27
29 (bobath or carr or brunnstrom or rood or johnstone).tw.
30 21 or 22 or 23 or 24 or 25 or 28 or 29
31 20 or 30
32 11 and 31
33 exp cerebrovascular disorders/rh
34 hemiplegia/rh
35 32 or 33 or 34
36 motor skills/
37 exp psychomotor performance/
38 motor activity/
39 learning/
40 “conditioning (psychology)”/
41 movement/
42 locomotion/ or walking/
43 gait/
44 range of motion, articular/
45 activities of daily living/
46 exp posture/
47 equilibrium/
48 exp leg/
49 exp back/
Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 87
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
50 weight-bearing/
51 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 or 47 or 48 or 49 or 50
52 (motor adj5 (skill$ or activit$ or function$)).tw.
53 (learning or conditioning).tw.
54 (movement or gait or locomotion or walk$).tw.
55 (equilibrium or balance or postur$).tw.
56 (body sway or stance or strength or weight?bearing or body weight support).tw.
57 (locomotor adj5 (recovery or training)).tw.
58 (ankle or leg or heel or calf or knee or hip or foot or trunk).tw.
59 lower limb.tw.
60 (weight adj5 (distribut$ or transfer$)).tw.
61 (sit or sitting or stand or standing or step or stepping or climb or climbing).tw.
62 52 or 53 or 54 or 55 or 56 or 57 or 58 or 59 or 60 or 61
63 51 or 62
64 63 and 35

WHAT’S NEW
Last assessed as up-to-date: 18 January 2006.

Date Event Description

30 September 2008 Amended Converted to new review format.

HISTORY
Protocol first published: Issue 1, 2000
Review first published: Issue 2, 2003

Date Event Description

19 January 2006 New search has been performed 2001 Version

• 4114 trials from electronic searching
• 167 abstracts screened
• 71 full papers assessed
• 11 trials included (362 patients): Dean 1997; Dean 2000; Duncan
1998; Gelber 1995; Inaba 1973; Langhammer 2000; Pollock 1998; Richards
1993; Stern 1970; Wagenaar 1990; Wellmon 1997
Data for:
• four trials of neurophysiological versus other;
• four trials of motor learning versus other;
• four trials of mixed versus other;
• two comparisons of subgroups of the same approach.
2005 Update
• 8408 (4294 new) trials from electronic searching

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 88
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)

• 266 (99 new) abstracts screened

• 185 (114 new) full papers assessed
• 20 (11 new) trials included (1087 patients; 809 new). New trials:
Duncan 2003, Green 2002, Hesse 1998, Howe 2005, Lincoln 2003,
McClellan 2004, Mudie 2002, Ozdemir 2002, Salbach 2004, Wade 1992,
Wang 2005a
Trials comparing subgroups of the same approach were excluded (excluded
Inaba 1973 and Wagenaar 1990, which were included in original version)
Data for:
• eight (four new) trials of neurophysiological (all Bobath) versus other;
• eight (four new) trials of motor learning versus other;
• nine (five new) trials of mixed versus other.

CONTRIBUTIONS OF AUTHORS
Alex Pollock (AP) planned and co-ordinated all stages of this review. AP carried out searches, identified relevant studies and screened
abstracts for relevant trials; co-ordinated and wrote the classification of treatment approaches; wrote the amendment to the original
protocol; classified the interventions administered in each trial; documented methodological quality of studies; contacted and com-
municated with trial authors; extracted data from included studies; planned the analyses and entered data into RevMan; and wrote all
drafts of the review.
Gill Baer (GB) screened abstracts for relevant trials; contributed to the written criteria for classifying treatment approaches; classified
the interventions administered in each trial and discussed any discrepancies with AP to reach consensus; documented methodological
quality of studies; extracted data from included trials; and commented on draft versions of the written review.
Valerie Pomeroy (VP) contributed to the formation of the protocol; screened abstracts for relevant trials for the first version of the
review; contributed to the written criteria for classifying treatment approaches; and commented on draft versions of the written review.
Peter Langhorne (PL) provided substantial input to the formation of the protocol and provided methodological support at all stages of
the review; discussed disagreements between independent reviewers (AP and GB) regarding inclusion and methodological quality of
trials; supervised data analysis; and commented on draft versions of the written review.

DECLARATIONS OF INTEREST
Alex Pollock carried out one of the trials in this review (Pollock 1998).

SOURCES OF SUPPORT

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke (Review) 89
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Internal sources
• No sources of support supplied

External sources
• Chest Heart and Stroke, Scotland, UK.
• The Big Lottery, UK.

INDEX TERMS

Medical Subject Headings (MeSH)

∗
Posture; Biofeedback, Psychology [∗ methods]; Leg [physiology]; Motor Skills; Physical Therapy Modalities; Proprioception [physiol-
ogy]; Randomized Controlled Trials as Topic; Stroke [∗ rehabilitation]

MeSH check words

Adult; Humans

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Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.