Impact of Active Physiotherapy on Physical Activity Level in Stroke Survivors: A Systematic Review and Meta-Analysis
Abstract
BACKGROUND:
Stroke survivors are frequently physically inactive. However, evidence of the effectiveness of active physiotherapy on physical activity level in stroke survivors is scarce.
METHODS:
We conducted a systematic review and meta-analysis of randomized controlled trials according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement, covering electronic searches from inception to March 16, 2022. Participants: Stroke survivors living in the community. Intervention: Any active physiotherapy, that is, involving exercises that require voluntary effort. Outcome measure: Objective and subjective physical activity level.
RESULTS:
Of 5590 identified references, 25 randomized controlled trials were eligible, and 21 had available data. The random-effects meta-analysis resulted in a small, significant effect size in favor of active physiotherapy measured using objective or subjective tools (21 studies, 1834 participants, standardized mean difference, 0.22 [95% CI, 0.04–0.40]; heterogeneity I2=65%), and a medium significant effect when objective tools were used (9 studies, 424 participants, standardized mean differences, 0.48 [95% CI, 0.03–0.92]; I2=73%). Meta-regression showed that 35% of the variance in trial outcome was explained by the measurement tool (objective or subjective) and 23% by age. None of the variances were associated with a specific dosage in terms of frequency, time, exercise duration, or the severity of the disability.
CONCLUSIONS:
Active physiotherapy seems to increase objective physical activity in community-dwelling stroke survivors. However, the evidence is of very low certainty.
REGISTRATION:
URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42022315639.
Graphical Abstract
Physical inactivity is associated with increased risk of recurrent stroke.1 Community-dwelling stroke survivors are often inactive,2 causing a vicious circle of physical deconditioning and insufficient activity. People with stroke only walk half as many steps daily as healthy individuals.3 Thus, increasing the physical activity level (PAL) of people with stroke is crucial.
Physiotherapists are well-placed to encourage physical activity.4,5 Their expertise enables them to tackle perceived barriers to physical activity and to strengthen key facilitators such as walking ability, mobility, balance, or endurance, which are positively associated with long-term adherence to physical activity.6
Six recent systematic reviews have examined the effectiveness of interventions to increase PAL after stroke.7–12 However, most emphasized the impossibility of concluding due to the heterogeneity of interventions, which could include general lifestyle advice and exercise programs.7–11 Therefore, they recommended that research independently investigates the contribution of each component of complex interventions.7
Physiotherapy treatments can be classed as passive or active. Passive physiotherapy implies no form of physical activity, defined as any skeletal muscle contraction resulting in energy expenditure,13 such as education or stretching. Conversely, active physiotherapy is defined as any “form of exercise carried out by the patient, under direct supervision from the physiotherapist or not, and requiring a voluntary effort on the part of the patient” (eg, functional task training, circuit class therapy, aquatic therapy, or gait training).14
Studies showed that the PAL of people with different pathologies undergoing outpatient physiotherapy increases when physiotherapists focus on active treatments.15 Furthermore, the most recent international stroke guidelines state that the active aspect of physiotherapy treatment should be emphasized.16
One systematic review examined active interventions designed specifically to increase stroke survivors’ PAL.12 It included exercise programs that complied with moderate to vigorous physical activity guidelines. However, the authors found insufficient evidence of their beneficial effects on PAL,12 suggesting that other types of active treatment should be investigated.
The research questions of this systematic review with meta-analysis were
1.
Does active physiotherapy increase the PAL of stroke survivors living in the community?
2.
How do the characteristics of active physiotherapy interventions (eg, type, duration, intensity), sample profiles, and physical activity measurement tools impact on change in PAL?
METHODS
The automatic tool Cochrane Handbook for Systematic Reviews of Interventions (Version 6.2, 2021) and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis updated guidelines were used (Supplemental Material).17
This review was registered prospectively on PROSPERO (International Prospective Register of Systematic Reviews). Data not published within the article are available from the corresponding author on reasonable request.
The method is briefly described below, more details are provided in the Supplemental Material.
Electronic Searches
Five core electronic databases were reviewed from inception to March 16, 2022: Medline via PubMed, Physiotherapy Evidence Database, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature via EBSCOhost, and Central (via the Cochrane Library). No language or date restrictions were applied.
Eligibility Criteria
Studies
Randomized controlled trials, quasi-randomized controlled trial, and controlled clinical trials in community-dwelling stroke survivors were included.
Participants
Participants included adults after a first or recurrent stroke, living in the community. Studies with participants who had a transient ischemic attack were excluded.
Interventions
Interventions involved exercises requiring volitional effort14 whether face-to-face, group, or remote. For remote interventions, we distinguished between interventions consisting of general advice on physical activity (studies not included) and specific unsupervised exercise programs (studies included).
If physiotherapy was not mentioned but the specified program could be prescribed or implemented by a physiotherapist, the study was included.
Comparators
Passive (eg, massage, education, manual therapy) or less active treatments than the intervention, waiting list, no intervention, or usual care were included if enough information on the active components of the comparator was provided. When the difference between interventions was not the active ingredient, the trial was excluded.
Contexts
Included outpatient and community settings.
Outcomes
Primary outcome was PAL measured objectively (ie, activity monitor, accelerometer, or pedometer) or subjectively (ie, self-reported questionnaire or diaries), whatever the follow-up duration.
Article Selection and Data Extraction
COVIDENCE (Veritas Health Innovation, Melbourne, VIC, Australia)18 was used to select articles. Titles, abstracts, and then full texts were screened independently by 2 reviewers (S.G., M.L., or N.D.). Disagreements were solved with a third examiner (S.G., M.L., or N.D.).
Two reviewers (S.G. and M.L.) independently extracted data (using the Cochrane Collaboration Checklist19) and discussed any disagreements.
Active physiotherapy interventions were categorized into functional task training, musculoskeletal, cardiopulmonary, and multicomponent interventions when at least 2 were mixed.20 Interventions were also described by frequency, intensity, time, and type (FITT [Frequency, Intensity, Time, and Type] principle). Outcomes were reviewed at the end point and follow-up.
RoB Assessment
Two reviewers (S.G. and M.L.) independently judged the risk of bias (RoB) of each included study using COVIDENCE with the RoB tool for randomized controlled trials (version 1) from the Cochrane Collaboration.21 As double blinding should not be considered a criterion for evaluating bias risk in physiotherapy research,22 item 3 was not considered. Disagreements were discussed between the 2 authors (S.G. and M.L.), and the third reviewer (N.D.) mediated if necessary.
Certainty of Evidence
The overall certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach.23
Statistical Analysis
Meta-analysis was performed using the “meta” and “metafor” packages of R (R Foundation for Statistical Computing, Vienna, Austria; available at http://www.R-project.org/; version 4.2.1) and the support of a statistician.
We used Wan’s method to deal with missing SD or mean values and convert reported statistics to those required.24,25
The effect of active physiotherapy on PAL was measured through a random-effects inverse variance meta-analysis to pool weighted standardized mean differences (SMD) with their 95% CIs. The restricted maximum-likelihood method was used for all analyses to estimate between-study variance. When studies had >1 relevant arm, we included group interventions as separate comparisons within the meta-analysis.
Findings were presented using forest plots and tables. Effect sizes (ie, SMD) were interpreted following Cohen magnitude criteria for rehabilitation treatment effects: d=0.14 to 0.31 small effect size; d=0.31 to 0.61 medium effect size; and d>0.61 large effect size.26 We quantified heterogeneity with I² statistic.27,28
Subgroup and meta-regression analyses were performed to identify differences in active physiotherapy on PAL and sources of heterogeneity. Heterogeneity across included studies was assessed using the χ² test for heterogeneity with a 5% level of statistical significance.29 The moderator variables, including population characteristics (age, sex, time since stroke, clinical phase of stroke, impairment severity, balance classification, gait classification), intervention details (type, supervision, frequency, duration, intensity), and PAL measurement tool are described in the Supplemental Material.30,31
We investigated publication bias using a funnel plot and assessed its asymmetry with the Pustejovsky test.32 P<0.05 was considered statistically significant.
Two sensitivity analyses were performed to assess the robustness of our main findings: a leave-one-out analysis, then, analysis of the study with an overall low RoB.
RESULTS
Study Selection
A total of 5590 references were found after removing duplicates. Among the 82 full-text eligible articles, 25 were included in the qualitative synthesis. Of these, 21 had data that could be quantitatively analyzed. The list of excluded studies and reasons for exclusion are provided in the Supplemental Material. A Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow diagram illustrates each step in the review process (Figure 1). We contacted the authors of 5 trials to obtain more information; only 1 answered.
Study Characteristics
A brief description is provided below; for details, see Supplemental Material.
Design
Participants
The 25 studies included 2448 stroke survivors, 948 (39%) women, mean age range from 52 to 77.7 years. Most included participants were in the chronic phase (range, 0.7–8.5 years) and most participants had mild deficit and were full community ambulators.
Intervention Characteristics
Six studies used cardiopulmonary interventions33,42,44,50,51,56: 1 used musculoskeletal interventions,45 4 used functional task training,46,49,52,55 and 14 studies used multicomponent interventions.34–41,43,47,48,53,54,57
Control Group Characteristics
Outcome Measures
Ten randomized controlled trials used an objective tool to measure PAL, such as an accelerometer33,38,43,46,52,55 or a pedometer,37,42,47,56 and 15 used a subjective measure. PAL was assessed as a secondary outcome in half of the studies, after physical or functional outcomes, such as walking ability.34,35,37,41–45,49,50,54,55
Meta-Analysis
Meta-analysis of 21 trials was performed, including 1834 participants. Two trials had 3 arms with 2 active intervention groups.45,49 We included each pair-wise comparison in the meta-analysis.
Overall, pooling resulted in a small significant effect size in favor of active physiotherapy (standardized mean difference, 0.22 [95% CI, 0.04–0.40]; heterogeneity I2=65%) compared with the control group (Figure 2). With a Z value of 2.41 and a P value of.02, active physiotherapy is, on average, effective in increasing PAL in stroke survivors.
A categorical prespecified subgroup analysis was performed and is summarized in Table S2.
When PAL was measured with an objective tool, active physiotherapy had a significant medium effect (9 studies, 424 participants, SMD, 0.48 [95% CI, 0.03 to 0.92]; I2=73%). With subjective measures, the effect was small and nonsignificant (14 studies, 1410 participants, SMD, 0.06 [95% CI, −0.08 to 0.21]; I2=34.9%).
Active physiotherapy had a significant medium, positive postintervention effect when compared with less active or passive interventions (16 studies, 826 participants, SMD, 0.34 [95% CI, 0.10–0.57]; heterogeneity I2=61.8%) and a nonsignificant effect when compared with usual care (7 studies, 1008 participants, SMD, −0.01 [95% CI, −0.19 to 0.19]; heterogeneity I2=50.4%).
A significant medium SMD in favor of active physiotherapy was found for the studies that included stroke survivors under 65 years (13 studies, 558 participants, SMD, 0.39 [95% CI, 0.10–0.68]; heterogeneity, I2=62.8%), without subgroup difference between younger and older participants (P=0.06). When mean time since stroke was < 3 years, active physiotherapy had a medium significant effect on PAL (7 studies, 578 participants, SMD, 0.23 [95% CI, 0.02–0.44]; heterogeneity, I2=11.8%). When mean time since stroke was >3 years, active physiotherapy had a nonsignificant effect on PAL (12 studies, 627 participants, SMD, 0.21 [95% CI, −0.09 to 0.51]; heterogeneity, I2=65.5%)
Among subgroups of types of interventions, functional task training had a significant medium beneficial effect on PAL, with no heterogeneity (5 studies, 182 participants SMD, 0.38 [95% CI, 0.08–0.67]; I2=0%), whereas other interventions had a nonsignificant effect on PAL (Table S2).
The meta-regression models identified the PAL measurement tool (R²=35.29, P=0.03) and participant age (R²=22.5, P=0.05) as significant moderators (Table S3).
Meta-regression found no relationship between SMD and the treatment dose (ie, frequency, duration, and intensity) or between SMD and clinical characteristics, such as impairment severity, balance, and gait classification (Table S3).
Ten studies assessed the long-term effects of the intervention (576 participants). The meta-analysis showed a nonsignificant effect (SMD, 0.06 [95% CI, −0.21 to 0.33]; I2=54.2%) of the experimental intervention compared with the control (Figure S1).
RoB, Sensitivity Analysis, and Certainty of Evidence
A brief description is provided below, for details, see the Supplemental Material.
RoB was low in 76% of studies for allocation concealment, 81% for masking of outcome assessors, 71% for incomplete outcome data, 52% for selective outcome reporting, and 81% for other sources of bias. Overall, 9 studies were at low RoB,33–37,41,47,49 3 at unclear RoB,43,44,48 and 10 at high RoB38–40,42,45,46,51,52,54,55 (Figure S2).
The sensitivity analysis restricting meta-analysis to studies at lower RoB (Table S2) found a statistically significant result (9 studies, 1011 participants, SMD, 0.15 [95% CI, 0.03–0.27]; I2=17.4%). The sensitivity analysis exploring the impact of excluding each trial on the results showed consistency with the overall findings (Figure 3). Publication bias was low according to the funnel plot and statistical method (P>0.05; Figure 4).
Because results appeared robust, we did not downgrade PAL for study limitations. Minimal clinically important difference thresholds in stroke survivors were not determined in any study for PAL outcome measures. Therefore, PAL was downgraded by 1 level for imprecision. The I2 value was 65%; therefore, PAL was downgraded due to inconsistency. Evidence was downgraded due to indirectness because participants appeared to have predominantly mild impairment and to be younger than stroke survivors who could benefit from these interventions. In summary, according to the Grading of Recommendations Assessment, Development, and Evaluation approach, the certainty of evidence was very low.
DISCUSSION
Our findings indicated a small positive, significant effect of active physiotherapy on PAL immediately after the intervention. Active physiotherapy not only increases stroke survivors’ activity level during treatment but also seems to increase participation in physical activity outside of sessions. Similar results were found in a review of the effectiveness of active physiotherapy in people with varied pathologies.15 However, the beneficial effect was not maintained at follow-up, in line with our results, reflecting the difficulty of promoting long-term physical activity.
Despite our expectations, which were based on previous research,58 the meta-regression found no dose-response relationship. This may be due to disparities in outcome measures (functional outcomes versus PAL) and the conceptualization of dose (only therapy duration versus consideration of all dose components). The intensities may have been insufficient to induce cardiorespiratory fitness adaptations,59 essential for participation in physical activity.6 Additionally, physiotherapy intensity significantly affects other PAL predictors, such as balance, comfortable gait speed, quality of life, and even depression.6,60 Furthermore, participants’ performance levels were rarely evaluated, as previously highlighted,61 and the true intensity may have been lower than the prescribed intensity. Finally, adherence, particularly when exercise is unsupervised, is challenging.34 The durations may also have been insufficient to impact PAL and demonstrate a dose-response relationship.
Interestingly, the PAL measurement tool was the strongest predictor of the overall effect of active physiotherapy: objective tools such as accelerometers found a stronger effect than subjective tools, likely because of their higher accuracy and the recall and desirability bias of subjective measures.62 However, few tools used had been validated for stroke. These findings encourage the development and use of validated, objective measurement tools to assess PAL and intervention effectiveness.63,64
We found a medium postintervention effect on PAL when active physiotherapy was compared with less active or passive interventions. Conversely, no effect was found when the intervention was compared with usual care. This could be explained by the “black box of usual care” and insufficient reporting of information about control group activity.65 For instance, in the LAST study (Life After Stroke),34 the control group received 45 minutes of physiotherapy per week for up to 6 months. This may have masked the impact of the intervention and led to neutral results. Therefore, improving reporting of usual care is crucial to understanding the impact of specific physiotherapy interventions compared with usual care.65
Similar to a systematic review,11 we found that functional task training is a promising approach to enhance PAL after stroke. This emphasizes the importance of task-oriented training as a guiding principle for effective neurorehabilitation.66 In addition, functional task training has the potential to induce a moderate-intensity workload,67 which is required to induce cardiorespiratory stress, as mentioned above. Multicomponent interventions had a nonsignificant effect, corroborating previous findings suggesting that interventions are more effective when they contain fewer components.7 Also, some programs were not developed for people with stroke, such as the Otago exercise program,35 WEBB (Weight-Bearing Exercise for Better Balance),37 HIFE (High-Intensity Functional Exercise Program),41,54 or FAME (Fitness and Mobility Exercise)48,57 for older people, emphasizing the importance of specifically designing programs for individuals after stroke. Importantly, most interventions were group-based, supporting evidence from previous work that the opportunity to interact with other stroke survivors is the strongest incentive to perform physical activity after stroke.68 Finally, the large variety of interventions in the studies reflects the complex issue of modifying physical activity behavior.
Active physiotherapy seems more effective in younger (<65 years old) than older individuals (≥65 years old). However, age increases the likelihood of being physically inactive 1 year after stroke,69 highlighting the need to use personalized approaches in this group. The lack of a relationship between clinical characteristics and the effect size could have resulted from the vast heterogeneity of interventions and participant profiles in terms of impairment severity, walking speed, and balance. Thus, additional research is warranted to define optimal interventions that are tailored to individuals’ capacities, goals, and preferences.70
This review has several limitations. First, judging a study at low RoB despite high RoB, masking could have introduced bias. Second, our classification of types of interventions could have modified the results.20 For instance, we classified circuit class therapy as multicomponent training, but it could have been classified as functional task training or cardiopulmonary training since it is provided in an intensive manner and is focused on functional tasks.71 Third, the lack of author responses led to study exclusion from meta-analysis, potentially altering findings. Fourth, the certainty of evidence was downgraded to very low for imprecision, inconsistency, and indirectness, leading to cautious conclusions. Fifth, most of the trials were small, which also constitutes a limitation.
Our findings may have important clinical, public health, and research implications. Beyond rehabilitation of function, active physiotherapy could influence the physical activity patterns of stroke survivors living in the community. However, as pointed out by Krakauer and Carmichael, interventions in the chronic stages of stroke are almost inexistent,72 despite the fact stroke survivors face functional and motor deterioration over time.73 Our results advocate for physiotherapy services to prevent the deconditioning cycle by increasing PAL. Furthermore, limited access to physiotherapy in the chronic poststroke phase in many countries74 calls for action to develop innovative approaches. Technological advancements offer exciting prospects,75 notably by providing high-dose behavioral interventions to reduce impairment,76 which is crucial to enable performance of regular physical activity. In addition, integrating valid activity trackers into programs would allow assessment of the effectiveness of interventions and provide support and motivation to improve and sustain PAL.63,64 Another challenge for future research will be investigating resource-efficient interventions to increase active physiotherapy, such as home-based rehabilitation and telerehabilitation.
CONCLUSIONS
The findings highlight the importance of active physiotherapy to increase physical activity in community-dwelling stroke survivors. However, improvements are not sustained over the long term, highlighting the need for strategies such as technology to address this issue. The certainty of the evidence is very low; therefore, further investigations are warranted, notably on the required content and dose of interventions to optimize their impact on PAL.
ARTICLE INFORMATION
Supplemental Material
PRISMA Checklist
Supplemental Methods
Supplemental Results
Tables S1–S3
Figures S1–S2
Acknowledgments
The authors thank Johanna Robertson, PhD, for English editing, and Dr Jean Joël Bigna Rim for statistical support
Footnote
Nonstandard Abbreviations and Acronyms
- PAL
- physical activity level
- RoB
- risk of bias
- SMD
- standardized mean difference
Supplemental Material
File (str_stroke-2023-043629_supp1.pdf)
- Download
- 721.57 KB
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© 2023 American Heart Association, Inc.
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Received: 20 April 2023
Revision received: 21 September 2023
Accepted: 5 October 2023
Published online: 1 November 2023
Published in print: December 2023
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Supported by French Society of Physiotherapy (Société Française de Physiothérapie, SFP).
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- A Home‐Based Behaviour Change Intervention With Sedentary Behaviour and Physical Activity in People With Stroke and Diabetes—A Feasibility and Safety Study, Physiotherapy Research International, 30, 2, (2025).https://doi.org/10.1002/pri.70048
- Efficacy of robot-assisted gait training on lower extremity function in subacute stroke patients: a systematic review and meta-analysis, Journal of NeuroEngineering and Rehabilitation, 21, 1, (2024).https://doi.org/10.1186/s12984-024-01463-1
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