Clinical Rehabilitation 2007; 21: 395410

Physiotherapy treatment approaches for the

recovery of postural control and lower limb
function following stroke: a systematic review
Alex Pollock Stroke Therapy Evaluation Programme, Academic Section of Geriatric Medicine, Glasgow Royal Infirmary,
Glasgow, Gillian Baer Department of Physiotherapy, Queen Margaret University College, Edinburgh, Peter Langhorne
Academic Section of Geriatric Medicine, Glasgow Royal Infirmary, Glasgow and Valerie Pomeroy Rehabilitation and
Ageing, Geriatric Medicine, St Georges University of London, London, UK
Received 30th September 2006; accepted 6th October 2006.

Objectives: To determine whether there is a difference in global dependency and

functional independence in patients with stroke associated with different
approaches to physiotherapy treatment.
Data sources: We searched the Cochrane Stroke Group Trials Register (last
searched May 2005), Cochrane Central Register of Controlled Trials (CENTRAL)
(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.
Review methods: Inclusion criteria were: (a) randomized or quasi-randomized
controlled trials; (b) adults with a clinical diagnosis of stroke; (c) physiotherapy
treatment approaches aimed at promoting postural control and lower limb function; (d) measures of disability, motor impairment or participation. Two independent
reviewers categorized identified trials according to the inclusion/exclusion criteria,
documented the methodological quality and extracted the data.
Results: Twenty trials (1087 patients) were included in the review. Comparisons
included: neurophysiological approach versus other approach; motor learning
approach versus other approach; mixed approach versus other approach for the
outcomes of global dependency and functional independence. A mixed approach
was significantly more effective than no treatment control at improving functional
independence (standardized mean difference (SMD) 0.94, 95% confidence interval
(CI) 0.08 to 1.80). There were no significant differences found for any other
comparisons.
Conclusions: Physiotherapy intervention, using a mix of components from different
approaches is more effective than no treatment control in attaining functional
independence following stroke. There is insufficient evidence to conclude that any
one physiotherapy approach is more effective in promoting recovery of disability
than any other approach.

Address for correspondence: Alex Pollock, Stroke Therapy

Evaluation Programme, Academic Section of Geriatric Medicine,
Room 34, Level 3, University Block, Queen Elizabeth Building, 10
Alexandra Parade, Glasgow Royal Infirmary University NHS Trust,
Glasgow G31 2ER, UK. e-mail: alex@strokerehab.fsnet.co.uk
2007 SAGE Publications

10.1177/0269215507073438

396

A Pollock et al.

Background
There are several different approaches to physiotherapy treatment following stroke. Prior to the 1940s these
primarily consisted of corrective exercises based on
orthopaedic principles related to the contraction and
relaxation of muscles, with the emphasis placed on
regaining function by compensating with the unaffected limbs.1,2 In the 1950s and 1960s techniques
based on available neurophysiological knowledge
were developed, including the methods of Bobath,3,4
Brunnstrm,5 Rood6 and the Proprioceptive
Neuromuscular Facilitation (PNF) approach.7,8 In the
1980s the potential importance of neuropsychology
and motor learning was highlighted9,10 and the motor
learning, or relearning, approach was proposed.11
This approach suggested that active practice of context-specific motor tasks with appropriate feedback
would promote learning and motor recovery.1117
The practical application of these approaches
results in substantial differences in patient treatment.
Approaches based on neurophysiological principles
have traditionally primarily involved the physiotherapist moving the patient through patterns of movement,
with the therapist acting as problem solver and decision maker and the patient being a relatively passive
recipient.18 In direct contrast, the motor learning
approaches emphasize the importance of active
involvement by the patient,11 while orthopaedic
approaches emphasize muscle strengthening techniques and compensation with the non-paretic side. At
present, the Bobath Approach, based on neurophysiological principles, remains probably the most widely
used approach in Sweden,19 Australia20 and the
UK.2123
Physiotherapists often seek evidence relating to
global approaches to treatment of stroke patients,
rather than evidence in support of individual treatments. The evaluation of this research evidence is
often difficult due to poor description and documentation of the approaches investigated. Often the treatment approach is vaguely described as conventional
or traditional (e.g. refs 2430) and few other details
are available. Although questionnaire-based studies
do demonstrate that physiotherapists often have a
preference for a particular approach, there is presently no convincing evidence to support any specific
physiotherapy treatment approach.21,31
This report details key findings from a Cochrane
Systematic Review.32 Readers are referred to the full

Cochrane Review for additional details. The objective

was to determine if there is a difference in the recovery from disability in patients with stroke if physiotherapy treatment is based on any one of orthopaedic
or neurophysiological or motor learning principles, or
on a mixture of these treatment principles.

Methods
Types of studies
Controlled trials were included if participants were
randomly or quasi-randomly assigned to one of two or
more treatment groups. Trials with or without blinding of participants, physiotherapists and assessors
were included.
Types of participants
Trials were included if participants were adults
(over 18 years) with a clinical diagnosis of stroke.33
Participants with diagnosis of either ischaemic stroke
or haemorrhagic stroke were included (confirmation
of the clinical diagnosis using imaging was not
compulsory).
Types of interventions
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) were included.
Interventions that had a more generalized stated aim,
such as improving functional ability, were also
included. Treatment approaches that were primarily
aimed at promoting recovery of upper limb movement
or function were excluded. Studies of specific interventions, such as electrical stimulation, biofeedback
and treadmill training, were excluded.
Types of outcome measures
Primary outcomes were defined as measures of disability. Relevant measures of disability were prestated
as (1) global dependency scales or (2) functional independence in mobility. (A number of secondary outcomes were also included; these are detailed in the
Cochrane Review.32)

Physiotherapy treatment approaches for stroke

Search strategy
Full details of the search strategy, including the full
bibliographic search history for electronic databases,
are provided within the Cochrane Review.32
The searching was based on the strategy developed
by the Cochrane Stroke Group and was done using
intervention-based search strategies developed in consultation with the Cochrane Stroke Group Trials
Search Co-ordinator. Searching included: Cochrane
Stroke Group Trials Register (May 2005); Cochrane
Central Register of Controlled Trials (CENTRAL)
(Cochrane Library Issue 2, 2005); MEDLINE (1966
to May 2005); EMBASE (1980 to May 2005);
CINAHL (1982 to May 2005). Experts and authors
were contacted and asked if they knew of any additional, unpublished or on-going trials, and the reference lists of all trials found using the above search
methods were searched.
Search results
The electronic searching resulted in 8408 potentially
relevant trials. One reviewer (AP) eliminated obviously irrelevant studies based on titles and, where available, abstracts. This eliminated 8161 studies, leaving
247 potentially relevant trials. Examination of the
reference lists of these potential trials, and communication with known experts and colleagues, added a
further 18 studies, making a total of 265 potentially
relevant trials.
Two independent reviewers (AP, GB) read the
abstracts for these 265 studies. Of these, 184 (69%)
were classified as relevant or possibly relevant.
Titles, introduction and methods sections of the
184 possible trials were independently scrutinized by
two reviewers (AP, GB). Based on a detailed written
description (which was based on the available literature, and which had been discussed between all
reviewers to ensure consensus) of the classification of
physiotherapy approaches based on motor learning,
neurophysiological or orthopaedic principles (see
Cochrane Review32 for details) reviewers independently classified the interventions administered in each
trial. Any disagreements were resolved through discussion involving a third reviewer (PL), and further
information was obtained from trialists where necessary (and possible).
This review process led to the identification of 20
relevant trials to be included in this review: Dean and
Shepherd,34 Dean et al.,35 Duncan et al.,36 Duncan

397

et al.,37 Gelber et al.,38 Green et al.,39 Hesse et al.,40

Howe et al.,41 Langhammer and Stranghelle,42
Lincoln,43 McClellan and Ada,44 Mudie et al.,45
Ozdemir et al.,46 Pollock,47 Richards et al.,48 Salbach
et al.,49 Stern et al.,24 Wade et al.,50 Wang et al.51 and
Wellmon and Newton.52
Brief descriptions of the included studies can be
found in Table 1; detailed descriptions are published
in the Cochrane Review.32
Methodological quality and data extraction
Two independent reviewers (AP, GB) judged the
methodological quality of studies and extracted data,
with any disagreements resolved through discussion
involving a third reviewer. Trial authors were contacted
for clarification where necessary.
The following quality criteria were documented:
randomization (allocation concealment); baseline
comparison of groups; blindness of recipients and
providers of care to treatment group/study aims;
blindness of outcome assessor; possibility of contamination/co-intervention by therapists providing intervention; completeness of follow-up; other potential
confounders.
Data extraction documented (where possible): trial
setting (e.g. hospital, community); details of participants (e.g. age, gender, side of hemiplegia, stroke
classification, comorbid conditions, premorbid disability); inclusion and exclusion criteria; all assessed
outcomes.
Details of the methodological quality and data
extraction from individual trials are fully presented
within the Cochrane Review.32
Data analysis was carried out using Cochrane
RevMan software. Standardized mean differences
(SMD) and 95% confidence intervals (CI) were calculated, using a random effects model, for all outcomes
analysed.

Results
The 20 included trials randomized 1087 patients.
Three of these studies (78 patients) have no data
included in any of the review analyses: we were
unable to obtain the data from the first phase of the
study by Hesse et al.40 (n 22); and Wellmon and
Newton52 (n 21) and Howe et al.41 (n 35) reported

RCT (blocked
randomization)

RCT (matched
pairs
randomized)

RCT (method
of randomization not
stated)

RCT (blocked
randomization)
RCT (method
of randomization not
stated)

RCT (blocked
randomization)

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

Dean 199734

Dean 200035

Duncan
199836

Duncan
200337

Green
200239

Hesse
199840

Gelber
199538

Design

Inadequate

Adequate

Unclear

Adequate

Adequate

Adequate

Adequate

Allocation
concealment

22

170

27

100

20

12

20

Number of
participants
randomized

Summary of characteristics of included studies

Trial

Table 1

Yes

3 months

Yes

1 year

Unclear

No

1 month

chronic
stroke

Yes

30150 days

Unclear

Yes

1 year

3090 days

Outcome
assessor
blinded to
group
allocation?

Inclusion
criteria: Time
since stroke

Neurophysiological
(NDT)
Orthopaedic
(traditional
functional
retraining)
Mixed
community
physiotherapy,
using
problem
solving
approach
Control
no intervention
Bobath
(walking
with
Bobath
facilitation)
Control
(walking
with no

Mixed
Control

Mixed
Control

Motor
learning
Placebo

Motor
learning
Placebo

Treatment
groups

(none)

(none)

(none)

Barthel
Index

(none)

(none)

Rivermead
Mobility
Index
Frenchay
Activities
Index.

Functional
Independence
Measure
(FIM)

Barthel
Fugl-Meyer
Index
motor score
Lawton
Instrumental
ADL
(none)
Fugl-Meyer
(lower limb)

(none)

(none)

No data
available

Secondary
outcomes
included in
Cochrane
review
Secondary
outcomes
included in
Cochrane
review

Outcome:
Outcome:
Notes
global
functional
dependency independence

398
A Pollock et al.

RCT
(stratified
according
to gender
and side
of lesion)
RCT
(blocked
randomization)

RCT

RCT

Langhammer
200042

McClellan
200444

Mudie
200245

Lincoln
200343

RCT (block
randomization)

Howe
200541

Adequate

Adequate

Adequate

Adequate

Adequate

40

26

120

61

35

Yes

18
months

Yes

Yes

2 weeks

Recent

Yes

Yes

Not stated

Acute

(Bobath)
Control (no
treatment)

Motor
learning
Placebo
control
(motor
learning,
upper
limb)
Feedback
only
Motor
learning
(task related
training)
Neurophysiological

Neurophysiological
(Bobath)
Motor
learning

Neurophysiological
(Bobath)
Motor
learning

intervention)
Aid (walking
with
walking
stick)
Mixed
(Neurophysiological
motor
learning)
Neurophysiological

Barthel
Index

Barthel
Index
Extended
Activities
of Daily
Living
scale
(none)

Barthel
Index

(none)

(none)

Motor
Assessment
Scale
(item 5)

Motor
Assessment
Scale
Rivermead
Motor
Assessment

Motor
Assessment
Scale Sodring
Motor
Evaluation

(none)

(continued)

Data from
feedback
only group
not used

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

Physiotherapy treatment approaches for stroke

399

Stern
197024

Salbach
200449

Richards
199348

RCT
(stratified
blocked
randomization,
stratified
according to
3 levels of
walking
deficit)
Quasi-randomized trial
(50 patients
were
originally

Quasi-random
controlled
trial (alternate
allocation
according to
order of
entry to
study)
RCT (blocked
randomization, with
2 control
(neurophys):1
intervention
(mixed))
RCT
(stratified
blocked
randomization,
stratified
according
to prognostic
category)

Ozdemir
200146

Pollock
199847

Design

continued

Trial

Table 1

Inadequate

Adequate

Adequate

Adequate

Inadequate

Allocation
concealment

62

91

27

28

60

Number of
participants
randomized

Unclear

Yes

1 year

Not stated

Yes

No

6 weeks

07 days

No

Outcome
assessor
blinded to
group
allocation?

Not stated

Inclusion
criteria: Time
since stroke

Outcome:
global
dependency

(none)

Barthel
Index

Barthel
Index

Orthopaedic
(none)
Mixed
(Orthopaedic
Neurophysiological)

Motor
learning
(mobility)
Placebo
control
(motor
learning,
upper
limb)

(Bobath)

Early Mixed
Early Neurophysiological
(Bobath)
Conventional
Neurophysiological

Neurophysiological
(Bobath)
Mixed
(neurophysiological
motor
learning)

Mixed
(none)
(orthopaedic
neurophysiological)
Control

Treatment
groups

Functional
status
(adapted
from rating
scale)

(none)

Fugl-Meyer
motor
assessment

(none)

Analysis
based on
comparison
of 2 early
groups, as
these 2
groups are
comparable
in terms of
timing and
intensity
Secondary
outcomes
included in
Cochrane
review

Considerable
numbers of
drop-outs not
followed-up

Functional
Intensity of
Independencethe 2
Measure
interventions
(FIM)
varied

Outcome:
Notes
functional
independence

400
A Pollock et al.

RCT (stratified
into patients
with
spasticity
(Brunnstrom
stage 2 or 3)
and patients
with relative
recovery
(Brunnstrom
stage 4 or 5))

RCT
(method of
randomization
not stated)

Wang
200551

Wellmon
199752

Wade
199250

recruited and
randomized.
Additional 12
patients then
selectively
assigned to
even out
differences
in important
characteristics)
RCT (blocked
randomization)

Adequate

Adequate

Adequate

21

44

94

Yes

No

150 days

Yes

Not stated

1 year

Motor
learning
Control
(no
treatment)

Neurophysiological
(Bobath)
Orthopaedic

Mixed
(problem
solving,
community
physiotherapy)
No treatment

(none)

(none)

Barthel
Index
Frenchay
Activities
Index
Nottingham
EADL scale

Rivermead
Comments
Mobility
from peer
Assessment reviewers
for the
updated
version led
to the
inclusion of
this trial
Motor
Data from
Assessment patients
Scale Stroke with
Assessment spasticity
Impairment entered
Set
under Wang
2005, and
data from
patients with
relative
recovery
entered
under Wang
2005a
(none)
No outcomes
included in
analysis

Physiotherapy treatment approaches for stroke

401

402

A Pollock et al.

no outcomes which were included in the analysis. A

further three studies (123 patients)34,35,49 did not
report a measure of disability, although they did
include secondary measures that are analysed in the
Cochrane review.32 These six studies are not included
in the analysis, results or discussion of this paper.
The remaining 14 trials were analysed within the
comparisons of (1) neurophysiological versus other, (2)
motor learning versus other, (3) mixed versus others.
Neurophysiological (Bobath) versus other
Comparisons of neurophysiological approaches
with other approaches were reported in seven studies,
with one of these studies45 comparing a neurophysiological approach to both another approach (motor
learning) and to a control group. The neurophysiological approach used for all seven studies was described
as Bobath. Time of follow-up was four weeks for
Lincoln43 and Wang et al.51, six weeks for Pollock47
and Richards et al.,48 three months for Langhammer
and Stranghelle,42 two weeks after the end of the intervention for Mudie et al.45 and at the time of discharge
for Gelber et al.38
The analyses are displayed in the figures and are
briefly described below.

Figure 1

Global dependency (Figure 1)

The Barthel Index was reported by six of the
trials.42,43,45 (2 comparisons),47,48 No trials compared the
neurophysiological approach with the orthopaedic
approach for global dependency. There were no
significant differences between neurophysiological
approach and motor learning approach (SMD 0.12,
95% CI 0.56 to 0.33), mixed approach (SMD 0.13,
95% CI 0.87 to 0.61) or no treatment/placebo
(SMD 0.71, 95%, CI 0.79 to 0.36), indicating that
there are no significant differences between neurophysiological and other approaches for global
dependency.
Functional independence (Figure 2)
Five trials reported measures of functional independence Gelber et al.38: Functional Independence
Measure (FIM); Langhammer and Stranghelle42 and
Wang et al.51: Motor Assessment Scale (MAS);
Lincoln43 and Richards et al.48: Fugl-Meyer motor
assessment lower limb score. No trials compared the
neurophysiologial approach with no treatment/
placebo for functional independence. There were no
significant differences between neurophysiological
approach and orthopaedic approach (SMD 0.02,
95% CI 0.55 to 0.59), motor learning approach

Neurophysiological versus other approaches; global dependency scale.

Physiotherapy treatment approaches for stroke

Figure 2

403

Neurophysiological versus other approaches; functional independence scale.

(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 neurophysiological and other approaches for
functional independence.

approach (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.

Motor learning (Carr and Shepherd) versus other

Comparisons of motor learning approaches with
other approaches were reported in seven studies. The
motor learning approach used for all seven studies
was described as, or referenced to, Carr and
Shepherd. Time of follow-up was two weeks for
Dean and Shepherd,34 four weeks for Lincoln,43 six
weeks for McClellan and Ada,44 two months for Dean
et al.35 and Salbach et al.49 and three months for
Langhammer and Stranghelle.42
The analyses are displayed in the figures and are
briefly described below.

Functional independence (Figure 4)

Langhammer and Stranghelle,42 Lincoln,43 and
McClellan and Ada44 reported 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
approach and neurophysiological approach (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.

Global dependency (Figure 3)

Langhammer and Stranghelle,42 Lincoln,43 and
Mudie et al.45 reported the Barthel Index. No trials compared the motor learning approach with the orthopaedic
approach or mixed approach for global dependency.
There were no significant differences between the
motor learning approach and neurophysiological

Mixed versus other

Eight studies reported comparisons using a mixed
approach. Time of follow-up was six weeks for
Pollock47 and Richards et al.,48 12 weeks for Duncan
et al.,36,37 Green et al.39 and Wade et al.50 and at the
time of discharge from rehabilitation for Stern et al.24

404

A Pollock et al.

Figure 3

Motor learning versus other approaches; global dependency scale.

Figure 4

Motor learning versus other approaches; functional independence scale.

and Ozdemir et al.46 There is considerable heterogeneity in these data. Stern et al.24 and Ozdemir
et al.46 are both quasi-randomized trials and sensitivity
analyses were therefore planned to explore the effect
of including these studies. As Stern et al.24 was the
only trial comparing a mixed approach with an
orthopaedic approach, it is not combined with any
other trials, and sensitivity analysis was therefore not
necessary.

The analyses displayed in the figures and are briefly

described below:
Global dependency (Figure 5)
Six of the nine studies included measures of global
dependency. The Kenny Institute of Rehabilitation
Scale was used by Stern et al.,24 and the Barthel Index
by Pollock,47 Richards et al.,48 Duncan et al.,36 Green
et al.39 and Wade et al.50 No trials compared the mixed

Physiotherapy treatment approaches for stroke

Figure 5

Mixed versus other approaches; global dependency scale.

Figure 6

Mixed versus other approaches; functional independence scale.

approach with the motor learning approach for global

dependency. There were no significant differences
between mixed approach and neurophysiological
approach (SMD 0.13, 95% CI 0.61 to 0.87),
orthopaedic approach (SMD 0.08, 95% CI 0.42 to
0.58) or no treatment/placebo (SMD 0.05, 95%

405

CI 0.28 to 0.19), indicating that there are no significant differences between mixed and other approaches.
Functional independence (Figure 6)
The Fugl-Meyer motor assessment lower limb
score was used by Richards et al.,48 Duncan et al.36,37;

406

A Pollock et al.

the Rivermead Mobility Index was used by Green

et al.39 and Wade et al.50 and the Functional
Independence Measure was used by Ozdemir et al. 46
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 et al.,36,37 Green et al.,39
Ozdemir et al.46 and Wade et al.50). If Ozdemir
et al.,46 which uses quasi-randomization is removed
from the analysis the result ceases to shows 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 approach and neurophysiological approach
(SMD 0.12, 95% CI 0.91 to 1.16).

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 which aimed to identify the burning questions of Scottish stroke rehabilitation workers, and
which identified different treatment approaches to be
amongst the most burning questions of physiotherapists.53 Hence this review was driven by an identified
clinical question, rather than originating from a scientific and logical standpoint. While the results of this
review may lead to the conclusion that no one physiotherapy treatment approach appears to be more advantageous to the promotion of recovery of lower limb
function or postural control, the difficulties encountered in the methodology of the review 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
control, for the recovery of functional independence.
Data from five trials (427 participants) demonstrated
that a mixed approach was significantly more
favourable than no treatment control in the recovery
of functional independence (SMD 0.94, 95% CI 0.08
to 1.80). One of the five trials did have a number of
methodological limitations.46 Ozdemir et al.,46 which
reported a much more significant result, did not use
random allocation 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 et al.46 removed from
the analysis the result ceases to be significant,
although there is a trend towards significance (SMD
0.28, 95% CI 0.03 to 0.58).
The data analysed in this review provide evidence
that a mixed physiotherapy intervention is significantly favourable to no treatment intervention in the
recovery of functional independence following stroke.
This significant effect arguably demonstrates that
any physiotherapy is better than none.
Limitations
Identification of relevant trials
The identification of all relevant trials was
confounded by a number of factors:

Inconsistent and poorly defined terminology:

Electronic searching was difficult as the names and

content associated with different physiotherapy
treatment approaches are poorly documented,
often have several derivations, and have varied
over time.
Lack of detail within abstract: Lack of information on study methodology, subjects 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 included databases, relevant trials may
have not been identified.
Non-English trials awaiting assessment: Twentysix non-English (23 Chinese) trials are currently
awaiting translation and formal assessment. With
so many studies awaiting assessment, 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.

Quality of included trials

Many of the included trials had methodological
limitations, which may have led to the introduction of

Physiotherapy treatment approaches for stroke

selection bias. Two key methodological factors which
reduced the quality of many of the included trials
were the method of randomization and blinding:

Randomization: Three of the identified studies

did not state the method of randomization36,38,52;

one study divided patients into matched pairs and
then randomly allocated the pairs35; one study used
quasi-random assignment based on order of entry
into the study46; and the method of randomization
of a fifth24 was identified to be potentially unreliable. Questions about the quality of randomization
must challenge the robustness of the study design,
and hence the results of this review.
Blinding and contamination: In the majority of
studies it was unclear whether or not the patients
were blinded to the 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 subjects this could confound
the study results. The treating therapist(s) was not
blinded in any of the trials. This was to be expected
as a treating therapist has to be familiar with the
intervention that they are administering. Therapists
who strongly favoured one approach over another
could introduce performance bias. In several of the
studies the same therapist(s) administered treatment to patients in both study groups: this potentially introduces considerable contamination
between groups. Pollock47 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 effects of lack of
blinding of patients and therapists. Only 13 of the
20 included trials stated that they used a blinded
assessor. The lack of blinding of assessor 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 the limitations of the study methodology, the studies included in the review had considerable heterogeneity within the interventions, outcomes
measures and patient samples.

407

Documentation of interventions
Clear, concise documentation of complex physical
interventions is exceptionally difficult to achieve.
All of the included studies either gave a brief
description of the techniques used, or referenced a
text in which techniques are described in more
detail. Where possible, authors were contacted and
asked 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 documentation is often
insufficient to allow confident and accurate repetition of the applied treatment approach. The problems of documentation 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 patients movement
disorders.
Furthermore, the common basis of the different
physiotherapy approaches are that they are holistic.
All body parts and movements can be assessed and
treated based on the selected approach; however a
physiotherapist may select to concentrate on the
treatment of one particular body part or movement
during a treatment session. Subsequently the treatments given to individual patients by individual therapists may vary enormously. This review attempted
to limit this variation slightly by excluding trials that
had only given interventions to the upper limb.
Nevertheless, although patients receiving treatment
based on a particular approach should receive
an intervention that conforms to the stated philosophy/theory of the approach, it is conceivable that
there were few similarities between the physical
interventions given to patients in the same treatment
group.
The argument that a physiotherapy approach is
based on an individual assessment of a unique
patients movement disorders has been used by some
therapists/researchers to perpetuate limited documentation and standardization. However recent studies
have demonstrated that clear concise documentation
of a treatment intervention does not necessarily mean
the removal of the therapists ability to select a treatment based on an individual patients problems. For
example, Wang et al.,51 within a detailed documentation of the intervention, highlights that the treatments
are individualised, constantly modified according to
subject response.

408

A Pollock et al.

Classification of treatment approaches

The classification of the treatment approaches used in
this review can potentially be criticized for combining
a number of different physiotherapy approaches under
very broad classifications (i.e. neurophysiological,
motor learning, orthopaedic). Subgroup analysis of
the individual named approaches within each classification was planned. However, as all of the neurophysiological approaches were described as
Bobath, and all of the motor learning approaches
are referenced to Carr and Shepherd, this review
cannot by default be criticized for combining a
variety of approaches under one classification heading, as this has not occurred.

The Bobath concept: This review includes eight

trials which stated that they were evaluating a

Bobath approach to stroke therapy. It is important
to note that there is considerable 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 descriptions, and that there is a
variation in the content of current therapy.1921,5456
It is beyond the scope of this review to determine
whether the interventions described as Bobath
had any practical or theoretical differences.
Motor learning and mixed approaches:
Reviewers found most difficulty in distinguishing
between a mixed approach (not a mixture of two
different approaches, such as Stern et al.24 mixing
orthopaedic and neurophysiological approaches,
but an unclassified mix) and a motor learning
approach. The mixed, intensive and focused
approach investigated by Richards et al.48 and the
problem-solving approach investigated by Green
et al.39 and Wade et al.50 had stated philosophies
very similar to that 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. While a motor relearning programme has been described by Carr and
Shepherd,11,14 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.
We suggest that if physiotherapists are to practise
evidence-based stroke rehabilitation their culture, attitudes and beliefs will have to shift away from the use
of compartmentalized approaches to judging the scientific and research base for each individual treatment
technique. This review supports this approach
because it suggests that a mixed approach is more
effective than no treatment and it fails to demonstrate
any superiority for any single approach relating to the
recovery of disability following stroke. Future randomized controlled trials and systematic reviews
should concentrate on investigating clearly defined
and described techniques and task-specific treatments,
and not on compartmentalized approaches.

Clinical messages

No one physiotherapy approach has been

shown to be more advantageous to the promotion of recovery of disability following stroke.
Physiotherapy which uses a mix of components from different approaches may be more
effective than no treatment or placebo control
in the recovery of functional independence
following stroke.

Acknowledgements
The Stroke Therapy Evaluation Programme is
funded by The Big Lottery Fund, and has previously
been funded by Chest Heart and Stroke Scotland and
The Health Foundation.

Competing interests
None.

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