Stroke is the leading cause of long-term even permanent disability and a second leading cause of death worldwide[1]. Moreover, the incidence of stroke occurred as an increasing trend in the young[2]. In the long term, 25–74% of patients have to rely on human assistance for basic ADLs like feeding, self-care, and mobility[3]. Because of declining fatality, together with the aging population and improvements in acute care[4], the prevalence of stroke is likely to increase in the future, and a growing number of individuals will have to deal with stroke-related disability[5]. The most widely recognized impairment caused by stroke is motor impairment, which restricts function in muscle movement or mobility[6]. Over 70% of stroke survivors have motor or other neurological functional disabilities[7], almost 64% cannot walk independently, even after rehabilitation[8], up to 85% of stroke survivors have hemiparesis that affects gait speed, among a hardy group of stroke survivors, much of the improvement in impairment and disability occurs during the first month and then reaches a plateau[9]. And thus handicap continues to be the main issue that results in difficulties in daily life, greater dependence and social isolation, as well as poorer quality of life. As we know, motor function plays a critical role in human daily lives. Stroke is a serious health issue that requires both immediate and long-term medical attention. It is expected that the burden of stroke further increases until effective stroke prevention strategies are more widely implemented. Most people (83%) survive but experience damage to their motor skills[10]. Physiotherapy (PT) is one of the key disciplines in interdisciplinary poststroke rehabilitation. Complementary to pharmacotherapy and neurosurgical treatments, the aim of physiotherapy is to improve multiple damaged-function, including physical capacity or activity, gait, posture, strength, transfers, coordination, endurance, balance and flexibility and so on[11–17].
It is assumed that interdisciplinary complex rehabilitation interventions[18, 19] would play a role as the mainstay of poststroke care[20, 21]. Physical therapy, as one of the key disciplines in interdisciplinary stroke rehabilitation[21]. Physiotherapy is composed of many different modalities and novel physiotherapy interventions are continuously being developed and applied in the clinic. Examples include Tai Chi[22] and Yoga[23] .We can found many small, randomized, clinical trials (RCT) that have studied interventions in the acute rehabilitation phase, but can barely read the reports focused on the chronic recovery phase in people with stroke[24, 25]. The recommendations in the first Dutch evidence-based ‘Clinical Practice Guideline for physical therapy in patients with stroke were based on meta-analyses of 123 randomized controlled trials (RCTs) and date back to 2004, in none of the studies was blinding possible for patient or therapist, and only 72 of the 123 RCTs had blinded the observer[26]. In view of the tremendous growth in the number of RCTs in this field and the methodological quality for RCTs is markedly improved, therefore, it is now necessary to update the ‘‘state of the art’’ concerning the evidence for physical therapy interventions in stroke rehabilitation. This aim is in line with the 2006 Helsingborg Declaration on European Stroke Strategies, which states that stroke rehabilitation should be based on evidence as much as possible[27, 28] .
During the past few decades, numerous studies have evaluated the effectiveness of the various physiotherapy modalities[17], in comparisons across different interventions on different limbs. For example, Electromechanical-assisted gait training for walking[6, 29] and Task-oriented physical fitness training for walking[30, 31] have been reported to be beneficial for the lower paretic limb. However, the methodologies applied in these studies were highly variable and many different even controversial outcomes for motor function were delivered in the program of different timing and intensity of acute rehabilitation. Due to these inconsistencies, it is necessary to up-to-date the understanding of this field for interpreting the available evidence and providing clear and concise treatment recommendations to people with stroke, which would help to refine strategies for primary intervention and to inform the design of future clinical trials.
Here, we aim to evaluate the effectiveness of multiple physiotherapy modalities, conventional physiotherapy, resistance training, treadmill training, strategy training, dance, martial arts, environmental enrichment, aerobic exercises, hydrotherapy, balance and gait training, dual tasking, exergaming, and Nordic walking by means of a meta-analysis and focus on motor function recovery of the motor function of stroke survivors.
According to our knowledge of the literature, ample summary of the efficacy of various interventions in stroke patients can be found in published systematic reviews and meta-analysis. In addition, since 2014 the most comprehensive meta-analysis so far was published[17], many new studies have been reported, creating a much larger body of evidence. We can find some guidelines of different physical activities for stroke servivors, however, the guideline of Physiotherapy for stroke in the chronic recovery phase cannot be found so far. Even in the most recent Guidelines for Adult Stroke Rehabilitation and Recovery released by the American Heart Association and the American Stroke Association in 2016[32], we cannot find the recommendation in the subacute recovery phase following stroke which greatly increased the difficulty of clinical work.
In short, the goal of our comprehensive review is to provide an overview involving: (1) To evaluate the effectiveness of various physiotherapy interventions on motor function; (2) To identify which areas require further research.