Posts Tagged meta-analysis

[Abstract] Action observation therapy for improving arm function, walking ability, and daily activity performance after stroke: a systematic review and meta-analysis

This study was to investigate the effectiveness of action observation therapy on arm and hand motor function, walking ability, gait performance, and activities of daily living in stroke patients.

Systematic review and meta-analysis of randomized controlled trials.

Searches were completed in January 2019 from electronic databases, including PubMed, Scopus, the Cochrane Library, and OTseeker.

Two independent reviewers performed data extraction and evaluated the study quality by the PEDro scale. The pooled effect sizes on different aspects of outcome measures were calculated. Subgroup analyses were performed to examine the impact of stroke phases on treatment efficacy.

Included were 17 articles with 600 patients. Compared with control treatments, the action observation therapy had a moderate effect size on arm and hand motor outcomes (Hedge’s g = 0.564; P < 0.001), a moderate to large effect size on walking outcomes (Hedge’s g = 0.779; P < 0.001), a large effect size on gait velocity (Hedge’s g = 0.990; P < 0.001), and a moderate to large effect size on activities of daily function (Hedge’s g = 0. 728; P = 0.004). Based on subgroup analyses, the action observation therapy showed moderate to large effect sizes in the studies of patients with acute/subacute stroke or those with chronic stroke (Hedge’s g = 0.661 and 0.783).

This review suggests that action observation therapy is an effective approach for stroke patients to improve arm and hand motor function, walking ability, gait velocity, and daily activity performance.

via Action observation therapy for improving arm function, walking ability, and daily activity performance after stroke: a systematic review and meta-analysis – Tzu-Hsuan Peng, Jun-Ding Zhu, Chih-Chi Chen, Ruei-Yi Tai, Chia-Yi Lee, Yu-Wei Hsieh, 2019

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[Abstract] Effectiveness of electrical stimulation therapy in improving arm function after stroke: a systematic review and a meta-analysis of randomised controlled trials

The aim of this study is to investigate the effectiveness of electrical stimulation in arm function recovery after stroke.

Data were obtained from the PubMed, Cochrane Library, Embase, and Scopus databases from their inception until 12 January 2019. Only randomized controlled trials (RCTs) reporting the effects of electrical stimulation on the recovery of arm function after stroke were selected.

Forty-eight RCTs with a total of 1712 patients were included in the analysis. The body function assessment, Upper-Extremity Fugl-Meyer Assessment, indicated more favorable outcomes in the electrical stimulation group than in the placebo group immediately after treatment (23 RCTs (n = 794): standard mean difference (SMD) = 0.67, 95% confidence interval (CI) = 0.51–0.84) and at follow-up (12 RCTs (n = 391): SMD = 0.66, 95% CI = 0.35–0.97). The activity assessment, Action Research Arm Test, revealed superior outcomes in the electrical stimulation group than those in the placebo group immediately after treatment (10 RCTs (n = 411): SMD = 0.70, 95% CI = 0.39–1.02) and at follow-up (8 RCTs (n = 289): SMD = 0.93, 95% CI = 0.34–1.52). Other activity assessments, including Wolf Motor Function Test, Box and Block Test, and Motor Activity Log, also revealed superior outcomes in the electrical stimulation group than those in the placebo group. Comparisons between three types of electrical stimulation (sensory, cyclic, and electromyography-triggered electrical stimulation) groups revealed no significant differences in the body function and activity.

Electrical stimulation therapy can effectively improve the arm function in stroke patients.

via Effectiveness of electrical stimulation therapy in improving arm function after stroke: a systematic review and a meta-analysis of randomised controlled trials – Jheng-Dao Yang, Chun-De Liao, Shih-Wei Huang, Ka-Wai Tam, Tsan-Hon Liou, Yu-Hao Lee, Chia-Yun Lin, Hung-Chou Chen, 2019

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[Abstract] Upper limb tendon/ muscle vibration in persons with subacute and chronic stroke: a systematic review and meta-analysis

 

INTRODUCTION: Results of several recent studies suggest that tendon/muscle vibration treatment may improve motor performance and reduce spasticity in individuals with stroke. We performed a systematic review and meta-analysis to assess the efficacy of tendon/muscle vibration treatment for upper limb functional movements in persons with subacute and chronic stroke.
EVIDENCE ACQUISITION: We searched MEDLINE (Ovid), EMBASE (Ovid), and the Cochrane Central Register of Controlled Trials (Wiley) from inception to September 2017. We included randomized controlled trials comparing upper limb tendon/muscle vibration to sham treatment/rest or conventional interventions in persons with subacute and chronic stroke. Our primary outcome was upper limb functional movement at the end of the treatment period.
EVIDENCE SYNTHESIS: We included eight trials enrolling a total of 211 participants. We found insufficient evidence to support a benefit for upper limb functional movement (standard mean difference -0.32, 95% confidence interval (CI) -0.74 to 0.10, I2 25%, 6 trials, 135 participants). Movement time for reaching tasks significantly decreased after using tendon/muscle vibration (standard mean difference -1.20, 95% CI -2.05 to -0.35, I2 65%, 2 trials, 74 participants). We also found that tendon/muscle vibration was not associated with a significant reduction in spasticity (4 trials).
CONCLUSIONS: Besides shorter movement time for reaching tasks, we did not identify evidence to support clinical improvement in upper limb functional movements after tendon/muscle vibration treatment in persons with subacute and chronic stroke. A small number of trials were identified; therefore, there is a need for larger, higher quality studies and to consider the clinical relevance of performance-based outcome measures that focus on time tocomplete a functional movement such as a reach.

via Upper limb tendon/ muscle vibration in persons with subacute and chronic stroke: a systematic review and meta-analysis – European Journal of Physical and Rehabilitation Medicine 2019 Mar 11 – Minerva Medica – Journals

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[Abstract] Repetitive transcranial magnetic stimulation of lower limb motor function in patients with stroke: a systematic review and meta-analysis of randomized controlled trials

The aim of this study was to evaluate the effects of repetitive transcranial magnetic stimulation (rTMS) on the post-stroke recovery of lower limb motor function.

We searched the databases of PubMed, Cochrane Library, and Embase. The randomized controlled trials were published by 25 January 2019.

We included randomized controlled trials that evaluated the effects of rTMS on lower limb motor recovery in patients with stroke. Two reviewers independently screened the searched records, extracted data, and assessed the risk of bias. The treatment effect sizes were pooled in a meta-analysis by using the RevMan 5.3 software. The internal validity was assessed using topics suggested by the Physiotherapy Evidence Database (PEDro).

Eight studies with 169 participants were included in the meta-analysis. Pooled estimates demonstrated that rTMS significantly improved the body function of the lower limbs (standardized mean difference (SMD) = 0.66; P < 0.01), lower limb activity (SMD = 0.66; P < 0.01), and motor-evoked potential (SMD = 1.13; P < 0.01). The subgroup analyses results also revealed that rTMS improved walking speed (SMD = 1.13) and lower limb scores on the Fugl-Meyer Assessment scale (SMD = 0.63). We found no significant differences between the groups in different mean post-stroke time or stimulation mode over lower limb motor recovery. Only one study reported mild adverse effects.

rTMS may have short-term therapeutic effects on the lower limbs of patients with stroke. Furthermore, the application of rTMS is safe. However, this evidence is limited by a potential risk of bias.

 

via Repetitive transcranial magnetic stimulation of lower limb motor function in patients with stroke: a systematic review and meta-analysis of randomized controlled trials – Yi-Chun Tung, Chien-Hung Lai, Chun-De Liao, Shih-Wei Huang, Tsan-Hon Liou, Hung-Chou Chen, 2019

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[Abstract] Effectiveness of botulinum toxin treatment for upper limb spasticity after stroke over different ICF domains: a systematic review and meta-analysis.

Abstract

Objective

To provide a comprehensive overview of reported effects and scientific robustness of botulinum toxin (BoNT) treatment regarding the main clinical goals related to post-stroke upper limb spasticity, using the ICF classification.

Data sources

Embase.com, PubMed, Wiley/Cochrane Library, and Ebsco/CINAHL were searched from inception up to 16 May 2018.

Study Selection

Randomized controlled trials comparing upper limb BoNT injections with a control intervention in stroke patients were included. A total of 1212 unique records were screened by two independent reviewers. Forty trials were identified, including 2718 stroke patients.

Data Extraction

Outcome data were pooled according to assessment timing (i.e. 4-8 and 12 weeks after injection), and categorized into six main clinical goals (i.e. spasticity-related pain, involuntary movements, passive joint motion, care ability, arm and hand use, and standing and walking performance). Sensitivity analyses were performed for the influence of study and intervention characteristics, involvement of pharmaceutical industry, and publication bias.

Data Synthesis

Robust evidence is shown for the effectiveness of BoNT in reducing resistance to passive movement, as measured with the (Modified) Ashworth Score, and improving self-care ability for the affected hand and arm after intervention (p<0.005) and at follow-up (p<0.005). In addition, robust evidence is shown for the absence of effect on ‘arm-hand capacity’ at follow-up. BoNT significantly reduced ‘involuntary movements’, ‘spasticity-related pain’, and ‘carer burden’, and improved ‘passive range of motion’, while no evidence was found for ‘arm and hand use’ after intervention.

Conclusions

In view of the robustness of current evidence, no further trials are needed to investigate BoNT for its favourable effects on resistance to passive movement of the spastic wrist and fingers, and on self-care. No trials are needed to further confirm the lack of effects of BoNT on arm-hand capacity, whereas additional trials are needed to establish the suggested favourable effects of BoNT on other ‘body functions’ which may result in clinically meaningful outcomes at ‘activity’ and ‘participation’ levels.

via Effectiveness of botulinum toxin treatment for upper limb spasticity after stroke over different ICF domains: a systematic review and meta-analysis – Archives of Physical Medicine and Rehabilitation

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[Abstract] Mental practice for upper limb motor restoration after stroke: an updated meta-analysis of randomized controlled trials

Abstract

OBJECTIVES:

Stroke is a common refractory disease that may cause dysfunctions in the motor system. The study aimed to evaluate the effects of mental practice (MP) compared with other methods on upper limb motor restoration after stroke.

METHODS:

Eligible studies were identified from Pubmed, Embase, and The Cochrane Library. The study quality was assessed with the Cochrane risk assessment tool and heterogeneity test was performed using I2 statistic and Q test. Random- and fixed-effects models were used and data were reported as weighted mean difference (WMD) and 95% confidence intervals (CIs). The publication bias was examined by Egger’s test and the sensitivity analysis was conducted by ignoring one literature at a time to observe whether this document could reverse the merged results.

RESULTS:

Total of 12 randomized controlled trials were identified. No evidence of publication bias was found. In a fixed-effect model, MP (experimental group) resulted in a significantly larger increase in Fugl-Meyer assessment (FMA) compared with other exercise methods (control group) (WMD = 2.0702, 95% CI: 1.2354-2.905, Z = 4.8606, P < 0.001). In a random-effect model, a significant pooled outcome was obtained for action research arm test (ARAT) (WMD = 4.0936, 95% CI: 1.9900-6.1971, Z = 3.8141, P < 0.001). Sensitivity analysis revealed that the merged WMDs of FMA and ARAT were not reversed.

CONCLUSIONS:

Mental practice is effective on upper limb motor restoration after stroke. It is recommended to treat with MP to improve the outcome of stroke.

 

via Mental practice for upper limb motor restoration after stroke: an updated meta-analysis of randomized controlled trials. – PubMed – NCBI

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[Abstract] The effectiveness of backward walking as a treatment for people with gait impairments: a systematic review and meta-analysis

To investigate the effectiveness of backward walking in the treatment of people with gait impairments related to neurological and musculoskeletal disorders.

Systematic review and meta-analysis of randomized and quasi-randomized control studies.

Searched from the date of inception to March 2018, and included PubMed, Scopus, Cochrane Library, PEDro, CINAHL, and the MEDLINE databases.

Investigating the effects of backward walking on pain, functional disability, muscle strength, gait parameters, balance, stability, and plantar pressure in people with gait impairments. The PEDro scale was used to assess the quality. Similar outcomes were pooled by calculating the standardized mean difference.

Of the 21 studies (neurological 11 and musculoskeletal 10), 635 participants were included. The average PEDro score was 5.4/10. The meta-analysis demonstrated significant standardized mean difference values in favour of backward walking, with conventional physiotherapy treatment for two to four weeks to reduce pain (−0.87) and functional disability (−1.19) and to improve quadriceps strength (1.22) in patients suffering from knee osteoarthritis. The balance and stability in cases of juvenile rheumatoid arthritis, and gait parameters and muscle strength in anterior cruciate ligament injury improved significantly when backward walking was included as an exercise. There was no significant evidence in favour of backward walking in any of the other conditions.

The systematic review and meta-analysis suggests that backward walking with conventional physiotherapy treatment is effective and clinically worthwhile in patients with knee osteoarthritis. Insufficient evidence was available for the remaining gait impairment conditions and no conclusions could be drawn.

 

via The effectiveness of backward walking as a treatment for people with gait impairments: a systematic review and meta-analysis – Tharani Balasukumaran, Benita Olivier, Mokgobadibe Veronica Ntsiea, 2019

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[Systematic Review] Effects of extracorporeal shock wave therapy on spasticity in post-stroke patients: A systematic review and meta-analysis of randomized controlled trials – Full Text

Abstract

Objective: To evaluate whether extracorporeal shock wave therapy significantly improves spasticity in post-stroke patients.

Design: Systematic review and meta-analysis.

Data sources: PubMed, EMBASE, EBSCO, Web of Science, Cochrane CENTRAL electronic databases.

Study selection: Randomized controlled trials assessing the effect of extracorporeal shock wave therapy on post-stroke patients with spasticity were selected for inclusion.

Data extraction: Two authors independently screened the literature, extracted data, and assessed the quality of included studies. Primary outcome was modified Ashworth scale (MAS). Secondary outcomes were Modified Tardieu Scale (MTS), H/M ratio and range of motion.

Data synthesis: Eight randomized controlled trial studies (n = 385 patients) were included in the meta-analysis. There was a high level of evidence that extracorporeal shock wave therapy significantly ameliorates spasticity in post-stroke patients according to the 4 parameters: MAS (standard mean difference (SMD) −1.22; 95% confidence interval (95% CI): −1.77 to −0.66); MTS (SMD 0.70; 95% CI 0.42–0.99,); H/M ratio (weighted mean difference (WMD) –0.76; 95% CI –1.19 to –0.33); range of motion (SMD 0.69; 95% CI 0.06–1.32). However, there was no statically significant difference on the MAS at 4 weeks (SMD –1.73; 95% CI –3.99 to 0.54).

Conclusion: Extracorporeal shock wave therapy has a significant effect on spasticity in post-stroke patients.

 

Lay abstract

The effect of extracorporeal shock wave therapy on spasticity in post-stroke patients has been evaluated in several clinical trials. In addition, a recent meta-analysis suggests that such therapy is effective; however, the measurement of spasticity was based mainly on the modified Ashworth scale, which is insufficient, and a lack of  randomized controlled trials studies in the study design may have biased the results. Therefore, considering the potential limitations of the previous meta-analysis, the aim of the current study was to perform a systematic review and meta-analysis of randomized controlled trials to evaluate the effectiveness of extracorporeal shock wave therapy on spasticity in post-stroke patients. Furthermore, subgroup analysis was performed to identify potential moderators or mediators.

 

Spasticity is a common complication of various neurological diseases, such as stroke, and is often defined as a velocity-dependent increase in muscle tone, with exaggerated tendon jerks, due to hyperexcitability of the stretch reflex (1). Stroke has a high morbidity and sequelae rate. Approximately 80% of stroke patients have motor dysfunction, and spasticity status is considered to be the main determinant of this (2). Approximately 20-–40% of stroke survivors will develop spasticity (3). Futhermore, only 15.6% of post-stroke patients have a clinically relevant degree of spasticity (MAS ≥ 3) (4), and the prevalence of disabling spasticity 1 year after first-ever stroke is 4% (5). Spasticity after stroke not only limits the subject’s limb movements, but also impacts on their ability in activities of daily living (ADL), and seriously reduces quality of life (QoL). Therefore, improving spasticity post-stroke would reduce the rate of disability.

Various therapeutic interventions can be used to reduce spasticity, including botulinum toxin (BTX) injections, pharmacological treatment, physical therapy (electrical stimulation, thermotherapy), occupational therapy, and chemical neurolysis (6–9). Extracorporeal shock waves have been reported to be a potential therapeutic intervention to improve spasticity (10, 11).

Extracorporeal shock waves are a group of mechanical pulse waves characterized by high peak pressure (100 MPa), fast pressurization speed (< 10 ns) and short cycle time (10 μs) (6). The treatments can be divided into focused extracorporeal shock waves (12) and radial extracorporeal shock waves (rESW) (13). rESW is a relatively new technique that was first applied in 1999. Extracorporeal shock wave therapy (ESWT) has been shown to be a safe, effective, non-invasive treatment for spasticity in patients with cerebral palsy, epicondylitis and multiple sclerosis (13–16). Several studies have shown that ESWT is effective for treating spasticity in post-stroke patients (17, 18). Dymarek et al. (19, 20) indicated that ESWT could effectively improve limb spasticity in post-stroke patients. In addition, a recent meta-analysis demonstrated the effectiveness of ESWT for spasticity in post-stroke patients (21). However, this was not a meta-analysis of randomized controlled trials (RCTs), and the quality of the included studies was not high. Considering the potential limitations of this earlier meta-analysis, the aim of the current study was to perform a systematic review and meta-analysis of RCTs to assess whether ESWT significantly improves spasticity in post-stroke patients. Furthermore, subgroup analysis was carried out to identify potential moderators or mediators.

Methods

Data sources

A systematic review and meta-analysis was performed according to the guidelines of the Cochrane Handbook for Systematic Reviews (22) and the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statement (23). PubMed, EMBASE, EBSCO, Web of Science, Cochrane CENTRAL electronic databases were searched systematically from the establishment of the database to December 2017, with the key search terms: “extracorporeal shock wave therapy” and “stroke”. The reference lists of the resulting publications and reviews identified in the initial searches were scanned for further references. The literature search was limited to publications in English.

Selection criteria

The inclusion criteria for selection of studies were: (i) double or single-blind RCTs; (ii) participants with a diagnosis of ischaemic stroke or haemorrhagic stroke who had spasticity of the lower or upper limb with a MAS score >1; (iii) experimental groups treated with ESWT alone or ESWT combined with other interventions; (iv) control groups treated with sham ESWT alone or sham ESWT combined with other interventions; (v) English language publications.

The exclusion criteria were: (i) studies that were not RCTs; (ii) studies in which the participants were children or adolescents (aged less than 18 years); (iii) reviews, case reports/series; (iv) non-English articles; (v) duplicated data; (vi) studies in which relevant outcome indexes were not reported.

 

Data extraction

Two reviewers (WW, WFJ) independently extracted the following data: (i) sample characteristics (sample size, mean age, sex); (ii) clinical features (diagnosis, spasticity at baseline and study end-point); (iii) ESWT therapy protocol (frequency, intensity, site, number of treatment sessions). Study outcome was based on MAS, MTS, H/M ratio and range of motion before and after ESWT.

Risk of bias assessment

The quality of RCTs was assessed independently using the methods recommended by the Cochrane review (24). Two investigators (WW, WFJ) independently assessed the quality of the study, and any disagreements were resolved by discussion and consensus with a third author (QCQ). The quality assessment includes 6 domains: random sequence generation, allocation concealment, blinding of investigators and/or participants, blinding of outcome assessment, degree of incompleteness of outcome data, and selective reporting of study outcomes. Each domain has low, moderate, or high risk.

Statistical analysis

All statistical analyses were conducted using RevMan 5.3 (The Cochrane Collaboration, Software Update, Oxford, UK) and Stata 12.0 (Stata Corp, College Station, TX, USA). All continuous outcomes are expressed as mean differences (standardized and weighted to be determined by available data). Sensitivity analysis was performed to examine the influence of a single study on the overall estimate by omitting 1 study in turn. A p -value <0.05 was considered statistically significant. If p < 0.05 and Ivalue > 50%, the random-effects model was used; otherwise, the fixed effects model was used.[…]

 

Continue —> Journal of Rehabilitation Medicine – Effects of extracorporeal shock wave therapy on spasticity in post-stroke patients: A systematic review and meta-analysis of randomized controlled trials – HTML

Fig. 1. Flowchart for study selection. RCT: randomized controlled trial.

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[Abstract] Effects of transcutaneous electrical nerve stimulation alone or as additional therapy on chronic post-stroke spasticity: systematic review and meta-analysis of randomized controlled trials

Purpose: To evaluate the effects and to compare transcutaneous electrical nerve stimulation protocols, alone or as additional therapy in chronic post-stroke spasticity through a systematic review and meta-analysis of randomized clinical trials.

Methods: Search was conducted in MEDLINE, Cochrane Library, EMBASE and Physiotherapy Evidence Database through November 2017 (CRD42015020146). Two independent reviewers performed articles selection, data extraction and methodological quality assessment using the Cochrane Collaboration’s risk of bias tool. The main outcome was spasticity assessed with Modified Ashworth Scale or other valid scale. Meta-analysis was conducted using random effects method, and pooled-effect results are mean difference with 95% confidence interval.

Results: Of 6506 articles identified, 10 studies with 360 subjects were included in the review. Transcutaneous electrical nerve stimulation alone or as additional therapy is superior to placebo TENS to reduce post-stroke spasticity assessed with Modified Ashworth Scale (−0.52 [−0.74 to −0.30] p < 0.0001, 6 studies), especially in lower limbs (−0.58 [−0.82 to −0.34] p < 0.0001, 5 studies), which is in accordance with the studies that used other scales. Low frequency TENS showed a slightly larger improvement than high-frequency, but without significant difference between subgroups. Most studies present low or unclear risk of bias.

Conclusion: Transcutaneous electrical nerve stimulation can provide additional reduction in chronic post-stroke spasticity, mainly as additional therapy to physical interventions. Studies with better methodological quality and larger sample are needed to increase evidence power.

  • Implications for Rehabilitation
  • Transcutaneous electrical nerve stimulation as additional treatment to physical interventions can lead to additional reduction in chronic post-stroke spasticity.

  • High and low frequency transcutaneous electrical nerve stimulation showed similar results, with a smaller numerical superiority of low frequency TENS.

  • More studies are needed to substantiate the best protocol of transcutaneous electrical nerve stimulation to the treatment of spasticity.

via Effects of transcutaneous electrical nerve stimulation alone or as additional therapy on chronic post-stroke spasticity: systematic review and meta-analysis of randomized controlled trials: Disability and Rehabilitation: Vol 0, No 0

 

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[ARTICLE] Interventions involving repetitive practice improve strength after stroke: a systematic review – Full Text

Article Outline

  1. Introduction
  2. Method
    1. Identification and selection of studies
      1. Participants
      2. Intervention
      3. Comparison
      4. Outcome measures
    2. Assessment of risk of bias
    3. Data extraction and analysis
      1. Sensitivity analyses
      2. Subgroup analyses
  3. Results
    1. Flow of studies through the review
    2. Characteristics of included trials
      1. Risk of bias
      2. Participants
      3. Intervention
      4. Outcome measures
    3. Effects of repetitive practice
      1. Strength
      2. Upper limb activity
      3. Lower limb activity
      4. Subgroup analyses
      5. Post-hoc analysis
      6. Sensitivity analysis
  4. Discussion
  5. Appendix 1. Supplementary data
  6. References

Abstract

Questions

Do interventions involving repetitive practice improve strength after stroke? Are any improvements in strength accompanied by improvements in activity?

Design

Systematic review of randomised trials with meta-analysis.

Participants

Adults who have had a stroke.

Intervention

Any intervention involving repetitive practice compared with no intervention or a sham intervention.

Outcome measures

The primary outcome was voluntary strength in muscles trained as part of the intervention. The secondary outcomes were measures of lower limb and upper limb activity.

Results

Fifty-two studies were included. The overall SMD of repetitive practice on strength was examined by pooling post-intervention scores from 46 studies involving 1928 participants. The SMD of repetitive practice on strength when the upper and lower limb studies were combined was 0.25 (95% CI 0.16 to 0.34, I2 = 44%) in favour of repetitive practice. Twenty-four studies with a total of 912 participants investigated the effects of repetitive practice on upper limb activity after stroke. The SMD was 0.15 (95% CI 0.02 to 0.29, I2 = 50%) in favour of repetitive practice on upper limb activity. Twenty studies with a total of 952 participants investigated the effects of repetitive practice on lower limb activity after stroke. The SMD was 0.25 (95% CI 0.12 to 0.38, I2 = 36%) in favour of repetitive practice on lower limb activity.

Conclusion

Interventions involving repetitive practice improve strength after stroke, and these improvements are accompanied by improvements in activity.

[…]

Continue —>  Interventions involving repetitive practice improve strength after stroke: a systematic review – Journal of Physiotherapy

 

Figure 1

Figure 1
Flow of studies through the review.

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