Review article (meta-analysis)| Volume 92, ISSUE 9, P1490-1500, September 2011

Extra Physical Therapy Reduces Patient Length of Stay and Improves Functional Outcomes and Quality of Life in People With Acute or Subacute Conditions: A Systematic Review

  • Casey L. Peiris
    Reprint requests to Casey L. Peiris, BPhys, Allied Health Clinical Research Office, Level 2, 5 Arnold St, Box Hill, Victoria, Australia 3128
    Musculoskeletal Research Centre and School of Physiotherapy, La Trobe University, Victoria, Australia

    Allied Health Clinical Research Office, Eastern Health Level 2, Victoria, Australia
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  • Nicholas F. Taylor
    Musculoskeletal Research Centre and School of Physiotherapy, La Trobe University, Victoria, Australia

    Allied Health Clinical Research Office, Eastern Health Level 2, Victoria, Australia
    Search for articles by this author
  • Nora Shields
    Musculoskeletal Research Centre and School of Physiotherapy, La Trobe University, Victoria, Australia
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      Peiris CL, Taylor NF, Shields N. Extra physical therapy reduces patient length of stay and improves functional outcomes and quality of life in people with acute or subacute conditions: a systematic review.


      To investigate whether extra physical therapy intervention reduces length of stay and improves patient outcomes in people with acute or subacute conditions.

      Data Sources

      Electronic databases CINAHL, MEDLINE, AMED, PEDro, PubMed, and EMBASE were searched from the earliest date possible through May 2010. Additional trials were identified by scanning reference lists and citation tracking.

      Study Selection

      Randomized controlled trials evaluating the effect of extra physical therapy on patient outcomes were included for review. Two reviewers independently applied the inclusion and exclusion criteria, and any disagreements were discussed until consensus could be reached. Searching identified 2826 potentially relevant articles, of which 16 randomized controlled trials with 1699 participants met inclusion criteria.

      Data Extraction

      Data were extracted using a predefined data extraction form by 1 reviewer and checked for accuracy by another. Methodological quality of trials was assessed independently by 2 reviewers using the PEDro scale.

      Data Synthesis

      Pooled analyses with random effects model to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs) were used in meta-analyses. When compared with standard physical therapy, extra physical therapy reduced length of stay (SMD=−.22; 95% CI, −.39 to −.05) (mean difference of 1d [95% CI, 0–1] in acute settings and mean difference of 4d [95% CI, 0–7] in rehabilitation settings) and improved mobility (SMD=.37; 95% CI, .05–.69), activity (SMD=.22; 95% CI, .07–.37), and quality of life (SMD=.48; 95% CI, .29–.68). There were no significant changes in self-care (SMD=.35; 95% CI, −.06–.77).


      Extra physical therapy decreases length of stay and significantly improves mobility, activity, and quality of life. Future research could address the possible benefits of providing extra services from other allied health disciplines in addition to physical therapy.

      Key Words

      List of Abbreviations:

      ADLs (activities of daily living), CI (confidence interval), PT (physical therapy), SF-36 (Medical Outcomes Study 36-Item Short-Form Health Survey), SMD (standardized mean difference)
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        • Borghans I.
        • Heijink R.
        • Kool T.
        • Lagoe R.J.
        • Westesrt G.P.
        Benchmarking and reducing length of stay in Dutch hospitals.
        BMC Health Serv Res. 2008; 8: 220-229
        • Clarke A.
        • Rosen R.
        Length of stay.
        Eur J Public Health. 2001; 11: 166-170
        • Chen C.C.
        • Heinemann A.W.
        • Granger C.V.
        • Linn R.T.
        Functional gains and therapy intensity during subacute rehabilitation: a study of 20 facilities.
        Arch Phys Med Rehabil. 2002; 83: 1514-1523
        • Brusco N.K.
        • Paratz J.
        The effect of additional physiotherapy to hospital inpatients outside of regular business hours: a systematic review.
        Physiotherapy. 2006; 22: 291-307
        • Kwakkel G.
        • van Peppen R.
        • Wagenaar R.C.
        • et al.
        Effects of augmented exercise therapy time after stroke: a meta-analysis.
        Stroke. 2004; 35: 2529-2539
        • Sackett D.L.
        • Straus S.E.
        • Richardson W.S.
        • Rosenburg W.
        • Haynes R.B.
        Evidence-based medicine.
        Churchill Livingstone, Edinburgh2000
        • Moher D.
        • Jadad A.R.
        • Nichol G.
        • Penman M.
        • Tugwell P.
        • Walsh S.
        Assessing the quality of randomized controlled trials: an annotated bibliography of scales and checklists.
        Control Clin Trials. 1995; 16: 62-73
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        J Clin Epidemiol. 2009; 62: e1-e34
      1. Who are physical therapists, and what do they do?.
        Phys Ther. 2001; 77 (Anonymous): 1177-1187
        • Centre for Evidence-Based Physiotherapy 2010
        The physiotherapy evidence database (PEDro).
        (Accessed June 14, 2010)The physiotherapy evidence database (PEDro) scale items. Centre for Evidence-Based Physiotherapy, 2010
        • Verhagen A.P.
        • De Vet H.
        • De Bie R.
        • et al.
        The Delphi list: a criteria list for quality assessment of randomized controlled clinical trials for conducting systematic reviews developed by Delphi consensus.
        J Clin Epidemiol. 1998; 5: 1235-1241
        • de Morton N.A.
        The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study.
        Aust J Physiother. 2009; 55: 129-133
        • Maher C.G.
        A systematic review of workplace interventions to prevent low back pain.
        Aust J Physiother. 2000; 46: 259-269
        • Cochrane Collaboration
        Data extraction template for Cochrane reviews 2010.
        (Accessed May 3, 2010)
        • Salter K.
        • Jutai J.W.
        • Teasell R.
        • Foley N.C.
        • Bitensky J.
        Issues for selection of outcome measures in stroke rehabilitation: ICF Body Functions.
        Disabil Rehabil. 2005; 27: 191-207
        • Hozo S.P.
        • Djulbegovic B.
        • Hozo I.
        Estimating the mean and variance from the median, range, and the size of a sample.
        BMC Med Res Methodol. 2005; 5: 13
      2. Higgins J.P.T. Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.2. The Cochrane Collaboration, 2009 (Accessed May 10, 2010)
        • Nouri F.M.
        • Lincoln N.B.
        An extended activities of daily living scale for stroke patients.
        Clin Rehabil. 1987; 1: 301-305
        • Cohen J.
        The statistical power of abnormal-social psychological research: a review.
        J Abnorm Soc Psychol Res. 1962; 65: 145-153
        • Higgins J.
        • Thompson S.
        • Deeks J.
        • Altman D.G.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
        • Richards C.L.
        • Malouin F.
        • Wood-Dauphinee S.
        • Williams J.I.
        • Bouchard J.P.
        • Brunet D.
        Task-specific physical therapy for optimization of gait recovery in acute stroke patients.
        Arch Phys Med Rehabil. 1993; 74: 612-620
        • Ruff R.M.
        • Yarnell S.
        • Marinos J.M.
        Are stroke patients discharged sooner if in-patient rehabilitation services are provided seven v six days per week?.
        Am J Phys Med Rehabil. 1999; 78: 143-146
        • Smith D.S.
        • Goldenberg E.
        • Ashburn A.
        • et al.
        Remedial therapy after stroke: a randomised controlled trial.
        Br Med J (Clin Res Ed). 1981; 282: 517-520
        • Bernhardt J.
        • Dewey H.
        • Thrift A.
        • Collier J.
        • Donnan G.
        A very early rehabilitation trial for stroke (AVERT): phase II safety and feasibility.
        Stroke. 2008; 39: 390-396
        • Brusco N.K.
        • Shields N.
        • Taylor N.F.
        • Paratz J.
        A Saturday physiotherapy service may decrease length of stay in patients undergoing rehabilitation in hospital: a randomised controlled trial.
        Aust J Physiother. 2007; 53: 75-81
        • Glasgow Augmented Physiotherapy Study
        Can augmented physiotherapy input enhance recovery of mobility after stroke?.
        Clin Rehabil. 2004; 18: 529-537
        • Lenssen A.F.
        • Crijns Y.H.
        • Waltje E.M.
        • et al.
        Efficiency of immediate postoperative inpatient physical therapy following total knee arthroplasty: an RCT.
        BMC Musculoskelet Disord. 2006; 7: 71
        • Partridge C.
        • Mackenzie M.
        • Edwards S.
        • et al.
        Is dosage of physiotherapy a critical factor in deciding patterns of recovery from stroke: a pragmatic randomized controlled trial.
        Physiother Res Int. 2000; 5: 230-240
        • Dorman P.J.
        • Slattery J.
        • Farrell B.
        • Dennis M.
        • Sandercock P.
        Qualitative comparison of the reliability of health status assessments with the EuroQOL and SF-36 questionnaires after stroke.
        Stroke. 1998; 29: 63-68
        • Aitken D.M.
        • Bohannon R.W.
        Functional independence measure versus short form-36: relative responsiveness and validity.
        Int J Rehabil Res. 2001; 24: 65-68
        • Hirschhorn A.D.
        • Richards D.
        • Mungovan S.
        • Morris N.R.
        • Adams L.
        Supervised moderate intensity exercise improves distance walked at hospital discharge following coronary artery bypass graft surgery—a randomised controlled trial.
        Heart Lung Circ. 2008; 17: 129-138
        • van der Peijl I.D.
        • Vliet Vlieland T.P.
        • Versteegh M.I.
        • Lok J.J.
        • Munneke M.
        • Dion R.A.
        Exercise therapy after coronary artery bypass graft surgery: a randomized comparison of a high and low frequency exercise therapy program.
        Ann Thorac Surg. 2004; 77: 1535-1541
        • Bischoff-Ferrari H.A.
        • Dawson-Hughes B.
        • Platz A.
        • et al.
        Effect of high-dosage cholecalciferol and extended physiotherapy on complications after hip fracture.
        Arch Intern Med. 2010; 170: 813-820
        • Candrilli S.
        • Mauskopf J.
        How much does a hospital day cost?.
        (Proceedings of the 11th Annual International Meeting of the International Society for Pharmacoeconomics and Outcomes Research; 2006 May 20-24, Philadelphia, PA) (Accessed November 11, 2010)
        • Jensen G.M.
        • Gwyer J.
        • Hack L.
        • Shepard K.
        Expertise in physical therapy practice.
        Butterworth-Heinemann, Boston1999
        • Norman G.R.
        • Sloan J.A.
        • Wyrwich K.W.
        Interpretation of changes in health related quality of life.
        The remarkable universality of half a standard deviation Med Care. 2003; 41: 582-592
        • Slade A.
        • Tennant A.
        • Chamberlain A.
        A randomised controlled trial to determine the effect of intensity of therapy upon length of stay in a neurological rehabilitation setting.
        J Rehabil Med. 2002; 34: 260-266
        • Craig J.
        • Young C.A.
        • Ennis M.
        • Baker G.
        • Boggild M.
        A randomised controlled trial comparing rehabilitation against standard therapy in multiple sclerosis patients receiving intravenous steroid treatment.
        J Neurol, Neurosurg, Psychiatr. 2003; 74: 1225-1230
        • Lincoln N.B.
        • Parry R.H.
        • Vass C.D.
        Randomized, controlled trial to evaluate increased intensity of physiotherapy treatment of arm function after stroke.
        Stroke. 1999; 30: 573-579
        • Martinsson L.
        • Eksborg S.
        • Wahlgren N.G.
        Intensive early physiotherapy combined with dexamphetamine treatment in severe stroke: a randomized, controlled pilot study.
        Cerebrovasc Dis. 2003; 16: 338-345
        • Sivenius J.
        • Pyorala K.
        • Heinonen O.P.
        • Salonen J.T.
        • Riekkinen P.
        The significance of intensity of rehabilitation of stroke – a controlled trial.
        Stroke. 1985; 16: 928-931
        • Stockton K.A.
        • Mengersen K.A.
        Effect of multiple physiotherapy sessions on functional outcomes in the initial postoperative period after primary total hip replacement: a randomized controlled trial.
        Arch Phys Med Rehabil. 2009; 90: 1652-1657
        • Allison R.
        • Dennett R.
        Pilot randomized controlled trial to assess the impact of additional supported standing practice on functional ability post stroke [with consumer summary].
        Clin Rehabil. 2007; 21: 614-619
        • Borello-France D.F.
        • Downey P.A.
        • Zyczynski H.M.
        • Rause C.R.
        • Borello-France D.F.
        • Downey P.A.
        • et al.
        Continence and quality-of-life outcomes 6 months following an intensive pelvic-floor muscle exercise program for female stress urinary incontinence: a randomized trial comparing low- and high-frequency maintenance exercise.
        Phys Ther. 2008; 88: 1545-1553
        • Britton E.
        • Harris N.
        • Turton A.
        An exploratory randomized controlled trial of assisted practice for improving sit-to-stand in stroke patients in the hospital setting [with consumer summary].
        Clin Rehabil. 2008; 22: 458-468
        • Chang W.
        • Yang Y.
        • Hsu L.
        • Chern C.
        • Wang R.
        Balance improvement in patients with benign paroxysmal positional vertigo.
        Clin Rehabil. 2008; 22: 338-347
        • de Lateur B.J.
        • Magyar-Russell G.
        • Bresnick M.G.
        • Bernier F.A.
        • Ober M.S.
        • Krabak B.J.
        • et al.
        Augmented exercise in the treatment of deconditioning from major burn injury.
        Arch Phys Med Rehab. 2007; 88: S18-S23
        • de Morton N.A.
        • Keating J.L.
        • Berlowitz D.J.
        • Jackson B.
        • Lim W.K.
        Additional exercise does not change hospital or patient outcomes in older medical patients: a controlled clinical trial.
        Aust J Physiother. 2007; 53: 105-111
        • Donald I.P.
        • Pitt K.
        • Armstrong E.
        • Shuttleworth H.
        Preventing falls on an elderly care rehabilitation ward [with consumer summary].
        Clin Rehabil. 2000; 14: 178-185
        • Dromerick A.W.
        • Lang C.E.
        • Birkenmeier R.L.
        • Wagner J.M.
        • Miller J.P.
        • Videen T.O.
        • et al.
        Very Early Constraint-Induced Movement during Stroke Rehabilitation (VECTORS): A single-center RCT.
        Neurology. 2009; 73: 195-201
        • Fang Y.
        • Chen X.
        • Li H.
        • Lin J.
        • Huang R.
        • Zeng J.
        A study on additional early physiotherapy after stroke and factors affecting functional recovery [with consumer summary].
        Clin Rehabil. 2003; 17: 608-617
        • Gilbey H.J.
        • Ackland T.R.
        • Wang A.W.
        • Morton A.R.
        • Trouchet T.
        • Tapper J.
        Exercise improves early functional recovery after total hip arthroplasty.
        Clin Orthop. 2003; 408: 193-200
        • Giovannelli M.
        • Borriello G.
        • Castri P.
        • Prosperini L.
        • Pozzilli C.
        Early physiotherapy after injection of botulinum toxin increases the beneficial effects on spasticity in patients with multiple sclerosis [with consumer summary].
        Clin Rehabil. 2007; 21: 331-337
        • Grasel E.
        • Schmidt R.
        • Biehler J.
        • Schupp W.
        Long-term effects of the intensification of the transition between inpatient neurological rehabilitation and home care of stroke patients.
        Clin Rehabil. 2006; 20: 577-583
        • Haines T.P.
        • Hill K.D.
        • Bennell K.L.
        • Osborne R.H.
        • Haines T.P.
        • Hill K.D.
        • et al.
        Additional exercise for older subacute hospital inpatients to prevent falls: benefits and barriers to implementation and evaluation.
        Clin Rehabil. 2007; 21: 742-753
        • Howe T.E.
        • Taylor I.
        • Finn P.
        • Jones H.
        Lateral weight transference exercises following acute stroke: a preliminary study of clinical effectiveness [with consumer summary].
        Clin Rehabil. 2005; 19: 45-53
        • Kammerlind A.S.
        • Ledin T.E.
        • Odkvist L.M.
        • Skargren E.I.
        Effects of home training and additional physical therapy on recovery after acute unilateral vestibular loss–a randomized study.
        Clin Rehabil. 2005; 19: 54-62
        • Kim J.R.
        • Oberman A.
        • Fletcher G.F.
        • Lee J.Y.
        Effect of exercise intensity and frequency on lipid levels in men with coronary heart disease: Training Level Comparison Trial.
        Am J Cardiol. 2001; 87 (A3): 942-946
        • Klaber Moffett J.A.
        • Jackson D.A.
        • Richmond S.
        • Hahn S.
        • Coulton S.
        • Farrin A.
        • et al.
        Randomised trial of a brief physiotherapy intervention compared with usual physiotherapy for neck pain patients: outcomes and patients' preference [with consumer summary].
        BMJ. 2005; 330: 75-78
        • Kwakkel G.
        • Wagenaar R.C.
        Effect of duration of upper- and lower-extremity rehabilitation sessions and walking speed on recovery of interlimb coordination in hemiplegic gait.
        Phy Ther. 2002; 82: 432-448
        • Langhammer B.
        • Stanghelle J.K.
        • Lindmark B.
        An evaluation of two different exercise regimes during the first year following stroke: a randomised controlled trial.
        Physioth Theory and Practice. 2009; 25: 55-68
        • Moseley A.
        • Sherrington C.
        • Lord S.
        • Barraclough E.
        • St G.R.
        • Cameron I.
        Mobility training after hip fracture: A randomised controlled trial.
        Age Ageing. 2009; 38: 74-80
        • Ntoumenopoulos G.
        • Greenwood K.
        Effects of cardiothoracic physiotherapy on intrapulmonary shunt in abdominal surgical patients.
        Aust J Phys. 1996; 42: 297-303
        • Platz T.
        • Eickhof C.
        • van K.S.
        • Engel U.
        • Pinkowski C.
        • Kalok S.
        • et al.
        Impairment-oriented training or Bobath therapy for severe arm paresis after stroke: a single-blind, multicentre randomized controlled trial.
        Clin Rehabil. 2005; 19: 714-724
        • Rau B.
        • Bonvin F.
        • de Bie R.
        Short-term effect of physiotherapy rehabilitation on functional performance of lower limb amputees.
        Prosthet Orthot Int. 2007; 31: 258-270
        • Rodgers H.
        • Mackintosh J.
        • Price C.
        • Wood R.
        • McNamee P.
        • Fearon T.
        • et al.
        Does an early increased-intensity interdisciplinary upper limb therapy programme following acute stroke improve outcome? [with consumer summary].
        Clin Rehabil. 2003; 17: 579-589
        • Sunderland A.
        • Tinson D.J.
        • Bradley E.L.
        • Fletcher D.
        • Langton Hewer R.
        • Wade D.T.
        Enhanced physical therapy improves recovery of arm function after stroke.
        J Neurol, Neurosurg, Psychiatr. 1992; 55: 530-535
        • Winett R.A.
        • Goodman J.M.
        • Marzolini S.
        Are multiple sets and usual aerobic training recommended for treatment of CHD?.
        Med Sci Sports Exerc. 2009; 41: 732-733