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

      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.

      Objectives

      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).

      Conclusions

      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)
      REDUCING PATIENT LENGTH of stay is a high priority for health service providers, and a short length of stay is considered to be an indicator of efficiency.
      • Borghans I.
      • Heijink R.
      • Kool T.
      • Lagoe R.J.
      • Westesrt G.P.
      Benchmarking and reducing length of stay in Dutch hospitals.
      • Clarke A.
      • Rosen R.
      Length of stay How short should hospital care be?.
      In addition to providing therapy, physical therapists have an important role in acute hospitals and rehabilitation centers to assist with discharge planning and to ensure that patients have adequate mobility to be safely discharged. Extra physical therapy (PT), defined as longer PT sessions or more frequent PT sessions, may have a positive effect on patient outcomes. If the benefit of providing extra PT outweighs the cost of providing this service, it may contribute to increased health service efficiency so that patients can achieve good functional outcomes earlier and discharge can occur sooner. From a health service perspective, it is important to determine whether extra PT services, provided to patients with a variety of health conditions, will improve health service efficiency.
      Previous studies have provided inconclusive or limited evidence that extra PT may contribute to increased functional gains.
      • 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.
      • Brusco N.K.
      • Paratz J.
      The effect of additional physiotherapy to hospital inpatients outside of regular business hours: a systematic review.
      • Kwakkel G.
      • van Peppen R.
      • Wagenaar R.C.
      • et al.
      Effects of augmented exercise therapy time after stroke: a meta-analysis.
      Observational data from 20 rehabilitation facilities reported that functional gains were significantly, albeit weakly, associated with therapy intensity (defined as total therapy time divided by length of stay) and longer duration of rehabilitation.
      • 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.
      A systematic review by Kwakkel et al
      • Kwakkel G.
      • van Peppen R.
      • Wagenaar R.C.
      • et al.
      Effects of augmented exercise therapy time after stroke: a meta-analysis.
      found that extra exercise therapy time after stroke had a small positive effect on activities of daily living (ADLs) and walking speed. The Kwakkel review included trials that examined the effect of specific therapy types (eg, facilitation exercise techniques when added to standard PT) and was conducted more than 7 years ago. Brusco and Paratz
      • Brusco N.K.
      • Paratz J.
      The effect of additional physiotherapy to hospital inpatients outside of regular business hours: a systematic review.
      studied the effects of additional PT given outside regular business hours, in a systematic review of 9 trials. Their results were inconclusive, and the review included poor-quality trials and a limited number of randomized controlled trials. Randomized controlled trials are preferred in systematic reviews of interventions because they are the study design that has the least chance of bias.
      • Sackett D.L.
      • Straus S.E.
      • Richardson W.S.
      • Rosenburg W.
      • Haynes R.B.
      Evidence-based medicine.
      • 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.
      Therefore, previous reviews have analyzed the effects of extra exercise in stroke
      • Kwakkel G.
      • van Peppen R.
      • Wagenaar R.C.
      • et al.
      Effects of augmented exercise therapy time after stroke: a meta-analysis.
      and PT given outside business hours,
      • Brusco N.K.
      • Paratz J.
      The effect of additional physiotherapy to hospital inpatients outside of regular business hours: a systematic review.
      but we were unable to locate any reviews that have synthesized data on the effect of providing extra PT on length of stay and the outcomes of patients with a variety of health conditions receiving PT intervention from a health service perspective. In recent years, new randomized controlled trials have been conducted that aim to evaluate the effect of extra PT on a variety of conditions.
      The primary aim of this review was to evaluate the current evidence for providing extra PT time to people with an acute or subacute condition to improve patient outcomes and reduce length of stay.

      Methods

      This review was conducted and reported with reference to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for high-quality reporting of systematic reviews and meta-analyses.
      • 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.

      Identification and Selection of Trials

      The search strategy combined search terms and synonyms for 2 main concepts: PT and the amount of therapy (available on request). The following electronic databases were searched from the earliest date available until May 12, 2010: CINAHL, MEDLINE, AMED, PEDro, PubMed, and EMBASE. Manual scanning of reference lists of included studies and previous systematic reviews and citation tracking (using Google Scholar to track citations of included trials) were also conducted to ensure all relevant trials were identified. Two reviewers (C.L.P., N.F.T.) independently applied the inclusion and exclusion criteria to the titles and abstracts of all captured trials, and those that clearly did not meet the criteria were excluded. Any disagreements were resolved by discussion between the 2 reviewers, and if consensus could not be reached, a third reviewer was consulted. Where it was uncertain whether the trial met the inclusion criteria, the full-text copies of the trials were obtained for review.

      Inclusion criteria

      The trials had to be randomized controlled trials comparing extra PT with a standard amount of PT for adult patients (aged ≥18y, with no upper limit) after an acute event, treated in an acute or rehabilitation setting. For the purpose of this review, PT refers to any PT intervention as described by the American Physical Therapy Association.
      Who are physical therapists, and what do they do?.
      We excluded risk factor management in conditions such as hypertension, obesity, osteoporosis, and heart disease, as well as the evaluation of exercise protocols in healthy people, but included trials that evaluated an acute exacerbation of a chronic condition receiving management in an acute or rehabilitation setting. Experimental group intervention had to be delivered or supervised by a physical therapist and had to consist of an increased amount (session length or frequency of sessions) of the same intervention the comparison group was receiving. Trials were excluded if they evaluated the effect of a specific therapy in addition to usual PT (such as adding acupuncture, upper limb exercises, or gait training), because it would be difficult to determine whether any differences were due to the specific therapy or receiving extra therapy. Trials were also excluded if the comparison group did not receive any PT.

      Assessment of Characteristics of Trials

      Quality assessment of trials and risk of bias

      All trials were critically appraised for methodological quality and risk of bias by 2 reviewers independently (C.L.P., N.F.T.) using the PEDro scale.
      Centre for Evidence-Based Physiotherapy 2010
      The physiotherapy evidence database (PEDro).
      The PEDro scale, based on the Delphi list described by Verhagen et al,
      • 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.
      is an 11-item scale assessing eligibility criteria, random allocation, concealed allocation, similarity at baseline, participant blinding, therapist blinding, assessor blinding, greater than 85% retention, intention-to-treat analysis, between-group statistical comparisons and point measures, and measures of variability. Each item that is satisfied according to standardized scoring criteria contributes 1 point to the total score (range, 0–10). The first item, which relates to external validity, is not scored. The PEDro scale has demonstrated evidence of validity as a measure of methodological quality of clinical trials.
      • de Morton N.A.
      The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study.
      Trials with a PEDro score of less than 4 out of 10 are considered to be of lower quality.
      • Maher C.G.
      A systematic review of workplace interventions to prevent low back pain.
      Interrater agreement was recorded, and any disagreements were resolved through discussion between the 2 reviewers. If consensus could not be reached, a third reviewer was consulted. Trials were not excluded based on their risk of bias.

      Data extraction

      We developed a data extraction form a priori based on the Cochrane Consumers and Communication Review Group's data extraction template,
      Cochrane Collaboration
      Data extraction template for Cochrane reviews 2010.
      which was revised to suit our review (available on request). The form was pilot-tested on a random selection of 5 included trials and subsequently refined. One reviewer (C.L.P.) independently extracted data, and the second reviewer (N.F.T.) checked extracted data for accuracy. If any discrepancies were evident, the reviewers referred back to the original trial report. Attempts were made to contact the authors of any trial with missing data. Information was extracted from each trial on participants' characteristics (age, sex), patient population (cardiac, neurologic, orthopedic), and trial setting (acute, rehabilitation, inpatient, outpatient); intervention (type, duration, frequency for experimental and comparison group); outcomes (primary and secondary outcomes, type of outcome measures, timing of assessment); results; adverse events; and patient satisfaction with the amount of therapy received. Outcome measures were classified according to the International Classification of Functioning, Disability, and Health domains of body function, activity, and participation according to the description by Salter et al.
      • Salter K.
      • Jutai J.W.
      • Teasell R.
      • Foley N.C.
      • Bitensky J.
      Issues for selection of outcome measures in stroke rehabilitation: ICF Body Functions.
      Based on Salter's definition, measures of walking ability were considered measures of body function, and quality-of-life measures were considered to represent participation.
      • Salter K.
      • Jutai J.W.
      • Teasell R.
      • Foley N.C.
      • Bitensky J.
      Issues for selection of outcome measures in stroke rehabilitation: ICF Body Functions.

      Data analysis

      Standardized mean differences (SMDs; effect sizes) were calculated for the outcomes based on postintervention means and the pooled estimate of postintervention SDs, by using Hedges' g. Because it is necessary to use mean and SD values when calculating the SMD, some values had to be transformed using methods suggested by Hozo et al
      • Hozo S.P.
      • Djulbegovic B.
      • Hozo I.
      Estimating the mean and variance from the median, range, and the size of a sample.
      and Higgins and Green.
      Where outcome data were measured at different times in the experimental and comparison groups depending on length of stay, data were transformed to change per day (n=3 trials). The earliest available data were used for calculation of SMDs (as this would be less subject to other variables such as time and additional therapy outside the trial), unless it was suggested that an outcome measure was more suited to a longer time frame (eg, extended ADL score, which is used to assess a person's ability when he/she has been discharged home after a stroke
      • Nouri F.M.
      • Lincoln N.B.
      An extended activities of daily living scale for stroke patients.
      ). Where weighted means were calculated, these were weighted according to participant numbers in each trial.
      Meta-analyses were performed with a random-effects model for outcomes using inverse variance methods (RevMan, Version 5.0).
      The Cochrane IMS. Available at: http://ims.cochrane.org/revman.
      The strength of the SMD was determined descriptively according to Cohen,
      • Cohen J.
      The statistical power of abnormal-social psychological research: a review.
      with 0.2 considered small, 0.5 as moderate, and 0.8 as a large effect. Trial results data were only pooled if they fitted into common functional outcome categories of length of stay, walking ability, activity, self-care, and quality of life.
      Statistical heterogeneity was assessed using the I2 statistic, with values of more than 50% representing substantial levels of heterogeneity.
      • Higgins J.
      • Thompson S.
      • Deeks J.
      • Altman D.G.
      Measuring inconsistency in meta-analyses.
      Where substantial levels of heterogeneity were present, subgroup analyses were performed post hoc to attempt to explain the heterogeneity—for example, by separating acute from rehabilitation trials and participants with stroke from participants with other diagnoses. Sensitivity analyses were conducted to confirm results of meta-analyses if 1 trial contributed more than 50% weight to the overall effect size or if certain trial properties brought the risk of bias (eg, poor quality, not using intention-to-treat analyses or other concurrent interventions). To assess the risk of publication bias, funnel plots were drawn if there were 10 or more trials in a meta-analysis (as tests for funnel plot asymmetry only have sufficient power when there are at least 10 trials).

      Results

      Study Selection

      The database search yielded a total of 2823 studies. Three additional studies were identified through reference scanning and citation tracking.
      • 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.
      • 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?.
      • Smith D.S.
      • Goldenberg E.
      • Ashburn A.
      • et al.
      Remedial therapy after stroke: a randomised controlled trial.
      After removal of duplicates, 1929 studies were screened on title and abstract. There was substantial agreement between reviewers on which trials did and did not fulfill inclusion criteria (κ=.72; 95% confidence interval [CI], .60–.85). Full-text copies of 43 trials were retrieved for closer examination. Of these, 27 were excluded (appendix 1). When evaluating the full-text trials, there was almost perfect agreement between the 2 reviewers on which trials were to be included or excluded (κ=.95; 95% CI, .86–1.00). Consensus was reached to retain a total of 16 trials for inclusion in the review (fig 1).

      Characteristics of Included Trials

      Methods

      All 16 trials in the review were randomized controlled trials published in English. The included trials had a mean PEDro score of 6.5 out of 10, ranging from 4
      • Smith D.S.
      • Goldenberg E.
      • Ashburn A.
      • et al.
      Remedial therapy after stroke: a randomised controlled trial.
      to 8.
      • Bernhardt J.
      • Dewey H.
      • Thrift A.
      • Collier J.
      • Donnan G.
      A very early rehabilitation trial for stroke (AVERT): phase II safety and feasibility.
      • 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.
      Glasgow Augmented Physiotherapy Study
      Can augmented physiotherapy input enhance recovery of mobility after stroke? A randomized controlled trial [with consumer summary].
      • Lenssen A.F.
      • Crijns Y.H.
      • Waltje E.M.
      • et al.
      Efficiency of immediate postoperative inpatient physical therapy following total knee arthroplasty: an RCT.
      • 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.
      One trial
      • 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.
      blinded participants to group allocation by randomly assigning them to different wards where therapy time differed. Nine trials used intention-to-treat analysis, and 10 had concealed allocation and assessor blinding. All trials had random allocation and groups that were similar at baseline, and reported between-group differences. There was substantial agreement between reviewers when rating individual items on the PEDro scale (κ=.75; 95% CI, .64-.85).

      Participants

      The review included 1699 participants (47% women), of whom 868 received extra PT. Participants had a weighted mean age of 69.8 years. Ten trials evaluated patients with a neurologic diagnosis including adults with stroke (n=8), adults with multiple sclerosis during acute relapse in an acute setting (n=1), and a mixed cohort of adults with neurologic conditions such as stroke and traumatic brain injury (n=1). Two trials evaluated patients with a cardiovascular diagnosis of post–coronary artery bypass surgery. Three trials evaluated patients with an orthopedic diagnosis including adults with total hip joint replacement (n=1), total knee joint replacement (n=1), and after hip fracture (n=1). One trial evaluated a mixed rehabilitation population (table 1).
      Table 1Study Characteristics
      AuthorsPatient Health ConditionSettingExtra OT (Y/N)PEDro ScoreUse of ITT (Y/N)No. of Participants (Exp/Comp)Men: Women (Exp/Comp)Mean Age (Exp/Comp) (y)Extra TherapyExtra PT (min/d)Outcomes
      Bernhardt
      • Bernhardt J.
      • Dewey H.
      • Thrift A.
      • Collier J.
      • Donnan G.
      A very early rehabilitation trial for stroke (AVERT): phase II safety and feasibility.
      StrokeAcute inpatient stroke unitN8Yes38/3322:16/16:1774.6/74.9Very early mobilization, 2×/d, 6d/wk7
      • Modified Rankin Scale
      • Falls
      Bischoff-Ferrari
      • Bischoff-Ferrari H.A.
      • Dawson-Hughes B.
      • Platz A.
      • et al.
      Effect of high-dosage cholecalciferol and extended physiotherapy on complications after hip fracture.
      Hip fractureAcute inpatientN7Yes87/8619:68/17:6983.4/85.530min/d extra15Falls
      Brusco
      • 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.
      Mixed rehabilitationInpatient rehabilitation wardN8Yes130/13253:77/58:7477/771h extra PT on Saturday11
      • Length of stay
      • EuroQOL
      • FIM
      • 10-m walk
      Craig
      • 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.
      MS with serious relapseNeurologic clinic or acute inpatientY5No20/209:11/4:1638/42Increased PT time36
      • Length of stay
      • Barthel Index
      • SF-36
      • Human Activity Profile
      GAPS
      Glasgow Augmented Physiotherapy Study
      Can augmented physiotherapy input enhance recovery of mobility after stroke? A randomized controlled trial [with consumer summary].
      StrokeInpatient rehabilitationN8Yes35/3524:11/17:1868/67Longer sessions of PT16
      • Length of stay
      • Barthel Index
      • EuroQOL
      • Rivermead Mobility Index
      Hirschhorn
      • 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.
      CABGSAcute inpatientN7Yes31/3127:4/26:563.2/63.6Longer, more intense sessions of PT20
      • Length of stay
      • SF-36
      • 6-min walk
      Lenssen
      • Lenssen A.F.
      • Crijns Y.H.
      • Waltje E.M.
      • et al.
      Efficiency of immediate postoperative inpatient physical therapy following total knee arthroplasty: an RCT.
      TKJRAcute inpatientN8Yes21/2215:6/17:570/67Extra PT session per day20
      • Length of stay
      • Knee Society Scale
      Lincoln
      • 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 with UL deficitsAcute and rehabilitation inpatientsN7No94/9551:43/45:5073/73Extra PT 2h/wk16Extended ADL Scale
      Martinsson
      • Martinsson L.
      • Eksborg S.
      • Wahlgren N.G.
      Intensive early physiotherapy combined with dexamphetamine treatment in severe stroke: a randomized, controlled pilot study.
      Stroke, impaired conscious levelAcute inpatientN7Yes15/157:8/4:1178/79Both longer and more PT sessions85
      • Activity Index
      • Lindmark Motor Assessment Chart
      Partridge
      • 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.
      StrokeAcute inpatient stroke unitN8No54/60NDDouble the amount of PT30
      • 5-m walk
      • Timed sit-to-stand
      Richards
      • 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.
      StrokeAcute inpatientN5No8/92:6/6:367.3/70.3Extra PT session per day64
      • Gait velocity
      • Barthel Index
      Sivenius
      • Sivenius J.
      • Pyorala K.
      • Heinonen O.P.
      • Salonen J.T.
      • Riekkinen P.
      The significance of intensity of rehabilitation of stroke – a controlled trial.
      StrokeAcute and rehabilitation inpatient and outpatientN5No50/4518:32/18:2771.5/70.1More PT timeNDADL Score
      Slade
      • 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.
      Adult neurologicInpatient rehabilitationY6Yes75/66ND52/54Longer PT sessions18
      • Length of stay
      • Barthel Index
      Smith
      • Smith D.S.
      • Goldenberg E.
      • Ashburn A.
      • et al.
      Remedial therapy after stroke: a randomised controlled trial.
      StrokeOutpatient rehabilitationY4No46/4331:15/31:1263/66Longer PT sessions and more sessions11ADL Index
      Stockton and Mengersen
      • 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.
      THJRAcute inpatientN6Yes30/2717:13/13:1468.3/68.2Extra PT session per dayND
      • Length of stay
      • Iowa Level of Assistance Scale
      Van der Peijl
      • 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.
      CABGSAcute inpatientN5No134/112107:27/87:2563.2/62.0Extra PT session per day and weekend PTND
      • Length of stay
      • FIM–locomotion
      Abbreviations: CABGS, coronary artery bypass graft surgery; Comp, comparison group; Exp, experimental group; ITT, intention to treat; MS, multiple sclerosis; N, no; ND, not done or not reported; OT, occupational therapy; SF-36, Medical Outcomes Study 36-Item Short-Form Health Survey; THJR, total hip joint replacement; TKJR, total knee joint replacement; UL, upper limb; Y, yes.

      Intervention

      In all trials, the experimental group received more PT than the comparison group. This was achieved in a variety of ways: extra sessions, longer sessions, or both extra and longer sessions (see table 1). Five trials did not specify how extra PT was delivered. Participants in the experimental group received a weighted mean of 19 minutes of extra PT per day (interquartile range, 15–30min) (see table 1). Participants in 3 trials received both extra PT and extra occupational therapy. Interventions varied depending on the participants' health condition, but all trials reported individualized treatments based on usual care.

      Outcomes measures

      The body function (or impairment) measures used were highly variable and included range of motion, strength, vital capacity, and dexterity measures. However, 7 studies included measures of walking ability (6-min walk test, gait velocity, and Lindmark motor assessment–mobility). Measures related to activity limitations were separated into 2 groups: self-care measures (FIM and Barthel Index) and ADLs (Human Activity Profile, Activity Index, sit to stand, Timed Up and Go test, Berg Balance, and various measures of ADL scores). Quality-of-life measures used were the EuroQOL and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). The physical function domain of the SF-36 was chosen for analysis because it has demonstrated sufficient responsiveness and high internal consistency and retest reliability in PT intervention trials after stroke
      • 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.
      and in orthopedic conditions.
      • Aitken D.M.
      • Bohannon R.W.
      Functional independence measure versus short form-36: relative responsiveness and validity.

      Effects of Extra Physical Therapy

      Attempts, via e-mails, were made to contact authors for missing data; no response was received in 2 instances, and information was not available in 1 instance. Therefore, all data were obtained from published results.

      Length of stay

      When compared with standard PT in 8 trials (n=920), extra PT reduced length of stay by a small but significant amount (SMD=−.22; 95% CI, −.39 to −.05; I2=32%) (fig 2). On subgroup analysis, this equated to a reduction in length of stay of 4 days (95% CI, 0–7; I2=0%) in rehabilitation settings and 1 day (95% CI, 0–1; I2=55%) in acute settings. Weighted mean length of stay was 7 days for participants in acute hospitals and 45 days for those in rehabilitation.
      Figure thumbnail gr2
      Fig 2SMD (95% CI) for effect of extra PT on length of stay by pooling data from 8 trials (n=920).

      Body function

      When compared with standard PT in 7 trials (n=665), extra PT significantly improved walking ability (SMD=.37; 95% CI, .05–.69; I2=71%) (fig 3). There was a moderate to large degree of heterogeneity in the analysis. When 1 trial
      • 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.
      with a very large positive effect was removed in a sensitivity analysis, a smaller effect resulted (SMD=.17; 95% CI, .01–.33; I2=0%).
      Figure thumbnail gr3
      Fig 3SMD (95% CI) for effect of extra PT on walking ability by pooling data from 7 trials (n=665).

      Activity

      When compared with standard PT in 8 trials (n=1001), extra PT did not have a significant effect on measures of self-care (SMD=.35; 95% CI, −.06–.77; I2=89%) (fig 4). There was a large degree of heterogeneity in the data. A subgroup analysis of the 2 trials (n=166) that included both extra PT and extra occupational therapy resulted in a moderate, significant effect on self-care (SMD=.51; 95% CI, .20–.82; I2=0%).
      Figure thumbnail gr4
      Fig 4SMD (95% CI) for effect of extra PT on self-care by pooling data from 8 trials (n=1001).
      When compared with standard PT in 9 trials (n=724), extra PT resulted in a small, but significant increase in measures of activity (SMD=.22; 95% CI, .07–.37; I2=4%) (fig 5). In addition, 2 trials reported activity data that were not expressed as means and SDs and, therefore, could not be included in the meta-analysis. Van der Peijl et al
      • 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.
      assessed the achievement of functional activity milestones daily in participants who underwent coronary artery bypass graft surgery. The extra PT group achieved 4 clinical activity milestones (bed to chair, walking in room, walking in the ward, and attending the exercise group) significantly faster than the participants receiving standard PT. Bernhardt et al
      • Bernhardt J.
      • Dewey H.
      • Thrift A.
      • Collier J.
      • Donnan G.
      A very early rehabilitation trial for stroke (AVERT): phase II safety and feasibility.
      assessed disability levels in participants with stroke on the Modified Rankin Scale. The odds of a good outcome (according to Modified Rankin Scale scores) were greater in the extra PT group than in the standard PT group at 3, 6, and 12 months.
      Figure thumbnail gr5
      Fig 5SMD (95% CI) for effect of extra PT on activity by pooling data from 9 trials (n=724).

      Participation

      When compared with standard PT in 4 trials (n=424), extra PT resulted in a moderate and significant increase in quality of life (SMD=.48; 95% CI, .29–.68; I2=0%) (fig 6). Because 1 trial
      • 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.
      was weighted heavily, we did a sensitivity analysis to confirm the results. With Brusco et al
      • 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.
      excluded, there was still a moderate and significant improvement in quality of life (SMD=.45; 95% CI, .07–.83; I2=31%).
      Figure thumbnail gr6
      Fig 6SMD (95% CI) for effect of extra PT on quality of life by pooling data from 4 trials (n=424).

      Safety

      The presence or absence of adverse events was recorded in 8 trials. Seven reported there was no significant difference between groups in the number of adverse events. One trial
      • Bernhardt J.
      • Dewey H.
      • Thrift A.
      • Collier J.
      • Donnan G.
      A very early rehabilitation trial for stroke (AVERT): phase II safety and feasibility.
      reported significantly fewer nonserious adverse events in individuals with stroke receiving extra PT when compared with those receiving standard PT (61 adverse events in the experimental group [n=38], 76 in the comparison group [n=33]; P=.04). Mortality rates were recorded in 11 trials. There were no significant differences in mortality rates between groups in any trials. Fall rates were reported in 2 trials. Bischoff-Ferrari et al
      • Bischoff-Ferrari H.A.
      • Dawson-Hughes B.
      • Platz A.
      • et al.
      Effect of high-dosage cholecalciferol and extended physiotherapy on complications after hip fracture.
      reported that extra PT significantly reduced the rate of falls by 25% (95% CI, −44% to −1%) in the 12 months after hip fracture. Bernhardt
      • Bernhardt J.
      • Dewey H.
      • Thrift A.
      • Collier J.
      • Donnan G.
      A very early rehabilitation trial for stroke (AVERT): phase II safety and feasibility.
      reported no difference in fall rates between groups of people with stroke.

      Patient satisfaction

      Two trials reported on levels of patient satisfaction. After total knee joint replacement,
      • Lenssen A.F.
      • Crijns Y.H.
      • Waltje E.M.
      • et al.
      Efficiency of immediate postoperative inpatient physical therapy following total knee arthroplasty: an RCT.
      participants reported high levels of satisfaction in both the standard PT and the extra PT groups. After coronary artery bypass graft surgery,
      • 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.
      significantly more participants in the extra PT group were satisfied with treatment compared with the standard PT group.
      Subgroup analyses investigating the differences between acute and rehabilitation settings showed similar magnitudes of SMD compared with the overall meta-analyses but wider CIs because of the smaller sample sizes for walking ability, self-care, activity, and quality of life (table 2). Sensitivity analyses removing the 3 trials that also included extra occupational therapy showed similar pooled SMDs for length of stay, walking ability, activity, and quality of life when compared with the overall analysis (see table 2). Another sensitivity analysis was conducted excluding the 7 trials that did not use intention-to-treat analysis. Again, results were of similar magnitude to the overall analysis (see table 2). A subgroup analysis comparing stroke with other participant populations showed similar SMDs and CIs for length of stay, activity, and quality of life, but reduced SMDs for walking ability and self-care (see table 2).
      Table 2Sensitivity or Subgroup Analyses Standardized Mean Difference (95% CIs)
      OutcomeTotal (n=16)
      Number of trials.
      Subacute Setting (n=6)
      Number of trials.
      Acute Setting (n=10)
      Number of trials.
      Trials With Extra Physiotherapy Only (No Extra OT) (n=13)
      Number of trials.
      Trials That Used ITT Analyses (n=9)
      Number of trials.
      Stroke Populations (n=8)
      Number of trials.
      Other Populations (All Except Stroke) (n=8)
      Number of trials.
      Length of stay−.22 (−.39 to −.05)−.18 (−.36 to 0)−.32 (−.66 to −.02)−.23 (−.44 to −.02)−.25 (−.44 to −.07)−.24 (−.71 to −.23)−.23 (−.42 to −.03)
      Mobility.37 (.05 to .69).20 (−.05 to .45).48 (−.06 to 1.01).37 (.05 to .69).56 (.01 to 1.10).17 (−.17 to .51).52 (.02 to 1.01)
      Activity.22 (.07 to .37).20 (.03 to .36).27 (−.13 to .68).24 (.06 to .43).28 (.04 to .51).20 (−.02 to .43).25 (.01 to .49)
      Self-care.35 (−.06 to .77).43 (−.27 to 1.12).23 (−.07 to .53).29 (−.25 to .53).61 (.10 to 1.31)−.10 (−.34 to .14).57 (.06 to 1.08)
      Quality of life.48 (.29 to .68).49 (.26 to .71).44 (−.24 to 1.13).53 (.33 to .73).53 (.33 to .75).43 (−.08 to .94).49 (.19 to .78)
      Abbreviations: ITT, intention-to-treat; OT, occupational therapy.
      low asterisk Number of trials.

      Discussion

      The results of this systematic review provide evidence from 16 randomized controlled trials, with 1699 participants, that extra PT reduces length of stay and improves the rate of improvement in walking ability, activity, and quality of life, but not self-care in people with acute or subacute conditions. Previous reviews focused on stroke
      • Kwakkel G.
      • van Peppen R.
      • Wagenaar R.C.
      • et al.
      Effects of augmented exercise therapy time after stroke: a meta-analysis.
      or PT given outside business hours
      • Brusco N.K.
      • Paratz J.
      The effect of additional physiotherapy to hospital inpatients outside of regular business hours: a systematic review.
      and included trials that were not randomized and controlled. The results of this systematic review are similar to, but the effect sizes are larger in magnitude than those reported in the review by Kwakkel
      • Kwakkel G.
      • van Peppen R.
      • Wagenaar R.C.
      • et al.
      Effects of augmented exercise therapy time after stroke: a meta-analysis.
      where augmented exercise improved performance of ADLs (standard effect size, .13; 95% CI, .03–.23) and increased walking speed (standard effect size, .19; 95% CI, .01–.36). Our results differ from the results of Brusco and Paratz,
      • Brusco N.K.
      • Paratz J.
      The effect of additional physiotherapy to hospital inpatients outside of regular business hours: a systematic review.
      who were unable to conclude that extra PT given outside business hours was effective in decreasing length of stay or improving patient discharge mobility status. These results add new evidence to previous reviews by evaluating the effect of extra PT on length of stay, incorporating recent randomized controlled trials and including patients across a broad range of health conditions. The results of this review and meta-analyses are valuable because almost all the individual trials included did not demonstrate statistically significant effects of extra PT, but when pooled in meta-analyses the results were significant. From a health service and health manager's perspective, these results are applicable and relevant because they show that providing extra PT services in acute or rehabilitation settings may be beneficial for patients with a variety of acute or subacute health conditions.
      In our review, it appears that an extra 19 minutes of PT per day was needed to achieve the benefits of reduced length of stay and an increased rate of improvement in mobility, activity, and quality of life. This extra PT could be provided through longer sessions, more sessions in a day, or extra sessions on the weekend. However, the provision of extra PT means higher costs, and the decision regarding whether to provide extra PT depends on whether the benefits of extra PT outweigh the costs. It is hard to draw definitive conclusions on whether the improvements in mobility, activity, and quality of life found in this review are sufficient to justify the higher costs of providing these services. However, we have provided evidence that extra PT may reduce acute hospital length of stay by 1 day and rehabilitation length of stay by 4 days in patients with a variety of health conditions such as stroke and after coronary artery bypass graft surgery, hip or knee joint arthroplasty, and hip fracture.
      The average cost of 1 day in an acute hospital is approximately U.S. $1237.
      • Candrilli S.
      • Mauskopf J.
      How much does a hospital day cost?.
      Our review indicates that extra PT may reduce length of stay, and although a formal cost analysis that should include consideration of health utilization costs after discharge has not been completed, this may lead to cost savings. The implications of such reductions in length of stay are significant for the patient, the health service, and for the community. It means that the individual can return to the community sooner, that individuals may not have to wait so long for a bed, that the health service can treat more patients, and that there may be considerable cost savings for the community. Future research could also investigate the most cost-effective way of providing the extra PT, whether it is longer sessions, extra sessions during the day, or extra sessions on the weekend or after hours.
      A likely explanation for why extra PT has significant effects on improving walking ability and activity is that PT interventions have a central focus on analyzing and solving problems of movement. Extra PT helps provide the repetitive practice required for motor skill learning and neuroplasticity, and minimizes the negative effects of inactivity that include reduced fitness, muscular atrophy, and even loss of joint range. This is consistent with the foundations of PT practice: a central focus on movement, sound knowledge, clinical reasoning skills, and virtues such as caring and providing empathy.
      • Jensen G.M.
      • Gwyer J.
      • Hack L.
      • Shepard K.
      Expertise in physical therapy practice.
      As the attainment of sufficient levels of physical mobility plays a role in determining when a person is ready for discharge, this provides a possible explanation for the observed reduction in length of stay.
      The improvements in quality of life may partially be explained by our use of the physical function domain of the SF-36 in our analyses, which is more responsive to PT interventions than other quality-of-life domains. Extra PT may have also contributed to increased quality of life through physical therapists helping to solve problems of mobility and their virtues of caring, acting as a moral agent, and providing empathy.
      • Jensen G.M.
      • Gwyer J.
      • Hack L.
      • Shepard K.
      Expertise in physical therapy practice.
      For health-related quality-of-life measures, an effect size of 0.5 is considered a clinically significant change.
      • Norman G.R.
      • Sloan J.A.
      • Wyrwich K.W.
      Interpretation of changes in health related quality of life.
      The results of our meta-analysis appear to reflect a clinically significant change in quality of life. Extra PT did not have a significant impact on self-care. There were, however, statistically significant improvements in self-care when we analyzed the participants receiving both extra PT and extra occupational therapy, as occupational therapists' interventions are more involved in the attainment of independent self-care skills.
      A strength of this review is that it follows the PRISMA guidelines for high-quality reporting of systematic reviews and meta-analyses.
      • 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.
      Rigorous subgroup and sensitivity analyses confirmed the strength of the results, which do not appear to be biased by occupational therapy intervention, trials not using intention-to-treat analysis, different settings, and different diagnoses. It includes all recent and relevant randomized controlled trials. It is clinically achievable, as the provision of an extra 19 minutes of PT per day is possible in the clinical setting.

      Study Limitations

      A limitation of this review is that relevant data were not reported in some trials and therefore could not be included in meta-analyses. A number of our meta-analyses demonstrated statistical heterogeneity. However, to account for this we conducted subgroup and sensitivity analyses as appropriate. The inclusion of 3 trials that included both extra occupational therapy and PT could also be viewed as a limitation because in these trials, any changes cannot be attributed to the provision of extra PT alone. However, our sensitivity analyses demonstrated that adding extra occupational therapy in addition to extra PT resulted in improved self-care but made no difference to the other outcomes. The review included diverse conditions and settings, which could be viewed as a limitation. We thought that it was important to have this diversity, as it reflects clinical practice from a health service perspective where managers have to make decisions about whether to provide extra PT services in a setting that includes patients with a variety of health conditions. In addition, multiple subgroup and sensitivity analyses were conducted to account for this variation. Another possible limitation is that the average length of stay of included rehabilitation trials was 45 days, which may not reflect current practice. These data may have been skewed by 2 included trials
      Glasgow Augmented Physiotherapy Study
      Can augmented physiotherapy input enhance recovery of mobility after stroke? A randomized controlled trial [with consumer summary].
      • 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.
      with long lengths of stay conducted in neurologic rehabilitation wards. However, a similar reduction in length of stay was also achieved in a rehabilitation trial with a shorter length of stay.
      • 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.
      Future research could address the possible benefits of providing extra services from other allied health disciplines in addition to PT, and explore the possibility of a dose-response relationship for the amount of extra therapy provided.

      Conclusions

      This systematic review has demonstrated that extra PT leads to small to moderate statistically significant reductions in length of stay that may be clinically significant for patients, the health service, health insurance premium payers, taxpayers, and the community. Also, our review has demonstrated that extra PT resulted in increased rates of improvement in walking ability, activity, and quality of life across acute and rehabilitation settings in patients with a variety of health conditions. An extra 19min/d per inpatient are required to achieve these benefits.
      Supplier
      aThe Cochrane IMS. Available at: http://ims.cochrane.org/revman.

      Appendix 1. Excluded Trials

      Tabled 1
      TrialReason for Exclusion
      Allison et al
      • 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].
      Evaluates a specific therapy: additional standing practice
      Borello-France et al
      • 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.
      Chronic condition/risk factor management: urinary incontinence
      Britton et al
      • 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].
      Evaluates a specific therapy: sit-to-stand exercises
      Chang et al
      • Chang W.
      • Yang Y.
      • Hsu L.
      • Chern C.
      • Wang R.
      Balance improvement in patients with benign paroxysmal positional vertigo.
      Evaluates a specific therapy: vestibular-stimulated exercise program
      de Lateur et al
      • 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.
      Evaluates a specific therapy: additional treadmill training
      de Morton et al
      • 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.
      Evaluates a specific therapy: additional exercise program
      Donald et al
      • Donald I.P.
      • Pitt K.
      • Armstrong E.
      • Shuttleworth H.
      Preventing falls on an elderly care rehabilitation ward [with consumer summary].
      Evaluates a specific therapy: additional leg-strengthening exercises
      Dromerick et al
      • 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.
      • Intervention not delivered/supervised by physical therapist: treatment delivered by an occupational therapist
      • Evaluates a specific therapy: constraint-induced movement therapy
      Fang et al
      • 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].
      Inadequate control group: comparison group did not receive PT
      Gilbey et al
      • 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.
      Evaluates a specific therapy: additional presurgery and postsurgery exercise programs
      Giovannelli et al
      • 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].
      Inadequate control group: comparison group did not receive PT
      Grasel et al
      • 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.
      Intervention not delivered/supervised by PT treatment delivered by nursing staff
      Haines et al
      • 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.
      Evaluates a specific therapy: additional exercise program aimed at reducing falls
      Howe et al
      • 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].
      Evaluates a specific therapy: lateral weight transference in sitting
      Kammerlind et al
      • 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.
      Inadequate control group: comparison group did not receive PT
      Kim et al
      • 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.
      Chronic condition/risk factor management: blood lipid levels in coronary heart disease
      Klaber Moffett et al
      • 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].
      Inadequate control group: usual PT vs brief therapy using cognitive behavioral principles
      Kwakkel et al
      • 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.
      Evaluates a specific therapy: upper limb emphasis vs lower limb emphasis
      Langhammer et al
      • Langhammer B.
      • Stanghelle J.K.
      • Lindmark B.
      An evaluation of two different exercise regimes during the first year following stroke: a randomised controlled trial.
      Inadequate control group: comparison group did not receive PT
      Mosely et al
      • Moseley A.
      • Sherrington C.
      • Lord S.
      • Barraclough E.
      • St G.R.
      • Cameron I.
      Mobility training after hip fracture: A randomised controlled trial.
      Evaluates a specific therapy: standing exercise vs sitting and lying exercise
      Ntoumenopoulos and Greenwood
      • Ntoumenopoulos G.
      • Greenwood K.
      Effects of cardiothoracic physiotherapy on intrapulmonary shunt in abdominal surgical patients.
      Not a randomized controlled trial: quasi-randomized controlled trial
      Platz et al
      • 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.
      Evaluates a specific therapy: upper limb therapy
      Rau et al
      • Rau B.
      • Bonvin F.
      • de Bie R.
      Short-term effect of physiotherapy rehabilitation on functional performance of lower limb amputees.
      Inadequate control group: comparison group did not receive PT
      Rodgers et al
      • 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].
      Evaluates a specific therapy: upper limb therapy
      Ruff et al
      • 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?.
      Not a randomized controlled trial: quasi-randomized controlled trial
      Sunderland et al
      • 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 A randomised controlled trial.
      Evaluates a specific therapy: intensive upper limb therapy and use of behavioral methods
      Winett et al
      • Winett R.A.
      • Goodman J.M.
      • Marzolini S.
      Are multiple sets and usual aerobic training recommended for treatment of CHD?.
      Not a randomized controlled trial

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