Review article (meta-analysis)| Volume 99, ISSUE 11, P2299-2312, November 2018

Additional Physical Therapy Services Reduce Length of Stay and Improve Health Outcomes in People With Acute and Subacute Conditions: An Updated Systematic Review and Meta-Analysis

  • Casey L. Peiris
    Corresponding author Casey L. Peiris, PhD, Level 5, HS3, La Trobe University, Melbourne, Australia, 3086.
    La Trobe University, College of Science, Health and Engineering, Department of Rehabilitation, Nutrition and Sport, School of Allied Health(Physiotherapy), Melbourne
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  • Nora Shields
    La Trobe University, College of Science, Health and Engineering, Department of Rehabilitation, Nutrition and Sport, School of Allied Health(Physiotherapy), Melbourne

    Northern Health, Northern Centre for Health Education and Research, Epping
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  • Natasha K. Brusco
    La Trobe University, College of Science, Health and Engineering, Department of Rehabilitation, Nutrition and Sport, School of Allied Health(Physiotherapy), Melbourne

    Cabrini Health, Physiotherapy, Malvern
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  • Jennifer J. Watts
    Deakin University, School of Health and Social Development, Faculty of Health, Burwood
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  • Nicholas F. Taylor
    La Trobe University, College of Science, Health and Engineering, Department of Rehabilitation, Nutrition and Sport, School of Allied Health(Physiotherapy), Melbourne

    Eastern Health, Eastern Health Clinical Research Office, Box Hill, Australia
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Published:April 07, 2018DOI:



      To update a previous review on whether additional physical therapy services reduce length of stay, improve health outcomes, and are safe and cost-effective for patients with acute or subacute conditions.

      Data Sources

      Electronic database (AMED, CINAHL, EMBASE, MEDLINE, Physiotherapy Evidence Database [PEDro], PubMed) searches were updated from 2010 through June 2017.

      Study Selection

      Randomized controlled trials evaluating additional physical therapy services on patient health outcomes, length of stay, or cost-effectiveness were eligible. Searching identified 1524 potentially relevant articles, of which 11 new articles from 8 new randomized controlled trials with 1563 participants were selected. In total, 24 randomized controlled trials with 3262 participants are included in this review.

      Data Extraction

      Data were extracted using the form used in the original systematic review. Methodological quality was assessed using the PEDro scale, and the Grading of Recommendation Assessment, Development, and Evaluation approach was applied to each meta-analysis.

      Data synthesis

      Postintervention data were pooled with an inverse variance, random-effects model to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs). There is moderate-quality evidence that additional physical therapy services reduced length of stay by 3 days in subacute settings (mean difference [MD]=–2.8; 95% CI, –4.6 to –0.9; I2=0%), and low-quality evidence that it reduced length of stay by 0.6 days in acute settings (MD=–0.6; 95% CI, –1.1 to 0.0; I2=65%). Additional physical therapy led to small improvements in self-care (SMD=.11; 95% CI, .03–.19; I2=0%), activities of daily living (SMD=.13; 95% CI, .02–.25; I2=15%), and health-related quality of life (SMD=.12; 95% CI, .03–.21; I2=0%), with no increases in adverse events. There was no significant change in walking ability. One trial reported that additional physical therapy was likely to be cost-effective in subacute rehabilitation.


      Additional physical therapy services improve patient activity and participation outcomes while reducing hospital length of stay for adults. These benefits are likely safe, and there is preliminary evidence to suggest they may be cost-effective.


      List of abbreviations:

      CI (confidence interval), GRADE (Grading of Recommendation Assessment, Development, and Evaluation), MD (mean difference), PEDro (Physiotherapy Evidence Database), SMD (standardized mean difference)
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        • Shaw K.D.
        • Taylor N.F.
        • Brusco N.K.
        Physiotherapy services provided outside of business hours in Australian hospitals: a national survey.
        Physiother Res Int. 2013; 18: 115-123
        • Caruana E.
        • Kuys S.S.
        • Clarke J.
        • Brauer S.G.
        Weekend therapy service provision in a sample of rehabilitation facilities throughout Australia.
        Physiotherapy. 2015; 101: e200-e201
        • Carey K.
        Hospital length of stay and cost: a multilevel modeling analysis.
        Health Serv Outcomes Res Methodol. 2002; 3: 41-56
        • Peiris C.L.
        • Taylor N.F.
        • 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.
        Arch Phys Med Rehabil. 2011; 92: 1490-1500
        • Peiris C.L.
        • Shields N.
        • Brusco N.K.
        • Watts J.J.
        • Taylor N.F.
        Additional Saturday rehabilitation improves functional independence and quality of life and reduces length of stay: a randomized controlled trial.
        BMC Med. 2013; 11: 198
        • English C.
        • Bernhardt J.
        • Crotty M.
        • Esterman A.
        • Segal L.
        • Hillier S.
        Circuit class therapy or seven-day week therapy for increasing rehabilitation intensity of therapy after stroke (CIRCIT): a randomized controlled trial.
        Int J Stroke. 2015; 10: 594-602
        • Guyatt G.
        • Oxman A.D.
        • Akl E.A.
        • et al.
        GRADE guidelines: 1. Introduction–GRADE evidence profiles and summary of findings tables.
        J Clin Epidemiol. 2011; 64: 383-394
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • PRISMA Group
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        BMJ. 2009; 339: b2535
      1. Higgins J. Green S. Cochrane handbook for systematic reviews of interventions version 5.0.2. 2009. The Cochrane Collaboration, 2009 (Available at:
        Date accessed: June 5, 2017
        • Landis R.J.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
      2. American Physical Therapy Association: Who are physical therapists? Aavailable at: Accessed April 25, 2018.

      3. Centre for Evidence-Based Physiotherapy 2010. The Physiotherapy Evidence Database (PEDro).
        (Available at:)
        Date accessed: June 2, 2017
        • 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
        • World Health Organization
        Towards a common language for functioning, disability and health: ICF.
        World Health Organization, Geneva2002
        • 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
        • Cohen J.
        The statistical power of abnormal-social psychological research: a review.
        J Abnormal Soc Psychol. 1962; 65: 145-153
        • Higgins J.
        • Thompson S.
        • Deeks J.
        • Altman D.G.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
        • Peiris C.L.
        • Taylor N.F.
        • Shields N.
        Additional Saturday allied health services increase habitual physical activity among patients receiving inpatient rehabilitation for lower limb orthopedic conditions: a randomized controlled trial.
        Arch Phys Med Rehabil. 2012; 93: 1365-1370
        • Brusco N.K.
        • Watts J.J.
        • Shields N.
        • Taylor N.F.
        Are weekend inpatient rehabilitation services value for money? An economic evaluation alongside a randomized controlled trial with a 30 day follow up.
        BMC Med. 2014; 12: 89
        • Brusco N.K.
        • Watts J.J.
        • Shields N.
        • Taylor N.F.
        Is cost effectiveness sustained after weekend inpatient rehabilitation? 12 month follow up from a randomized controlled trial.
        BMC Health Serv Res. 2015; 15: 165
        • 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
        • 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
        • Cavalcante E.S.
        • Magario R.
        • Conforti C.A.
        • et al.
        Impact of intensive physiotherapy on cognitive function after coronary artery bypass graft surgery.
        Arq Bras Cardiol. 2014; 103: 391-397
        • 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
        • Donaldson C.
        • Tallis R.
        • Miller S.
        • Sunderland A.
        • Lemon R.
        • Pomeroy V.
        Effects of conventional physical therapy and functional strength training on upper limb motor recovery after stroke: a randomized phase II study.
        Neurorehabil Neural Repair. 2009; 23: 389-397
        • Fuller L.M.
        • Button B.
        • Tarrant B.
        • et al.
        Longer versus shorter duration of supervised rehabilitation after lung transplantation: a randomized trial.
        Arch Phys Med Rehabil. 2017; 98: 220-226.e3
        • Glasgow Augmented Physiotherapy Study (GAPS) Group
        Can augmented physiotherapy input enhance recovery of mobility after stroke? A randomized controlled trial.
        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
        • 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
        • 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 Psychiatry. 2003; 74: 1225-1230
        • Slade A.
        • Tennant A.
        • Chamberlain M.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
        • Hirschhorn A.D.
        • Richards D.
        • Mungovan S.F.
        • 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
        • Calthorpe S.
        • Barber E.A.
        • Holland A.E.
        • et al.
        An intensive physiotherapy program improves mobility for trauma patients.
        J Trauma Acute Care Surg. 2014; 76: 101-106
        • 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
        • Kimmel L.A.
        • Liew S.M.
        • Sayer J.M.
        • Holland A.E.
        HIP4Hips (High Intensity Physiotherapy for Hip fractures in the acute hospital setting): a randomised controlled trial.
        Med J Aust. 2016; 205: 73-78
        • Cooke E.V.
        • Tallis R.C.
        • Clark A.
        • Pomeroy V.M.
        Efficacy of functional strength training on restoration of lower-limb motor function early after stroke: phase I randomized controlled trial.
        Neurorehabil Neural Repair. 2010; 24: 88-96
        • 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
        • 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
        • Bischoff-Ferrari H.A.
        • Dawson-Hughes B.
        • Platz A.
        • et al.
        Effect of high-dosage cholecalciferol and extended physiotherapy on complications after hip fracture: a randomized controlled trial.
        Arch Intern Med. 2010; 170: 813-820
        • Sivenius J.
        • Pyörälä K.
        • Heinonen O.P.
        • Salonen J.T.
        • Riekkinen P.
        • et al.
        The significance of intensity of rehabilitation of stroke: a controlled trial.
        Stroke. 1985; 16: 928-931
        • Peiris C.L.
        • Taylor N.F.
        • Shields N.
        Patients value patient-therapist interactions more than the amount or content of therapy during inpatient rehabilitation: a qualitative study.
        J Physiother. 2012; 58: 261-268
        • Resnick L.
        • Plow M.A.
        Measuring participation as defined by the International Classification of Functioning, Disability and Health: an evaluation of existing measures.
        Arch Phys Med Rehabil. 2009; 90: 856-866
        • Brusco N.K.
        • Taylor N.F.
        • Watts J.J.
        • Shields N.
        Economic evaluation of adult rehabilitation: a systematic review and meta-analysis of randomized controlled trials in a variety of settings.
        Arch Phys Med Rehabil. 2014; 95: 94-116.e4