研究問題
我們想知道以復健的方式是否能有效恢復中風患者的功能和活動能力，以及是否有一種復健的方法比其他任何方式更有效。
研究背景
中風會導致身體某些部位癱瘓和其他各種身體機能的困難。復健是中風患者康復的一個重要部分。多年來，根據人們對中風後恢復方式的不同看法，已經開發出各種復健方式。物理治療師通常會遵循一種特定的方法，而排除其他方法，但這種做法通常是基於個人偏好而不是科學原理。物理治療師之間對於不同方法的相對益處之爭論仍繼續；因此，重要的是匯集研究證據並強調在選擇這些不同方法時應該採用哪些為最佳方式。
研究特徵
截至 2012 年 12 月，我們納入了 96 項研究進行文獻回顧。這些研究涉及 10,401 名中風倖存者，研究調查目的在比較復健方式相較於沒有治療、常規照護、注意力控制，或比較不同的復健方式對於臨床診斷為中風的成年受試者之功能恢復或活動能力。每項研究的平均受試者人數為 105 人:大多數研究 (93%) 的受試者人數少於 200 人，其中一項研究的受試者人數超過 1,000 人，六項研究的受試者人數在 250 至 1,000 人之間，還有 10 項研究的受試者人數在 20 人或以下。結果包括日常生活活動 (ADL) 獨立能力的測量、運動功能（功能性運動）、平衡、步行速度和停留時間。超過一半的研究 (50/96) 在中國進行。這些研究表明，與中風類型和嚴重程度有關的許多差異，以及治療的差異，這些差異因治療類型和持續時間而異。
重要结果
這篇文獻回顧匯集了證實復健（通常由物理治療師或復健師提供）可以改善中風後功能、平衡和行走的證據。當治療師從廣泛的可用治療中為個體患者選擇不同治療的組合時，這似乎是最有益的。
我們結合了 27 項研究（3,243 名中風倖存者）的結果，這些研究比較了復健與不治療。在這 27 項研究中有 25 項在中國進行。結果表明，復健可以改善功能，而且這種改善可能會持續很長時間。當我們進一步觀測額外的復健與常規照護或對照介入進行比較的研究時，我們發現有證據表明額外的物理治療改善了運動功能（12 項研究，887 名中風倖存者）、站立平衡（5 項研究，246 名中風倖存者）和步行速度（14 項研究，1,126 名中風倖存者）。非常有限的證據表明，對於復健與不治療以及與常規照護相比，每天 30 至 60 分鐘、每週 5 至 7 天的治療似乎有效，但需要進一步的研究來證實這一點.我們還發現證據表明，中風後到復健的時間越短，獲益越大，但仍需要進一步的研究來證實這一點。
我們發現證據表明，沒有一種復健方法比任何其他方法更有效。這一發現意味著物理治療師應根據特定治療的可用證據來選擇每個患者的治療，而不應將他們的治療限制在單一的 “指定” 方法。
證據的品質
我們很難判斷證據的品質，因為我們發現報告不佳、不完整或僅有簡短的資訊。我們確定只有不到 50% 的研究具有良好的品質，並且對於大多數研究，從所提供的資訊來看，證據的品質並不清楚。
Physical rehabilitation, comprising a selection of components from different approaches, is effective for recovery of function and mobility after stroke. Evidence related to dose of physical therapy is limited by substantial heterogeneity and does not support robust conclusions. No one approach to physical rehabilitation is any more (or less) effective in promoting recovery of function and mobility after stroke. Therefore, evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin.
Various approaches to physical rehabilitation may be used after stroke, and considerable controversy and debate surround the effectiveness of relative approaches. Some physiotherapists base their treatments on a single approach; others use a mixture of components from several different approaches.
To determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.
For the previous versions of this review, the objective was to explore the effect of 'physiotherapy treatment approaches' based on historical classifications of orthopaedic, neurophysiological or motor learning principles, or on a mixture of these treatment principles. For this update of the review, the objective was to explore the effects of approaches that incorporate individual treatment components, categorised as functional task training, musculoskeletal intervention (active), musculoskeletal intervention (passive), neurophysiological intervention, cardiopulmonary intervention, assistive device or modality.
In addition, we sought to explore the impact of time after stroke, geographical location of the study, dose of the intervention, provider of the intervention and treatment components included within an intervention.
We searched the Cochrane Stroke Group Trials Register (last searched December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) ( The Cochrane Library Issue 12, 2012), MEDLINE (1966 to December 2012), EMBASE (1980 to December 2012), AMED (1985 to December 2012) and CINAHL (1982 to December 2012). We searched reference lists and contacted experts and researchers who have an interest in stroke rehabilitation.
Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke. Outcomes included measures of independence in activities of daily living (ADL), motor function, balance, gait velocity and length of stay. We included trials comparing physical rehabilitation approaches versus no treatment, usual care or attention control and those comparing different physical rehabilitation approaches.
Two review authors independently categorised identified trials according to the selection criteria, documented their methodological quality and extracted the data.
We included a total of 96 studies (10,401 participants) in this review. More than half of the studies (50/96) were carried out in China. Generally the studies were heterogeneous, and many were poorly reported.
Physical rehabilitation was found to have a beneficial effect, as compared with no treatment, on functional recovery after stroke (27 studies, 3423 participants; standardised mean difference (SMD) 0.78, 95% confidence interval (CI) 0.58 to 0.97, for Independence in ADL scales), and this effect was noted to persist beyond the length of the intervention period (nine studies, 540 participants; SMD 0.58, 95% CI 0.11 to 1.04). Subgroup analysis revealed a significant difference based on dose of intervention (P value < 0.0001, for independence in ADL), indicating that a dose of 30 to 60 minutes per day delivered five to seven days per week is effective. This evidence principally arises from studies carried out in China. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.003, for independence in ADL).
We found physical rehabilitation to be more effective than usual care or attention control in improving motor function (12 studies, 887 participants; SMD 0.37, 95% CI 0.20 to 0.55), balance (five studies, 246 participants; SMD 0.31, 95% CI 0.05 to 0.56) and gait velocity (14 studies, 1126 participants; SMD 0.46, 95% CI 0.32 to 0.60). Subgroup analysis demonstrated a significant difference based on dose of intervention (P value 0.02 for motor function), indicating that a dose of 30 to 60 minutes delivered five to seven days a week provides significant benefit. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.05, for independence in ADL).
No one physical rehabilitation approach was more (or less) effective than any other approach in improving independence in ADL (eight studies, 491 participants; test for subgroup differences: P value 0.71) or motor function (nine studies, 546 participants; test for subgroup differences: P value 0.41). These findings are supported by subgroup analyses carried out for comparisons of intervention versus no treatment or usual care, which identified no significant effects of different treatment components or categories of interventions.
翻譯者：蔡穩穩 (奇美醫院，神經內科住院醫師) 【本翻譯計畫由臺北醫學大學考科藍臺灣研究中心(Cochrane Taiwan)及東亞考科藍聯盟(EACA)統籌執行。聯絡E-mail :cochranetaiwan@tmu.edu.tw.tw】