Exercise for Adults With Stroke to Improve ADL and/or Functional Mobility Performance (2012–2019)

Full Systematic Review Question

This systematic review addressed the question “What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve performance and participation in activities of daily living (ADL) for adult stroke survivors?”

Current Theme(s) Reported

The main theme of the studies included in this systematic review brief is exercise (i.e., yoga, tai chi, balance training, and muscle strengthening).

Clinical Scenario

Stroke is the leading cause of adult disability in the United States with more than 7 million survivors (Tsao et al., 2022). Many stroke survivors have great limitations in activities of daily living (ADL) and participation (Gadidi et al., 2011), which is correlated with overall increased life dissatisfaction (Hartman-Maeir et al., 2007). Exercise has been identified to support improvement of ADLs, such as basic ADLs (BADL) and functional mobility (Nilsen et al., 2015). The systematic review theme presented here addresses exercise in main different forms such as tai chi, yoga, balance training, and muscle strengthening for improved ADL performance including basic ADL (i.e., Short Form 12 [Jakobsson et al., 2012] and Barthel Index [Hsueh et al., 2001]) and functional mobility (i.e., Timed Up and Go [TUG; Flansbjer et al., 2005] and Berg Balance Scale [BBS; Berg et al., 1995]).

Summary of Key Findings

Five Level 1A (meta-analyses) and nine Level 1B (randomized control trials) studies met the criteria for inclusion to examine the effectiveness of exercise for functional mobility and ADL. The risk of bias (ROB) for most of the studies was low, with three studies showing moderate ROB. The studies in the exercise theme were subdivided into six areas: tai chi, yoga, hydrotherapy, balance training, muscle strengthening, and multiexercise regimes (Table 1). The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009). The strength-of- evidence designations are based on the guidelines of the U.S. Preventive Services Task Force (2018).

Bottom Line for Occupational Therapy Practice

The results of the included studies indicate that occupational therapy practitioners should include tai chi and balance training for both BADL and functional mobility and hydrotherapy for functional mobility for adults with stroke. However, hydrotherapy only showed significance in the chronic stroke population, not the subacute. Furthermore, there were no BADL outcome measures for hydrotherapy; thus, there is no evidence to support or refute this approach for BADL performance. Although yoga showed no significant differences than the control group, one could argue that meta-analysis pooled two studies that had very low quality of evidence due to high ROB (i.e., small sample sizes and incomplete data); therefore, more research is required to make a definitive conclusion. In addition, because there were no BADL measures used in the yoga studies, there is no evidence for or against yoga for BADL (Lawrence et al., 2017).

Muscle strengthening and multiexercise regimes should be used with caution, as they provide low evidence for improvement in both functional mobility and BADL in the stroke population. Pooling of the functional mobility outcome measures, more specifically the BBS (Berg et al., 1995) data, showed significant differences in favor of the intervention group, however, not for the TUG (Flansbjer et al., 2005). In addition, it should be noted that most of the studies only used a functional mobility measure, not a BADL measure. However, of the three studies that used a BADL measure, only one study showed significant improvements for the intervention group as compared with the control and only at postintervention, not at follow-up. Although muscle strengthening and multiexercise regimes appear to have small positive results, it should not be the focus of occupational therapy intervention.