, Seungwon Leeb,c* 
This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.Stroke is a sudden onset of neurological symptoms caused by cerebrovascular injury, often leading to physical disabilities such as hemiplegia. Approximately 10-12% of patients with stroke do not survive, while more than 50% of survivors experience long-term disabilities that significantly affect their daily lives [1]. Post-stroke patients commonly experience motor and sensory impairments [2]. Sensory impairments, affecting 50-80% of stroke survivors [3,4], can disrupt the brain’s ability to process and integrate somatosensory input, which is essential for maintaining body awareness [5].
Deficits in body awareness can lead to a decline in physical function, balance, and gait performance [6]. Body awareness refers to the ability to perceive and regulate one’s body condition and movements, the loss of this ability can negatively affect the effectiveness of rehabilitation [7]. Body awareness therapy (BAT) is a rehabilitation intervention designed to improve body awareness deficits by integrating sensory stimulation and movement. It focuses on restoring body awareness and enhancing the functional independence of patients [8].
BAT has been recognized as an effective intervention for various neurological impairments, including deficits in body awareness. It plays a significant role in rehabilitation aimed at improving physical function, balance, and gait in patients with stroke [9]. Within its conceptual framework, interventions such as motor imagery training (MIT) and kinaesthetic awareness training (KAT) have been highlighted for their focus on sensory feedback and motor control. MIT enhances body awareness and motor function through the mental practice of movements, while KAT emphasizes on improving proprioception and kinesthetic control to regulate movement patterns [10]. These approaches align with BAT’s overarching goal of restoring body awareness, making them integral components of its application in stroke rehabilitation [8]. For example, MIT has been shown to effectively enhance motor recovery in patients with stroke through targeted mental imagery exercise [11]. These methods contribute to BAT’s potential to comprehensively address deficits in body awareness, balance, and mobility. BAT focuses on helping patients achieve a clearer perception of their bodies and to effectively regulate their movements. Thus, it has the potential to simultaneously improve physical function, balance and gait, thereby maximizing rehabilitation outcomes [12]. For example, BAT helps patients improve their body awareness by adjusting asymmetrical movement patterns and utilizing sensory feedback to maintain a stable gait.
These effects of BAT have been reported to positively influence motor function recovery in stroke patients [13]. However, despite the growing recognition of BAT as a valuable rehabilitation approach, there is limited evidence of its quantitative impact on physical function, balance, and gait performance. While existing systematic reviews have summarized the potential benefits of BAT, no meta-analysis has been conducted to quantitatively synthesize findings across studies [13]. As a result, there remains a gap in understanding the precise effect size of BAT on these key rehabilitation outcomes. This study aimed to addresses this gap by conducting a meta-analysis to evaluate the effectiveness of BAT in improving physical function, balance, and gait in patients with stroke. By synthesizing evidence from randomized controlled trials, this meta-analysis aimed to provide robust, quantitative insights into the clinical applicability of BAT. The results of this study will help to validate BAT as an evidence-based intervention and offer practical guidance for its use in stroke rehabilitation programs. This meta-analysis not only builds upon the foundation laid by previous reviews but also offers a more comprehensive understanding of the potential of BAT to enhance rehabilitation outcomes.
This systematic review and meta-analysis synthesized the effects of BAT on patients with stroke through qualitative and quantitative analyses. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guidelines and was prospectively registered in the PROSPERO (International Prospective Register of Systematic Reviews) database (No. CRD42024616385).
Studies were included if they involved adult patients (≥ 18 years old) diagnosed with stroke ≥ (ischemic or hemorrhagic), as confirmed through clinical or imaging criteria. Participants could be at any stage of stroke recovery (acute, subacute, or chronic) and could present with motor, sensory, or body awareness deficits. BAT has been shown to be applicable across different recovery stages in stroke rehabilitation. Thus, all stages were included to ensure a comprehensive evidence synthesis.
This review included studies evaluating the effects of BAT as a primary intervention. BAT is a therapeutic approach aimed at enhancing body awareness through the integration of sensory input and movement, with specific goals of improving physical function, balance, and gait performance. Interventions within the conceptual framework of BAT, such as MIT and KAT, were also included. MIT focuses on enhancing motor control and gait performance through mental imagery exercises, whereas KAT emphasizes on improving balance and proprioception through kinesthetic feedback and body awareness techniques. These interventions align with BAT’s overarching goal of restoring body awareness and functional independence in stroke patients.
The included studies compared BAT with standard rehabilitation, usual care, no intervention, or other active interventions aimed at improving physical function and gait. Studies with control groups that involving conventional therapy, exercise-based rehabilitation, or other non-BAT interventions were eligible for inclusion.
Measures evaluating physical function, balance, and gait performance in patients with stroke were included.
Published randomized controlled trials (RCTs) retrieved from databases were included.
Studies were included if they were published between 2013 and 2024, focused on subcategories of BAT in randomized controlled trials (RCTs), were conducted on human patients, and were published in English. Conference abstracts or studies that did not meet the inclusion criteria were excluded.
The overall framework of the search strategy was consistent with that of similar previous studies. For this review, searches were conducted independently by two researchers with experience in meta-analysess in November 2024. The search strategy combined terms representing P (population), I (intervention), and SD (Study Design) and was developed with reference to Medical Subject Headings (MeSH). Preidentified keywords and Boolean operators were used to refine the search strategy. The primary keywords included “randomized controlled trial” AND “stroke patients” AND “(body awareness therapy OR motor imagery training OR kinaesthetic awareness training).” Additional terms, such as “balance,” “gait,” and “physical function,” were included to narrow the scope of the search and focus on rehabilitation outcomes. The search was performed using international electronic databases, including the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (Embase), Medical Literature Analysis and Retrieval System Online (MEDLINE), and Web of Science.
The studies identified through the database search were organized and duplicate records were systematically removed using Microsoft Excel (Microsoft, Redmond, Washington, USA). Following the PRISMA guidelines, the titles and abstracts of the remaining studies were screened independently. Full-text reviews were conducted for studies that met the inclusion criteria, and any discrepancies between reviewers were resolved through joint consultation and detailed full-text analysis to finalize the selection process.
The risk of bias (RoB) of the included RCTs was assessed using a standardized tool, developed by the Cochrane Bias Methods Group, specifically to evaluate the RoB in randomized trials. The tool consists of seven domains. Two researchers independently evaluated the RoB as low (+), high (-), or unclear (?) Any discrepancies were resolved through a joint review of the original studies to reach a consensus [14].
Data synthesis was conducted using software designed for systematic reviews (RevMan 5.4, The Cochrane Collaboration, England). Meta-analysis was performed when at least three studies had comparable variables or quantitative data measured before and after the intervention. The effect size was calculated as the standardized mean difference (SMD) for comparable variables, and analyses were conducted using a random-effects model, which adjusts for variability between studies [15]. Heterogeneity among the included studies was assessed using the I2 statistic and Cochrane Chi-squared test. An I2 value ≥ 75% indicated high heterogeneity, whereas a value < 40% indicated low heterogeneity [16]. Publication bias was assessed using funnel plots provided in RevMan 5.4 [17].
A total of 69 studies were identified using international databases. Using Microsoft Excel, one duplicate study was identified and excluded. An initial screening of the titles and abstracts resulted in the exclusion of 57 studies. During the full-text review, five additional studies were excluded: two study owing unavailable data, one owing to irrelevant interventions, one owing to an inappropriate study design, and two owing to unsuitable outcomes. Consequently, five RCTs were included for qualitative and quantitative analysis [11,18-21] (Figure 1).
The methodological quality assessment of the five RCTs showed 100% agreement between the researchers. The results of the evaluation using the RoB tool for the seven domains were as follows: random sequence generation (low risk: 4, unclear risk: 1), allocation concealment (low risk: 2, unclear risk: 3), blinding of participants and personnel (low risk: 1, high risk: 4), blinding of outcome assessors (low risk: 2, high risk: 3), incomplete outcome data (low risk: 5), selective reporting (low risk: 5), and other biases (low risk: 5) (Figure 2).
The five RCTs included in this systematic review involved 280 patients with stroke. The interventions consisted primarily of BAT and MIT. BAT focused on sensory- motor integration to enhance body awareness, whereas MIT involved the mental rehearsal of movements to improve motor control. The intervention durations ranged from 4 to 8 weeks, and all studies were included to ensure consistency. The outcome measures included validated tools for assessing physical function, balance, and gait (Table 1).
Three RCTs including 172 patients with stroke were analyzed to evaluate the effects of BAT on physical function (Figure 3). The results showed that the experimental group that received BAT demonstrated significant improvements in physical function compared to the control group. The meta-analysis, performed using a random-effects model, reported an effect size of SMD 1.16 (95% confidence interval = [CI]: 0.20 to 2.11), with considerable heterogeneity observed (χ2=13.58, df =2, I2=85%). The overall effect was statistically significant (Z=2.38).
Three RCTs, including 154 patients with stroke were analyzed to assess the effects of BAT on balance (Figure 4). The results demonstrated that the experimental group that received BAT showed significant improvements in balance compared to the control group. The meta-analysis, conducted using a random-effects model, yielded an effect size of SMD=1.02 (95% CI: 0.68 to 1.36), with moderate heterogeneity observed (χ2=1.67, df=2, I2=0%). The overall effect was statistically significant (Z=5.91).
Three RCTs, including 82 patients with stroke were analyzed to evaluate the effects of BAT on gait performance (Figure 5). The results indicated that the experimental group that received BAT did not show a statistically significant improvement in gait performance compared to the control group. The meta-analysis, performed using a random-effects model, yielded an effect size of SMD=-1.24 (95% CI: -2.54 to 0.07), with high heterogeneity observed (χ2=11.71, df=2, I2=83%). However the overall effect was not statistically significant (Z=1.85).
This meta-analysis evaluated the effects of BAT on the physical function, balance, and gait performance in patients with stroke. The analysis revealed that BAT had a significant positive effect on improving physical function and balance; however, its effect on gait performance was not statistically significant.
The meta-analysis results for physical function demonstrated that BAT is effective in improving patients’ ability to perform daily living activities. It enhances physical function by improving sensorymotor coordination, addressing asymmetric movement patterns, and facilitating smooth motor control. In terms of balance, BAT effectively improves postural stability by enhancing sensory feedback and proprioception, which are essential for maintaining balance and reducing fall risk in patients with stroke. These mechanisms align with previous findings highlighting the importance of sensory integration in functional recovery [22]. However, the high heterogeneity (I2 =85%) indicated substantial variability among studies, highlighting the need to further explore potential factors such as intervention duration, intensity, and patient characteristics.
The effects of BAT on balance were significant and consistent (SMD=1.02; 95% CI: 0.68 to 1.36, I2=0%), with low heterogeneity observed. These findings indicate that BAT effectively enhance stability by improving sensory feedback and postural control. Balance impairments is particularly common in patients with stroke and significantly increases the risk of falls [23-25]. Improving balance through sensory feedback and input is a critical factor for patients with stroke [26]. These findings have significant clinical implications.
In contrast, the effects of BAT on gait performance were not statistically significant (SMD=-1.24; 95% CI: -2.54 to 0.07, I2=83%). Despite the lack of statistical significance, the large effect size suggests that BAT may have a meaningful impact on certain aspects of gait performance, particularly in specific subgroups of patients or under optimized intervention conditions. This finding highlights the potential of BAT in influencing gait recovery, although the observed effects were inconsistent across studies. BAT primarily targets balance and postural control by enhancing sensory feedback and sensorymotor integration [22]. Although these aspects are fundamental to stable and coordinated walking, gait recovery encompasses multiple dimensions, including strength, cardiovascular endurance, spatiotemporal gait parameters, and neuromuscular coordination [27]. The inability of BAT to comprehensively address these broader elements may limit its overall impact on gait performance [28].
Furthermore, the limited number of included studies and the small sample sizes may have resulted in insufficient statistical power. The high heterogeneity observed in gait outcomes could be attributed to variations in intervention protocols, assessment tools, or patient characteristics.
These findings indicate that BAT has significant potential for improving physical function and balance, providing a strong basis for its practical application in rehabilitation programs. Balance improvement can directly contribute to reducing the fall risk and enhancing patient mobility [29]. However, the effects of BAT on gait performance warrant further investigation with a larger number of studies. Therapists may achieve optimal outcomes by tailoring BAT interventions according to the individual needs of their patients. This meta-analysis had several limitations, including the small number of included studies and participants. The high heterogeneity observed in the results highlights the need for further exploration of factors, such as intervention protocols, duration, and patient characteristics. Additionally, the lack of proper blinding in many studies warrants caution when interpreting these findings. Future research should focus on validating the effects of BAT through larger, higher-quality randomized controlled trials and developing standardized intervention protocols to address specific outcomes, such as gait performance.
This meta-analysis is the first to systematically evaluate the effects of BAT on physical function, balance, and gait performance in patients with stroke. These findings highlight the significant potential of BAT in improving physical function and balance, supporting its integration into stroke rehabilitation programs. However, its effects on gait performance remain inconclusive, necessitating further research with larger sample sizes and standardized protocols. These results provide a foundation for future studies and emphasize the importance of tailoring BAT interventions to individual patients to optimize outcomes.
Characteristics of included studies
| Study | Sample size | Therapeutic intensity | outcomes |
|---|---|---|---|
| Anwar, et al., 2021 [30] | EG=21 CG=23 |
A total of 6 weeks of therapy was administered, with participants receiving 30 minutes of MIT followed by 30 minutes of gait training three times per week in the EG. The CG underwent 30 minutes of gait training only. The intervention aimed to improve gait performance through a combination of physical practice and MIT. | Physical function=FMA |
| Bang and Cho 2016 [19] | EG=33 CG=33 |
A total of 4 weeks of intervention was administered, with participants in the EG receiving 20 minutes of BAT, followed by 30 minutes of walking training, 5 days a week. The CG received 30 minutes of walking training only, 5 days a week. The BAT program included sensory awareness exercises, body tension observation, and stability limit training through repetitive movements performed in sitting and standing positions. | Balance=BBS Gait performance=TUG |
| Cho et al., 2013[11] | EG=15 CG=13 |
The intervention was conducted over 6 weeks, with participants in the EG receiving MIT for 15 minutes, followed by gait training on a treadmill for 30 minutes, three times per week. CG participated in gait training alone for 30 minutes, three times per week. The motor imagery training included both visual and kinematic imagery, focusing on normal gait movements, with patients imagining the sensory and motor processes involved in walking. A low-intensity protocol (40∼50% heart rate reserve) was used during gait training to ensure patient safety. | Physical function=FMA Gait performance=TUG |
| Lindvall and Forsberg 2018[20] | EG=21 CG=21 |
The intervention consisted of BAT delivered in groups for eight weeks, with sessions conducted once a week, each lasting 60 minutes. Participants in the EG received BAT in addition to their usual daily activities, while the CG continued with their daily activities without any additional intervention. The BAT sessions included repetitive movements performed in sitting, standing, and supine positions, focusing on postural stability, free breathing, and self-awareness. The intensity and difficulty of the movements were progressively adjusted by the physiotherapist over the eight-week period, tailored to the participants' capabilities. | Balance=BBS Gait performance=TUG |
| Sui, et al., 2023[21] | EG=50 CG=50 |
The intervention lasted for 4 weeks, with participants in the EG undergoing 30 minutes of MIT followed by routine rehabilitation therapy, five times a week. The CG received routine rehabilitation therapy alone for the same duration and frequency. MIT included task illustration, guided mental practice, and repetitive motor imagery exercises, emphasizing trunk movements such as sitting balance and posture control. Routine rehabilitation therapy incorporated neuromuscular facilitation, motor relearning, and daily activity training, with a focus on improving motor function and balance. | Physical function=FMA Balance=BBS |
BIT=body awareness therapy; BBS=berg balance scale; CG=control group; EG=experimental group; FMA=fugl myer assessment; MIT= motor imagery therapy; TUG=timed up and go test.
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