Review question
Does more time spent in rehabilitation improve activity? What matters? Is it the total time spent in rehabilitation that is important, or is it the way rehabilitation is delivered (the schedule)? Is it, for example, the amount of time spent per week? Or the frequency of sessions?
Background
Stroke rehabilitation helps people who have had a stroke to recover and resume their activities. Different countries have different guidelines about the amount of therapy they should receive. In England, a minimum of 45 minutes of each appropriate therapy, every day is recommended. In Canada, the guidelines recommend more – three hours of task-specific training, five days per week. Previous research has found no clear evidence in favour of one approach or the other: the effect of total time spent in rehabilitation, or the schedule by which it is delivered. The English recommendation of 45 minutes is based on the results of studies that compared different types of rehabilitation as well as different amounts of the same type of rehabilitation – which is not the same thing. This is why our review compares only different amounts of the same type of stroke rehabilitation.
Study characteristics
We included 21 studies amounting to 1412 people with stroke. Each study compared groups of people who had received different amounts of the same type of rehabilitation. Different types of rehabilitation were included, but the comparison within each study was always only different amounts of the same type. We included rehabilitation of the arms, legs, walking, and general rehabilitation. In 16 studies, participants were in the first six months after stroke. In the remaining five studies, participants were more than six months after stroke.
Search date
We searched for studies up to June 2021.
Key results
We found that, for measures of activities involved in daily living (e.g. washing and dressing), activity measures of the arm (e.g. picking up an item), and activity measures of the leg (e.g. walking) there was neither harm to nor benefit for groups that received more rehabilitation compared with groups that received less. For measures of movement of the arm and leg (e.g. strength or range of movement), there was a benefit from receiving more rehabilitation. However, when we compared only the studies that had a bigger contrast between groups, there was a beneficial effect from additional therapy in terms of daily living activities, activity measures of the arm and leg, and movement measures of the arm. This suggests that people with stroke need a large amount of extra rehabilitation for it to make a difference in their recovery and ability to do everyday activities.
Certainty of the evidence
Certainty of the evidence, which is measured by the quality of each of the studies included in the review, was either low or very low. Therefore, we can only draw tentative conclusions from the findings of this review. It also indicates that more, better quality, studies are needed.
An increase in time spent in the same type of rehabilitation after stroke results in little to no difference in meaningful activities such as activities of daily living and activities of the upper and lower limb but a small benefit in measures of motor impairment (low- to very low-certainty evidence for all findings). If the increase in time spent in rehabilitation exceeds a threshold, this may lead to improved outcomes. There is currently insufficient evidence to recommend a minimum beneficial daily amount in clinical practice. The findings of this study are limited by a lack of studies with a significant contrast in amount of additional rehabilitation provided between control and intervention groups.
Large, well-designed, high-quality RCTs that measure time spent in all rehabilitation activities (not just interventional) and provide a large contrast (minimum of 1000 minutes) in amount of rehabilitation between groups would provide further evidence for effect of time spent in rehabilitation.
Stroke affects millions of people every year and is a leading cause of disability, resulting in significant financial cost and reduction in quality of life. Rehabilitation after stroke aims to reduce disability by facilitating recovery of impairment, activity, or participation. One aspect of stroke rehabilitation that may affect outcomes is the amount of time spent in rehabilitation, including minutes provided, frequency (i.e. days per week of rehabilitation), and duration (i.e. time period over which rehabilitation is provided). Effect of time spent in rehabilitation after stroke has been explored extensively in the literature, but findings are inconsistent. Previous systematic reviews with meta-analyses have included studies that differ not only in the amount provided, but also type of rehabilitation.
To assess the effect of 1. more time spent in the same type of rehabilitation on activity measures in people with stroke; 2. difference in total rehabilitation time (in minutes) on recovery of activity in people with stroke; and 3. rehabilitation schedule on activity in terms of: a. average time (minutes) per week undergoing rehabilitation, b. frequency (number of sessions per week) of rehabilitation, and c. total duration of rehabilitation.
We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, eight other databases, and five trials registers to June 2021. We searched reference lists of identified studies, contacted key authors, and undertook reference searching using Web of Science Cited Reference Search.
We included randomised controlled trials (RCTs) of adults with stroke that compared different amounts of time spent, greater than zero, in rehabilitation (any non-pharmacological, non-surgical intervention aimed to improve activity after stroke). Studies varied only in the amount of time in rehabilitation between experimental and control conditions. Primary outcome was activities of daily living (ADLs); secondary outcomes were activity measures of upper and lower limbs, motor impairment measures of upper and lower limbs, and serious adverse events (SAE)/death.
Two review authors independently screened studies, extracted data, assessed methodological quality using the Cochrane RoB 2 tool, and assessed certainty of the evidence using GRADE. For continuous outcomes using different scales, we calculated pooled standardised mean difference (SMDs) and 95% confidence intervals (CIs). We expressed dichotomous outcomes as risk ratios (RR) with 95% CIs.
The quantitative synthesis of this review comprised 21 parallel RCTs, involving analysed data from 1412 participants.
Time in rehabilitation varied between studies. Minutes provided per week were 90 to 1288. Days per week of rehabilitation were three to seven. Duration of rehabilitation was two weeks to six months. Thirteen studies provided upper limb rehabilitation, five general rehabilitation, two mobilisation training, and one lower limb training. Sixteen studies examined participants in the first six months following stroke; the remaining five included participants more than six months poststroke. Comparison of stroke severity or level of impairment was limited due to variations in measurement.
The risk of bias assessment suggests there were issues with the methodological quality of the included studies. There were 76 outcome-level risk of bias assessments: 15 low risk, 37 some concerns, and 24 high risk.
When comparing groups that spent more time versus less time in rehabilitation immediately after intervention, we found no difference in rehabilitation for ADL outcomes (SMD 0.13, 95% CI −0.02 to 0.28; P = 0.09; I2 = 7%; 14 studies, 864 participants; very low-certainty evidence), activity measures of the upper limb (SMD 0.09, 95% CI −0.11 to 0.29; P = 0.36; I2 = 0%; 12 studies, 426 participants; very low-certainty evidence), and activity measures of the lower limb (SMD 0.25, 95% CI −0.03 to 0.53; P = 0.08; I2 = 48%; 5 studies, 425 participants; very low-certainty evidence). We found an effect in favour of more time in rehabilitation for motor impairment measures of the upper limb (SMD 0.32, 95% CI 0.06 to 0.58; P = 0.01; I2 = 10%; 9 studies, 287 participants; low-certainty evidence) and of the lower limb (SMD 0.71, 95% CI 0.15 to 1.28; P = 0.01; 1 study, 51 participants; very low-certainty evidence). There were no intervention-related SAEs. More time in rehabilitation did not affect the risk of SAEs/death (RR 1.20, 95% CI 0.51 to 2.85; P = 0.68; I2 = 0%; 2 studies, 379 participants; low-certainty evidence), but few studies measured these outcomes.
Predefined subgroup analyses comparing studies with a larger difference of total time spent in rehabilitation between intervention groups to studies with a smaller difference found greater improvements for studies with a larger difference. This was statistically significant for ADL outcomes (P = 0.02) and activity measures of the upper limb (P = 0.04), but not for activity measures of the lower limb (P = 0.41) or motor impairment measures of the upper limb (P = 0.06).