Questions: In people receiving rehabilitation aimed at reducing activity limitations of the lower and/or upper limb after stroke, does adding extra rehabilitation (of the same content as the usual rehabilitation) improve activity? What is the amount of extra rehabilitation that needs to be provided to achieve a beneficial effect? Design: Systematic review with meta-analysis of randomised trials. Participants: Adults aged 18 years or older that had a diagnosis of stroke. Intervention: Extra rehabilitation with the same content as usual rehabilitation aimed at reducing activity limitations of the lower and/or upper limb. Outcome measures: Activity measured as lower or upper limb ability. Results: A total of 14 studies, comprising 15 comparisons, met the inclusion criteria. Pooling data from all the included studies showed that extra rehabilitation improved activity immediately after the intervention period (SMD = 0.39, 95% CI 0.07 to 0.71, I2 = 66%). When only studies with a large increase in rehabilitation (> 100%) were included, the effect was greater (SMD 0.59, 95% CI 0.23 to 0.94, I2 = 44%). There was a trend towards a positive relationship (r = 0.53, p = 0.09) between extra rehabilitation and improved activity. The turning point on the ROC curve of false versus true benefit (AUC = 0.88, p = 0.04) indicated that at least an extra 240% of rehabilitation was needed for significant likelihood that extra rehabilitation would improve activity. Conclusion: Increasing the amount of usual rehabilitation aimed at reducing activity limitations improves activity in people after stroke. The amount of extra rehabilitation that needs to be provided to achieve a beneficial effect is large.
Stroke is the leading cause of disability worldwide.1 Difficulty walking and using the arm to complete self-care tasks are the most common activity limitations reported by stroke survivors.2 and 3 Practice is essential for motor learning and needs to be structured to offer a progressive challenge to reduce activity limitations.4, 5, 6 and 7 Consequently, clinical practice guidelines for stroke rehabilitation worldwide recommend that programs deliver a large amount of practice in order to maximise outcome after stroke.8, 9 and 10
Several systematic reviews have explored the effect of the amount of practice on outcome after stroke.5, 6, 7, 11, 12, 13 and 14 Three systematic reviews with meta-analyses have specifically investigated the effect of extra practice on motor outcomes after stroke. Kwakkel et al11 found that extra rehabilitation improved activities of daily living (SMD 0.13, 95% CI 0.03 to 0.23, 24 randomised trials). Verbeek et al6 found that extra lower limb rehabilitation within 6 months of stroke improved walking ability (SMD 0.32, 95% CI 0.11 to 0.52, 11 randomised trials) and walking speed (SMD 0.22, 95% CI 0.01 to 0.43, eight randomised trials). Most recently, Lohse et al5 found that extra rehabilitation improved outcome (SMD 0.35, 95% CI 0.26 to 0.45, 34 randomised trials). Furthermore, previous reviews have suggested that there is a dose-response relationship, where the greater the extra rehabilitation, the greater the benefit,5, 6, 7, 11, 12 and 14 regardless of time after stroke.5
Importantly, however, these previous systematic reviews included trials that did not investigate different doses of the same content of rehabilitation. For example, some of the included trials compared the effect of rehabilitation with no rehabilitation. Other included trials provided extra rehabilitation that was of different content to the usual rehabilitation, thereby confounding the analysis of amount of rehabilitation with type of rehabilitation. Cooke et al12 recognised these limitations and examined seven trials where the extra rehabilitation was delivered on top of usual rehabilitation and was of the same content. A meta-analysis of the seven studies was not performed, but the effect sizes of several trials with the same outcomes suggested that there was some evidence supporting the hypothesis that extra rehabilitation on top of usual rehabilitation improves outcomes after stroke.12
Rehabilitation is resource intensive, both on the part of the patient and the healthcare system. It is therefore important to determine the effect of increasing the amount of usual rehabilitation after stroke, and to ensure that this estimate is not confounded by the effect of extra rehabilitation of different content. Therefore, the aim of this review was to examine the effect of extra rehabilitation of the same content on top of usual rehabilitation.
Therefore, the research questions for this systematic review were:
In people receiving rehabilitation aimed at reducing activity limitations of the lower and/or upper limb after stroke, does adding extra rehabilitation (of the same content as the usual rehabilitation) improve activity?
What is the amount of extra rehabilitation that needs to be provided to achieve a beneficial effect?