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. 2021 Oct 25;10(10):CD012612.
doi: 10.1002/14651858.CD012612.pub2.

The effect of time spent in rehabilitation on activity limitation and impairment after stroke

Beth Clark  1 , Jill Whitall  2 , Gert Kwakkel  3 , Jan Mehrholz  4 , Sean Ewings  5 , Jane Burridge  6
Affiliations

The effect of time spent in rehabilitation on activity limitation and impairment after stroke

Beth Clark et al. Cochrane Database Syst Rev. .

Abstract

Background: 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.

Objectives: 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.

Search methods: 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.

Selection criteria: 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.

Data collection and analysis: 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.

Main results: 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).

Authors' conclusions: 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.

Trial registration: ClinicalTrials.gov NCT02980796 NCT03259932 NCT01694992 NCT02507466 NCT03230370 NCT00369668 NCT01767480 NCT03168360.

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Conflict of interest statement

BC

  1. Funding

    1. Health Education Wessex: paid tuition fees for academic years 2013/2014, 2014/2015, and 2015/2016, and contributed to tuition fees for academic year 2016/2017 for Doctorate in Clinical Practice Studies at the University of Southampton. Contributed to tuition fees for academic year 2019/2020 for Philosophical doctorate (transferred from Doctorate in Clinical Practice Program) at the University of Southampton (funds paid to institution).

    2. Poole Hospital NHS Foundation Trust: contributed to tuition fees for academic year 2016/2017 for Doctorate in Clinical Practice Studies at the University of Southampton (funds paid to institution).

    3. Elizabeth Casson Trust: contributed to tuition fees for academic year 2016/2017 for Doctorate in Clinical Practice Studies at the University of Southampton. Provided full tuition fees for academic year 2020/2021 for Philosophical doctorate (transferred from Doctorate in Clinical Practice Program) at the University of Southampton (funds paid to institution).

  2. Employment

    1. Poole Hospital NHS Foundation Trust: employed by Poole Hospital prior to July 2019 (although 13 months of unpaid leave taken prior to this date).

    2. University of Southampton: currently I am employed by the University of Southampton as a Senior Research Fellow on an unrelated project.

JW: none.

JB: none.

GK

  1. Board memberships: European Managing Editor NeuroRehabilitation and Neural Repair; Co‐editor Stroke; Co‐editor Journal of Rehabilitation Medicine; Co‐editor International Journal of Stroke (money received by author).

JM: none.

SE: none.

Figures

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Scatter diagram plotting difference in total minutes of rehabilitation against outcomes (SMD) for activities of daily living, immediately after intervention
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Scatter diagram plotting difference in total minutes of rehabilitation against outcomes (SMD) for activity measures of the upper limb, immediately after intervention
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Scatter diagram plotting difference in total minutes of rehabilitation against outcomes (SMD) for activity measures of the lower limb, immediately after intervention
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Scatter diagram plotting difference in total minutes of rehabilitation against outcomes (SMD) for motor impairment measures of the upper limb, immediately after intervention
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Scatter diagram plotting difference in minutes of rehabilitation per week against outcomes (SMD) for activities of daily living, immediately after intervention
10
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Scatter diagram plotting difference in minutes of rehabilitation per week against outcomes (SMD) for activity measures of the upper limb, immediately after intervention
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Scatter diagram plotting difference in minutes of rehabilitation per week against outcomes (SMD) for activity measures of the lower limb, immediately after intervention
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Scatter diagram plotting difference in minutes of rehabilitation per week against outcomes (SMD) for motor impairment measures of the upper limb, immediately after intervention
1.1
1.1. Analysis
Comparison 1: Objective one: more time spent in rehabilitation vs less time spent in rehabilitation – immediate outcomes, Outcome 1: Activities of daily living outcomes
1.2
1.2. Analysis
Comparison 1: Objective one: more time spent in rehabilitation vs less time spent in rehabilitation – immediate outcomes, Outcome 2: Activity measures of the upper limb
1.3
1.3. Analysis
Comparison 1: Objective one: more time spent in rehabilitation vs less time spent in rehabilitation – immediate outcomes, Outcome 3: Activity measures of the lower limb
1.4
1.4. Analysis
Comparison 1: Objective one: more time spent in rehabilitation vs less time spent in rehabilitation – immediate outcomes, Outcome 4: Motor impairment measures of the upper limb
1.5
1.5. Analysis
Comparison 1: Objective one: more time spent in rehabilitation vs less time spent in rehabilitation – immediate outcomes, Outcome 5: Motor impairment measures of the lower limb
1.6
1.6. Analysis
Comparison 1: Objective one: more time spent in rehabilitation vs less time spent in rehabilitation – immediate outcomes, Outcome 6: Serious adverse events/death
2.1
2.1. Analysis
Comparison 2: Objective one: more time spent in rehabilitation vs less time spent in rehabilitation – medium‐term outcomes, Outcome 1: Activities of daily living outcomes: medium‐term outcomes
2.2
2.2. Analysis
Comparison 2: Objective one: more time spent in rehabilitation vs less time spent in rehabilitation – medium‐term outcomes, Outcome 2: Activity measures of the upper limb: medium‐term outcomes
2.3
2.3. Analysis
Comparison 2: Objective one: more time spent in rehabilitation vs less time spent in rehabilitation – medium‐term outcomes, Outcome 3: Activity measures of the lower limb: medium‐term outcomes
2.4
2.4. Analysis
Comparison 2: Objective one: more time spent in rehabilitation vs less time spent in rehabilitation – medium‐term outcomes, Outcome 4: Motor impairment measures of the upper limb: medium‐term outcomes
2.5
2.5. Analysis
Comparison 2: Objective one: more time spent in rehabilitation vs less time spent in rehabilitation – medium‐term outcomes, Outcome 5: Motor impairment measures of the lower limb: medium‐term outcomes
2.6
2.6. Analysis
Comparison 2: Objective one: more time spent in rehabilitation vs less time spent in rehabilitation – medium‐term outcomes, Outcome 6: Serious adverse events/death: medium‐term outcomes
3.1
3.1. Analysis
Comparison 3: Objective one: more time spent in rehabilitation vs less time spent in rehabilitation – long‐term outcomes, Outcome 1: Activities of daily living outcomes: long‐term outcomes
3.2
3.2. Analysis
Comparison 3: Objective one: more time spent in rehabilitation vs less time spent in rehabilitation – long‐term outcomes, Outcome 2: Activity measures of the lower limb: long‐term outcomes
4.1
4.1. Analysis
Comparison 4: Objective two: effect of total time spent in rehabilitation, Outcome 1: Activities of daily living outcomes: immediately after intervention
4.2
4.2. Analysis
Comparison 4: Objective two: effect of total time spent in rehabilitation, Outcome 2: Activity measures of the upper limb: immediately after intervention
4.3
4.3. Analysis
Comparison 4: Objective two: effect of total time spent in rehabilitation, Outcome 3: Activity measures of the lower limb: immediately after intervention
4.4
4.4. Analysis
Comparison 4: Objective two: effect of total time spent in rehabilitation, Outcome 4: Motor impairment measures of the upper limb: immediately after intervention
5.1
5.1. Analysis
Comparison 5: Objective three: effect of rehabilitation schedule , Outcome 1: Activities of daily living outcomes: immediately after intervention
5.2
5.2. Analysis
Comparison 5: Objective three: effect of rehabilitation schedule , Outcome 2: Activity measures of the upper limb: immediately after intervention
5.3
5.3. Analysis
Comparison 5: Objective three: effect of rehabilitation schedule , Outcome 3: Activity measures of the lower limb: immediately after intervention
5.4
5.4. Analysis
Comparison 5: Objective three: effect of rehabilitation schedule , Outcome 4: Motor impairments of the upper limb: immediately after intervention
See this image and copyright information in PMC

Update of

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Hubbard 2010 {published data only}
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Huijben‐Schoenmakers 2014 {published data only}
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Klassen 2020 {published data only}
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Krebs 1997 {published data only}
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Lamberti 2017 {published data only}
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Langhorne 2010 {published data only}
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Li 2000 {published data only}
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Lin 2017 {published data only}
    1. Lin Y. Does the enhanced rehabilitation programs facilitate the motor recovery after stroke? clinicaltrials.gov/ct2/show/NCT03230370 (first received 26 July 2017).
Lo 2010 {published data only}
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Martinsson 2003 {published data only}
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McDonnell 2017 {published data only}
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Mikulecka 2005 {published data only}
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Outermans 2010 {published data only}
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Richards 2006a {published data only}
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Roderick 2001 {published data only}
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Rodgers 2019 {published data only}
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Scrivener 2012 {published data only}
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References to studies awaiting assessment

Aksu 2001 {published data only}
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Bernhardt 2019 {published data only}
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