Increasing the amount of usual rehabilitation improves activity after stroke: a systematic review

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.