# Does more rehabilitation lead to better upper limb outcomes after stroke? A systematic review

## TL;DR

This study finds that doubling the duration of upper-limb rehabilitation after stroke may significantly improve outcomes.

## Contribution

The study identifies a potential threshold of 200% increased rehabilitation duration for meaningful upper-limb recovery.

## Key findings

- A 200% increase in rehabilitation duration significantly improved upper-limb function on the Action Research Arm Test.
- Smaller increases in rehabilitation duration (50%-150%) showed limited benefits.
- Results were based on low-certainty evidence from a small number of studies.

## Abstract

To determine whether increased rehabilitation duration improved upper-limb outcomes in people with subacute and chronic stroke. Where possible, we explored evidence for dose-response relationship or a ceiling effect for recovery.

A systematic review was conducted by searching Medline, EMBASE, EMCARE and PsycInfo. Randomised trials delivering the same type of upper-limb rehabilitation, but with a > 50% greater duration in one group (high dose) compared to another (low dose) were included. Risk of bias was assessed using the Cochrane risk of bias tool. Certainty of evidence was assessed using GRADE. Meta-analyses explored effects of increased rehabilitation duration and subgroup analyses explored a 50%–100%, 100%–150% and ≥200% increases in dose.

Four studies (n = 151) were included. Fugl-Meyer Assessment data were available from a single multi-arm trial, from which two intervention-control comparisons were derived based on therapy dose (n = 25), demonstrating greater rehabilitation duration led to improvement (p = 0.009). Meta-analyses including three studies (n = 89) found and a non-significant effect on the Action Research Arm Test (p = 0.266), both with a low certainty of evidence. Subgroup analyses showed that smaller dose increases (50%–150%) had limited benefits but doses ≥200% led to significant improvements in upper-limb function on the Action Research Arm Test (MD = 13.86, 95% CI: 3.43 to 24.29; p = 0.009).

Greater rehabilitation duration can lead to better upper-limb outcomes; however, an increase of at least 200% in duration might be required.

PROSPERO CRD42024604104.