Abstract
Question: Repetitive practice facilitates motor learning after stroke but the effect of a rehabilitation program which provides an extra amount of the same, repetitive practice per week remains unknown. This protocol paper describes the methods to address the questions of a planned systematic review: (1) Does extra practice per week of the same rehabilitation lead to improved activity in stroke survivors? and (2) What is the amount of extra rehabilitation that needs to be provided to achieve an effect? Method: A systematic review will be conducted, commencing with a search of Medline, EMBASE, CINAHL, and CENTRAL databases. Randomised and non-randomized controlled trials that compare stroke rehabilitation programs involving similar content but different duration (recorded as therapy time per day or week) will be included. The outcome of interest will be activity, represented by walking ability or upper limb ability. The methodological quality of included studies will be assessed independently by two reviewers using the PEDro scale. Data will be extracted by two reviewers and will be pooled in a meta-analysis where there is sufficient homogeneity. We will calculate mean differences (MD) or standardized mean differences (SMD) and 95% CI for continuous outcomes as appropriate. We will calculate a Pearson correlation coefficient and ROC calculation to define the amount (in hours) of extra rehabilitation that needs to be provided to achieve improved activity in stroke survivors. Discussion: Findings will explore the relationship between increasing intensity of rehabilitation and improved activity in stroke survivors, and provide guidance to rehabilitation clinicians, inform policy and provide future directions for research. Systematic review registration: PROSPERO CRD42012003221.
Highlights
Stroke is a leading cause of disability among adults worldwide; approximately 80% of stroke survivors are left with impairments affecting activity and participation [1,2]
Repetitive practice promotes motor learning in stroke survivors and prior investigations have shown that an increase in the amount of practice can improve motor outcomes for stroke survivors [3,4,5,6,7,8]
Since 1996 previous systematic reviews have explored the effect of increased amounts of practice in rehabilitation programs; each review has included between 7 and up to 30 randomized and non-randomized controlled trials, and all have consistently generated findings that suggest an overall trend of a positive effect [49], i.e. that providing more therapy leads to better outcomes
Summary
Stroke is a leading cause of disability among adults worldwide; approximately 80% of stroke survivors are left with impairments affecting activity and participation [1,2]. Repetitive practice promotes motor learning in stroke survivors and prior investigations have shown that an increase in the amount of practice can improve motor outcomes for stroke survivors [3,4,5,6,7,8]. Despite this overarching finding, confounding factors have been identified when investigating the relationship between increased rehabilitation intensity and patientlevel outcomes [5,6,9]. Earlier reviews found a small to medium positive effect on walking ability from additional walking practice (summary effect size of 0.32, SD 0.110.52) [8], and significant improvement in ADL from an additional 16 hours of exercise therapy stroke
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