Effects of intensity of rehabilitation after stroke. A research synthesis.
OBJECTIVE
A research synthesis was performed to (1) critically review controlled studies evaluating effects of different intensities of stroke rehabilitation in terms of disabilities and impairments and (2) quantify patterns by calculating summary effect sizes. The influences of organizational setting of rehabilitation management, blind recording, and amount of rehabilitation on the summary effect sizes were calculated.


METHODS
A Medline literature search was performed for a critical review of the literature. The internal and external validity of the studies was evaluated. In addition, a meta-analysis was performed by applying the fixed (Hedges's g) effects model.


RESULTS
The effects of different intensities of rehabilitation were studied in nine controlled studies involving 1051 patients. Analysis of the methodological quality revealed scores varying from 14% to 47% of the maximum feasible score. Meta-analysis demonstrated a statistically significant summary effect size for activities of daily living (0.28 +/- 0.12). Lower summary effect sizes (0.19 +/- 0.17) were found for studies in which experimental and control groups were treated in the same setting compared with studies in which the two groups of patients were treated in different settings (0.40 +/- 0.19). Variables defined on a neuromuscular level (0.37 +/- 0.24) showed larger summary effect sizes than variables defined on a functional level (0.10 +/- 0.21). Weighting individual effect sizes for the difference in amount of rehabilitation between experimental and control groups resulted in larger summary effect sizes for activities of daily living and functional outcome parameters for studies that were not confounded by organizational setting.


CONCLUSIONS
A small but statistically significant intensity-effect relationship in the rehabilitation of stroke patients was found. Insufficient contrast in the amount of rehabilitation between experimental and control conditions, organizational setting of rehabilitation management, lack of blinding procedures, and heterogeneity of patient characteristics were major confounding factors.
Kwakkel
G
G
Department of Physical Therapy, University Hospital Vrije Universiteit, Amsterdam, Netherlands. Fysiother@AZVU.NL
Wagenaar
R C
RC
Koelman
T W
TW
Lankhorst
G J
GJ
Koetsier
J C
JC
D000203:Activities of Daily Living; D002561:Cerebrovascular Disorders / Q000503:physiopathology / Q000534:rehabilitation*; D006801:Humans; D009788:Occupational Therapy; D026741:Physical Therapy Modalities; D012046:Rehabilitation / Q000379:methods; D013997:Time Factors