Does providing more exercise-based therapy enhance motor recovery after stroke? A systematic review and meta-analysis

Objectives: To determine the strength of current evidence for provision of a higher dose of the same types of exercise-based therapy to enhance motor recovery after stroke. Data Sources: An electronic search of: MEDLINE, EMBASE, CINAHL, AMED, and CENTRAL. Study Selection: 2 independent reviewers selected studies using predetermined inclusion criteria: randomized or quasi-randomized controlled trials with or without blinding of assessors; adults, 18 years or older, with a clinical diagnosis of stroke; experimental and control group interventions identical except for dose; exercise-based interventions investigated; and outcome measures of motor impairment, movement control or functional activity. Data Extraction: 2 reviewers independently extracted outcome and follow-up data. Effect sizes and 95% confidence intervals were interpreted with reference to risk of bias in included studies. Data Synthesis: 8 papers reporting 7 studies were included. The risk of bias was assessed as low predominantly. Intensity of the control intervention ranged from a mean of 9 to 28 hours. Experimental groups received between 14 and 92 hours. The included studies were heterogeneous with respect to types of therapy, outcome measures and time-points for outcome and follow-up. Consequently, most effect sizes relate to 1 study only. Single study effect sizes suggest a trend for better recovery with increased dose at outcome but this trend was less evident at follow-up. Meta-analysis was possible at outcome for: hand-grip strength, -10.1 (-19.1 to -1.2); Action Research Arm Test (ARAT), 0.1 (-5.7 to 6.0); and comfortable walking speed, 0.3 (0.1 to 0.5). At follow-up, between 12 and 26 weeks after start of therapy, meta-analysis findings were: Motricity Arm, 10.7 (1.7 to 19.8); ARAT, 2.2 (-6.0 to 10.4); Rivermead Mobility, 1.0 (-0.6 to 2.5); and comfortable walking speed, 0.2 (0.0 to 0.4). Conclusions: Current evidence provides some, but limited, support for the hypothesis that a higher dose of the same type of exercised–based therapy enhances motor recovery after stroke. Prospective dose-finding studies are required.