Priority 7 Stroke Rehabilitation and Long-term Care

UNCERTAINTY: What is the best time, place and amount of therapy (e.g. speech and language therapy, physiotherapy, occupational therapy) to get the best outcomes for stroke survivors, and is this different than advised in the Stroke Guidelines (5 times a week for 45 minutes)? (JLA PSP Priority 7)
Overall ranking 7
JLA question ID 0106/7b
Explanatory note

Rehabilitation is key to stroke survivors and their loved ones rebuilding and adapting to life after stroke. Stroke has complex effects and survivors may require different types of therapy and at various times in their recovery journey. This can contribute to a high burden of treatment and be costly to deliver. Therefore it’s important to understand optimal strategies that can be applied in patient-centred care.

However, no guidelines report the recommended length of stay for each rehabilitation setting. A Cochrane review (Langhorne et al, 2020) suggested that future trials need to focus on what the key components of stroke unit care are and different models of care (see Evidence). Guidelines are not evidenced-based, rather formed from discussion so research is needed.

Some evidence exists relating to setting and dose of specific therapies. For example speech and lanugage therapy for aphasia (Brady et al 2016, see Evidence). Additional insights may come from individual patient data network meta-analysis but additional definitive trials remain a requirement. Another review found that 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 (Schneider et al, see Evidence). A Cochrane review of telerehabilitation concluded that the field is still emerging and more studies are needed to draw more definitive conclusions (see Evidence).

Evidence (this is a Protocol)
Langhorne  P, Ramachandra  S. Organised inpatient (stroke unit) care for stroke: network meta‐analysis. Cochrane Database of Systematic Reviews 2020, Issue 4. Art. No.: CD000197. DOI: 002/14651858.CD000197.pub4.
Brady et al
Shneider et al 

Health Research Classification System category Stroke
Extra information provided by this PSP
Original uncertainty examples Research on if and how intensive post stroke therapy - Speech and Language Therapy, Physical and Physio-therapy - could improve recovery. By that I am thinking if the post-stroke rehab sessions were not controlled by costs and staff availability but by personal needs what would the result be? Particularly immediately post-stroke. ~ The stroke guidelines say 5 x week therapy for 45mins, what is the intensity needed for best recovery?  
Submitted by

Stroke Survivor x 91, Carer x 38, Health/social care professional x 110, Research Recommendations x 3, Not stated x 11

PSP information
PSP unique ID 0106
PSP name Stroke Rehabilitation and Long-term Care
Total number of uncertainties identified by this PSP. 93  (To see a full list of all uncertainties identified, please see the detailed spreadsheet held on the JLA website)
Date of priority setting workshop 19/20th April 2021