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Intensity of rehabilitation: some answers and more questions?
  1. P Langhorne
  1. Academic Section of Geriatric Medicine, 3rd Floor, Centre Block, Royal Infirmary, Glasgow G4 0SF, UK
  1. Correspondence to:
 Dr P Langhorne;

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No benefits to intensive rehabilitation in the long term

For many years rehabilitation researchers have pondered whether the observed recovery of patients from stroke occurs at the optimum natural recovery rate or may be further enhanced by rehabilitation interventions, in particular by increasing the intensity of rehabilitation input. A carefully conducted randomised trial by Kwakkel et al1 indicated that increasing the intensity of physical training after middle cerebral artery stroke brought about improvements in the recovery during the first 6 months. When the additional training was focused on the upper limb improvements in dexterity were observed; when the lower limb was targeted walking ability and Barthel activities of daily living (ADL) scores improved. In their follow up paper (Kwakkel et al this issue pp 473–479)2 they address the question of whether these benefits continue in the longer term. This follow up paper indicates that there were no significant differences between the treatment groups at one year after randomisation, an observation that appears to confirm previous similar trials.3,4

Why did the early benefits of intensive training disappear at a later stage? The first possibility is that there were differences in treatment after the intervention period ended but this appears unlikely. None of the patient groups received much rehabilitation input after six months. The second possibility is that the treatment group suffered a decline in function after their intensive treatment was removed. This also appears unlikely, as it is not supported by the longitudinal data. A third possibility is that the control group continued to improve until their function matched that of the intervention groups. On balance, this seems the most compelling explanation.

An additional observation was that patients who were noted to have made an incomplete functional recovery at 6 months showed the largest subsequent changes (including both improvement and deterioration) in impairments and disability. This observation is probably not an artefact of the measures used and does indicate that there is potentially a subgroup of patients in whom increased therapy could be targeted at a later stage.

The main message appears to be that increasing the intensity of upper and lower limb training for selected patients after a stroke can speed up recovery but the longer term effects are uncertain. It remains to be established whether we can identify patients who are exceptions to this general rule and would benefit from later intervention to optimise their recovery.

No benefits to intensive rehabilitation in the long term