Update on Rehabilitation After Stroke: Global Changes and the Continued Importance of Therapy Intensity, Dose, and Timing

Stroke rehabilitation research has seen an unprecedented expansion in the volume of randomized controlled trials. This sets the stage for conducting meta-analyses and network meta-analyses, which help compensate for the large number of smaller phase 2 studies. Over half of randomized controlled trials are conducted in the chronic phase when neuroplasticity is reduced, and the timing of the intervention is not directly generalizable to clinical care. Meanwhile, research productivity has plateaued in high-income countries over the past decade. Therapy intensity and dosage are regarded as important to improving recovery, but the optimal intensity and dose are still uncertain. However, timing also matters when it comes to therapy intensity and dosage. Therapy conducted in the chronic phase, when neuroplasticity has declined, requires a much higher dose to have a comparable impact as the same therapy delivered in the acute/subacute phase. More randomized controlled trials are now being conducted in low- and middle-income countries, focusing on different outcome measures and more acute/subacute randomized controlled trials when compared with trials from high-income countries.