Examining the recommendation for 45 minutes of therapy following stroke

Abstract

Most people receive Occupational Therapy and/or Physiotherapy as part of stroke rehabilitation. The Royal College of Physicians recommends a minimum of 45 minutes of each therapy required, every day. This recommendation is based on expert consensus, underpinned by limited evidence that more therapy achieves better outcomes. The Sentinel Stroke National Audit Program (SSNAP) monitors achievement of the 45 minute guideline; currently it is achieved for 37% and 34% of people considered appropriate for Occupational Therapy and Physiotherapy respectively. Reasons for non-achievement are unclear. This study examined the recommendation for a minimum of 45 minutes of therapy after stroke, using multiple and mixed methods. A Cochrane review analysed the effect of time spent in rehabilitation on activity limitation and impairment after stroke. To our knowledge, this is the first systematic review with meta-analysis, investigating the effect of time spent in rehabilitation after stroke, to control for type of rehabilitation within included studies. It found that ‘more time in therapy is better’ is false, but ‘a lot more therapy’ might lead to better outcomes. The Cochrane review concluded that there is insufficient evidence to recommend a specific minimum amount of therapy after stroke. Therapist focus groups explored why some people do not receive the recommended minimum amount of therapy. Findings were used to inform a Delphi study to gain consensus from therapists on reasons why a person might not receive a minimum of 45 minutes of therapy. Collectively, these studies found issues with the suitability of the guideline for some people after stroke. Some people are not able to consistently tolerate this amount of therapy, but the SSNAP audit lacks sensitivity to account for this variability. Other people require more than 45 minutes of daily therapy; this study found that they may not receive it. Non-delivery of the guideline is not only due to its suitability, but also due to lack of resources. There is insufficient therapy time to deliver the recommended minimum amount due, in part, to the organisation of stroke care, but also due to lack of therapy personnel. Findings from these studies, together with those of other published literature, contributed to a discussion regarding whether the 45 minute guideline is fit for purpose. It concluded that, although the guideline has increased the amount of therapy received, it does not meet all the requirements of a good clinical guideline according to literature sources. Therefore, this research identifies that the 45 minute guideline and its measurement via the SSNAP audit would benefit from review.

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Identifiers

ORCID for Beth Clark: orcid.org/0000-0003-4493-166X

ORCID for Ruth Turk: orcid.org/0000-0001-6332-5353

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