Stroke rehabilitation in China: a systematic review and meta-analysis

Background: Stroke rehabilitation is regarded as an essential component of organized care, therefore withholding treatment is considered unethical in Western trials. Poststroke rehabilitation is not standard in China, and trials with no treatment controls have been possible. We believed aggregation of these data represented a unique opportunity to examine the 'effect size' of this intervention.

Aim: The aim of this study was to systematically review randomized controlled trials that compare rehabilitation to standard care after stroke in China.

Methods: We searched 24 databases including Wanfangdata (China), MEDLINE, EMBASE, CENTRAL, Cochrane Stroke Group Register, and Cochrane Central Register of Controlled trials. The primary outcome of interest was activities of daily living (Barthel Index), and the secondary outcome was disability (Fugl-Meyer Score). Random-effect meta-analysis was performed.

Results: Thirty-seven randomized controlled trials consisting of 5916 patients met inclusion criteria. Mean age reported in each study range from 47.2 to 72.5 years, 52.6% were male and 23.8% had a haemorrhagic stroke. Rehabilitation interventions varied between studies, but all included additional exercise therapy. Control patients had no formal rehabilitation. Patients who received rehabilitation showed marked improvements in Barthel Index (standardized mean difference: 1.04, 95% confidence interval: 0.88-1.21, P < 0.001, I(2) = 85.9%) and Fugl-Meyer Score (standardized mean difference: 1.10, 95% confidence interval: 0.82-1.38, P < 0.001, I(2) = 94.3%) compared with controls. However, reporting quality was low, and time to start of rehabilitation was often unclear.

Conclusion: These data provide some evidence that rehabilitation poststroke is more effective than no rehabilitation, improving activities of daily living and reducing disability. Although results are limited by low reporting quality and study heterogeneity, conducting research in countries in which rehabilitation is not standard care provides an opportunity to advance our understanding and should be encouraged.