If you have read anything we have written before, you will know we think the amount of rehabilitation someone gets after a stroke matters.
So here is the paper that argues with us.
In 2021 a Cochrane review — the kind of review that pools every decent trial on a question and asks what they say together — looked at exactly this. Does more time in rehabilitation after a stroke produce better results? It gathered 21 randomised trials covering 1,412 people.
On the outcome that matters most to families, the answer was: probably not, and we are not sure.
For activities of daily living — washing, dressing, getting to the toilet, making a cup of tea, the things that decide whether someone can stay in their own home — more time in rehabilitation produced a standardised difference of 0.13, with a confidence interval running from −0.02 to 0.28. In plain terms: a small effect that might be nothing at all, because the range of possible answers includes zero. That finding came from 14 of the trials, covering 864 people, and the review graded the certainty of it as VERY LOW. Very low certainty means the authors are saying, in their own technical language, that further research is quite likely to change this number.
Put in the review's own terms, there is very low certainty about whether the amount of time spent in rehabilitation makes any difference to most of the outcomes measured, with a modest benefit appearing only in measures of motor impairment immediately after the intervention.
That second half is the part that survives. For upper-limb motor impairment — how much movement and control has come back in the arm and hand, measured directly rather than inferred — more time did show a benefit: a standardised difference of 0.32, confidence interval 0.06 to 0.58, from 9 of the trials, covering 287 people. That one does not cross zero, so it is a real effect rather than a possible one. But the review graded it LOW certainty, which is one step up from very low and still a long way from settled.
And the review was explicit that the evidence is not good enough to recommend a minimum number of minutes or hours a day. There is no number in it. Anyone who tells you the research proves you need three hours a day of anything is going further than the research goes.
Why we are publishing the paper that argues with us
Because the argument is more interesting once you read what it actually found, and because a rehab provider that only quotes the studies that flatter it is not a provider you should trust with a member of your family.
Read the two results next to each other and a pattern appears. More time produced a measurable change in the arm — the thing being practised, measured directly. It did not clearly produce a change in daily life. The most reasonable reading of that is not "dose does not matter". It is that MORE OF THE SAME is a weak lever. Adding hours to a programme changes the total, and it does not necessarily change what is being practised, how many times, or whether the thing being practised is the thing the person actually needs to be able to do on Tuesday morning.
That is a harder claim to sell than "more therapy is better". It is also the one the evidence supports.
What we think it means in practice
Three things, and we would rather say them carefully than confidently.
ONE. Time is a container, not a treatment. The question to ask about any rehabilitation programme is not only how many hours it contains, but what happens inside them — how many repetitions, of what, aimed at which specific task. An hour in which someone completes a handful of practice attempts and an hour in which they complete hundreds are the same hour on a timetable and not the same intervention.
TWO. What is being practised should be the thing that is wanted. The ADL result is a reminder that improving an impairment measure and improving somebody's actual day are not automatically the same event. If the goal is getting off the sofa without help, the practice should look like getting off the sofa, not only like an exercise that ought in principle to help with it.
THREE. Measure it, including when it does not move. The reason the arm result is more trustworthy than the daily-living one is that the arm was measured with standardised tools. The same applies at the scale of one person: if nothing is being scored, nobody can tell the difference between a programme that is working slowly and a programme that is not working. At HoliHab, every programme is designed around a defined set of published outcome measures, scored at set points in the block and reported as they come out — including a score that has not changed. A number that did not move is information, not a failure, and hiding it would make the ones that did move worth less.
To be straight about our own position: we can show you the measures we use and the format we report them in. We are a young service and we do not yet hold outcome data across a caseload, and we are not going to pretend otherwise while the evidence library is still being built.
What this does not say
It does not say rehabilitation does not work. Every trial in that review gave rehabilitation to everybody; the question was only whether MORE of it, of the same kind, added something on top.
It does not say the NHS is getting this wrong. NHS stroke teams are working inside commissioned capacity and staffing that they do not set, and the clinicians in them are the people who got most of these patients this far. The gap this research points at is a gap in what gets commissioned and what gets measured, not a gap in the people doing the work.
And it does not say anything about any individual. Recovery after a stroke varies enormously between people, for reasons that include the stroke itself, the person, their health, and their circumstances. A pooled average across 1,412 people in 21 trials cannot tell you what will happen to one person, and nobody should let it.
The one question worth asking
If you are choosing rehabilitation for someone — privately, through the NHS, or both — the question this research suggests is not "how many hours do I get?"
It is: "what will actually be practised in those hours, how many times, and how will we know whether it is working?"
A service that can answer that in specifics is worth more than one offering a bigger number.
This article is general information and not a substitute for assessment by your GP, stroke team or physiotherapist. Every recovery is different.