Rehabilitation interventions for improving health-related quality of life after stroke: A systematic review and meta-analysis

Background: The ultimate goal of stroke rehabilitation is to regain optimal Health-Related Quality of Life (HRQoL). However, rehabilitation interventions are usually targeted to specific goals, such as improvement of physical functioning, cognitive problems or symptoms of depression. This raises the question whether rehabilitation interventions may also improve HRQoL as a global outcome measure after stroke. Furthermore, different study designs are used to evaluate outcome of rehabilitation interventions: randomized controlled trials (RCTs) and studies that use a pre-post design, which may lead to different conclusions.
Objective: To present a systematic review and meta-analysis of rehabilitation intervention studies for improving HRQoL after stroke and to compare the evidence from RCTs and pre-post designs.
Methods: PubMed and Web of Science were searched for studies that evaluated the effects of a rehabilitation intervention on HRQoL after stroke.
The following inclusion criteria were used:
1) study population of at least 10 patients with stroke;
2) intervention study;
3) SF-36 outcomes reported;
4) RCT or pre-post design and
5) in- or outpatient rehabilitation or community setting.
Primary outcomes were the Mental Component Score (MCS) and Physical Component Score (PCS) of the SF-36 at first follow-up. A random-effects meta-analysis was performed on all RCTs and on the prepost studies. PRISMA guidelines and GRADE quality assessment were followed.
Results: In total, 32 articles were selected, including 18 RCTs and 14 pre-post design studies. A total of 1744 patients were included, of which 968 were in the RCTs and 776 were in the pre-post designs. In the RCTs the MCS improved significantly over the intervention time (effect size (ES)=0.2, p =.001), but PCS did not improve significantly (ES = 0.1, p =.058). In the pre-post studies, both MCS and PCS significantly improved over the intervention time (ES = 0.3, p <.001).
Conclusions: Evidence was found that rehabilitation interventions may be effective in improving the mental component of HRQoL after stroke. Studies that use pre-post designs may overestimate the effect of rehabilitation interventions, especially on the physical component of HRQoL.