65395

cle2015
CRE0010.1177/0269215514565395Clinical RehabilitationHayward and Brauer

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

Dose of arm activity training during 2015, Vol. 29(12) 1234­–1243

© The Author(s) 2015
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DOI: 10.1177/0269215514565395

post stroke: a systematic review cre.sagepub.com

of the literature

Kathryn S Hayward and Sandra G Brauer

Abstract
Aim: To determine the dose of activity-related arm training undertaken by stroke survivors during acute
and subacute rehabilitation.
Methods: A systematic review of PubMed, CINAHL and EMBASE up to December 2014 was completed.
Studies were eligible if they defined the dose (time or repetitions) of activity-related arm training using
observational methods for a cohort of adult stroke survivors receiving acute or subacute rehabilitation.
All studies were quality appraised using an evidence-based learning critical appraisal checklist. Data was
analysed by method of documented dose per session (minutes, repetitions), environment (acute or
subacute rehabilitation) and therapy discipline (physiotherapy, occupational therapy).
Results: Ten studies were included: two observed stroke survivors during acute rehabilitation and eight
during subacute rehabilitation. During acute rehabilitation, one study reported 4.1 minutes per session
during physiotherapy and 11.2 minutes during occupational therapy, while another study reported
5.7 minutes per session during physiotherapy only. During inpatient rehabilitation, activity-related arm
training was on average undertaken for 4 minutes per session (range 0.9 to 7.9, n = 4 studies) during
physiotherapy and 17 minutes per session (range 9.3 to 28.9, n = 3 studies) during occupational therapy.
Repetitions per session were reported by two studies only during subacute rehabilitation. One study
reported 23 repetitions per session during physiotherapy and occupational therapy, while another
reported 32 repetitions per session across both disciplines.
Conclusion: The dose of activity-related arm training during acute and subacute rehabilitation after
stroke is limited.

Keywords
Physiotherapy, occupational therapy, dose, upper extremity, cerebrovascular accident

Received: 2 April 2014; accepted: 1 December 2014

Division of Physiotherapy, The University of Queensland, Corresponding author:

Brisbane, Australia Kathryn S Hayward, Division of Physiotherapy, School
of Health and Rehabilitation Sciences, The University of
Queensland, Brisbane 4072, Australia.
Email: k.hayward@uq.edu.au
Hayward and Brauer 1235
Introduction
Up to 80% of people have functional deficits of
their arm initially after stroke.1–3 This suggests that
a large proportion of stroke survivors will require
physiotherapy and/or occupational therapy to
address arm disability during acute and subacute
rehabilitation. Yet, at six months post stroke, over
60% have failed to achieve full recovery of arm
function.2 This is in comparison to leg function,
where almost 80% of stroke survivors are reported
to regain walking ability.4 The disparity in out-
comes may be linked to the complexity of arm
functions compared with leg, which require a wide
inventory of coordinated multi-joint movements.5
However, it is also possible that poor outcomes
may be compounded by lower prioritization6 or
insufficient training dose7 of activity-related arm
training (or active training, task-oriented training,
task-specific training, functional task practice or
upper extremity control training) during acute and
subacute rehabilitation after stroke.
The dose of activity-related arm training
undertaken has been suggested to be a critical
factor contributing to successful rehabilitation
after stroke8 as it focuses on use of the affected
arm in specific, meaningful and appropriately
challenging functional tasks.9 From animal models
of stroke, a high dose (>400 repetitions) of activity-
related arm training has been found to lead to
recovery of arm function and neuroplastic
changes, such as an expansion and reorganization
of motor maps,10–13 and increased cortical synapse
number14 and synaptic strength.15 Within human
stroke populations, activity-related training has
also been found to improve arm function.16 There
is growing evidence from both animal models
and human stroke populations, that an increased
dose (minutes or repetitions) may be respon-
sible for acceleration in the rate of functional
recovery.8,17,18
On the premise that more is better, current
clinical practice guidelines around the world
generally recommend that stroke survivors
engage in as much training as possible, with
some recommending between 45 to 60 minutes
of daily physiotherapy and occupational therapy
during rehabilitation.19–21 Yet, during this time,
the arm is just one domain to be addressed and
activity-related training one of many interventions
available. It remains unclear how much activity-
related arm training is actually undertaken in
clinical practice. Therefore, the aim of this
review was to synthesize the current evidence
base and define the dose (minutes or repetitions)
of activity-related arm training that is provided to
stroke survivors during routine acute or subacute
rehabilitation within physiotherapy and/or occu-
pational therapy training sessions. As early arm
movement is predictive of a greater recovery
potential,22–24 the review was limited to studies
describing dose provided during acute and suba-
cute rehabilitation. In addition, we aimed to
document activity-related arm training dose as a
proportion of total training dose.
Methods
A systematic review of the literature was under-
taken. A search strategy (see Appendix 1, available
online) was defined to identify studies indexed in
PubMed, CINAHL and EMBASE up to December
2014. Studies of all designs were eligible if dose
was captured as minutes or repetitions of activity-
related arm training using observational methods
(including behavioural mapping, video monitoring
or self-report by the therapists) for a cohort of
adult stroke survivors receiving acute or subacute
rehabilitation (as defined by individual studies). In
the case of uncertainty of a study’s eligibility, e.g.
with regards to definition of activity-related train-
ing, the primary study author was contacted and/or
previous related studies reviewed. Articles that
reported on more than one neurological condition,
e.g. traumatic brain injury and stroke, were only
included if a separate analysis of stroke was per-
formed. Studies that included participants from
only outpatient and/or community settings were
excluded as the frequency and access to services
could vary dramatically from an acute or subacute
setting and therefore skew the dose administered.
One researcher independently screened all titles and
abstracts to identify potentially relevant articles,
which were obtained in full text and assessed
1236 Clinical Rehabilitation 29(12)
according to the selection criteria by two reviewers.
To ensure all articles were found, a citation-tracking
database of Web of Science was used, along
with hand-scanning the reference lists of included
articles, clinical guidelines and key reviews in the
area.
Critical appraisal of the included studies was
performed using an evidence-based learning critical
appraisal checklist that has been previously used
to appraise observational studies evaluating the
dose of training undertaken post stroke.25 It is
designed to appraise the quality of observational
studies in four categories: population, data collec-
tion, study design and results. Two reviewers
independently appraised the included studies
and subsequently met to compare ratings. When
reviewers identified an item as unclear, the primary
author of the study was contacted. When disagree-
ment between reviewers occurred, a consensus was
reached through discussion. Where consensus
could not be reached, the opinion of a third inde-
pendent reviewer was sought.
Two reviewers extracted all data for the purposes
of this study. Dose was extracted in minutes and/or
number of repetitions of activity-related arm training
completed per session by discipline (physiotherapy
or occupational therapy) where possible. If the dose
was unclear, the primary author was contacted. The
average dose (duration and repetitions) per session
across included studies was subsequently calculated.
In addition, activity-related arm training dose as a
proportion of total training dose was calculated
where possible. Demographic characteristics of par-
ticipants (e.g. mean age, gender, stroke severity,
time since stroke) and study details (e.g. setting,
location, method of observation) were also extracted.
Results
The search strategy yielded 5261 studies (PubMed
n = 3334, CINAHL n = 880, EMBASE n = 1047),
with 3165 retained after removal of duplicates. The
primary reasons for exclusion were lack of mention
of arm activity or dose within the abstract or title.
A total of 50 full-text studies were retrieved
and assessed for eligibility against the criteria. The
primary reason for exclusion was lack of description
or quantification of activity-related arm training
dose. Ten studies met the inclusion criteria and
were included in this study.26–35 A further three
studies were identified from included reference
lists, but none were included owing to insufficient
reporting of activity-related arm training dose. Two
primary authors were contacted for further informa-
tion: (1) definition of activity-related arm training29
and (2) dose of activity-related arm training.27 In
addition, we reviewed previous related studies
completed by the authors of one study to clarify
their definition of activity-related arm training.31
Figure 1 depicts the flow of studies throughout the
review process.
The majority of studies were assessed to be high
quality and have a low risk of bias (mode score of
7/9), with one exception of the study by Peurala,35
which was scored 2/9. See Appendix 2, available
online. Consensus between quality reviewers was
achieved through discussion and at no point was a
third reviewer required. The primary author of one
study was contacted to clarify the item of investi-
gator concealment.26 Individual items highlighted
several studies with a potentially elevated risk of
bias and may have led to an overestimation of dose:
three studies failed to use an independent observer
to document therapy dose30,31,35 and five studies
had an inadequate sample size to make precise
estimates.26,28,29,32,35 Also, the main aim for only
three out of the ten studies30,32,34 was to document
arm training dose.
Activity-related arm training was observed
using methods of behavioural mapping (n = 3);
video recording (n = 2); researcher recording
(n = 2); and therapist recording (n = 3). Two studies
observed acute rehabilitation and eight studies sub-
acute rehabilitation. The average time since stroke
onset ranged from 5.627 to 16133 days. Stroke survi-
vors with mild through to severe arm functional
limitations (as described by the study) were
included. Studies were included from Australia
(n = 5), North America (n = 4) and Europe (n = 1).
Eight studies (two acute and six subacute reha-
bilitation) described dose in terms of minutes of
activity-related arm training per session during
physiotherapy or occupational therapy (Table 1).
During acute rehabilitation, one study reported
Hayward and Brauer 1237
Articles identified, n = 5 261:
Pubmed n = 3 334; CINAHL n =
880; EMBASE n = 1047
After removal of duplicates,
n = 3 165
Full text appraisal n = 53: primary
search n = 50; reference check n= 3
Studies included in review, n = 10
Figure 1.  Flow of identification and selection of studies.
4.1 minutes per session was spent on activity-
related arm training within physiotherapy and
11.2 minutes per session within occupational ther-
apy, which represented 17% of the session for
physiotherapy and 49% of the session for occupa-
tional therapy.27 Another study completed in acute
rehabilitation reported 5.7 minutes per session during
physiotherapy, which represented 15% of the
session.35 During subacute rehabilitation, stroke
survivors completed activity-related arm training
for a mean of 4 minutes per session (range 0.9 to
7.9, n  = 
4 studies) during physiotherapy, which
ranged from 2% to 10% of the session (n = 3 studies).
With regards to occupational therapy, a mean of
17 minutes per session (range 9.3 to 28.9, n = 3
studies) of activity-related arm training was
completed, which represented 23% to 70% of the
session (n = 2 studies).
No studies described activity-related arm repeti-
tions during acute rehabilitation, but two studies32,34
did report repetitions completed per session during
subacute rehabilitation (Table 2). Across both
Duplicates removed, n = 2 096
Excluded after screening
title/abstract, n = 3 115
Excluded after full text appraisal,
n = 43
Primary reason for exclusion was
failure to report activity-related arm
training dose as a function of
physiotherapy/occupational therapy
disciplines, one study reported 23 repetitions per
session,34 while another reported 32 repetitions
per session (which represented 15% of all
repetitions).32
Discussion
This study identified that stroke survivors are
engaged in a limited dose (captured in minutes
or repetitions) of activity-related arm training per
session during acute and subacute rehabilitation
post stroke across physiotherapy and occupational
therapy. Less than six minutes was documented
during acute rehabilitation within a physiotherapy
session and less than 12 minutes within an occupa-
tional therapy session.27,35 Studies completed during
subacute rehabilitation demonstrated a similar
pattern, with a mean of four minutes within a phys-
iotherapy session26,28,30,33 and 11 minutes within an
occupational therapy session.29–31 With regards to
movement repetitions, 23 to 32 activity-related arm
repetitions were performed per session across both
1238 Clinical Rehabilitation 29(12)

Table 1.  Activity-related minutes per session of physiotherapy and occupational therapy.

Study Participants Study details Minutes/session % session

PT OT PT OT
Bernhardt et al., n = 58, 29 males Acute hospital 4.1 11.2 17 49
200727 Mean age: 71.3 years Australia  
Mean days since stroke: 5.6 Behavioural mapping  
Mild to severe arm function  
Peurala et al., n = 19, 10 males Acute hospital 5.7 – 15 –
200735 Mean age: 66.4 years Finland  
Mean days since stroke: 8 Therapist recording  
Severity arm function not  
reported
Hayward et al., n = 32, 21 males Inpatient rehab 5.0 11.8 – –
201330 Mean age: 54.0 years Australia  
Mean days since stroke: 41 Therapist recording  
Severe arm function  
Gustafsson et al., n = 9, 1 male Inpatient rehab – 28.9 – 70
201229 Mean age: 70.6 years Australia  
  Mean days since stroke: 49.8 Behavioural mapping  
  Severity arm function not  
  reported
Elson et al., n = 15, 7 males Inpatient rehab 0.9 –  2 –
200928 Mean age: 65.1 years Australia
Mean days since stroke: 47.3 Video recording  
Severity arm function not
reported
Kuys et al., n = 30, 14 males Inpatient rehab 2.9 –  6 –
200633 Mean age: 67 years Australia  
Mean days since stroke: 161 Video recording  
Moderate arm function  
Horn et al., n = 830, 436 males Inpatient rehab –  9.3 – 23
200531 Mean age: 67 years USA  
  Mean days since stroke: 15 Therapist recording  
  Moderate to severe arm  
  function
Ada et al., 199926 n = 16, 11 males Inpatient rehab 7.9 – 10 –
  Mean age: 69 years Australia  
  Mean days since stroke: 46.9 Behavioural mapping  
  Severe arm function  

OT: occupational therapy; PT: physiotherapy.

disciplines during subacute rehabilitation.32,34
Based on this, it could be postulated that the poor
rate of arm recovery is a reflection of the low dose
of training undertaken rather than actual recovery
potential.
The dose reported to be undertaken during rou-
tine rehabilitation may be insufficient to enable
stroke survivors to drive optimal arm recovery.
Despite growing evidence to support a higher
dose (minutes) of therapy, it has remained low
Hayward and Brauer 1239
Table 2.  Activity-related repetitions per session during physiotherapy and occupational therapy.
Study Participants Study details
 
Kimberley et al., n = 28, 15 males Inpatient rehab
201032
  Age mean: 63 years USA
  Days since stroke: 42 Researcher recording
  Severity arm function
not reported
Lang et al., n = 187, 105 males Inpatient rehab
200934
  Age mean: 58 years USA and Canada
  Days since stroke: 118 Researcher recording
  Moderate arm function
OT: occupational therapy; PT: physiotherapy.
*Activity and functional repetitions combined.
and relatively unchanged over the last decade.
This is evidenced by the minutes of activity-
related arm training during physiotherapy
reported by Hayward et al.,30 in 2013, which was
comparable with that reported by Ada et al.,26 in
1999. The dose (movement repetitions) is also
inconsistent with animal models of stroke:
the number of repetitions reported by studies
included in this review was 23 to 32 repeti-
tions,32,34 which is well below that found to be
efficacious within animal models of stroke (>400
repetitions).13,36 While there is some concern that
the dose performed within animal models of
stroke is unrealistic, there is evidence that it is
feasible to translate into clinical practice. A
recent study within the subacute rehabilitation
setting found that stroke survivors could perform
on average 289 activity-related arm movements
within a one-hour training session,37 which is con-
sistent with another study where stroke survivors
completed on average 251 movements within a
one-hour training session.38 This suggests that a
high dose is achievable, but indicates there is a
need to identify strategies to support clinicians to
translate a high dose of training to occur within
routine clinical practice.
The reasons for a limited dose of arm training
need to be investigated. It is possible that the low
dose of activity-related arm training reflects its
Repetitions/session % session
PT OT PT OT
32* 15
 
 
 
23* –
 
 
 
lower priority for the stroke survivor, therapist or
rehabilitation service compared with other func-
tions. Achieving mobility goals is often linked to
discharge,39 and studies frequently report more time
being spent in physiotherapy on these tasks,28,33
likely at the expense of arm training. However, a
recent study has found that prioritizing arm training
does not appear to detract from achievement of
other activities of daily living goals,37 so strategies
to efficiently manage sessions should be investi-
gated. Another potential reason why some people
with stroke participate in a limited dose arm train-
ing is a lack sufficient voluntary control to engage
in repetitions or task-related practice. Modalities,
such as functional electrical stimulation and robotic
therapy, are gaining use in clinical practice as they
make such training possible.40,41
The most meaningful measure of dose of therapy
for the arm after stroke remains unknown. Dose
defined as minutes per session has been most
frequently used in the literature, however, clinical
benefits derived from greater training time remain
unclear. A recent systematic review demonstrated a
positive relationship between time scheduled for
training and functional outcomes early after
stroke,18 however a recent randomized controlled
trial not included in the review (n = 283) found that
greater training time did not equate to a meaning-
ful increase in physical activity during subacute
1240 Clinical Rehabilitation 29(12)
rehabilitation.42 Time as a representation of dose is
a rather crude estimate and does not provide
evidence of the actual amount of movement or
types of movements, and it may not take into
account periods of inactivity or rest. Demonstrating
this, a recent study found that during a 30-minute
inpatient rehabilitation therapy session, stroke sur-
vivors completed between 4 and 369 repetitions of
functional tasks.43 Dose defined by number of
movement repetitions would appear to be more
meaningful, however, the ability to efficiently cap-
ture movement repetitions is a clinical challenge.
Studies in the current review used an external
observer to record repetitions, which is labour
intensive and unlikely to be clinically feasible.
However, it has been demonstrated that some stroke
survivors can independently and accurately record
the number of repetitions performed in therapy.43 In
addition, there is growing interest in the use of arm
activity monitors (or accelerometers) to provide an
activity count, with purposeful repetitions and
activity count found to be significantly correlated.38
Inherent to these approaches to capture movement
repetitions is not only their low cost, but also their
capacity to provide real-time feedback and actively
involve the stroke survivor in training. Following
on from identification of the most meaningful rep-
resentation of dose and approach to efficient
measurement, there is a need to characterize if a
dose–response relationship exists. Exploring such
gaps will help to determine the optimal dosage of
early activity-related arm training post stroke.
It is well known that there is a considerable
amount of inactive time both within and outside of
therapy25 during acute hospitalization27,44 and
inpatient rehabilitation.26,28,33,45 It is possible that
this time could be better exploited to provide an
increased dose of arm training. Time spent outside
of therapy appears to be most underexploited and
therefore, an ideal avenue to explore. Studies have
demonstrated that stroke survivors spend as little
as 5%27,46 and as much as 40%47 of their day with
therapists. During time spent without therapists,
up to 83% does not involve use of the affected
arm.27 Therefore, not surprisingly, stroke survivors
have described time outside of therapy as ‘dead
and wasted’.48 This provides a strong rationale for
the development and implementation of simple,
efficient and efficacious interventions that exploit
time outside of therapy for arm recovery. One
example is the GRASP (Graded Repetitive Arm
Supplementary Program), which is a supplemen-
tary training programme designed to increase
self-directed arm training outside of time with a
therapist and has been found to improve arm
recovery.49 Alternatively, therapists could enlist
the support of nursing staff, who are engaged
with patients more frequently throughout the day.
Through interdisciplinary communication, nursing
staff could encourage greater incidental arm use
when they interact with patients (e.g. reaching
for objects during showering) and could have a
role in encouraging stroke survivors to practice
appropriate arm training on the ward.46
A strength of this study is that it provides a
systematic and comprehensive review of the dose
of activity-related arm training performed during
acute and subacute rehabilitation across both
physiotherapy and occupational therapy where
available. However, as always, there are some
limitations. First, we applied strict eligibility crite-
ria to include only those studies that had collated
activity-related arm training. The amount and
influence of any passive dose of therapy is thus
unknown. Only one person completed the first
review of titles and abstracts, which may have
resulted in some articles being missed. However,
a thorough check of secondary sources failed to
yield any additional eligible studies. The small
number of studies, especially for occupational
therapy, limited a comparison between the dose
administered by physiotherapy and occupational
therapy. A further limitation is the generalizability
of findings. The majority of dosage reports of
activity-related arm training in minutes per session
were from Australian-based sites, while all
reports of repetitions were from North America.
While other international sites have completed
observational dose studies, they did not report
activity-related arm training dose separate to
other training provided. Taken together, these
limitations indicate a further need for studies that
explore the dose of activity-related arm training
undertaken and seek to identify strategies used to
enhance the dose both inside and outside of time
with a therapist.
Hayward and Brauer 1241
Clinical messages
•• Stroke survivors engage in a limited
time of activity-related arm training
during rehabilitation: less than four
minutes during physiotherapy and 11
minutes during occupational therapy in
acute rehabilitation; and less than six
minutes during physiotherapy and 12
minutes during occupational therapy in
subacute rehabilitation.
•• Stroke survivors perform few activity-
related arm movements, with less than 32
recorded during subacute rehabilitation
across physiotherapy and occupational
therapy.
Conflict of interest
KS Hayward and SG Brauer are involved in the com-
mercialisation of the SMART Arm, a device to retrain
reaching after stroke.
Contributors
KS Hayward and SG Brauer were both involved in study
design, study selection and quality rating, manuscript
preparation and editing.
Funding
This research received no specific grant from any fund-
ing agency in the public, commercial, or not-for-profit
sectors.
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