Evidence of chronic stroke rehabilitation interventions in activities and participation outcomes: systematic review of meta-analyses of randomized controlled trials.

INTRODUCTION: Stroke is a leading cause of long-term disabilities worldwide. A great deal of meta-analyses of randomized controlled trials (RCTs) address rehabilitation in chronic stroke, several of them with focus on activities and participation, considered critical outcomes of successful rehabilitation. Nevertheless, substantial heterogeneity might exist between studies, the reported associations may be causal, but they might also be flawed, as inherent study biases such as residual confounding and selective reporting of positive results may exaggerate the effect of interventions in chronic phase. Furthermore, most RCTs might focus on specific rehabilitation domains, not paying the same attention to others. EVIDENCE ACQUSITION: Formal evaluation of published systematic reviews of meta-analyses (January 2008 to November 2018) of rehabilitation in chronic phase to 1) assess the strength of evidence: participants, publication biases, heterogeneity, prediction intervals (PIs) 2) grade the evidence to perform qualitative analysis on effects sizes and heterogeneity, 3) perform meta-regressions and sensitivity analysis on relevant covariates 4) map outcomes to activities and participation domain of the World Health Organization's International Classification of Functioning, Disability and Health (ICF). Systematic review on meta-analyses of RCTs addressing activities and participation will be performed in Medline, Web of Science, Scopus, Cochrane and Google Scholar. EVIDENCE SYNTHESIS: A total of 97 meta-analyses on 31 different rehabilitation interventions involving 25,275 participants were included. Thirty-nine meta-analyses (40.74%) reported statistically significant findings (P<0.05) in both fixed and random effects sizes. Their magnitude was small in 62.96% cases, moderate in 19.75% and large in 17.28%. Heterogeneity was low in 48,48%, moderate and high in 21.2%. The mean number of participants is 815, far away from the convincing, highly suggestive, or suggestive required evidence levels. All PIs include the null value. Mobility is addressed by 87% of the identified meta-analyses, with 75% of them focusing exclusively in mobility.
CONCLUSIONS: The findings of this study show a clear need for high quality RCTs examining the effectiveness of rehabilitation interventions addressing activities and participation. The ICF framework may contribute to a holistic approach in chronic stroke rehabilitation, including not only motor functioning but also the ability to participate in everyday life activities.