I am not aware of any article that answers the question of whether 5 versus 7 days of therapy in the stroke population is optimal. However, in general, a greater intensity of therapy seems to produce better results, which is actually an important issue for the Centers for Medicare and Medicaid Services.

An older review article with a component of meta-analysis found that intensity was associated with therapy outcomes:

Kwakkel, Gert, et al. "Effects of intensity of rehabilitation after stroke a research synthesis." Stroke 28.8 (1997): 1550-1556.

However, I assume that you are thinking of inpatient rehabilitation in some form (either Inpatient Rehabilitation Facility or Skilled Nursing Facility). Medicare recently published a report with the link below in which they developed the CARES Tool. The idea was to compare outcomes across the spectrum of post-acute care (this could not previously be done, because each level of care reported resutls using different outcome measures). Notably, patients with a stroke had greater functional gains at the IRF level of care than at lower levels of care. The key distinction is that IRF is a high-intesity rehabilitation setting with at least 3 hours of therapy per day and typically 5-7 days of therapy per week.

So does 5 vs 7 matter? Well, I can't say that I know the answer to this, but in general more therapy seems to be better.

A number of CAREs tool reports have been released. Here is one particular document that may address your question (Answers are scattered throughout the document, but scroll to around page 300 for starters):

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/downloads/GAGE_PACPRD_RTC_Supp_Materials_May_2011.pdf

Worthy question.

I agree with Paul, I am not sure of any article proving it but in our department we used 5/6 day in a week. I think until we got a proven no of session per week we can still continue intensive rehabilitation with 5/6 session per week.

EBP recommends more frequent treatment sessions during the initial period, the intensity can be varied alternating between Active assisted to active, followed by treatment technique of choice.

At this time, there is evidence concerning minutes per day, not days per week. More minutes per day of therapy is associated with better outcomes (functional and discharge. Here is a reference:Jette DU, Warren RL, Wirtalla C. The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities. Arch Phys Med Rehabil. 2005;86(3):373-379.

Very interesting. As long as I know, as Dr. O'Brien posted, minutes per day are more valid for therapy, specially in the first 3 months after the stroke. There are some questions regarding if only with rehabilitation facilities or also with the family participation this approach could be improved.

researches are very poor on this topic. It is very important to consider patient`s situation. I agree with massed and intensive therapy, but in practice I see many patients do not have the endurance and tolerance of these intensive therapy especially at the hospital. We have to discuss about the rehabilitation methods. Doing the NDT approach 7 days a week, differs from 4 days NDT+3 days ADL consultation or task oriented training.

I agree with all: intensity may relate to success. Still, distributed practice schedule, adequate rest and sleep may help with learning and it's consolation. Weinstein et al. And others have discussed the importance of random practice, contextual interference and distributed practice.

In the UK it would be highly unlikely someone with chronic stroke ie more than 6 months was being treated as an in-patient.

The NICE guidelines for stroke indicate offering 45 minutes of each relevant therapy on a minimum of 5 days per week. This is based on a SLT article

http://www.nice.org.uk/nicemedia/live/14182/64098/64098.pdf

I think more importantly is when therapy is delivered and the amount of time patients are spent sedentary. Classically, if you can call it that, therapy services operate 8-4 or 9-5, Mon-Fri. This leaves a large amount of time when patients aren't engaged in activity.

Simply extending the working week, gives patients more opportunity to be seen but are they any more active?

I would like to see a shift towards engaging patients in a range of activities over the whole day, week and month that best enables them to get moving, learn, speak, get dressed etc. Whilst we still insist on framing rehabilitation in terms of a 8-4, 9-5 etc. we will inevitably miss opportunities where patients can improve

Stroke. 2006 Aug;37(8):2134-9. Epub 2006 Jun 29.

Temporal profiles of axon terminals, synapses and spines in the ischemic penumbra of the cerebral cortex: ultrastructure of neuronal remodeling.

Ito U1, Kuroiwa T, Nagasao J, Kawakami E, Oyanagi K.

Author information

Abstract

BACKGROUND AND PURPOSE:

Because the recovery process of axon terminals, synapses, and spine-dendrites in the ischemic penumbra of the cerebral cortex is obscure, we studied the temporal profile of these structures up to 12 weeks after the ischemic insult, using a gerbil model.

METHODS:

Stroke-positive animals were selected according to their stroke index score during the first 10-minutes left carotid occlusion done twice with 5-hour interval. The animals were euthanized at various times after the second ischemic insult. Ultra-thin sections including the 2nd to 4th cortical layers were obtained from the neocortex coronally sectioned at the infundibular level, in which the ischemic penumbra appeared. We counted the number of synapses, spines and multiple synapse boutons, measured neurite thickness, and determined the percent volume of the axon terminals and spines by Weibel point counting method.

RESULTS:

The number of synapses, synaptic vesicles and spines and the total percent volume of the axon terminals and spines decreased until the 4th day. From 1 to 12 weeks after the ischemic insult, these values increased to or exceeded the control ones, and neuritic thickening and increase in number of multiple synapse boutons occurred.

CONCLUSIONS:

In the ischemic penumbra, the above structures degenerated, with a reduction in their number and size, until 4 days and then recovered from 1 to 12 weeks after the ischemic insult.

PMID: 16809554 [PubMed - indexed for MEDLINE] Free full text

Description: Same as clinical evidences, the injuries of neuronal network continued until 4 days after ischemia, and then recovered during the following 3 months after the ischemic episode. There may be a difference between animal and human, though. Neuronal remodeling of the ischemic injury terminated within 3 months after ischemic episode, intensive rehabilitation during the 3 months after ischemia is necessary. Rehabilitation of muscular system should be continued afterwards for long period.

Thank you everyone for your contribution. I recently conducted search of articles to find the evidence and I found interesting articles. These studies tried to identify that whether by increasing frequency of rehabilitation to 6 or 7 days per week as compared to 5 days per week had any benefits in term of reduced Length of stay (LOS) in rehabilitation unit or cost effectiveness, changes in FIM score and Health related Quality of life measures. Some other measures such as difference in mobility status, timed up and go test were also investigated.

Most of the good quality RCTs suggested that there was decrease in length of stay in hospital with increased frequency of therapy sessions. Some studies suggested decrease by up to 3.2 days. some studies found no statistically significant difference between two groups. However, decrease in hospital length of stay is was associated with reduced chances of contracting nosocomial infections.

Decreased LOS also proved to be cost effective. Though none of the studies came up with exact calculation. The financial saving obtained can be used for providing additional services or may come up as savings to health care services.

Increased FIM score was obtained in people receiving 6 to 7 days per week therapy as compared to 5 days per week therapy. Some studies suggested no difference and other good quality RCTs suggested Increased FIM score. In one RCT (PEDro score 9) it was reported that this increased FIM score was maintained up to 6 months post discharge but not 12 months. Similar results were obtained in relation to health related Quality of life measures were increased score was found in group receiving 6 to 7 days per week therapy and was maintained up to 6 months post discharge but not up to 12 months.

Studies also suggested that increased frequency of therapy was associated with increased activity levels. Patients receiving weekend therapy services tend to be more active as compared to control group (5 days/week).

Other secondary outcome measures like mobility status, timed up and go test and others did not show significant difference.

This is in consonance to earlier studies which suggested increased intensity of therapy is associated with better outcome. In fact in a meta analysis of 20 RCTs done by Kwakkel (2004) it was suggested that augmented exercise therapy time by at least 16 hours has small but favourable effect on improving ADLs and that also when initiated within first six months.

I could locate only few articles and they were from medium to good quality. In order to be clinically acceptable and established good quality RCTs are needed with proper randomization and blinding and in a large multi centre trials.

We did a post-hoc analysis about the effect of rehab treatment intensity on a group of post-stroke patients. Maybe the results will be useful for this discussion. Attached an extended abstract authored by Rune Thorsen on this topic.

As Ela Plow and others have mentioned, the type of intervention, the delivery , and the contextual environmental factors all have an summative effect on recovery. Understanding current thinking in motor learning such as : timing of initiation of rehabilitation, difference between impairment recovery and compensation on a neuronal-physiologic level, cross limb interference, learned non use, mass practice versus random, rest for consolidation, brain synchronization and coherence of functional network connectivity as a platform for learning, and the summative effect of an adjunctive approach. Five or seven days a week will be inconsequential ( for the record I am a DPT, NCS physical therapist who has worked in every possible setting treating patients with Neurological impairments over 30 years ) if current evidence based interventions and models of neuroscience are not integrated into the approach and consistently applied.

It seems important to consider "outcomes" from several perspectives. LOS and cost effectiveness drive some of this discussion. However, we have yet to define terminal rehabilitative potential for stroke, how such potential may vary with specific patient demographics, the effect on potential of treatment dosing variables such as timing, intensity, duration and expertise. Studies do show augmentation effects of combination therapies such as rehabilitation and amphetamine. Neuroendocrine and immunological factors must also be investigated in stroke patients with appropriate interventions provide to augment a patient's ultimate functional recovery. Finally, attention must be paid to avoidance of compensatory strategies early on when neurotrophic factor up regulation is highest. Compensatory strategies wherein intact extremities become overused results in over recruitment neurologically effectively competing for neuronal resource that might be utilized to recover lost function.

Charlotte, Nicely stated, you may find support for your thoughts on enriched environment and frequency in the attached article.

you can look at CIRCIT trial, early results have been published recently on stroke journal ( English C, Stroke 2014).

After some review of my own work, I returned to an article which is nearly on point to your question, except that it investigated 6 verses 7 days of therapy per week. Ruff, RM,  Yarnell S, Marinos JM. Are stroke patients discharges sooner if inpatient rehabilitation services are provided 6 v 7 days per week? Am J Phys Med Rehabil. 1999;78:143-46. This is a small study and to my knowledge no one has ever repeated it with a large sample. Also unfortunate and leading to the lack of new investigations, is at least in the US, due to policy and payment forces, inpatient treatment (at least in inpatient rehab facilities, our most intense form of rehab) has been typically 7 days/week for at least 10 years and likely longer in many places. It has not been 5 days a week for some time.