The future of high-dose, high-intensity neurorehabilitation: Consensus-based core recommendations from the fourth Stroke Recovery and Rehabilitation Roundtable.

Abstract

Objective Convergent evidence indicates that high-dose, high-intensity rehabilitation (HDHI) improves outcomes beyond usual care after stroke, yet implementation remains limited. While questions of optimal dose, timing, and delivery format continue to be refined, the biological plausibility and clinical rationale for HDHI are well established. The fourth Stroke Recovery and Rehabilitation Roundtable convened to identify principal barriers to wider HDHI uptake and derive actionable solutions. Methods Sixteen international experts from nine countries used a structured consensus process, including surveys, barrier ranking, targeted evidence reviews, and a 2-day in-person meeting. Results Four interrelated barriers were identified: (1) a conceptual knowledge gap persists regarding HDHI's targets, mechanisms, and effects; (2) scale and delivery constraints prevent the required dose from being delivered by current conventional care models, making home- and community-based hybrid pathways essential; (3) resistance to change despite the evidence because it places strain on clinicians given their time constraints, inflexible remuneration, and low levels of administrative support; and (4) insufficient system-level enablers to provide longitudinal continuity, patient coordination, and readily accessible technology. Recommendations The primary limitation to HDHI is implementation capacity, not biological plausibility or lack of evidence. Implementation research should now proceed in parallel with ongoing efficacy refinement. Priorities include building mechanistic and evidentiary literacy, clarifying professional roles, enabling home-based delivery, aligning reimbursement with long-term economic evaluation, and developing the infrastructure and protocols for scalable longitudinal care.