During inpatient rehabilitation, providing additional allied health services helped patients to get better quicker. Patients who received additional Saturday rehabilitation were discharged at a higher level of functional independence and with higher health-related quality of life than those who received Monday to Friday rehabilitation despite being discharged home sooner. The likely reduction in length of stay did not come at the expense of poorer discharge outcomes. Participants who received Monday to Saturday rehabilitation were just as likely to be discharged home (and not to a residential facility) and just as likely to need follow-up outpatient services on discharge compared to those in the control group. These results confirm findings from a systematic review about the benefits of providing additional therapy  and add to previous research on the provision of additional weekend rehabilitation services [13, 14] by providing evidence from an adequately-powered, prospective, randomized controlled trial including 12-month follow-up.
In this trial, patients who received Monday to Saturday rehabilitation did not receive a great deal more rehabilitation (mean 53 minutes, 13% extra) than patients who received Monday to Friday rehabilitation but this additional rehabilitation did improve outcomes. The amount of additional rehabilitation was somewhat less than the expected, which could be due to missed sessions of therapy as a consequence of feeling unwell, day leave on a Saturday or because patients were admitted late in the week and had not been recruited, assessed and randomized to be scheduled for weekend therapy. However, the additional rehabilitation provided did improve outcomes.
Rehabilitation in the form of physiotherapy and occupational therapy typically focused on task specific training and discharge planning. This additional rehabilitation alone may have been enough to improve outcomes if patients made gains during the extra sessions of therapy. However, other factors may have also contributed to improved outcomes. Patients who received Saturday rehabilitation did not have a 2-day break in therapy, which may have reduced time for functional decline due to inactivity. Analysis of the physical activity levels of a subset of participants in the current trial found that those receiving Saturday rehabilitation were more physically active on both days of the weekend compared to those who received Monday to Friday rehabilitation . In addition, higher levels of physical activity during rehabilitation were associated with higher levels of functional independence on discharge and shorter length of stay . Therefore, the additional physical activity associated with weekend rehabilitation may have contributed to improving outcomes. In a qualitative study on another subset of participants in the current trial, additional Saturday rehabilitation was reported to change patient perceptions of what weekends in rehabilitation were for . Patients who received Saturday rehabilitation expected to be working towards their rehabilitation goals over the weekend while those who received Monday to Friday rehabilitation expected to rest over the weekend. These changed patient expectations may have contributed to improved outcomes with Monday to Saturday rehabilitation in the current trial.
We also found that benefits in functional independence and health-related quality of life gained from additional weekend rehabilitation may have been maintained for up to 6 months post discharge suggesting that the more successful outcome achieved during rehabilitation may have had ongoing effects. Most improvement occurred during inpatient rehabilitation when therapy was being provided with only relatively small gains following discharge (Table 2). Previous trials on functional outcomes following rehabilitation for stroke [38–40] and hip fracture  also found that most functional gains were made between admission and discharge from rehabilitation with results maintained (but not improved upon) at 6-month or 12-month follow-up. Therefore, it cannot be assumed that patients are going to get better on their own at home following discharge from rehabilitation, reinforcing the importance of maximizing functional gains during the inpatient rehabilitation period.
There were no significant differences between groups in terms of most secondary outcomes, including the timed up and go test, PC-PART and the modified Motor Assessment Scale. This may reflect the goals of rehabilitation where interventions were focused on improving overall functional independence for discharge back to living in the community rather than specific activities such as balance, walking speed or upper limb function.
Recent debate has highlighted the issue of weekend healthcare provision and the benefits and difficulties in providing weekend healthcare [8, 9]. Our trial demonstrated that providing weekend rehabilitation services, at least on a Saturday, improved functional independence and health-related quality of life and reduced length of stay, which may have clinical implications for both patients and health services. These results may also be applicable to settings and cultures where rehabilitation is currently provided 5 days a week even if Saturday may be a usual work day as the Saturday rehabilitation in this trial reflects an additional day, or a sixth day of rehabilitation. Patients may not have to wait for as long for a rehabilitation bed, and can return home sooner with better function to resume their usual activities in the community. However, one of the key concerns about providing weekend care is the question of who will pay for the additional services [8, 42]. Because intervention group participants achieved better clinical outcomes at discharge despite likely having a shorter length of stay in our trial, health service providers may be able to treat more patients throughout the year which may lead to cost advantages. A formal economic evaluation is being conducted separately alongside the current trial.
This trial included participants with a variety of health conditions requiring rehabilitation, non-English speaking participants, and participants with cognitive impairment making the results generalizable to many metropolitan inpatient rehabilitation facilities. A limitation is that subgroup analyses were not planned or completed, therefore we do not know if the results are particularly applicable to patients with certain diagnoses. However, our trial was not powered for subgroup analyses and such post hoc analyses are discouraged . In addition, we took a health service perspective about staffing a service rather than providing therapy based on a specific diagnosis. Risk of bias was minimized through concealed, random allocation of participants and the use of blinded assessors throughout the clinical trial and follow-up period; however, patients, therapists and other clinical staff were not blinded to group allocation. Follow-up measurements at 6 and 12 months were completed by telephone and not face-to-face which may have introduced error; however, all project officers were credentialed to administer the FIM, there were high compliance rates, and there is evidence that telephone administration of the FIM and EQ-5D is suitable for older adults following hospitalization [44, 45]. Another potential limitation is that the additional rehabilitation was only provided by physiotherapists and occupational therapists. We acknowledge the important contributions of other members of the rehabilitation team such as social workers, podiatrists and dietitians. However, we chose physiotherapy and occupational therapy as they are the most commonly required and provided interventions during rehabilitation .