Therapy that includes restraining the less-impaired arm or hand of a stroke patient appears effective in improving movement and functional use of the paralyzed arm or hand, according to a study in the November 1 issue of JAMA.
Each year, more than 730,000 Americans experience a new or recurrent stroke, with resulting direct health care costs totaling $35 billion, according to background information in the article. Up to 85 percent of the approximately 566,000 stroke survivors experience hemiparesis (partial paralysis affecting only one side of the body), resulting in impairment of an upper extremity immediately after stroke, and between 55 percent and 75 percent of survivors continue to experience upper-extremity functional limitations, which are associated with diminished health-related quality of life, even 3 to 6 months later.
One rehabilitation approach involves restraining the less-impaired upper extremity (arm or hand; usually by placing the entire arm in a sling or placing the hand in a mitt for most waking hours), thereby encouraging usage of the more-affected extremity (often referred to as "forced use"). This type of rehabilitation, called constraint-induced movement therapy (CIMT), includes work with a clinician and repetitive task practice. Single-site studies have suggested that a 2-week program of CIMT can improve upper-extremity function.
Steven L. Wolf, Ph.D., P.T., of the Emory University School of Medicine, Atlanta, and colleagues compared the effects of a 2-week multisite program of CIMT vs. usual care on improvement in upper-extremity function among patients who had a first stroke within the previous 3 to 9 months. The Extremity Constraint Induced Therapy Evaluation (EXCITE) Trial, a randomized, multisite clinical trial, was conducted at 7 U.S. academic institutions between January 2001 and January 2003. The study included 222 individuals with predominantly ischemic stroke. Participants were assigned to receive either CIMT (n = 106; wearing a restraining mitt on the less-affected hand while engaging in repetitive task practice and behavioral shaping with the hemiplegic [partially paralyzed] arm and hand) or usual and customary care (n = 116; ranging from no treatment after concluding formal rehabilitation to pharmacologic or physiotherapeutic interventions).
Patients were evaluated using the Wolf Motor Function Test (WMFT), a measure of laboratory time and strength based ability and quality of movement (functional ability); and the Motor Activity Log (MAL), a measure of how well and how often 30 common daily activities are performed.
The researchers found that from baseline to 12 months, the CIMT group showed greater improvements than the control group in both the WMFT Performance Time, with a between-group difference of 34 percent reduction in time to complete a task; and in the MAL measurements. The CIMT group also achieved a 65 percent increase in the proportion of tasks performed with the partially-paralyzed arm, and a greater decrease in self-perceived hand function difficulty, compared to the control group.
"In summary, among patients who had experienced stroke between 3 and 9 months prior, administration of CIMT resulted in statistically significant and clinically relevant improvements in paretic arm motor ability and use compared with participants receiving usual and customary care. Improvements were present following the 2-week intervention, persisted for up to 1 year, and were not influenced by age, sex, or initial level of paretic arm function. These findings suggest that further research exploring central nervous system changes that accompany the observed motor gains and research on alternate models of CIMT delivery are warranted," the authors write.
(JAMA. 2006;296:2095-2104. Available pre-embargo to the media at www.jamamedia.org.)
Editor's Note: This research was supported by a National Institutes of Health grant from the National Center for Medical Rehabilitation Research (National Institute of Child Health and Human Development) and the National Institute of Neurological Diseases and Stroke. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Editorial: Stroke Recovery-Moving in an EXCITE-ing Direction
In an accompanying editorial, Andreas R. Luft, M.D., of the University of Tübingen, Germany, and Daniel F. Hanley, M.D., of Johns Hopkins University, Baltimore, comment on the findings of Wolf and colleagues.
"The EXCITE trial clearly suggests that more recovery after stroke is possible than neuroscientists currently teach in professional schools or training programs and than clinicians have been telling patients to expect. Recovery of lost or impaired motor functions has been demonstrated in animal models and is biologically feasible for humans, and now has been confirmed by data from a well-designed randomized clinical trial. Knowledgeable physicians and scientists must reject the nihilism that bases the projection of best recoveries on observations of therapies without defined benefit.
"If training is new brain, many more therapeutic and mechanistic clinical trials of stroke recovery must be conducted. Despite decades of research and discovery, there is still no clear idea as to the maximal amount of benefit that can be achieved with interventions that harness the learning powers of the human brain. A little more excitement in the lives of stroke survivors can only be good," the authors write.
(JAMA. 2006;296:2141-2143. Available pre-embargo to the media at www.jamamedia.org.)
Editor's Note: The authors' research is supported by Deutsche Forschungsgemeinschaft, Interdiziplinäres Zentrum für klinische Forschung (University of Tübingen), and the NIA Claude A. Pepper program, University of Maryland and Johns Hopkins University. Financial disclosures - none reported.
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