Intensive PT in Stroke: More Not Necessarily Better

February 26, 2015

NASHVILLE, TENNESSEE — Intensive physiotherapy focusing on the arms and hands of stroke patients accelerated some patient-reported improvements at the end of the therapy period but was not associated with any significant benefit over usual care at 1 year, new research shows.

Presenting the primary results of the ICARE phase 3 stroke rehabilitation trial, at the International Stroke Conference (ISC) 2015, Carolee Winstein, PhD, professor of biokinesiology and physical therapy at the University of Southern California, Los Angeles, concluded that "more is not necessarily better."

"The bottom line is that more than a 2-fold increase of arm and hand therapy did not improve motor performance or patient-reported outcomes at 1 year. We were very surprised at this result, which flies in face of 'more is better' in terms of neuroplasticity responding to repetitive task training, but it is consistent with other studies," she added.

Commenting on the finding that the intensive therapy did appear to accelerate some patient-reported outcomes by the end of the therapy period, she said, "It does seem to get patients to the same point more quickly. We now need to focus on how we maintain that accelerated benefit."

Dr Winstein noted that better neurorehabilitation is needed for stroke because after 6 months 65% of patients cannot effectively incorporate their affected arm and hand into daily activities.

Although task-based, intense motor therapy training approaches are well accepted, the effect of the dose and contents of such therapy on motor recovery is unknown.

The ICARE trial is only the fourth randomized study of stroke rehabilitation and is the first such trial to be conducted in the first weeks after stroke, when the opportunity for learning-dependent plasticity is high and the recovery trajectory is positive, she added.

Patient-Perceived Improvements

The study tested a behavioral task-based therapy known as the Accelerated Skill Acquisition Program (ASAP), a patient-centered intervention focused on meaningful task practice, capacity building, and motivational enhancements. Therapy was initiated between 14 and 106 days after stroke in the outpatient setting.

For the study, 361 patients were assigned to 1 of 3 groups:

  • Intensive therapy with the ASAP program, delivered as three 1-hour sessions each week for 10 weeks

  • Dose-equivalent therapy, consisting of the same number of sessions of usual occupational therapy

  • Usual occupational therapy provided as whatever the treating physician prescribed, with a specific number of sessions not specified

Study participants had pure motor hemiparesis without substantial cognitive or sensory impairments, with an average National Institutes of Health Stroke Scale score of 3.6. Dr Winstein said the patients could be described as "moderately impaired with some function in their affected arm but slow speed of movement and impaired ability to open and close the hand and manipulate objects."

Patients had a mean age was 60 years and were an average of 45 days post-stroke. In 49% of patients, the stroke affected the dominant arm and hand, and 29% had received 6 hours of outpatient occupational therapy or less before randomization; this did not differ across groups.

All three groups improved with regard to motor function and hand movements, with 70% of patients meeting the endpoint for hand function improvement.

The mean improvement in motor performance score was substantial (46%), but there was no difference among the three groups at the 1-year post-stroke primary endpoint.

However, compared with the two control groups, the group receiving the intensive therapy did show early improvements in secondary patient-perceived outcomes (on the Stroke Impact Scale), including physical function and quality of life.

These improvements were seen at the end of therapy, approximately 4 months after randomization and 6 months after stroke, but the differences were not present at 12 months.

"Building on end-of-therapy group differences in the context of the continuum of care is an important challenge for future research," Dr Winstein concluded.

She pointed out that the current study did not have a "no therapy" group. This differs from the EXCITE trial, which did have a "no therapy" control and did show a difference.

The ICARE study was funded jointly by the National Institute of Neurological Disorders and Stroke and National Center for Medical Rehabilitation Research of the National Institutes of Health.

International Stroke Conference (ISC) 2015. Presented February 13, 2015. Abstract LB15.

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