Trial adds piece to stroke rehabilitation puzzle

By Eleanor McDermid, Senior medwireNews Reporter

High-intensity, repetitive, task-focused upper extremity training does not offer benefits beyond standard rehabilitation for patients within the first few months after a stroke, shows a trial in JAMA.

The Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) trial aimed to confirm previous studies suggesting that intensive, task-orientated training enhanced motor recovery in stroke patients.

However, not only did it fail to demonstrate benefits of task-focused training for patients at this stage of their recovery, it also showed that an increased dose of standard training does not improve patients’ motor outcomes, so neither increased specificity nor increased dose of training were of benefit.

“The findings from this study provide important new guidance to clinicians who must choose the best treatment for patients with stroke”, say Carolee Winstein (University of Southern California, Los Angeles, USA) and co-researchers.

All patients in the trial had moderate upper extremity motor impairment and were randomised between 14 and 106 days after stroke onset. The primary outcome was the 12-month change in log-transformed Wolf Motor Function Test (WMFT) time, but this did not differ between patients who received task-focused and standard rehabilitation.

The 119 patients randomly assigned to receive task-focused training undertook the Accelerated Skill Acquisition Program, in three 1-hour sessions per week for 10 weeks, and a further 120 patients received usual occupational therapy, but to an equivalent dose of 30 hours.

Both groups had improved after 12 months, but by similar amounts, with reductions in log-transformed WMFT times of 0.8 and 0.9 seconds, respectively.

A final group of 122 patients undertook usual occupational therapy to no specified dose; the amount received ranged from 0 to 46 hours. This group also improved to an equivalent extent, by 0.8 seconds, and all three groups reported similar improvements on the Stroke Impact Scale hand function subscale.

The researchers say their findings underscore the importance of studying the effects of therapy at different times after stroke.

“Different physiological and psychological responses to rehabilitation training might occur at different times after stroke onset, raising the possibility that dosing and timing are not independent factors in stroke rehabilitation intervention trials”, say Winstein et al.

This “time window hypothesis” may account for the apparently conflicting results of trials in this area, they say, explaining why studies of very early intervention found that intensive rehabilitation could harm, rather than help, whereas studies conducted later, after the timeframe of ICARE, reported benefits for high-dose intensive rehabilitation.

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