[ARTICLE] Long-Dose Intensive Therapy Is Necessary for Strong, Clinically Significant, Upper Limb Functional Gains and Retained Gains in Severe/Moderate Chronic Stroke – Full Text

Background. Effective treatment methods are needed for moderate/severely impairment chronic stroke.

Objective. The questions were the following: (1) Is there need for long-dose therapy or is there a mid-treatment plateau? (2) Are the observed gains from the prior-studied protocol retained after treatment?

Methods. Single-blind, stratified/randomized design, with 3 applied technology treatment groups, combined with motor learning, for long-duration treatment (300 hours of treatment). Measures were Arm Motor Ability Test time and coordination-function (AMAT-T, AMAT-F, respectively), acquired pre-/posttreatment and 3-month follow-up (3moF/U); Fugl-Meyer (FM), acquired similarly with addition of mid-treatment.

Findings. There was no group difference in treatment response (P ≥ .16), therefore data were combined for remaining analyses (n = 31; except for FM pre/mid/post, n = 36). Pre-to-Mid-treatment and Mid-to-Posttreatment gains of FM were statistically and clinically significant (P < .0001; 4.7 points and P < .001; 5.1 points, respectively), indicating no plateau at 150 hours and benefit of second half of treatment. From baseline to 3moF/U: (1) FM gains were twice the clinically significant benchmark, (2) AMAT-F gains were greater than clinically significant benchmark, and (3) there was statistically significant improvement in FM (P < .0001); AMAT-F (P < .0001); AMAT-T (P < .0001). These gains indicate retained clinically and statistically significant gains at 3moFU. From posttreatment to 3moF/U, gains on FM were maintained. There were statistically significant gains in AMAT-F (P = .0379) and AMAT-T P = .003.

Many stroke survivors do not fully recover upper limb function following stroke, leading to significant disability and diminished quality of life.1 Effective treatments are needed for chronic, severely impaired stroke survivors.2 Other studies showed improved upper limb motor function in chronic stroke for mild/moderately impaired,313 with traditional “constraint induced” treatment studies enrolling only those with preserved wrist and finger extension (acceptance rate, 10%).14 However, for those with moderate/severe impairment after stroke, improvement in function has been more difficult to realize. A recent study of constraint-induced movement therapy in more severe stroke reported no clinically significant change in upper limb Fugl-Meyer assessment scores.15 Others have also tested the application of technologies and devices, in moderately/severely impaired chronic stroke survivors, with the following: functional electrical stimulation (FES),1618 sequenced bilateral and unilateral task orientated training,19 mirror therapy,20 progressive abduction loading therapy,21 contralaterally controlled FES,22 and robotics.2327 Limitations included small sample size,1618,2223 lacking control group,16,23 lacking statistically significant gains on impairment or functional measures,23 lacking clinically significant change,20,21,2325,27 lacking retention of clinically significant gains,16,19,25,26 or lacking study of retention.20,23 Furthermore, many studies do not include both a measure of impairment and an array of actual everyday functional tasks. Our work has focused on moderately/severely impaired chronic stroke survivors, and in prior work we developed and tested a protocol that combines technology applications and motor learning.28,29 We found clinically and statistically significant gains for those with moderate/severe stroke considerably beyond that reported by others (eg, gains in coordination, Fugl-Myer coordination scale [FM], and gains on the Arm Motor Ability Test [AMAT; 13 complex functional tasks]).

Others have cited this work stating that “a change in impairment of this magnitude was previously considered almost impossible in chronic stroke patients,”30 and that this is important first evidence for use of high dose neurorehabilitation.31 Therefore, we considered it important to replicate the administration of the upper limb motor learning protocol in a follow-on study and again quantify response. Another consideration was that we had not given technology a full chance in application to the “whole arm,” that is, both distal and proximal upper limb regions. Therefore, a first purpose was to replicate administration of the upper limb motor learning protocol and to include a treatment group that would receive technology applications to both distal and proximal limb regions. In addition, there were 2 important and unanswered questions regarding the dose and efficacy of this new treatment protocol.

The first question is whether a shorter treatment duration (ie, <300 hours) could produce the same degree of recovery, given that the existing protocol was tested in the paradigm of long-duration dose of 300 hours of therapy. Therefore, in the current work, we administered the same protocol as in prior work,28 and acquired mid-treatment (at 150 hours of treatment) data on the Fugl-Meyer impairment measure, which underlies complex functional task performance. We studied whether a mid-treatment plateau occurred or whether significant recovery occurred in response to the second half of treatment (mid-treatment to posttreatment).

The second question is whether the observed gains can be retained after cessation of treatment. Therefore, we studied retention of gains at 3 months after treatment ended.[…]

 

Continue —> Long-Dose Intensive Therapy Is Necessary for Strong, Clinically Significant, Upper Limb Functional Gains and Retained Gains in Severe/Moderate Chronic Stroke – Janis J. Daly, Jessica P. McCabe, John Holcomb, Michelle Monkiewicz, Jennifer Gansen, Svetlana Pundik, 2019

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