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In patients with moderate upper extremity impairment following a stroke, a task-oriented rehabilitation program was not found superior to dose-equivalent usual care or lower dose usual care, according to research published in JAMA.
Currently, there is a lack of evidence to guide physicians in determining the best type or amount of outpatient rehabilitation for motor stoke. To date, 2 large trials have suggested improvement in upper extremity motor outcomes with task-oriented, intensive, and high-repetition programs.
To investigate whether a structured, task-oriented rehabilitation program would result in better motor function recovery than usual rehabilitation, Carolee Winstein, PhD, of the University of Southern California in Los Angeles and colleagues conducted the Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) trial , randomly assigning 361 patients with a history of moderate upper extremity motor impairment to either a structured, task-oriented program (N=119), a dose-equivalent occupational therapy program (N=120), or monitored occupational therapy (N=122).
The task-oriented rehabilitation therapy under investigation, known as the Accelerated Skill Acquisition Program (ASAP), was a patient centered, self-directed, intense, and task-specific program administered for 1 hour, 3 times weekly for 10 weeks. The other 2 groups received customary care outpatient occupational therapy, with the dose-equivalent occupational therapy (DEUCC) group receiving 30 hours of therapy , and the monitoring-only occupational therapy (UCC) group receiving no specific dose.
Participants had a mean age of 60.7 years and were 42% African American and 56% male. Ischemic stroke accounted for most of diagnoses (83%), 49% had impairment of the dominant upper extremity, and the mean number of days from stroke was 45.8 at randomization.
At 12 months, the researchers found no significant differences between the 3 groups (ASAP versus DEUCC mean difference 0.14, 95% CI: -0.05 to 0.33, P=0.16; ASAP versus UCC mean difference -0.01, 95% CI: -0.22 to 0.21, P=0.94; DEUCC versus UCC mean difference -0.14, 95% CI: -0.32 to 0.05, P=0.15). The mean log-transformed Wolf Motor Function Test (WMFT) times were 1.4 for the ASAP group, 1.2 for the DEUCC group, and 1.3 for the UCC group.
The baseline WMFT time was 14.9 in all groups. At the end of the study, the mean time was 6.8 seconds (1.3 seconds age matched normal mean), “indicating persistent motor impairment.”
Likewise, changes in WMFT were not significantly different between the groups: all groups demonstrated improvement with 8.8, 8.1, and 7.2 seconds for ASAP, DEUCC, and UCC, respectively.
The researchers also found no significant differences for hand function improvement (defined as greater than 25 points on the Stroke Impact Scale (SIS)).
“The results suggest that usual and customary community-based therapy, provided during the typical outpatient rehabilitation time window by licensed therapists, improves upper extremity motor function and that more than doubling the dose of therapy does not lead to meaningful differences in motor outcomes,” the authors wrote.
The authors note that these results can be used to help estimate the effects and cost of outpatient post-stroke care, and also highlight the need for studies investigating dose-response therapy at specific time points after a stroke.
This study was supported by the National Institutes of Health, the National Institute of Neurological Disorders and Stroke, and the National Center for Medical Rehabilitation Research. The authors report no disclosures.
Reference
Winstein CJ, Wolf SL, Dromerick AW et al. Effect of a Task-Oriented Rehabilitation Program on Upper Extremity Recovery Following Motor Stroke: The ICARE Randomized Clinical Trial. JAMA. 2016;315(6):571-581. doi:10.1001/jama.2016.0276.
