Exercising Restraint in Stroke Therapy

Summarized by Robert W. Griffith, MD
November 21, 2006

Summary

Constraint-induced movement therapy - restraining the non-affected arm while intensively exercising the limb affected by the stroke - produces improved recovery measurements.

Introduction

Six years ago we posted an article about a novel way of improving the recovery of immobile limbs in stroke patients: constraint-induced movement therapy (see first link below). The idea is to restrict any movement in the unaffected arm for nearly all the waking hours, and give intense repetitive training exercises for the affected arm, 6 hours daily for 2-3 weeks. The concept was developed by researchers at the University of Alabama, USA, and the Friedrich-Schiller University, Jena, Germany.

Surprisingly, there wasn't much news of this approach in the subsequent years until March of 2006, when another small study by the same researchers appeared in the journal Stroke. Now the results of a multi-center trial involving over 200 patients have been published in the Journal of the American Medical Association; here's a summary of the chief findings.

What was done

Seven clinical sites in the USA participated after relevant personnel from each had completed a standardization process at Emory University in Atlanta. Each site tried to recruit 40 patients who had experienced a stroke with loss of arm function in the previous 3 to 9 months. Patients were assigned at random to receive either constraint-induced movement therapy (CIMT) or 'usual and customary care'.

Participants in the CIMT group were taught to wear a protective safety mitt on their unaffected arm for up to 90% of their waking hours, for a period of 2 weeks. On each weekday they received standard training of the affected limb for up to 6 hours a day; tasks included functional activities done continuously for 15 to 20 minutes, e.g. eating, writing. After completing each treatment, the patients were encouraged to practice 2 or 3 tasks daily at home. There was a sensor and timer in the mitt that allowed its use to be monitored.

'Usual and customary care' ranged from no treatment (in roughly half the patients) to various types of occupational and physical therapy, given either in the home or a hospital setting.

The assessments made included the Wolf Motor Function Test (WMFT), which measured time-and-strength movement ability, and the Motor Activity Log (MAL), which measured the performance of 30 common daily activities. The MAL was completed by both the subject and his/her caregiver, if possible. There were 5 separate assessments: at baseline, after the 2-week treatment, and at 4-, 8-, and 12-month follow-up.

What the results showed

There were 106 CIMT and 116 control patients available for analysis. Their average age was 62, and 40% were women. The average time since their stroke was 6 months.

The CIMT group showed greater improvements than the control (usual care) group in the 12-month measurements of both the WMFT and MAL tests. There were significantly larger improvements immediately after the 2-week treatment in the quality and speed of the affected arm movement (WMFT) and in the quality and amount of use of the arm in daily life (MAL); and these improvements persisted for 12 months.

Small but significant improvements were seen in the control group, too. However, this sort of improvement might be expected, due to spontaneous recovery. The improvements with CIMT were statistically significantly greater than those in the usual care subjects.

Not surprisingly, there were a number of severe adverse events during the 12-month study in these subjects. However, there were no significant differences between those seen in the two treatment groups, and no evidence that CIMT itself caused adverse effects.

What these findings mean

This study substantiates an effective therapeutic approach to improved recovery of movement after stroke - constraint-induced movement therapy. It seems, in fact, quite logical that forcing the patient to use the afflicted limb is likely to make recover faster. It's therefore a bit surprising that CIMT hasn't been adapted more widely. This may be because of a number of questions.

1. How clinically relevant were these improvements with CIMT? The best measure of this was the number of tasks that subjects could complete on the WMFT scale. CIMT patients were significantly better in this respect at 2 weeks, 4 and 8 months, compared with usual treatment, Significantly higher scores on the MAL scale, especially when given by the caregiver, were also indicative of clinically relevant improvements with CIMT.

2. How 'expensive' is CIMT? Two weeks of physical therapy directed at keeping the affected limb moving for at least 6 hours a day is personnel-intensive, and therefore quite expensive. More studies like this one will probably be required before health providers are willing to cover costs.

3. When is the optimal time to begin CIMT? In this study the gap between stroke and CIMT ranged from 3 to 9 months, with an average of 6 months. Further work to establish the optimal period after a stroke would be worthwhile.

4. What about lower limb paralysis? Earlier studies have been reported on the use of this approach for afflicted legs, but without full restraint of the unaffected limb in most cases. This probably represents a more difficult therapeutic condition to assess improvements accurately.

In spite of these questions, this study clearly shows that more recovery after stroke is possible than presently expected by clinicians. Let us hope that stroke physicians and therapists meet the challenge.

Source

• Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke. The EXCITE randomized clinical trial. SL. Wolf, CJ.  Winstein, JP.  Miller,  et al. , JAMA, 2006, vol. 296, pp. 2095--2104

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