Higher-dose, higher-repetition upper limb motor rehabilitation program after stroke is not superior to dose-matched or usual-dose customary occupational therapy [synopsis]

摘要

Summary of: Winstein CJ, Wolf SL, Dromerick AW, Lane CJ, Nelson MA, Lewthwaite R, et al, for the Interdisciplinary Comprehensive Arm Rehabili- tation Evaluation (ICARE) Investigative Team. Effect of a task-oriented rehabilitation program on upper extremity recovery following motor stroke. The ICARE randomized clinical trial. JAMA. 2016;315:571-581. Question: Does intensive, high-repetition, task-oriented training during outpatient rehabilitation improve upper extremity motor function after stroke compared to dose-equivalent usual occupational therapy or conventional (low-dose) occupational therapy. Design: Phase 3, parallel 3- group, assessor-blinded, randomised, controlled trial with stratification by motor severity and time from stroke onset. Setting: Seven sites (predominantly inpatient rehabilitation). Participants: Individuals who were an average of 46 days post stroke (SD 22) with moderate upper limb motor impairment. Key exclusion criteria were severe cognitive and sensory impairments. Randomisation of 361 patients allocated 119 to the Accelerated Skill Acquisition Program, 120 to receive dose-equivalent usual and customary occupational therapy care, and 122 to receive observation only (low-dose) customary occupational therapy. Interven- tions: The Accelerated Skill Acquisition Program, which was delivered three times per week for 1 hour per session for 10 weeks, was an intensive, task-specific intervention in which purposeful movement was empha- sised; constraint of the less affected hand was optional. Dose-equivalent usual and customary occupational therapy care received usual and customary care at the same dose as the Accelerated Skill Acquisition Program intervention. The observation only (low-dose) customary occupational therapy was a usual-care group, where the dose was not manipulated. Outcome measures: The primary outcome measure was change in log-transformed Wolf Motor Function Test time score at 12 months. Secondary outcome measures were change in Wolf Motor Function Test time (minimal clinically important difference: 19 seconds) and the proportion of participants who increased by at least 25 points on1836-9553/ 2016 Australian Physiotherapy Association. Published by Elsevier B creativecommons.org/licenses/by-nc-nd/4.0/).the hand subscale of the Stroke Impact Scale. Results: Eighty-four percent of patients (n = 306) completed the study with no significant difference in attrition between groups. The mean between-group differences in the log- transformed Wolf Motor Function Test time score at 12 months were not statistically significant: the Accelerated Skill Acquisition Program versus dose-equivalent usual and customary occupational therapy care was 0.14 log-transformed seconds (95% CI C0.05 to 0.33); the Accelerated Skill Acquisition Program versus observation only (low-dose) customary occupational therapy was C0.01 (95% CI C0.22 to 0.21); the dose-equivalent usual and customary occupational therapy care versus Accelerated Skill Acquisition Program was C0.14 (95% CI C0.32 to 0.05). These between-group mean differences corresponded to small changes in absolute values, ranging from 0.5 to 2.0 seconds. Across all participants, the mean improvement in Wolf Motor Function Test time over 12 months was 6.8 seconds (95% CI 5.3 to 8.3). The proportion of patients in each group with hand function scale improvement ( 25 points) was 73%, 72% and 69%, respectively, with no between-group differences. Conclusion: Providing a structured and intensive (27 hours) upper limb motor rehabilitation program was not superior to usual occupational therapy (either dose-equivalent or low dose, 11 hours). Moreover, mean improvements did not exceed clinically meaningful thresholds in upper limb motor function. Provenance: Invited. Not peer reviewed. Prudence Plummer Department of Allied Health Sciences, The University of North Carolina at Chapel Hill, United States E-mail address: pplummer@med.unc.edu http://dx.doi.org/10.1016/j.jphys.2016.07.010 2016 Published by Elsevier B.V. on behalf of Australian Physiotherapy Ass creativecommons.org/licenses/by-nc-nd/4.0/).ociation. This is an open access article under the CC BY-NC-ND license (http://.