Stroke: Intense PT Gets Quick Results - But no gain in 12 month limb function

I can explain this even if these experts don't.  This exercise probably saved the functions at the edges of the penumbra but did not stop the majority of the neuronal cascade of death. This would be so easy to prove one way or another. Daily MRI scans showing the progression of the dead area in the brain.
 This study supposedly shows patients who initiated rehabilitation early (within 7 days after stroke) had better long-term outcomes than those who initiated the rehabilitation after more than 1 month
Musicco M, Emberti L, Nappi G, Caltagirone C, Italian Multicenter Study on Outcomes of Rehabilitation of Neurological Patients. Early and long-term outcomeof rehabilitation in stroke patients: the role of patientcharacteristics, time of initiation, and duration of interventions, Arch Phys Med Rehabil, 2003;84(4):551–8. 
Stroke: Intense PT Gets Quick Results - But no gain in 12 month limb function
An accelerated, task-based rehabilitation program helped patients with pure motor strokes recover hand and arm function quicker, but it did not produce better long-term outcomes compared with usual care, researchers found.
Patients in the accelerated arm of the Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) trial averaged more than twice as much physical therapy (PT) as patients in other arms of the trial, but this extra, more intense therapy did not result in better recovery at 12 months follow up, according to Carolee Winstein, PhD, PT, of the University of Southern California in Los Angeles, and colleagues.

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"We were very surprised by the fact that a more than a two-fold increase in the amount of therapy these patients received produced no differences in motor performance or patient reported outcomes," Winstein said at the American Heart Association/American Stroke Association (AHA/ASA) International Stroke Conference. "This flies in the face of the idea that more is better in terms of neuroplasticity and responding to repetitive task training, but it is consistent with some other studies on arm recovery."
Even though all outcomes were the same at 12-months follow up, the accelerated group did show more improvement than patients who got less intensive therapy at 4 months, and they perceived their progress as being better.
"At 4 months our accelerated group actually did just what it said," she said. "It accelerated patients' perceived outcomes of physical function, overall strength, reintegration to normal living, and quality of life as better."
The ICARE study included 361 patients with motor strokes who did not have stroke-related sensory or cognitive deficits. Approximately 78% of the patients had moderate arm and hand impairment associated with their strokes at study entry.
Over a 10-week period and within 14-106 days of having their strokes, 119 patients completed the intense, patient-centered motor therapy, which was task based and stressed skill building, capacity, and motivation. The goal was 3-hour therapy sessions each week for 3 weeks.

"The ICARE trial is the first rehabilitation study to be done in the early weeks after a stroke where the opportunity for learning-dependent plasticity is high and the recover trajectory is very positive," Weinstein told MedPage Today. "It is also the first to consider the specific ingredients of rehabilitation therapy and the first to have two comparison control groups."
A second group of patients (n=120) received usual care but more of it, with the goal of having the same amount of therapy (30 hours) over the 10-weeks as the accelerated therapy group. A third group (n=122) received usual care without a prescribed number of sessions per week.
At the end of the active therapy period, the usual care group had received approximately 11 hours of physical therapy, compared to 28 and 27 hours, respectively, in the accelerated and dose-equivalent usual care groups.
The primary outcome was functional improvement at 12 months post randomization on the Wold Motor Function Test (WMFT) and a >25 point increase on the Stroke Impact Scale hand domain.
At 1-year follow-up, there was a 46% improvement in WMFT mean time scores across all groups and an average 36-point improvement in Stroke Impact Scale Scores. Seventy percent of the study participants had met the efficacy endpoint for hand function by the end of the observation period and there were no group differences in outcomes.
"In this study, more therapy did not prove to be better for the endpoints we looked at," Winstein said.
However, Winstein expressed concern that the study findings may be misinterpreted by clinicians and patients as the findings do not suggest that this therapy is not beneficial.
There is not a lot of research on the impact of PT on motor improvement following stroke, but what data there are overwhelmingly show treatment to be beneficial, she said.
"We are just beginning to recognize that stroke is not a single event. It is a chronic disease that patients have to live with for the rest of their lives," she said. "And we need a lot more data on [how to maximize] recovery."
AHA/ASA spokesman Larry B. Goldstein, MD, agreed, adding that the suggestion from the trial that the specific type and dose of therapy patients receive has little impact on long-term outcomes definitely deserves more study.
"This study looked at whether standardized care made a difference and the finding was that it really didn't when all was said and done," Goldstein, director of the Duke Stroke Center at Duke University School of Medicine in Durham, N.C., told MedPage Today.