Early, Intensive, Lower Extremity Rehabilitation Shows Preliminary Efficacy After Perinatal Stroke: Results of a Pilot Randomized Controlled Trial

You're declaring invalid success since you didn't get to 100% recovery. Will you please stop using the tyranny of low expectations, survivors want 100% recovery, not partial recovery. I don't know where you got such an invalid assumption.  

Early, Intensive, Lower Extremity Rehabilitation Shows Preliminary Efficacy After Perinatal Stroke: Results of a Pilot Randomized Controlled Trial

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Caitlin Hurd, PT, MSc, Donna Livingstone, BSc, PT, Kelly Brunton, MSc, PT, ...

First Published April 15, 2022 Research Article Find in PubMed 

https://doi.org/10.1177/15459683221090931

Article information

Abstract

Background

Perinatal stroke injures motor regions of the brain, compromising movement for life. Early, intensive, active interventions for the upper extremity are efficacious, but interventions for the lower extremity remain understudied.

Objective

To determine the feasibility and potential efficacy of ELEVATE—Engaging the Lower Extremity Via Active Therapy Early—on gross motor function.

Methods

We conducted a single-blind, two-arm, randomized controlled trial (RCT), with the Immediate Group receiving the intervention while the Delay Group served as a 3-month waitlist control. A separate cohort living beyond commuting distance was trained by their parents with guidance from physical therapists. Participants were 8 months to 3 years old, with MRI-confirmed perinatal ischemic stroke and early signs of hemiparesis. The intervention was play-based, focused on weight-bearing, balance and walking for 1 hour/day, 4 days/week for 12 weeks. The primary outcome was the Gross Motor Function Measure-66 (GMFM-66). Secondary outcomes included steps and gait analyses. Final follow-up occurred at age 4.

Results

Thirty-four children participated (25 RCT, 9 Parent-trained). The improvement in GMFM-66 over 12 weeks was greater for the Immediate than the Delay Group in the RCT (average change 3.4 units higher) and greater in younger children. Average step counts reached 1370-3750 steps/session in the last week of training for all children. Parent-trained children also improved but with greater variability.

Conclusions

Early, activity-intensive lower extremity therapy for young children with perinatal stroke is feasible and improves(NOT CURES!) gross motor function in the short term. Longer term improvement may require additional bouts of intervention.

Clinical trial registration

This study was registered at ClinicalTrials.gov (NCT01773369).

Keywords

neuroplasticity, early intervention, cerebral palsy, motor skill training, intensive training, exercise

Introduction

Perinatal stroke is a cerebrovascular event that occurs between gestational age of 20 weeks and 28 days postnatal, and has an incidence between one in 1600 to 2300 live births.^1,2 It is the leading cause of hemiparetic cerebral palsy (CP), which may involve weakness, spasticity and impaired coordination in the affected upper and lower extremity.³ The life-long gross motor impairments contribute to long-term musculoskeletal complications, impaired gait, reduced physical activity and participation.^4,5

Intensive, active approaches to rehabilitation have been effective for improving upper extremity function (e.g., constraint-induced movement therapy [CIMT] and bimanual training, reviewed in 6-8). In contrast, active treatment approaches for the lower extremity are limited for young children with CP,⁷ although some studies combining upper and lower extremity training show promise^9,10 or are underway.¹¹ Optimizing lower extremity function is especially important now because of the recent reduction in severity of CP among developed countries, resulting in more children with the potential to walk.¹²

Current clinical practice for lower extremity function in young children with CP is often passive in nature, typically waiting until clinical signs appear, then focusing on static stretching, the traditional Neural Developmental Therapy (NDT), bracing with ankle-foot orthoses and botulinum toxin injection of spastic muscles,^13-15 a “wait-and-see”approach.¹⁶ Yet targeted walking training in school-aged children improves walking performance in children with CP.^17,18 The passive, infrequent and delayed approach to treatment of the lower extremity for young children with hemiparetic CP is in contrast to evidence from animal models of early brain injury, which demonstrates the importance of early, intensive rehabilitation.

Inactivating the primary motor cortex in kittens during a critical period of development impairs the development of motor circuits and motor function.^19,20 Initiating motor training of the affected limb while kittens are young improves motor function and the integrity of motor circuits, whereas training at an older age is less effective.²¹ Critical periods of lower extremity motor development in the human may occur before the age of 2 years because post-mortem studies have shown mature myelin on the corticospinal tract at the lumbar neurological level around this age.²² Since mature myelin is associated with reduced neuroplasticity,²³ we suggest that plasticity would be greatest prior to the emergence of mature myelin. Therapeutic approaches to enhance developmental neuroplasticity of children with perinatal stroke have been reviewed recently.²⁴ In a separate pilot study with no participant overlap with this study, we showed that intensive activity-based rehabilitation for the lower extremity in children with hemiparesis under the age of 2 resulted in large improvements in walking.²⁵

We hypothesized that early, intensive, child-initiated therapy for the lower extremity in children with perinatal stroke would result in greater improvements in motor function than usual care. Here, we focus on the changes in gross motor function.