Long-term Effectiveness of Intensive Therapy in Chronic Stroke

For your doctor to update your stroke protocols for your out-patient therapy.
http://nnr.sagepub.com/content/30/6/583?etoc

1. Xiaotian Wu, MS1,2
2. Peter Guarino, MPH, PhD1,2
3. Albert C. Lo, MD PhD3,4
4. Peter Peduzzi, PhD1,2
5. Michael Wininger, PhD1,2,5⇑

1. ¹Yale University, New Haven, CT, USA
2. ²VA Connecticut Healthcare System, West Haven, CT, USA
3. ³VA RRD Center of Excellence for Neurorestoration and Neurotechnology, Providence, RI, USA
4. ⁴Brown University, Providence, RI, USA
5. ⁵University of Hartford, West Hartford, CT, USA

1. Michael Wininger, PhD, Department of Veterans Affairs, VA Connecticut Healthcare System, Cooperative Studies Program, 950 Campbell Avenue, Building 35 (151-A), West Haven, CT 06516, USA. Email: michael.wininger@va.gov

Abstract

Background. While recent clinical trials involving robot-assisted therapy have failed to show clinically significant improvement versus conventional therapy, it is possible that a broader strategy of intensive therapy—to include robot-assisted rehabilitation—may yield clinically meaningful outcomes.  

Objective. To test the immediate and sustained effects of intensive therapy (robot-assisted therapy plus intensive conventional therapy) on outcomes in a chronic stroke population.  

Methods. A multivariate mixed-effects model adjusted for important covariates was established to measure the effect of intensive therapy versus usual care. A total of 127 chronic stroke patients from 4 Veterans Affairs medical centers were randomized to either robot-assisted therapy (n = 49), intensive comparison therapy (n = 50), or usual care (n = 28), in the VA-ROBOTICS randomized clinical trial. Patients were at least 6 months poststroke, of moderate-to-severe upper limb impairment. The primary outcome measure was the Fugl-Meyer Assessment at 12 and 36 weeks. Results. There was significant benefit of intensive therapy over usual care on the Fugl-Meyer Assessment at 12 weeks with a mean difference of 4.0 points (95% CI = 1.3-6.7); P = .005; however, by 36 weeks, the benefit was attenuated (mean difference 3.4; 95% CI = −0.02 to 6.9; P = .05). Subgroup analyses showed significant interactions between treatment and age, treatment and time since stroke.  

Conclusions. Motor benefits from intensive therapy compared with usual care were observed at 12 and 36 weeks posttherapy; however, this difference was attenuated at 36 weeks. Subgroups analysis showed that younger age, and a shorter time since stroke were associated with greater immediate and long-term improvement of motor function.