The Doctor Weighs In

Having a stroke changes your life in many dramatic ways. People, who were previously mobile and independent, often find themselves unable to do many of the things they did prior to the stroke. With one side of the body paralyzed, simple tasks, such as opening a can of food or making a bed, can present daunting challenges to stroke survivors.

The results of a new study, published earlier this month in the Journal of the American Medical Association, offers some hope that some lost motor (movement) function can be reversed. The study is named EXCITE (which stands for Extremity Constraint Induced Therapy Evaluation)…and the results are, well, EXCITE-ing.

Steven Wolf, a PhD, physical therapist was the lead researcher on the study. The study had a strong clinical design, known as a multi-site, randomized, single-blind clinical trial. Patients who were left with a limited disability of their hand 3 to 9 months after a stroke were recruited from seven different clinical centers. They were randomly assigned to be in one of two intervention groups. One group received a treatment called “constraint-induced movement therapy (or CIMT). The other group of stroke patients received “usual care.” The patients, of course, knew what kind of therapy they received, but the evaluators of their clinical response did not.

Constraint-induced movement therapy (or CIMT) improved functional outcomes

CIMT, in this study, consisted of two major components. Participants received up to 6 hours per day of physical therapy per day for two weeks. The physical therapy emphasized repetitive motion of the affected arm. They were also asked to wear a safety mitt on their good hand that prevented the use of that hand for at least 90% of waking hours daily for 14 days. The group receiving “usual care” ranged from no treatment at all to the use of orthotics, or different types of occupational and/or physical therapy.

Individuals treated with CIMT has significantly improved functional use of the affected hand and reduced disability compared to people who only received “usual care.” Further, the benefits were maintained for at least 12 months -- the duration of the study.

In an editorial accompanying the research article, neurologists Andreas Luft, MD and Daniel Hanley, MD, note that “early mechanistic work suggests that constraint-induced therapy modifies brain circuitry, particularly motor and premotor cortices in the affected hemisphere, to produce its benefit. Further studies, using sophisticated brain imaging techniques, need to be done in order to confirm if structural brain changes underlie the functional improvement.

Ready for prime time?

A number of questions still remain about the generalizability of the results of this study:

• Will individuals with more severe paralysis, say a dense hemiparesis (or complete paralysis of one-half of the body) have the same benefit?
• Is it safe in people with larger neurologic deficits? Would they fall more if a good limb is immobilized? Would they have more post-stroke injuries?
• How long after a stroke can CIMT be initiated and still produce benefits? People in this study were 3 to 6 months post stroke. Can CIMT produce functional improvements in people who have been paralyzed for 1 year, 2 years, or more after stroke?
• Is the improvement sustainable beyond the initial post-treatment period? Improvements lasted for up to a year in this study. Will these improvements last for 5 years? 10 years?

Despite these remaining questions – which will undoubtedly be subjected to study in the near future – the results of this study are indeed, EXCITE-in. For the first time, in a well-designed study, an aggressive intervention -- 2 weeks of CIMT -- has been shown to significantly improve functional outcomes in stroke patients compared to the usual array of interventions we have employed so far. This study produces more than a few rays of hope in the area of post-stroke rehabilitation.