An experimental "patient-centered" rehabilitation technique may not be better than conventional physical therapy, at least when it comes to the immediate treatment of stroke patients with upper limb paralysis.

That’s the verdict offered by a randomized clinical trial published Tuesday in JAMA. The study authors, members of the Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) Investigative Team, recruited over 300 stroke patients soon after they left the hospital, and randomly placed them into three treatment groups. One group received a standard course of physical therapy; the second was enrolled in a 10-week, 30-hour long, “structured, task-oriented motor training program” known as the Accelerated Skill Acquisition Program, or ASAP; and the third received standard care for the same duration of time as the ASAP group, more than doubling the amount of physical therapy compared to the first group.

Differences aside, all three groups roughly experienced the same degree of motor recovery along their affected upper extremities by a year’s end, on average cutting down their level of impairment by half. More tellingly, the greater length of time in physical therapy experienced by two-thirds of the participants didn’t noticeably help along their recovery any better than those given usual and customary occupational therapy (UCC).

"Among patients with motor stroke and primarily moderate upper extremity impairment, use of a structured, task-oriented rehabilitation program did not significantly improve motor function or recovery beyond either an equivalent or a lower dose of UCC upper extremity rehabilitation," concluded the authors. "These findings do not support superiority of this program among patients with motor stroke and primarily moderate upper extremity impairment."

A Novel Approach

The results are likely disappointing given earlier positive findings from studies looking at other task-oriented rehab programs.

ASAP’s advocates, which include members of the ICARE team, tout it as a novel approach to physical rehabilitation, one that encompasses existing research from fields as diverse as "motor learning, neuroscience, and the psychological science of behavior change."

The underlying principle behind ASAP is that by training people with motor impairments to perform the same variety of tasks they’d normally perform in the real world, they would encourage better recovery than emphasizing physical motions intended to help them better care for themselves. Not only would patients become more motivated once they saw a more naturalistic application to their grueling bouts of therapy, but their brains would better make the new neural connections needed to recover.

"The primary difference is that ASAP is designed to focus on the recovery of the person with the paretic (partially paralyzed) arm in contrast to a focus on the recovery of the arm that is attached to the person," explained lead author Dr. Carolee Winstein to Medical Daily. "However, both ASAP and usual care use task-specific training to drive recovery of the arm and hand after stroke."

An example of ASAP highlighted in a 2014 paper might be centering physical therapy sessions around a patient’s desire to someday paint again. The therapist and patient would work together to figure out how best to accomplish that over the course of however many weeks, with the patient trying to paint during and in between sessions. Another tool of ASAP might be the voluntary donning of a mitt to restrict use of a person’s good hand, encouraging them to rely more on the impaired limb.

Despite the findings, the ICARE team doesn’t believe it’s the end of the road for ASAP. Winstein noted they did find ASAP patients self-reported greater improvement in both motor and non-motor recovery by the end of their respective therapy sessions compared to the other two groups. They also found evidence suggesting that ASAP may allow patients to achieve "stronger patient satisfaction and participant-percieved outcomes of physical function, strength, motor activity, confidence and reintegration," into society. Her team will publish further research on these specific aspects of recovery for ICARE patients in the near future.

In the paper itself, they noted the timing of the study (soon after a stroke) could have skewed results, since stroke patients often spontaneously recover some motor function very early on. Perhaps by enrolling patients in ASAP at a later stage of their rehabilitation or scheduling ASAP sessions closer together, you might be able to see a physiological improvement over standard therapy.

For the time being, Winstein and her team at least hope their results better inform the field of upper limb rehabilitation — a field not often filled with high-quality research, according to the Cochrane Collaboration, one of the largest independent scientific organizations in the world.

"Clinicians and patients can be assured that, for now, unstructured community-based therapy provided by licensed therapists remains unsurpassed for its efficacy in restoring upper extremity motor function during outpatient rehabilitation, and that more than doubling the dose of therapy does not appear to lead to meaningful differences in motor outcomes in those with motor stroke and moderate upper extremity impairment," said Winstein.

Source: Winstein C, Wolf S, Dromerick A, et al. Effect of a Task-Oriented Rehabilitation Program on Upper Extremity Recovery Following Motor Stroke. The ICARE Randomized Clinical Trial. JAMA. 2016.

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