The use of a structured, task-oriented rehabilitation program, compared with usual rehabilitation, did not result in better motor function or recovery after 12 months for patients with moderate upper extremity impairment following a stroke, according to a study in JAMA.
Clinicians providing care for patients with stroke lack evidence for determining the best type and amount of motor therapy during outpatient rehabilitation. Clinical trials suggest that higher doses of task-oriented training are superior to current clinical practice for patients with stroke with upper extremity motor deficits.
Carolee J. Winstein, Ph.D., of the University of Southern California, Los Angeles, and colleagues randomly assigned 361 participants with moderate motor impairment following a stroke to structured, task-oriented upper extremity training (n = 119); dose-equivalent occupational therapy (DEUCC; n = 120); or monitoring-only occupational therapy (UCC; n = 122). The DEUCC group was prescribed 30 one-hour sessions over 10 weeks; the UCC group was only monitored, without specification of dose. Participants were recruited from 7 U.S. hospitals, treated in the outpatient setting, and tested at 12 months on various measures of motor function and recovery.
Among the 361 patients (average age, 61 years), 304 (84 percent) completed the 12-month primary outcome assessment. The researchers found there were no group differences in upper extremity motor performance; specifically, the structured, task-oriented motor therapy was not superior to usual outpatient occupational therapy for the same number of hours, showing no additional benefit for an evidence-based, intensive, restorative therapy program. In addition, there was no advantage to providing more than twice the average dose (average, 27 hours) of therapy compared with the average 11 hours received by the observation-only group, showing that substantially more therapy time was not associated with additional motor restoration.
"These findings do not support superiority of this task-oriented rehabilitation program for patients with motor stroke and moderate upper extremity impairment," the authors write.
"With payer pressures on reducing inpatient rehabilitation, outpatient rehabilitation may be of greater importance for patients with stroke. The findings from this study provide important new guidance to clinicians who must choose the best treatment for patients with stroke," the researchers write. "The results suggest that usual and customary community-based therapy, provided during the typical outpatient rehabilitation time window by licensed therapists, improves upper extremity motor function and that more than doubling the dose of therapy does not lead to meaningful differences in motor outcomes."
"The data pertaining to dose of rehabilitation therapy may be important to policy makers and may be useful to estimate the cost and expected effect of aftercare in the outpatient setting."