By Eleanor McDermid, Senior medwireNews Reporter
A randomised trial from Germany has attempted to turn constraint-induced movement therapy (CIMT) into a cost-effective home-based treatment for stroke survivors.
Anne Barzel (University Medical Center Hamburg-Eppendorf) and team adapted CIMT for ambulatory care by keeping core elements such as repetitive training of the most affected side and immobilisation of the least affected limb, but focused them on activities of daily living. Therapists visited the patients five times over the 4 weeks of the study, but nonprofessional coaches, such as family members, supervised the patients’ training on a daily basis.
“The therapists’ role in home CIMT differed substantially from conventional physical or occupational therapy since the therapeutic contact time is mainly used for instruction and supervision of the patients and the coach”, write Barzel et al in The Lancet Neurology.
They say that the high resource use and therapeutic dose needed to administer CIMT are often cited as barriers to effective delivery of the therapy.
The study participants had mild or moderate impairment of arm function and minimal residual hand function following a stroke at least 6 months previously (4 to 5 years, on average). After 4 weeks of treatment, the 85 patients randomly assigned to the CIMT group had a significantly larger improvement in subjective function from baseline, compared with the 71 patients who received standard physical therapy, at adjusted average Motor Activity Log of Quality of Movement scores of 0.56 versus 0.31.
However, objectively measured changes in motor function on the Wolf Motor Function Test of Performance Time did not significantly differ between the groups, at a 25.60% improvement in the CIMT group, compared with 27.52% in the standard therapy group. Improvements in objective functional ability also did not differ between the groups, and the same was true for secondary endpoints such as hand function and finger dexterity.
“Anne Barzel and colleagues have made an important contribution by adapting modified CIMT for stroke rehabilitation into clinical practice, and their findings should provide a basis for future stroke research”, write Ching-Yi Wu and Ku-Chou Chang, from Chang Gung University in Taoyuan, Taiwan, in an accompanying commentary.
They identify several issues that need to be addressed in future, larger trials, including the large imbalance of treatment dose between the CIMT and standard therapy groups, and the potential drawbacks of using nonprofessional coaches, who may, for example, not recognise patients’ compensatory strategies during practice, thus weakening the benefits of the treatment.
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