Elsevier

The Lancet Neurology

Volume 7, Issue 1, January 2008, Pages 33-40
The Lancet Neurology

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Retention of upper limb function in stroke survivors who have received constraint-induced movement therapy: the EXCITE randomised trial

https://doi.org/10.1016/S1474-4422(07)70294-6Get rights and content

Summary

Background

The aim of constraint-induced movement therapy (CIMT) is to promote use of a limb that is functionally impaired after a stroke. In one form of CIMT to treat upper limb impairment, use of the less severely affected arm is restricted for many hours each weekday over 2 consecutive weeks. The EXCITE trial has previously shown the efficacy of this intervention for patients 3–9 months poststroke who were followed-up for the next 12 months. We assessed the retention of improvements 24 months after the intervention.

Methods

In the EXCITE trial, 106 of 222 participants who had mild to moderate poststroke impairments were randomly assigned to receive CIMT rather than usual and customary care. We assessed this group of patients every 4 months for the primary outcome measure of impaired upper limb function, as measured with the Wolf motor function test (WMFT) and the motor activity log (MAL). Health-related quality of life, measured with the stroke impact scale (SIS), was a secondary outcome measure. Analysis was per protocol. This trial is registered with ClinicalTrials.gov, number NCT00057018.

Findings

The effects at 24 months after treatment did not decline from those at 12 months for time taken to complete the WMFT (−0·32 s, 95% CI −3·70 to 3·06), for weight lifted in the WMFT (−1·39 kg, −2·74 to −0·04), for WMFT grip strength (−4·39 kg, −6·91 to −1·86), for amount of use in the MAL (−0·17, −0·38 to 0·04), or for how well the limb was used in the MAL (−0·14, −0·34 to 0·06). The additional changes were in the direction of increased therapeutic effect. For the strength components of the WMFT, p<0·0001.

Interpretation

Patients who have mild to moderate impairments 3–9 months poststroke have substantial improvement in functional use of the paretic upper limb and quality of life 2 years after a 2-week CIMT intervention. Thus, this intervention has persistent benefits.

Introduction

Constraint-induced movement therapy (CIMT) requires patients who have had a stroke to practise functionally relevant repetitive tasks, including shaping procedures, with the paretic limb for up to 6 h each weekday, and the less affected wrist and hand are restrained during most waking hours.1, 2 This form of CIMT differs from so-called forced use,3, 4 in which the patient must use the impaired limb during restraint of the better limb but without formal training, and from a distributed form of CIMT5 in which the patient wears a restraint for 5 h each weekday for 10 weeks and receives periodic rehabilitation sessions.

Use of CIMT within the first month after a stroke6 and during long-term poststroke disability1, 7, 8, 9, 10, 11, 12, 13 has been successful in patients who can initiate extension movements at the wrist and fingers before treatment.11, 14 The extremity constraint-induced movement therapy evaluation (EXCITE) trial15 showed that CIMT 3–9 months poststroke resulted in significant and clinically relevant improvements in upper limb function during the following year compared with those achieved with usual and customary care. Here, we assess retention of these effects and further improvements during the 24-month period after CIMT therapy in patients with subacute symptoms.

Section snippets

Participants

Methods used in the EXCITE trial have been published previously.16 At each of the seven study sites, potential participants were first screened by telephone (figure). Patients who had a disability caused by a first-time ischaemic or haemorrhagic stroke within the past 3–9 months received an on-site physical examination to establish whether they met higher functioning or lower functioning criteria.14, 17 Patients who could actively extend the wrist at least 20° and the metacarpophalangeal and

Results

The figure shows the trial profile. In this paper we report results from only the arm of the EXCITE trial in which patients received CIMT immediately after allocation. 22% of these patients had dropped out at 12 months and 34% at 24 months. These rates were 15% and 24% for 12 and 24 months, respectively, when dropout caused by death or deterioration of medical status was not included.

Table 1 shows least-square means at four time points, means for the whole post-CIMT period (post-CIMT through to

Discussion

Previous results from the EXCITE trial have shown that CIMT can produce statistically and clinically meaningful improvements in WMFT, MAL, and the SIS hand function domain after the intervention and 1 year later compared with those in participants who receive usual and customary care.15 When examined by functional level, concordance, or sex, the WMFT and MAL results did not change. Although the number of randomised clinical trials of stroke neurorehabilitation therapy is growing, so far none

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