New Therapy for Partial Paralysis

In some stroke survivors with partial paralysis on one side, intensive physical therapy that restrains their good arm and hand may lead to lasting improvements in the paralyzed one.

Medically Reviewed by Louise Chang, MD on November 01, 2006
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Nov. 1, 2006 -- In some stroke survivors with partial paralysis on one side, short-term, intensive physical therapy that restrains their good arm and hand may lead to lasting improvements in the paralyzed one, a new study shows.

In the study, patients who underwent the new therapy took a third less time to complete a task and could perform the task 34% more efficiently than those treated with the usual care.

"This study offers a completely new hope that's never been there before, that following through with a difficult regimen of physical therapy will actually lead to significant improvements in physical function, happiness, and quality of life," says John Marler, MD, associate director of clinical trials at the National Institute of Neurological Disorders and Stroke (NINDS), which co-funded the study.

The study results appear in the Nov. 1 issue of The Journal of the American Medical Association.

Stephen L. Wolf, PhD, of the Emory University School of Medicine in Atlanta, and colleagues studied 222 survivors of first-time, mild-to-moderate strokes.

In order to participate in the study, the patients had to successfully complete a simple test: resting their impaired forearm on a table with their hand extended over the edge and raising their wrist and fingers in a "waving goodbye" gesture.

Only 5%-30% of stroke survivors are able to complete this test, Wolfe tells WebMD.

Patients Worked Hard

Three to nine months after their strokes, 106 of the patients were assigned to receive constraint-induced movement therapy (CIMT).

The other 116 received usual or customary care, which included physical and occupational therapy, orthotics, day treatment programs, etc.

All the subjects were followed for a year.

During the two-week CIMT intervention, patients wore a mitt over their good hand during waking hours. They also met every day with a physical therapist to practice physical tasks for up to six hours with their impaired hand.

"They chose 30 real-world tasks that were most meaningful to them," Wolf says. "These included adaptive tasks such as eating, washing, bathing, grooming, and opening doors. They also included tasks such as writing, drawing, and -- for those who like gardening -- using a shovel to lift potting soil into a pot."

To keep patients from getting frustrated, each task was broken down into its component parts. "So each patient was literally relearning the sequence of events that go into completing a task and reformulating a motor plan to do it correctly," Wolf says.

Big Improvements

Both the CIMT group and the usual-care group were studied over the year to see how quickly and effectively they could perform the tasks they had chosen.

The researchers used two different tests to monitor their progress: one to measure the patients' task speed and functional ability; the other to measure how well they could perform the tasks.

Although both groups improved over the year, the improvements were significantly more impressive in the CIMT group.

Compared with the usual-care group, the CIMT patients took 34% less time to complete a task and could perform the task 34% more efficiently.

The CIMT group also saw a 65% increase in the number of tasks they could successfully perform with their impaired arm compared with the usual-care group.

They also reported that they felt significantly less functional disability.

Improvements May Be Permanent

"One of the most convincing things about this trial is that it showed the durability of CIMT," Marler says. "The effects of a relatively short intervention could still be seen a year later. This is solid evidence that there is a benefit."

This benefit persisted even after the researchers adjusted for age, sex, and the level of disability in the impaired arm.

Because Wolf and his team are continuing to assess the study participants, the researchers are hopeful the benefits will continue two years or more.

CIMT is thought to work because it strengthens areas of the brain associated with muscle movement, either by making patients repeat a task over and over or by challenging them to problem-solve.

"The question of how it works hasn't yet been answered," Wolf says. "But brain scans indicate that there are real changes occurring in the brain."

"A lot of people who start physical therapy don't realize that exercise can solve a problem with the wiring in the brain," Marler says. "This trial would suggest that it can."

Future Looks Promising

Researchers are now evaluating whether CIMT might be even more effective if it's started earlier -- one to three months after a strokestroke -- or if it continues longer than two weeks.

One of Wolfe's colleagues has developed a modified CIMT program in which patients wear a mitt five hours a day for 10 weeks and undergo physical therapy once or twice a week. "It's proving to be effective as well," Wolf says.

Even though fewer than a third of stroke survivors may benefit from CIMT, Wolf expects the demand for the therapy to increase dramatically in light of the new research.

But there are hurdles to overcome.

Only about 10-12 medical centers in the U.S. now have competently trained CIMT therapists, Wolf says, although efforts are under way to develop a certification and standardization process.

Also, CIMT may not be covered by insurance. "Most of the subjects in our study had to pay for CIMT out-of-pocket," says Wolfe, who is pushing to expand coverage.

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SOURCES: Steven L. Wolf, PhD, PT, Emory University School of Medicine, Atlanta. John Marler, MD, associate director of clinical trials, National Institute of Neurological Disorders and Stroke. Wolf, S. The Journal of the American Medical Association, Nov. 1, 2006; vol 296: pp 2095-2104.

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