Effect of a task-oriented rehabilitation program on upper extremity recovery following motor stroke

Article Reviews
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Read Full Text: Effect of a Task-Oriented Rehabilitation Program on Upper Extremity Recovery Following Motor Stroke: The ICARE Randomized Clinical Trial
Journal: Journal of the American Medical Association
Year Published: 2016
Ranked 5th on our 2014-2019 list of the 50 most influential articles

Article Overview for OT Practitioners

If you’ve read our past article reviews, you know that researchers are really interested in discovering more about a “dose effect” in OT. (This means that they want to study whether higher doses of therapy can lead to greater recovery.) Researchers are also very eager to discover possible “windows” of time when these increased therapy dosages might be most effective.

This week’s article, which comes from a highly influential journal, throws a wrinkle in the “more is better” trend.

Its general conclusion was that patients with moderate upper extremity (UE) impairment following stroke, who completed an intense, task-oriented OP OT protocol over 10 weeks did not fair any better in the long run than stroke patients who had customary OP OT care.

More information on the patients and treatment groups

The patients:

The patients in this study all experienced a stroke resulting in moderate UE impairment, and all were deemed fit to participate in an intense therapy program.

The randomization process began 14 to 106 days after the patients’ respective strokes.

The treatment groups:

The patients were divided up into three treatment groups, all of which had similar outcomes 12 months after the study began.

  1. One group received “usual and customary” OT, as determined by the therapists, payer guidelines, and participant preferences.

  2. Another group received the same “usual and customary” OT, but the interventions were specifically delivered in 30 one-hour sessions across a 10-week period (rather than being dictated by payer, participant, or therapist preferences).

  3. The last group received a rehab protocol that was designed to reflect best practices: it was task-specific, intense, and client-centered. Patients received three hours of OT treatment per week, delivered over 10 weeks.

Assessments that were utilized (that you can use too!)

Limitations of this study

The article cites some interesting limitations of this study that are worth considering.

1. Spontaneous recovery might have been greater than the treatment effect during this time window. During the first six to 10 weeks following a stroke, spontaneous recovery is still occuring. Researchers posit that this natural recovery process might have trumped the effects of the treatment that was being provided during this particular window of time.
2. The dose increase might not have been high enough. While the dose of therapy delivered in the study was significantly higher than what is typically provided, perhaps it still wasn’t enough. Especially in constraint-induced movement therapy research, research is indicating that a significantly higher dose of therapy and repetitions are needed to make a functional difference.
3. Maybe the usual care provided by OTs was already representative of best practices. It could be that the interventions delivered weren’t really that different from what OTs tend to provide in current clinical practice.

Takeaways for OTs

On one hand, research like this can make it confusing when we try to understand how much therapy and what type of therapy we should be giving to patients following stroke.

On the other hand, it can be reassuring that in outpatient therapy in the first months following a stroke your clinical reasoning is just as effective as a fancy protocol.

If nothing else, this research tells us that at this time, there simply is not an easy, one-size-fits-all protocol. So, take the time to really listen to your patient and assess their situation, because your own clinical judgment is very likely what they need most.

Listen to a summary in podcast form

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What questions/thoughts does this article raise for you?

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This is a topic that is still of much debate. How much repetition is enough for motor improvement? The challenge of some of these dose studies are the items that you mentioned, Sarah.
The findings were definitely confounded by having such a mixed group of patient types, many of whom were likely still in spontaneous recovery. This makes it difficult to determine whether or not their improvement was actually coming from the intervention.
Additional literature talks about the intensity needed for motor improvement and there has been evidence of improvement at 17 hours per week over 10 weeks. The “intensive” program at 3 hours per week in the iCARE study, we’re understanding, is far less than necessary to see lasting cortical changes.
Even if patients don’t qualify for intensive therapy like CIMT, using the Motor Activity Log or another translation to home is SUPER important. There are also home based technologies that can increase repetition and intensity. What we’re able to do in the clinic is not nearly enough. What have other OTs found to be helpful to get patients to increase their number of repetitions at home?

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I agree, @lauren2! I see OTs role in this scenario moving towards overseeing some type of repetition program completed at home or in a rehab gym. 3 hours/week simply does not seem like enough to move the needle!

Great call on the Motor Activity Log! For people who haven’t used it before here is link to this free tool: https://www.uab.edu/citherapy/images/pdf_files/CIT_Training_MAL_manual.pdf

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Hi Lauren and welcome!!! Great topic Sarah. I appreciate the call out to consider what is helping patients who have had a stroke be more consistent and active overall once they are home. And I will be honest and say (as a home health OT), it’s quite difficult. Most clients that I’ve worked with are in need of CG support and that CG is BARELY making it happen when their routine does NOT involve counting reps for exercises because they are too busy trying to keep income coming in and freshish food on the tabel. So it reminds me of being transparent and prioritizing their goals. As a therapist, it’s easy to assume I know what’s important, but especially in home health, I get to also experience the hard realities with these folks and their families (of often not having full recoveries). Will 30 min per day of repetition be worth it for the outcomes (that are not guaranteed)? It seems the biggest link is finding out who or what can help with consistency. Because even if technology can help with reps, it often can take… a caregiver to put it on and set it up. Such. A. Good. Topic. The biggest thing that helps with reps: clear communication from me about this being a crucial aspect for recovery, total buy-in to the goal from all involved, a very clear HEP to fit the patient’s learning preference and cognition, and a CG (if applicable) who is 100% on board. What else is helping others? Yes, I’m so curious!

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Great discussions so far! It does seem that the spontaneous recovery point puts a big dent in this study - but nonetheless the idea of dosing is so interesting here. It connects with a broader concept in therapy in general: the reality that we spend so little time with people compared with their overall life.

The way I like to think about it is: we have 168 hours in a week, and most people will spend 1-3 hours in rehab if they’re lucky which equates to less than 2% of their week (or as Lauren mentioned, 17 hours…although that’s a crazy amount of treatment…which would be still only 10%). So what are people doing with the other 98% of their time? Unless a study controls or takes into account that 98% there is just no good way to compare across different people.

You pose some good questions too Monika. Outside of a research context, how important is counting reps anyway? Is that even what we should be focusing on? Unless someone is highly competitive and derives meaning from reps and counting, it’s not really occupational therapy to give them basic exercises and have them ensure enough reps. We can do WAY better than that! But it’s tough to really study a more nuanced approach like activity or occupation based treatment in this context, compared to tasks.

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Welcome, Lauren!

As an outpatient OT, I find that teaching the patients about similar activities to perform at home helps with carryover. For instance, we create, implement, and establish their HEP with exercises and go over a set amount of repetitions, sets, etc. but, as others here have stated, how likely is it that a person will be able to/will sit and perform these exercises as many times as necessary to see these results? In response, I have started educating patients on functional tasks and activities that they can perform at home in addition to the HEP that incorporate the same movement patterns into their daily routines. I’ve found that this has helped to increase the number of repetitions and increased their participation in functional tasks and confidence with activities that they may or may not have tried otherwise yet.

@SarahLyon Thank you for providing the link for the Motor Activity Log! I have yet to use this.

Happy OTing!

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