Latest research on stroke rehab gives hope, opens doors for rehab facilities
Experts say this is an exciting time for stroke rehab
A new study offering hope for greater recovery among people with disabilities from strokes has resulted in thousands of phone calls to the researchers involved in the study. Patients and their families even tracked down the e-mail addresses and phone numbers of people who were not involved in the research but had been quoted in the articles. The interest was so intense that one investigator in the new study says it has overwhelmed his office at the University of Alabama at Birmingham.
"Everyone is inundated with phone calls," says Edward Taub, PhD, professor of psychology at the University of Alabama at Birmingham. "This treatment is in high demand because this is an untreated population." Taub’s and other investigators’ studies, published in Stroke in June, provide the latest evidence that people who have strokes causing them to lose function in an upper limb can regain some of that function through two weeks of intense, constraint-induced (CI) movement rehabilitation therapy. The study uses focal transcranial magnetic stimulation to map the cortical motor output area of a hand muscle on both sides in 13 stroke patients before and after the CI therapy. The mapping shows that the muscle output area is significantly enlarged in the affected hemisphere after treatment.1 (See story on new study, p. 92.)
"This particular study is not in itself an indication of a cure, but it’s really a very interesting and potentially promising first step," says Gregory del Zoppo, MD, associate professor in the department of molecular and experimental medicine at The Scripps Research Institute in La Jolla, CA. del Zoppo also is a practicing internist and hematologist active in acute stroke care at the Scripps Clinic.
"This may not be helpful for everyone who has had a stroke, but overall, it’s very exciting," says Martin Schaeffer, MD, medical director of the department of physical medicine and rehabilitation at DuBois (PA) Regional Medical Center.
While there have been a great number of exciting medical breakthroughs in preventing and limiting the damage caused by strokes, this research into a new therapy for stroke patients is unique because it offers promising treatment to people who have been disabled for decades after a stroke.
"In the last couple of years, we’ve seen an explosion of new treatments for stroke, both in trying to prevent stroke from happening and with new stroke medicines," Schaeffer adds. "So I think this is an exciting time where you’re developing emergent stroke treatment, developing medicines to prevent it, and now we’re finding new treatments for the therapy end of it, too."
The University of Alabama research found functional improvements among patients who were injured by stroke from three months to 21 years previously, Taub says. "There was no difference in treatment outcome, and we have enough patients, so we have a pretty good statistical analysis," he says.
The latest research may symbolize a watershed moment for CI therapy. Not only is the public interest high, but the National Institutes of Health (NIH) in Washington, DC, provided funding for a five-year, multisite clinical trial to study CI therapy. The NIH study, which began in April, is a controlled trial involving 260 people who are three to six months post-stroke at six sites in Alabama, Georgia, Florida, North Carolina, Ohio, and California.
The NIH study involves recent stroke survivors who are subacute patients because this population is more readily available for treatment, and it’s easier to obtain insurance reimbursement for them, Taub says.
Thousands to treat
Taub, who continued his stroke rehab research this summer at the University of Jena in Jena, Germany, and at Germany’s University of Konstanz, says the public response shows how important it is to stroke patients to receive rehabilitation in order to gain additional function.
"Certainly, a year after a person has a stroke, the traditional wisdom in the rehabilitation field is that motor capacity in these individuals is not modifiable," Taub says. "Whatever they have at one year or six months is what they’ll have the rest of their lives, and they won’t get better."
That means tens of thousands of stroke victims are not treated. "They’re discarded on the trash heap of society, and not because society is uncaring," Taub says, "but because there’s not anything that could be done for them."
Rehab facilities no longer have to stick to the conventional wisdom. The CI research opens up whole new possibilities. The challenge is convincing insurers to pay for the intense and costly rehab treatment.
"The effective therapeutic factor is the intensity of training," Taub explains. "It’s seven hours a day, five days a week, in a treatment center for two weeks."
University of Alabama at Birmingham CI research projects used unlicensed but trained staff, supervised by a physical therapist, to provide the treatment. Rehab facilities, however, would need to use licensed staff, which raises the cost, he adds.
Still, if rehab facilities at least begin to try CI treatment and market its benefits to payers, it might make a difference. "If you can show that you can take someone who wasn’t using his arm and treat him to where he is using his arm, I don’t think insurance companies would have a problem paying for it," Schaeffer says.
Has there been enough research into CI therapy to convince insurers of its benefits? Taub says yes. He has been involved in more than 10 related studies over the past decade, including research with monkeys and other work that led to the development of CI therapy.2,3,4,5 There have been many other research studies in this area, as well.
For instance, a similar study is under way at Northeastern University in Boston, where Judith Schaechter, PhD, MSPT, an assistant professor in the department of physical therapy, is studying CI therapy using a functional MRI technology to monitor changes in brain activity.
Schaechter, who was trained by Taub, is studying the results of CI therapy on stroke patients who have decent balance and are not dependent on an assistive device for walking. "They have to have enough judgment to understand when it’s safe and when it’s not safe to use a sling on their [unaffected] arm," she says. "They have to have enough physical function so that when the unaffected arm is put in a sling or splint, they can actually function during the day."
The therapy is provided one-on-one for four to eight hours per day, five days a week, and the research study is for a two-week period, she says.
While the research results are still being analyzed, Schaechter says they have shown functional changes among the patients receiving CI therapy. The functional MRI scans after therapy, however, are not showing increases in the volume of activation, as appears to occur with Taub’s transcranial magnetic stimulation technology scans, she adds.
Stroke patients are most concerned about the functional results. If they feel the therapy helps them regain use of their affected arm, it may be immaterial whether brain scans illustrate those changes.
Taub says he’s convinced there is enough demand for CI therapy that some stroke patients and their families will be willing to pay for it on a private-pay basis. He’s involved with opening a private-pay clinic this fall in Birmingham, AL, where 10 patients at a time can be treated.
While a price for CI therapy has not yet been established, Taub says it will be comparatively inexpensive. "I feel badly for the people who can’t pay for the treatment and could benefit from it just as much," Taub says. "But at least more people than we can handle in our research will receive the treatment."
If the demand remains high, the clinic may even expand to handle more than 10 patients.
Aside from offering private-pay CI therapy services, rehab facilities can offer a scaled-down version of the therapy. Brooks Rehab Hospital in Jacksonville, FL, for example, has been using CI therapy for about two years on some stroke patients in the inpatient setting, say Lori-Ann Pietruski, OT, OTR/L, and Donni Welch-Rawls, MS-PT, manager of physical therapy. (See story on Brooks’ CI therapy program, p. 91.)
"It’s usually started a few weeks post-stroke, lasting three hours a day for five days a week, and then one hour and one half-hour on Saturday and Sunday," Pietruski says.
Taub says a less intense CI program is fine, but studies have shown it will not work as well as the intense program. A German study compared the functional improvements between a group that received six hours per day of shaping therapy and a group that received three hours per day of shaping therapy, both combined with constraining the unaffected limb. The research showed that the group receiving six hours of therapy had twice as large a treatment effect as the three-hour group.
"A number of clinical facilities are doing whatever they can do, two hours three times a week, and they get a treatment effect that’s better than nothing," he says. "But we do know they’re getting a fraction of the treatment effect we’re able to get in Birmingham."
More research is under way to see if the same results can be obtained from a combination of intense one-on-one physical therapy and group CI therapy or supplemented by at-home therapy conducted by trained caregivers.
References
1. Liepert J, Bauder H, Miltner WHR, et al. Treatment-induced cortical reorganization after stroke in humans. Stroke 2000; 31:1,210.
2. Taub E. Somatosensory deafferentation research with monkeys: Implications for rehabilitation medicine. Behavioral Psychology in Rehabilitation Medicine: Clinical Applications. In: L.P. Ince., ed. Williams & Wilkins: New York City; 1980, pp. 371-401.
3. Taub E, Miller NE, Novack TA, et al. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil 1993; 74:347-354.
4. Taub E. New Discovery equals change in clinical practice. J Rehab Res Devel 1999; 36:vii-viii.
5. Taub E, Uswatte G, Pidikiti R. Constraint-induced movement therapy: A new family of technique with broad application to physical rehabilitation — a clinical review. J Rehab Res Devel 1999; 36:237-251.
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