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An EXCITE-ing Treatment for Post-Stroke Upper-Extremity Paresis

Constraint-induced movement therapy was effective, but questions remain about optimal treatment intensity, duration, and timing.

Constraint-induced movement therapy (CIMT) has been proposed as a new treatment for post-stroke upper-extremity paresis. Now, researchers have conducted a multicenter, controlled study (the EXCITE study) of the efficacy of this technique. CIMT entails an intensive upper-limb exercise program that consists of repetitive task practice and behavioral shaping while the patient wears a restraining mitt on the less affected hand.

Researchers randomized 222 stroke survivors in the subacute phase (3 to 9 months post-stroke) to either a 2-week program of CIMT or usual care (control). Subjects were required to have at least 10 degrees of active wrist extension and at least 10 degrees of active extension in the thumb and two other fingers of the affected hand.

Compared with the control group, the CIMT group showed a significant 34% greater improvement on timed tasks of the Wolf Motor Function Test, and a difference of 0.48 on the 6-point Motor Activity Log, in daily use of the affected limb. Subjects were stratified based on initial motor control for a subanalysis; those with more-severe impairments at baseline showed smaller functional improvements than did the less impaired subjects.

Comment: Although CIMT was found to be effective post-stroke therapy, important questions remain unanswered. Is the constraint of the less involved upper limb a necessary component of this treatment? What is the optimal intensity and duration of this therapy? How soon after stroke should this therapy be initiated? Are there other therapies that might be equally or more effective?

While these questions are being answered, the evidence seems sufficient to support incorporating CIMT into routine clinical treatment. Establishing insurance coverage for this technique will be an important step in facilitating its adoption clinically.

— Joel Stein, MD

Dr. Stein is Chief Medical Officer, Spaulding Rehabilitation Hospital, Boston.

Published in Journal Watch Neurology March 6, 2007

Citation(s):

Wolf SL et al. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: The EXCITE randomized clinical trial. JAMA 2006 Nov 1; 296:2095-104.

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