February 2, 2017

Research on Therapy Can Be Misleading

Researchers found stroke survivors regained hand function after Wii therapy (1).  They targeted clients who already had some finger movement before treatment began.  I know this for two reasons.  First, subjects must have small finger movements to be eligible for the modified constraint therapy given to the control group.  Second, the outcome measure was the Wolf Motor Function Test which is loaded with high level test items (e.g. turn key in lock, pick up a paper clip).  Only stroke survivors with significant hand recovery can perform test items on the Wolf Test.

An efficacy study of the Smart Glove also used subjects who were high functioning enough to pass items on the Purdue Pegboard Test, the Jebsen-Taylor Test (e.g. write, scoop up beans with a spoon), and the Fugle-Meyer Test, distal items (e.g. pick up Coke can and piece of paper) (2). 

Treatment may be appropriate only for a particular sub-set of clients so you should always read the description of the sample and outcome measures used in the study.  Researchers of therapy approaches may have used a sample of high functioning subjects for their proof of concept study.  This makes the treatment look good, but can create false hope.

1) Trinh T, Scheuer S, Thompson-Butel A, Shiner C, McNulty P. Cardiovascular fitness is     
    improved post-stroke with upper-limb Wii-based movement therapy but not dose-matched  
    constraint therapy. Top Stroke Rehabil. 2016; June 23(3):206-16.
2) Shin J, Kim M, Lee J, et al. Effects of virtual reality-based rehabilitation on distal upper    
    extremity function and health-related quality of life: a single-blinded, randomized controlled     
    trial. jrneuroengrehab.biomedcentral.com/articles/10.1186/s12984-016-0125-x. Accessed   
    January 31, 2017.

1 comment:

  1. Rebecca,
    I completely agree with your comments, but proving anything works for stroke rehab is extremely difficult. There are just too many variables and testing methods, but no standardized testing methods, and test methods often subjective.

    So far, I have made use of Botox 10 times, months of daily e-stim just to get initial movement of many muscles, over 135 PT /OT sessions, various hand & arm splints, 4 AFO's, myopro arm device, baclofen, Prozac, the Milestone clinical trial, etc. Don’t ask me what was best, because I am never doing just one thing, so I never know what is actually helping, or a waste of time & money. Overall, exercise & stretching for hours every day does the most good.

    I am a few months short of my 4th year stroke anniversary and still making slow steady progress. Fortunately, I did not lose memory, cognition, speech, etc., but I did have severe left side hemi-paresis and, after 2 weeks in patient acute rehab, came home in a wheelchair and could not move my left arm. Now I walk with a cane & AFO and arm has getting stronger, but I still do not have functional use of my left hand. I can reach & grab things, but nothing very dexterous. Spasticity & nerve pain are my main problems. I also have a lot of learned non-use. I am encouraged that in the last 6 months I feel to pace of improvement has increased & more & more I am remembering to use my left hand & put weight on left leg.

    I bought your book early 2016 My Last Degree: A Therapist Goes Home After a Stroke - Second Edition and learned a great deal from your book. I have also read 15 books on stroke and checkout Dean's blog daily.

    After all the research I have done, looking for ways to speed my recovery and the things I have tried, I have concluded that only motion with intention restores motion. There is no pill, treatment, or therapy that does much. Simply put, only moving as much as you can, as soon as you can, for as long as you can, results in lasting improvement.

    I am very frustrated there is so such resistance to this kind of "technical rehab" by our providers, insurance companies, & Medicare. They say it is “experimental” and do not want to pay for anything that is not evidence based medicine. Just a tactic to not pay.
    Dean’s blog has info on hundreds of devices, that should not cost that much, and really would help the patient move much more on their own, and only need a therapist to monitor & guide them in their efforts to improve. If a few devices could break out of the crowd and get widespread use, the cost should come down like any other technological device or software.

    I started using the Smart Glove 05/01/16, which was 3 years post-stroke. I like it, because I find the video games, PROM & AROM measurement & tracking much more motivating than stacking cups or pegboard games & such. I pay $99 per month to rent the device, which is really just a motion sensor Bluetooth connected to a tablet that is tracking 6 different hand & forearm movements.

    There are no magic bullets out there, but VR, video games, WII, etc. should simply be available to help the patient move more on their own.