Accelerating Stroke Recovery: Body Structures and Functions, Activities, Participation, and Quality of Life Outcomes From a Large Rehabilitation Trial

Abstract

Background: Task-oriented therapies have been developed to address significant upper extremity disability that persists after stroke. Yet, the extent of and approach to rehabilitation and recovery remains unsatisfactory to many.

Objective: To compare a skill-directed investigational intervention with usual care treatment for body functions and structures, activities, participation, and quality of life outcomes.

Methods: On average, 46 days poststroke, 361 patients were randomized to 1 of 3 outpatient therapy groups: a patient-centered Accelerated Skill Acquisition Program (ASAP), dose-equivalent usual occupational therapy (DEUCC), or usual therapy (UCC). Outcomes were taken at baseline, posttreatment, 6 months, and 1 year after randomization. Longitudinal mixed effect models compared group differences in poststroke improvement during treatment and follow-up phases.

Results: Across all groups, most improvement occurred during the treatment phase, followed by change more slowly during follow-up. Compared with DEUCC and UCC, ASAP group gains were greater during treatment for Stroke Impact Scale Hand, Strength, Mobility, Physical Function, and Participation scores, self-efficacy, perceived health, reintegration, patient-centeredness, and quality of life outcomes. ASAP participants reported higher Motor Activity Log-28 Quality of Movement than UCC posttreatment and perceived greater study-related improvements in quality of life. By end of study, all groups reached similar levels with only limited group differences.

Conclusions: Customized task-oriented training can be implemented to accelerate gains across a full spectrum of patient-reported outcomes. While group differences for most outcomes disappeared at 1 year, ASAP participants achieved these outcomes on average 8 months earlier (ClinicalTrials.gov: Interdisciplinary Comprehensive Arm Rehabilitation Evaluation [ICARE] Stroke Initiative, at www.ClinicalTrials.gov/ClinicalTrials.gov . Identifier: NCT00871715).

Keywords: International Classification of Disability and Functioning (ICF); patient-centered; quality of life; rehabilitation; task-oriented.

Figure 1. Body Structure and Function

Illustrates changes in Body Structure and Function over time. On the horizontal axis, the left side in each figure (Treatment) indicates changes (improvements) from baseline assessment to the end-of-treatment time point while the right side (Follow-up) reflects end-of-treatment to end-of-study change. The slopes of the lines correspond to the statistics provided in the “Improvement Trajectories” rows of Table 2. Longitudinal plots across the two phases of recovery for (A) the Fugl-Meyer Assessment of Upper Extremity motor ability, FMA-UE, (B) Stroke Impact Scale (SIS) Strength subscale, (C) Confidence in Arm and Hand Movement, CAHM, and (D) the Euroqol-5D Visual Analog Scale, EQ-5D-VAS. Solid blue line (Accelerated Skill Acquisition Program, A), dashed orange line (Dose-equivalent Usual and Customary Care, D), dotted green line (monitoring-only Usual and Customary Care, U). Means and standard error of the means are represented. Group differences at time points are denoted above the data lines; group × time trajectory differences are found below the data lines. * P < .05, ** P < .01, *** P < .001.

Figure 2. Activity

Illustrates changes in Activities over time. On the horizontal axis, the left side in each figure (Treatment) indicates changes (improvements) from baseline assessment to the end-of-treatment time point while the right side (Follow-up) reflects end-of-treatment to end-of-study change. The slopes of the lines correspond to the statistics provided in the “Improvement Trajectories” rows of Table 2. Longitudinal plots across the two phases of (A) SIS Hand function, (B) SIS Mobility, (C) SIS-16, and (D) Motor Activity Log-28 Quality of Movement, MAL-28 QOM. Solid blue line (Accelerated Skill Acquisition Program, ASAP), dashed orange line (Dose-equivalent Usual and Customary Care, DEUCC), dotted green line (monitoring-only Usual and Customary Care, UCC). Means and standard error of the means are represented. Group differences at time points are denoted above the data lines; group × time trajectory differences are found below the data lines. * P < .05, ** P < .01.

Figure 3. Participation and Quality of Life

Illustrates changes in Participation and Quality of Life over time. On the horizontal axis, the left side in each figure (Treatment) indicates changes (improvements) from baseline assessment to the end-of-treatment time point while the right side (Follow-up) reflects end-of-treatment to end-of-study change. The slopes of the lines correspond to the statistics provided in the “Improvement Trajectories” rows of Table 2. Longitudinal plots across the two phases of (A) Reintegration to Normal Living Index, RNLI, (B) Quality of life improvements attributed to ICARE study participation, ICARE QOL, (C) Ability to return to work or hobbies, (D) Satisfaction with Life Scale. Solid blue line (Accelerated Skill Acquisition Program, ASAP), dashed orange line (Dose-equivalent Usual and Customary Care, DEUCC), dotted green line (monitoring-only Usual and Customary Care, UCC). Means and standard error of the means are represented. Group differences at time points are denoted above the data lines; group × time trajectory differences are found below the data lines. * P < .05, ** P < .01, *** P < .001.