A04_Christine Meier Khan

Impact of 3 different treatment approaches
on arm and hand function in stroke patients
- a randomized controlled trial
Christine Meier Khan*, Peter Oesch*, Urs Gamper*,
Jan Kool°, Serafin Beer*
*Klinik Valens; °Fachhochschule Winterthur

Background
Conventional neurological therapy (CNT)
• Bobath/PNF, functional task-oriented training
• widely used � (Kollen & Lennon 2009)
Constraint induced movement therapy (CIT)
• evaluated in different studies
(Taub 1993, Miltner 1999, Page 2005, Wolf 2006)
• high time demands
mitt on the less-affected UE 14 h/d
repetitive task-oriented training 6h/d
� low compliance (Page 2002)
Therapeutic climbing (TC)
• bilateral arm training (Luft 2004, McCombe 2008)
• promising results: case study
• no controlled data available

Objectives & Methods
• Objective: To compare the impact of
� CNT
� CIT
� TC
on arm and hand function in stroke patients.
• Design: RCT with 6 months follow-up
• Setting: Inpatient rehabilitation
• Participants: Stroke patients with
- at least minimal upper extremity function
- no shoulder-pain
- at least able to walk 20m
• Blinded assessor at baseline, discharge, follow-up

Interventions
CNT
Conventional physical and occupational therapy, group
therapies
�Intensity: 3-4h/d
CIT
Constraint training in physical and occupational therapy
and group therapies
�Intensity: 3-4h/d, additionally 1h/d constraint self- training
TC
Therapeutic climbing and occupational therapy, group
therapies
�Intensity: 3-4h/d

Outcome measures
Primary outcomes: UE-function and ADL-related use
• Wolf Motor Function Test (WMFT):
15 movements/ADL-tasks graded for time + quality-scale 0-5
2 strength-items
• Motor Activity Log (MAL): semistructured interview for
- amount of use of UE: 0-5
- satisfaction about use of UE: 0-5
Secondary outcomes:
• Shoulder-pain: subscale of Chedoke McMaster Stroke Assessm.
• ROM: active shoulder flexion
• Isometric strength: shoulder flex/ext, elbow flex/ext

Study flowchart
Not fulfilling inclusion
criteria n = 237
No informed consent
n = 2
CNT
n = 15
Drop out
n = 1
Discharge
n= 14
6 months follow-up
n = 14
All hemiplegic stroke patients
n = 283
Considered
for randomization n = 46
Randomized n = 44
CIT
n = 14
Drop out
n = 1
Discharge
n = 13
6 months follow-up
n = 13
TC
n = 15
Discharge
n = 15
Drop out
n = 3
6 months follow-up
n = 12

Results
No significant differences between groups at baseline
Significant improvement in all groups from baseline (BL) to discharge (DC)
WMFTtime 58.7 ±
38.6
CNT n = 14 CIT n = 13 TC n = 15
at BL at DC at BL at DC at BL at DC
at 6 ms FU at 6 ms FU at 6 ms FU
30.2 ± 37.0
29.1 ± 36.3*
MAL as 0.6 ± 0.7 2.2 ± 1.4
2.5 ± 1.4
CMSA
shoulder pain
6.2 ± 0.8 6.4 ± 0.8
6.1 ± 1.3
64.5 ± 38.4 33.0 ± 34.7#
27.9 ± 29.1#
1.0 ± 1.2 2.7 ± 1.6
2.5 ± 1.9
6.0 ± 0.8 6.4 ± 0.1 #
6.9 ±0.4#∆∆∆∆
51.2 ± 45.7 39.2 ±47.9
37.5 ±51.4
0.9 ± 1.1 2.0 ± 1.7
2.5 ± 1.9
6.3 ± 0.7 6.1 ± 0.9
5.6 ± 1.2
* Significant difference of CNT compared with TC p

Conclusions
• CIT and CNT equivalent in restoring UE-function after stroke,
consistent with the results of 2 reviews (Langhorne 2009, French, 2008)
� 50% reduction of WMTFtime from BL to DC clinically relevant
• TC with lower grade of improvement
� constraint and task-oriented approach better
• CIT with lower risk of shoulder pain
� CIT preventing misuse? improved stabilization of shoulder?
• No significant differences in strength and ROM
� not determining for functional improvement
• Limitations: highly selected patient group
� no general conclusions for other stroke subgroups
� small patient groups

This study showed, that the goal is reached best with
constraint and task-oriented training.
Group therapy and self-training are feasible means to
provide high intensity with the available resources.
Engraziel,
Grazie,
Merci, Danke