Intensive Motor Arm Therapy Improves mRS Scores in Poststroke Patients

Steven C. Cramer, MD

Data from a recent study published in Neurology suggest that intensive arm motor therapy can improve modified Rankin scale (mRS) scores in poststroke patients, although specific motor impairments may be better rehabilitation therapy targets than others.

The researchers found that the median mRS score decreased from 3 (interquartile range [IQR], 2-3) to 2 (IQR, 2-3) 30 days post-therapy (P <.0001). The proportion of patients with mRS scores less than or equal to 2 increased from 46.8% at baseline to 66.2% 30 days post-therapy (P = .015). Altogether, mRS score decreased in 24 (31.2%) patients. Patients with a treatment-related mRS score improvement, compared to those without, had similar overall motor gains in Fugl-Meyer motor scale (FM) score (P = .63).

First author Steven C. Cramer, MD, department of neurology, Ronald Reagan UCLA Medical Center, and colleagues wrote that “[we] examined results from a trial of intensive rehabilitation therapy targeting the arm that reported body structure/function gains (FM score), here hypothesizing that intensive rehabilitation therapy also improves activities limitations (mRS scores). To further probe this issue, mRS gains were explored in relation to improvements in body structure/function, both at the summary level (change in total FM score) and at the level of specific motor impairments.”

Cramer and colleagues analyzed data from 77 patients at 160 days (standard deviation [SD], 48) post-stroke at baseline. The patients were an average age of 62.0 years (SD, 13.1) and 23 (29.9%) were women. The majority of patients were White (n = 50; 64.9%), followed by Black patients (n = 18; 23.4%) and Asian patients (n = 8; 10.4%). 

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Ischemic stroke was experienced by 66 (85.7%) patients while intracerebral hemorrhage was experienced by 11 (14.3%). Baseline FM score was 40.6 points (SD, 8.3) and increased by 7.5 points (SD, 5.8) at 30 days post-therapy (P <.0001).

Median mRS score decreased from baseline (3 [IQR, 2-3]) to 30 days post-therapy (2 [IQR, 2-3; range, 1-4]; P <.0001). mRS changes were driven by 5 patients that experienced a 2-point drop and 19 with a 1-point drop. On the other side of the spectrum, 50 patients (64.9%) experienced no change and 3 (3.9%) experienced a 1-point increase. 

Cramer and colleagues also found that similar proportions (P = .07) of patients in the telerehabilitation group (17 of 43; 39.5%) and the in-clinic therapy group (7 of 34; 20.6%) had mRS score decreases. MRS score decreases were also similar (P = .73) between patients with ischemic stroke (n = 20; 30.3%) and intracerebral hemorrhage (n = 4; 36.4%). 

The researchers found that patients who had an mRS score (n = 24; mRS, 3 [IQR, 3-3.75]) decrease had higher baseline mRS scores than those who did not (n = 53; mRS, 2 [IQR, 2-3]; P = .0002). The likelihood of mRS score decrease was unrelated to the number of days post-stroke at study entry (odds ratio [OR], 1.49; [95% CI, 0.3-7.3]; P = .62). 

The 2 groups did not differ in the number of study-provided treatment sessions (P = .70) or number of hours at any rehabilitation therapy outside of study procedures (P = .92). The 2 groups also did not differ in the change in the total FM motor score over the same period (P = .63). Change in total FM score was not related to change in mRS score (P = .25) or to the likelihood of a mRS score decrease (P = .70).

Cramer and colleagues found differences in specific motor impairments that improved in patients with mRS improvements vs without. They examined the 4 specific motor impairments with the highest OR of mRS improvement logistic regression analysis and found that together they did predict likelihood of improvement (P = .034). These motor impairments were (1) flexing all fingers at the metacarpophalangeal and interphalangeal joints, (2) full shoulder girdle elevation, (3) no reflex hyperactivity in the arm, and (4) circumduction of the wrist through full range of motion in a smooth manner.

“These findings emphasize the importance of understanding the relationship between changes in activities limitations and loss of body structure/function after stroke. This would be aided by including both types of measures in acute stroke trials and in stroke recovery trials, as has been recommended44. Such knowledge would foster a more cohesive system for understanding the benefit of stroke therapeutics, from acute to recovery targets,” Cramer and colleagues concluded.

REFERENCE

Cramer SC, Le V, Saver JL, et al. Intense arm rehabilitation therapy improves the modified Rankin scale score: Association between gains in impairment and function. Neurology. Published online February 15, 2021. doi: 10.1212/WNL.0000000000011667