Negative Finding (1) - Sophisticated Physical Therapy for Stroke

There’s a tendency for medical research findings to emphasize the positive – e.g. reports like “breakthrough in treating XYZ syndrome” outnumber “treatment ABC doesn’t work”.  That’s only natural, given the inherent optimism of man (and the pockets of the pharmaceutical industry).  However, it’s important to know about things that really don’t work, to avoid waste of time and hope in re-trying them. 

The first example I bring concerns rehabilitation after stroke.  A large clinical trial of a sophisticated method of locomotor training has been done to assess possible benefits of using body-weight support in treadmill stepping in trying to improve the walking ability after a stroke.  The results are published in the New England Journal of Medicine.

The Duke University investigators enrolled 408 participants who were at least 2 month’s post-stroke; they were classified based on their walking speed into two groups: those with moderately impaired walking, and those with severe impairment.  They were then randomly assigned to one of three treatments:  early locomotor  training (body-weight support during treadmill use) 2 months after their stoke; late locomotor training i.e. 6 months after their stroke; and a home-exercise program managed by a physical therapist, starting 2 months after their stroke.  Each treatment consisted of 36 sessions of 90 minutes each for 12 – 16 weeks.  The main outcome measure was the proportion of patients in each group who were walking better at 1 year after stroke.

At one year, 52% of all participants had increased walking ability.  There were no significant differences in improvement between the various groups (early locomotor vs. late locomotor vs. home-based, and moderate vs. severe impairment at outset).  On the other hand, those getting locomotor training had more adverse events – chiefly dizziness, fainting and falling – than those given home-based therapy.  They were seen in 2.2% with early, 3.5% with late locomotor training, and in 1.6% of those doing home exercises.

As locomotor training is more expensive, requires more staff, more staff training, and patient transport to and from sessions, home exercise is clearly a more pragmatic form of therapy with fewer side effects than the more sophisticated approach.  High-tech therapy is not always better therapy.