Squeezing the arms as a treatment for acute ischemic stroke

Abstract

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In August, JAMA published (Chen et al., 2022) an open label randomized trial from China testing remote ischemic limb conditioning (RIC) in 1,893 patients with acute ischemic stroke. Supported by preclinical literature, the investigators aimed to test a new approach that they advocate is a neuroprotective strategy—inflate a cuff to both arms to cause limb ischemia. Preclinical studies have shown that remote limb ischemia reduces infarct size in rodent stroke models, and there have been smaller studies suggesting feasibility and safety of RIC in stroke patients. The study was conducted and published in a time frame when RIC is becoming very popular in the cardiac and rehabilitation literature.

Patients were randomized to usual care or usual care with the intervention. The intervention was 5 successive cycles of inflating a cuff placed around both arms to 200 mg Hg for 5 min followed by 5 min of deflation. The 5 cycles of compression were completed twice a day, started on average at 24 h after stroke, and were intended to continue for 14 days. Compared to the control group, there was a significantly higher percentage (5% difference) in the intervention group achieving an excellent outcome on the mRS disability score of 0–1.

Is RIC a new emerging treatment? In our opinion, the answer is no based solely on this publication. Here's a breakdown of our findings.

In summary, we think the trial is thought provoking. Is RIC worth further study to promote recovery after stroke? Inflating a cuff to the arms is easy, should not be costly, and likely poses some discomfort that many will consider worth tolerating to achieve better recovery after stroke. We hope to see a replication trial that takes into account the above issues in a diverse patient population and analyzes all data from randomized patients. We would recommend a multi-arm trial that includes a better control and can test different types/duration of the RIC. Adding an arm that only undergoes treatment for a set number of days, that reflects the shorter length of stay of other countries, should be considered. Lastly, we recommend a secondary outcome assessment using a standardized quality of life measurement (e.g., EQ-5D-5L) which can provide additional evidence of a treatment effect.

Author contributions

Both authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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