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April 2012
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483
onstraint-induced
therapy
(CIT)13 and its modified4 and
distributed5,6
derivatives
reduce movement deficits, improve
movement
performance,
and
improve real-world functional use of
the hemiparetic upper extremity
(UE) by providing repetitive practice
of the affected arm and restraint of
the unaffected arm. Although CIT
and its derivatives improve motor
function, as measured with clinical
tools, kinematic analyses performed
in a previous study suggested that
CIT may increase patients reliance
on compensatory movement of the
trunk,7 which is considered to be
maladaptive and an impairment to
potential recovery.8,9 Furthermore,
CIT and its derivative protocols do
not specifically aim to reduce trunk
compensation.10 Therefore, CIT
should be further developed as an
intervention7 through decreasing
patients reliance on compensatory
movement strategies and restoring
normal motor function and daily
function. More evidence is needed to
understand whether CIT-induced
improvements are related to more
efficient, compensatory movement
strategies, such as trunk-shoulder
movements, or reflect the reappearance of premorbid movement
patterns.11
Physical Therapy
cated that the CIT sessions were distributed over a longer period and
that the duration of each session was
shorter than in the original protocol.
We hypothesized that people who
received dCIT-TR and therefore
were expected to have better movement control in the affected UE and
trunk, as previous studies showed,
would exhibit greater functional status and better QOL than those who
received dCIT and standard therapy.
Method
Design Overview
This study was a single-blind, randomized, control group investigation.
All
participants
signed
informed consent forms that
included the study purposes and
were approved by the institutional
review boards of the participating
sites.
Setting and Participants
We recruited, from the rehabilitation
departments of 4 hospitals, 57 people who had had a stroke 6 to 55
months earlier. Inclusion criteria
were as follows: more than 6 months
after the onset of an ischemic or
hemorrhagic cerebrovascular event,
residual motor ability of the affected
UE (score on the arm motor subscale
of the Fugl-Meyer Assessment of
15)21; considerable nonuse of the
affected UE (score for amount of
use [AOU] on the Motor Activity Log
[MAL] of 2.5)22; no serious cognitive deficits (Mini-Mental State
Examination score of 24)23; no
excessive spasticity in the affected
arm, including shoulder, elbow,
wrist, and fingers (Modified Ashworth Scale score of 2 in any
joint), that might preclude the ability
to perform the functional movements24; no balance problems sufficient to compromise safety when
wearing the experimental constraint
device; and no participation in any
experimental rehabilitation or drug
studies. Table 1 summarizes the
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Table 1.
Demographic and Clinical Characteristics of Study Participantsa
dCIT-TR
Group
(n20)
Variable
Women
April 2012
16
14
14
12
13
Statistic
Pb
0.23
.89
4.36
.11
12
Age, y, X (SD)
Left
54.0 (9.7)
56.3 (12.2)
58.6 (11.6)
0.79
.46
15.7 (13.5)
13.7 (7.3)
17.7 (13.4)
0.55
.58
43.0 (9.6)
39.1 (11.3)
36.7 (13.2)
1.48
.24
27.2 (2.0)
27.1 (3.5)
26.1 (3.5)
0.71
.50
Randomized (n=57)
dCIT-TR (n=20)
Randomization and
Interventions
All participants were unaware of the
study hypotheses and were randomized to the dCIT-TR, dCIT, or control
group by a prestratification strategy
Control
Group
(n18)
Sex
Men
dCIT
Group
(n19)
Analyzed
dCIT (n=19)
Control (n=18)
Analyzed
Analyzed
Figure 1.
Flow diagram showing the randomization procedure. dCIT-TRdistributed constraintinduced therapy with trunk restraint.
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Physical Therapy f
485
Figure 2.
Trunk-restraint harness used for participants who received distributed constraintinduced therapy with trunk restraint.
Physical Therapy
Outcome Measures
Primary outcome measures: functional performance and QOL.
We used the Action Research Arm
Test (ARAT), MAL, Frenchay Activities Index (FAI), and Stroke Impact
Scale (SIS) to evaluate motor function, daily function, and QOL. These
4 scales have good reliability and
validity.2733
Motor function was evaluated by the
ARAT,30 which assesses UE motor
functional limitations with 19 items
in 4 ordinal subscales: grasp, grip,
pinch, and gross movement. Each
item is rated from 0 to 3; the maximum score of 57 indicates normal
functional performance.
Daily function was tested with the
MAL,22 which provides a functional
measurement of a persons perception of real-world use of the affected
UE in 30 important daily activities.
This instrument assesses the AOU
and the quality of movement (QOM)
of the affected arm on a 5-point
response scale.
The FAI,29,34 a self-report scale, measures a persons perception of instrumental ADL participation at 3 or 6
months. It contains 15 items that can
be separated into 3 factors: domestic
chores, leisure/work, and outdoor
activities. Each item is rated from 0
to 3; higher scores indicate better
performance.
We used the SIS,28 a self-report scale,
to assess QOL. This instrument evaluates the difficulty experienced by a
person in performing activities during the preceding week. A 5-point
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April 2012
Results
All characteristics were comparable
among the groups at baseline. The
mean durations of daily restraint
were 5.51 and 5.13 hours for the
dCIT-TR and dCIT groups, respectively; these values indicate similar
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487
After Intervention
ANCOVA
Pair-wise Comparison P
dCIT-TR dCIT-TR
vs
vs
dCIT vs
dCIT
Control Control
dCIT-TR
Group
(n20)
dCIT
Group
(n19)
Control
Group
(n18)
dCIT-TR
Group
(n20)
dCIT
Group
(n19)
Control
Group
(n18)
12.8 (5.2)
11.1 (6.3)
10.0 (6.7)
13.8 (4.6)
13.5 (4.6)
11.2 (7.1)
.23
.71
.13
7.4 (4.1)
7.7 (4.2)
6.1 (4.7)
9.2 (3.0)
8.3 (4.2)
6.7 (4.7)
.02
.01
.75
Pinch
9.2 (7.0)
10.1 (6.2)
8.2 (7.3)
12.9 (5.8)
13.2 (5.0)
9.9 (6.9)
.78
.04
.08
Gross movement
6.5 (2.8)
7.0 (1.9)
5.9 (2.4)
7.5 (1.9)
7.7 (1.6)
6.1 (2.6)
.88
.03
.05
35.9 (16.7) 35.8 (16.5) 30.1 (19.8) 43.4 (13.9) 42.8 (12.8) 33.9 (20.3) 3.40 .04 .11
.75
.02
.04
Variable
Motor function
ARAT
Grasp
Grip
Total
Daily function
MAL
AOU
0.8 (0.7)
0.6 (0.6)
0.7 (0.6)
1.5 (0.8)
1.5 (0.8)
1.1 (0.8)
.78
.13
.01
QOM
0.9 (0.8)
0.7 (0.7)
0.7 (0.6)
1.8 (1.0)
1.7 (0.9)
1.1 (0.9)
.60
.03
.01
Domestic chores
6.1 (7.0)
11.3 (10.7)
6.7 (8.8)
5.2 (3.6)
9.3 (10.2)
3.8 (4.5)
.42
.28
.07
Leisure/work
4.6 (3.6)
5.1 (3.7)
3.3 (2.6)
5.1 (3.4)
5.6 (3.3)
3.4 (2.9)
.88
.24
.20
FAI
Outdoor activities
7.0 (2.5)
7.2 (3.9)
5.9 (3.6)
8.0 (2.8)
7.6 (3.4)
5.5 (3.9)
.33
.01
.09
15.8 (7.2)
18.6 (9.7)
12.8 (9.3)
18.3 (6.0)
20.2 (9.6)
12.7 (9.0)
.63
.01
.04
Strength
2.7 (0.4)
2.3 (0.6)
2.2 (0.6)
2.7 (0.5)
2.8 (0.7)
2.4 (0.5)
.01
.78
.02
ADL
3.9 (0.7)
3.9 (0.5)
3.3 (0.7)
4.1 (0.6)
3.9 (0.7)
3.5 (0.9)
.30
.76
.52
Mobility
4.5 (0.4)
4.5 (0.6)
3.9 (1.0)
4.5 (0.6)
4.6 (0.5)
4.2 (1.0)
.60
.82
.80
Hand function
2.4 (0.9)
2.0 (0.8)
2.1 (0.8)
2.9 (1.0)
2.6 (0.8)
2.2 (0.9)
.92
.01
.01
Total
Quality of life
SIS PF
Values are reported as means (standard deviations). P values of .05 were statistically significant. ANCOVAanalysis of covariance; dCIT-TRdistributed
constraint-induced therapy with trunk restraint; dCITdistributed constraint-induced therapy; 2SSbetween/SStotal, where SS is sum of squares;
ARATAction Research Arm Test; MALMotor Activity Log; AOUamount of use; QOMquality of movement; FAIFrenchay Activities Index; SISStroke
Impact Scale; PFphysical function; ADLactivities of daily living.
a
488
Physical Therapy
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April 2012
Variable
dCIT-TR
Group
(n20)
dCIT
Group
(n19)
After Intervention
Control
Group
(n18)
dCIT-TR
Group
(n20)
dCIT
Group
(n19)
ANCOVA
Control
Group
(n18)
Pair-wise Comparison P
dCIT-TR
vs
dCIT
dCIT-TR
vs
Control
dCIT
vs
Control
Trunk slope
Start
0.7 (3.3)
1.1 (4.4)
2.5 (6.2)
5.5 (8.9)
1.2 (5.3)
0.2 (4.6)
3.41
.04
.11
.07
.02
.48
Middle
1.6 (2.4)
1.9 (3.1)
End
0.5 (1.4)
0.3 (1.9)
2.9 (3.5)
2.4 (4.5)
2.0 (3.6)
2.2 (1.9)
1.06
.35
.04
.43
.15
.50
1.2 (2.5)
0.1 (1.8)
0.2 (2.8)
0.7 (1.9)
0.39
.68
.02
.46
.45
.97
Normalized
shoulder
flexion
0.14 (0.07)
0.14 (0.05)
0.17 (0.07)
0.19 (0.07)
0.14 (0.06)
0.17 (0.07)
3.24
.05
.11
.02
.14
.36
Normalized
elbow
flexion
0.07 (0.05)
0.07 (0.05)
0.14 (0.17)
0.10 (0.07)
0.08 (0.06)
0.10 (0.05)
0.54
.59
.02
.31
.56
.70
a
Values are reported as means (standard deviations). P values of .05 were statistically significant. ANCOVAanalysis of covariance; dCIT-TRdistributed
constraint-induced therapy with trunk restraint; dCITdistributed constraint-induced therapy; 2SSbetween/SStotal, where SS is sum of squares.
April 2012
Discussion
This is the first study to investigate
the possible benefits of dCIT-TR for
functional performance and QOL.
Participants in both the dCIT-TR
group and the dCIT group exhibited
better overall motor function, movement quality, overall instrumental
ADL performance, and hand function than those in the control group.
In addition, participants in the
dCIT-TR group showed greater
improvements on the ARAT grip subscale and FAI outdoor activities scale
than participants in the other
groups; this finding partially supported our hypotheses. An unexpected finding was that participants
in the dCIT group but not those in
the dCIT-TR group perceived less difficulty with the strength domain of
the SIS after training than those in
the control group. Less trunk compensation during the start phase of
reaching and more shoulder joint
recruitment were found in the
dCIT-TR group; this finding was generally consistent with previous study
findings.10
Compared with control therapy,
dCIT-TR and dCIT equally benefited
overall motor function, as measured
with the ARAT. Participants in both
groups received intensive practice of
the affected UE, which might have
produced extensive use-dependent
cortical reorganization that facilitated improvements in motor function.1 Furthermore, the use of functional tasks with the appropriate
levels of challenge might have provided participants in both groups
with opportunities to solve the
movement problem through task
practice, which reinforced the integration of motor skills and facilitated
the restoration of motor function.40
Participants in the dCIT-TR group
specifically obtained greater gains in
grip function, as measured with 1
subscale of the ARAT, than those in
the dCIT and control groups.
Because dCIT-TR involved blocking
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490
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Conclusion
The present study is the first to demonstrate the possible benefits of
dCIT-TR for functional performance
and QOL, especially grip function
and outdoor activities. The findings
indicated that this combined therapy
could translate gains in motor control into functional performance by
quantitative and qualitative measures. The use of dCIT-TR and dCIT
also led to benefits in general hand
function in people with stroke, as
assessed with overall ARAT scores,
AOU determined with the MAL, and
hand function determined with the
SIS. However, a long-term study to
April 2012
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