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The Bottom Line

	What problems did the researchers set out to study and why?

 
Evidence supports the benefit of intense exercise programs that include functional tasks for people with stroke, but there is concern about adverse symptoms such as pain and fatigue. Constraint-induced movement therapy (CI therapy) is an example of intensive task practice that involves multiple repetitions to achieve a challenging motoric goal. With CI therapy, the patient undertakes task practice with the more involved upper extremity 6 hours per day, 5 days per week, for a minimum of 2 or 3 weeks after stroke, while the less affected upper extremity is restrained for 90% of the patient's waking hours. These researchers sought to determine if there was a relationship among pain, fatigue, intensity of function and motor function in people receiving CI therapy in the subacute and chronic recovery periods.

	What types of patients participated in the study?

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A subset of subjects (22 men who were an average of 64 years old and 10 women who were an average of 57 years old) who participated in a larger randomized clinical trial.¹ Participants had had a stroke but were required to have minimal elbow, hand, and wrist active range of motion in extension. Sixteen participants had right-side hemiparesis and 16 had left-side hemiparesis; the majority were right-hand dominant. Eighteen participants received 2 weeks subacute CI therapy 3 to 9 months after stroke onset, and 14 received chronic CI therapy at least 1 year after stroke onset.

	What new information does this study offer?

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Motor function improved in both groups. Both groups exercised an average of 4.5 hours per day for 10 days during a 2-week period, indicating that both the subacute group and the chronic therapy group were able to tolerate the same level of therapy. There was no significant increase in pain throughout the upper extremity before and immediately after CI therapy in either group. Reported pain during therapy was not associated with intensity of CI practice for either group. Average daily morning and afternoon reported pain scores were below 3 on a scale of 1 to 10 throughout the daily CI therapy for both groups. Reported joint pain did not increase after CI therapy, but the chronic therapy group reported that pain increased slightly as motor function improved. Average daily morning and afternoon fatigue scores remained below 4.5 on a scale of 1 to 10 throughout the daily CI therapy for both groups. There was not a significant relationship between fatigue and motor function after CI therapy in either the subacute therapy group or the chronic therapy group. Additional analysis suggested that upper-extremity functional gains were associated with more fatigue in the chronic therapy group but not in the subacute therapy group. Reported fatigue was higher at the end of the daily session than at the end of the morning therapy session in both groups. There was no relationship between the average daily pain and fatigue scores during therapy in the subacute therapy group, but in the chronic therapy group, there was a trend for more pain during therapy being associated with more fatigue.

	How did the researchers go about the study?

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Measurements related to pain, fatigue, and intensity of practice were collected during the 2-week CI therapy period. Before CI therapy and after the completion of the 2 weeks of therapy, joint pain and upper-extremity function were assessed by evaluators who were unaware of when the participants received the intervention. The relationships among pain, fatigue, and function were examined for participants receiving CI therapy within and between both the subacute CI therapy group and the chronic CI therapy group. Upper-extremity function was measured with the Wolf Motor Function Test, an impairment-based assessment used to measure the functional level of the upper extremity. The test consists of 15 timed performance items (maximum time=120 seconds) and 2 strength items. Upper-extremity joint pain was measured with the joint pain subscale of the Fugl-Meyer Assessment for the upper extremity. Pain during passive range of motion of the more affected side for the shoulder, elbow, wrist, fingers, and forearm was rated by the evaluator. The total pain score ranged from 0 to 24, with 0 indicating marked pain and 24 indicating no pain experienced in the upper extremity with passive range of motion. Pain during CI therapy was measured by use of a single-item rating scale, with a rating of 1 indicating no pain and a rating of 10 indicating unbearable pain. Fatigue during CI therapy was measured using a single-item scale with a rating of 1 to 10, with 1 indicating no fatigue and 10 indicating absolute exhaustion. For each scale, participants were asked to "indicate on this scale the amount of pain/fatigue you experienced today during treatment." Scales were completed by participants at the end of the morning activities and again at the end of the afternoon activities during each day of CI therapy.

	How might the results of this study apply to patients who are treated by physical therapists from this point forward?

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The participants in this study reported relatively low levels of pain prior to the CI therapy, and pain did not increase significantly despite the intensity of the 2-week intervention. The careful screening of subjects who participated in this study to exclude patients with reported pain that interfered with activities of daily living and who were minimally or moderately involved suggest that clinicians might want to use similar criteria prior to implementing intensive programs of exercise for people after stroke. Although people who had a stroke within 1 year or more demonstrated the same functional gains as those who had a stroke within less than 9 months, the amount of improvement reported was related to increased reports of pain and fatigue. This finding stresses the importance of monitoring pain and fatigue each day during the intervention. Because fatigue did not interfere with completion of this intensive CI therapy in people with subacute stroke or chronic stroke, clinicians should not be reluctant to use this intervention for a select group of patients with stroke.

	What are the limitations of the study, and what further research is needed?

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The findings of this study were based on a small sample of participants who were carefully selected based on a number of criteria. In order to generalize the findings, studies should be conducted to examine the effect of this intervention on people whose strokes had occurred more than 3 months previously and to examine the effect of CI therapy on people who have more involved upper extremities during acute, subacute, and chronic stages. People who have had CI therapy should be examined at intervals after intervention has stopped to examine retention of motor recovery and its relationship to pain and fatigue. Optimal timing and dose for CI therapy is yet to be established.

	References

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1. Winstein C, Miller J, Blanton S, et al. Methods for a multisite randomized trial to investigate the effect of constraint-induced therapy in improving upper extremity function among adults recovering from cerebrovascular accident. Neurorehabil Neural Repair. 2003;17:137–152.[Abstract/Free Full Text]

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This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when Rapid Responses are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Search for Related Content Related Collections Adaptive/Assistive Devices Therapeutic Exercise Stroke (Neurology) Stroke (Geriatrics) Related Article Social Bookmarking                      What's this?