Pain, fatigue, and intensity of practice in people with stroke who are receiving constraint-induced movement therapy.

Strong evidence is emerging that patients with stroke benefit from exercise programs in which functional tasks are directly and intensively trained. (1-4) Intensive task practice, that is, multiple repetitions to achieve a challenging motoric goal, is identified as one of the most crucial components for recovery after stroke. (3,5,6) Constraint-induced movement therapy (CI therapy) is an example of an approach that involves repetitive task practice, that was developed directly from basic science research, and that provides an avenue for significant functional improvements in the hemiparetic limb. (7,8) This intervention has been shown to facilitate cortical reorganization possibly by increasing the excitability of neurons innervating functionally relevant muscles and by increasing excitable neuronal tissue in the infarcted hemisphere. (8-11) The fundamental premise underlying the benefit of CI therapy requires that the patient undertake task practice with both behavioral shaping and repetition within the context of an intensive therapy regimen while the less affected upper extremity is restrained for 90% of the patient's waking hours. (7,12) Patients participate in this intensive therapy with the affected limb for 6 hours 5 days per week over a 2- or 3-week period after stroke, (12-15) although distributed practice of CI therapy has been provided over longer time intervals, often up to 10 weeks. (16,17) Deter mining whether the therapy exacerbates adverse symptoms, such as pain and fatigue, is an important consideration with this type of intensive therapy regimen.

In that context, shoulder pain after stroke is a common problem (18) with devastating sequelae. (19) Development of a painful hemiplegic shoulder complicates and prolongs rehabilitation, increases the length of hospitalization, and can result in poor arm function 12 weeks after stroke. (20) In addition, the presence of shoulder pain related to weakness of the upper limb and restriction in active range of motion ultimately may contribute to poor functional recovery of the upper limb during rehabilitation. (20) Despite multiple studies evaluating CI therapy, little has been written about the occurrence of shoulder pain. Ploughman and Corbett (21) documented the incidence of shoulder pain in patients at less than 16 weeks after stroke and undergoing up to 6 hours per day of forced-use therapy (restraint of the stronger upper extremity only, no intensive therapy). The amount of restraint wearing did not correlate with worsening of shoulder pain, and shoulder pain did not correlate with recovery. However, there was a clinical trend toward less recovery in the small female subgroup that experienced more pain. Conversely, in a CI therapy case study involving a patient in the chronic recovery period after stroke, Bonifer and Anderson (22) noted that the patient actually reported a decrease in shoulder pain as the therapy progressed.

Along with pain, fatigue after stroke is a serious and frequent symptom. This fatigue interferes with the rehabilitation process, may decrease the potential for the patient to regain function, and often is mentioned by patients as one of the most difficult symptoms to which to adjust after stroke. (23) Fatigue also was an independent predictor for dying within 3 years after a stroke and, among these patients, a strong correlation between pain and fatigue after 2 years was observed. (23) Fatigue may interfere with rehabilitation and measurement of a patient's ability to use the paretic arm for functional activities but is rarely documented. (23) In one CI therapy case study, investigators noted that the patient was so fatigued after a day of training that "her activities at home were limited to eating dinner, watching television, and going to bed earlier than she normally would." (24)(p851) However, a clear understanding of how fatigue affects rehabilitation activities or how therapy may augment fatigue remains elusive.

Given that CI therapy involves intensive demands of focused use of the upper extremity over an extended time period, determining the effects of pain and fatigue on a patient's ability to participate in such a challenging practice schedule is important. Surprisingly, the effect of this intervention on fatigue or pain has never been evaluated systematically. Consequently, there is a need to explore the relationship between these important post-stroke symptoms and the application of CI therapy. Accordingly, this report represents the first effort to evaluate this relationship as part of the Extremity Constraint-Induced Therapy Evaluation (EXCITE) trial (12) by examining this relationship in participants at one EXCITE site (Emory University). Understanding the relationship among these variables is fundamental for physical therapists in determining whether adherence to and effectiveness of, CI therapy are affected if patients experience pain or fatigue. This study addressed the following key research questions for people receiving CI therapy in the subacute and chronic recovery periods. What are the relationships among pain, fatigue, intensity of practice, and motor function? Do pain and fatigue change over time during CI therapy? Are there differences in pain, fatigue, and motor function on the basis of whether CI therapy takes place in the subacute or in the chronic recovery period?

Method

Participants

Data for this EXCITE trial substudy were obtained from 41 people seen at Emory University. These participants met the eligibility criteria, which included minimal elbow, hand, and wrist active range of motion in extension. These criteria and the data collection procedures for the larger multicenter clinical trial have been described in detail elsewhere. (12) All participants had a stroke 3 to 9 months earlier and were randomly assigned to either a subacute therapy group (CI therapy 3-9 months after stroke) or a chronic therapy group (CI therapy 1 year after enrollment). The information in Figure 1 shows that for 32 participants, complete data were available for analysis; 18 participants were randomly assigned to the subacute therapy group, and 14 participants were randomly assigned to the chronic therapy group. The participants were 22 men (mean age=63.8 years, SD=12.2) and 10 women (mean age=56.8 years, SD=15.4). There were 16 participants with right-side hemiparesis and 16 participants with left-side hemiparesis. The majority were right-hand dominant. Of the 3 participants with left-side dominance, only 1 had left-side hemiparesis.

[FIGURE 1 OMITTED]

Design

The clinical trial involved a randomized 2-group design and included a dynamic, random assignment process to ensure that the groups were balanced with respect to functional capability, sex, hemiplegic side, and hand dominance. The institutional review boards at all sites, including Emory University, approved the protocol for the primary study, and written consent was obtained from all participants.

For the analysis of this subset of participants, measures related to pain, fatigue, and intensity of practice were collected during the 2-week CI therapy intervention 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.

CI Therapy

Participants received CI therapy for 6 hours per day for 10 days over a 2-week period. Two procedures were used during training: shaping (adaptive task practice) and standard repetitive task practice. (12) During adaptive task practice, the primary goal of a chosen functional task was approached through emphasis on distinct parts of the task that may be limited by the participant's impairments (eg, repeating the action of bringing a fork toward the mouth when a participant was limited in elbow flexion as part of the task practice for eating). The task was made progressively difficult through manipulation of temporal or spatial elements to create a demanding and challenging motor learning environment for skill acquisition. Each adaptive task practice activity was carried out in a set of 10 trials, and explicit feedback was provided with regard to the participant's performance in each trial. Standard repetitive task practice was less structured and consisted of functionally based activities performed continuously for 15 to 20 minutes. These activities tended to be more complex and often contained component subtasks that were practiced during adaptive task practice (eg, eating lunch or writing). More global feedback regarding performance was provided at the end of the 15- to 20-minute period. For the larger national clinical trial, a large bank of tasks was created for each type of training procedure. Tasks were chosen on the basis of each participant's preferences, goals, and movement limitations. Frequent rest breaks were provided throughout the 6-hour training day. The amounts of time spent on each task in addition to the rest breaks were recorded to ensure accurate data collection regarding time actually spent by participants performing the CI therapy training.

Measures

Upper-extremity motor function. Upper-extremity function was measured before and after the intervention with the Wolf Motor Function Test (WMFT). The WMFT is an impairment-based assessment used to measure the functional level of the upper extremity. The WMFT consists of 15 timed performance items (maximum time=120 seconds) and 2 strength items. Performance items progress from simple joint movements to complex movements. The average of the timed tasks was used for this study to obtain a total score. In the data analysis, a log transformation of the mean scores was used to adjust for skewness of the data (because of the variance between participants with high performance and those with low performance). The WMFT has been shown to have good clinimetric properties in people with stroke (25,26) and to correlate well with the Fugl-Meyer Assessment (FMA). (25,27)

Upper-extremity joint pain. Upper-extremity joint pain was measured with the joint pain subscale of the FMA for the upper extremity. The FMA is a well-established instrument used to evaluate recovery from hemiplegic stroke, and it yields data with excellent intrarater reliability, (28) interrater reliability, (29,30) and construct validity. (31,32) The pain experienced by a participant during passive range of motion (PROM) of the more affected side for the shoulder (flexion, abduction to 90[degrees], external rotation, and internal rotation), elbow (flexion and extension), wrist (flexion and extension), fingers (flexion and extension), and forearm (pronation and supination) was rated by the evaluator. A total of 12 items were rated on a scale of 0 to 2 on the basis of the participant's response during PROM of a joint as no pain (2), some pain (1), or marked pain (0) through the range of motion. Thus, the total pain score ranged from 0 to 24, with 0 indicating marked pain throughout the arm and 24 indicating no pain experienced with PROM.

Intensity of therapy. For each of the 10 training days, the intensity of therapy was measured in minutes of total time that participants actually spent engaged in the task practice of CI therapy. This time was recorded by the therapist and excluded rest breaks.

Fatigue and pain during training. Fatigue during CI therapy was measured by use of a single-item scale with a rating of 1 to 10, with 1 indicating no fatigue and 10 indicating absolute exhaustion. This single-item scale was selected because of the established validity of a single-item measure and because of its clinical relevance and ease of use. (33) Pain during CI therapy was measured by use of a similar single-item rating scale, with a rating of 1 indicating no pain and a rating of 10 indicating unbearable pain. In contrast to the FMA joint pain measure, in which higher scores indicated less severe pain, in the daily pain measure, higher scores indicated more severe pain. This scale was selected because of its common use in clinical practice, ease of administration, and demonstrated validity and reliability in a sample of subjects with chronic illness. (34) 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.

Data Analysis

Data were analyzed by SPSS software. * Data for 2 participants were not included in the analysis because more than 3 consecutive data points were missing. Single data points missing for daily pain were replaced by averaging the other known morning or afternoon pain data points for that same week. (35) Only 4.5% of the total data points (640) each for pain and fatigue were missing. Descriptive statistics, paired and independent t tests, and repeated-measures analysis of variance (ANOVA) were used to determine the relationships among pain, fatigue, and function for participants receiving CI therapy. Although parametric tests are robust to violations of assumptions for the test, violations of these assumptions are a concern in small sample sizes. One approach is to conduct both parametric and nonparametric tests and compare results, and that was done. The results of parametric and nonparametric tests were similar; therefore, parametric test results are reported. When there was a difference in significance with these approaches, that difference is noted. For all statistical analyses, the significance was set at P<.05. The Pearson correlation was used to examine relationships among pain, fatigue, and upper-extremity function. For both groups, the participants' average (over 10 days) morning and afternoon fatigue (r=.81, P<.01) and morning and afternoon pain (r = .72, P<.01) scores were significantly related. Thus, overall total fatigue and pain scores for each day were used in some analyses.

Results

WMFT

Motor function improved in both groups, as indicated by significant changes in scores before CI therapy and after CI therapy (Tab. 1). However, there were no significant differences between groups in upper-extremity function and joint pain before CI therapy or after CI therapy, except that the chronic therapy group reported less joint pain before receiving CI therapy (Tab. 2).

Overall, there were low, nonsignificant correlations (Tab. 3) between joint pain (as measured by the FMA) and the WMFT (log mean) before CI therapy or at the completion of CI therapy and daily pain reports during therapy for both groups. A separate analysis that examined change scores for the WMFT and average daily pain reports did not reveal a relationship in the subacute therapy group (r =-.04, P=.87), but there was a relationship between change scores for motor function and daily pain reports in the chronic therapy group (r=-.53, P=.05) (nonparametric tests: [r.sub.s]=-.26, P>.05). Among participants in the chronic therapy group, as motor function improved (less time), pain increased slightly.

There were low, nonsignificant correlations (Tab. 3) between fatigue and the WMFT before CI therapy or after CI therapy in both the subacute therapy group and the chronic therapy group. However, again, an additional analysis of WMFT change scores yielded gains in upper-extremity function that were associated with more fatigue in the chronic therapy group (r=-.75, P<.01) but not in the subacute therapy group (r=-.17, P>.05).

Intensity

Overall, both groups averaged approximately 4.5 hours of therapy per day (Tab. 2). There was no significant difference between the subacute and the chronic therapy groups with regard to intensity of therapy (Tab. 2), indicating that both groups were able to tolerate the same level of therapy. However, individual characteristics of participants were related to intensity of therapy. Faster performance on the WMFT in the subacute therapy group (Tab. 3), indicating better upper-extremity function before training, was associated with significantly more time spent in therapy, relative to the time spent by participants with slower performance on the WMFT. After therapy, intensity (amount of time spent in therapy) and upper-extremity function (WMFT times) remained moderately correlated. In contrast, in the chronic therapy group (Tab. 3), there was no relationship between average intensity and the WMFT before CI therapy or after CI therapy.

Additional analyses showed that, for both groups, there was no relationship between time spent in therapy and upper-extremity joint pain (FMA) before CI therapy (subacute therapy group: r=.16, P>.05; chronic therapy group: r =.05, P>.05). Pain during therapy was not associated with intensity of CI practice (subacute therapy group: r=.04, P>.05; chronic therapy group: r=.11, P>.05). There were moderate correlations, indicating that less time spent in therapy was associated with more fatigue (subacute therapy group: r=-.27, P>.05; chronic therapy group: r =-.53, P=.05).

Fatigue

Overall average daily morning and afternoon fatigue scores were below 4.5 on a scale of 1 to 10 throughout the daily CI therapy for both groups (Fig. 2A). Repeated-measures ANOVA revealed that there was no change over the 10 days in morning fatigue (Greenhouse-Geisser test: F=.10, P=-.41) or afternoon fatigue (Greenhouse Geisser test: F=l.70, P=-.12) or between groups (morning fatigue, Greenhouse-Geisser test: F=.77, P=.59; afternoon fatigue, Greenhouse-Geisser test: F=.77, P=.60). Generally, the highest fatigue scores were found in the subacute therapy group participants at the end of the daily training. The chronic therapy group participants had lower average fatigue scores at the end of the morning training (Tab. 2).

[FIGURE 2 OMITTED]

As expected, in both the subacute and the chronic therapy groups, the average levels of fatigue reported at the end of the daily therapy were significantly higher than the average fatigue levels reported at the end of the morning therapy session (subacute therapy group: t=4.2, df=17, P<.01; chronic therapy group: t=3.4, df=13, P<.05) (Tab. 2).There was no relationship between the average daily pain and fatigue scores during therapy in the subacute therapy group (r=-.13, P>.05), but in the chronic therapy group, there was a trend for more pain during therapy being associated with more fatigue (r=.50, P=.07).

Pain

Average daily morning and afternoon pain scores were below 3 on a scale of 1 to 10 throughout the daily CI therapy for participants early and later in the recovery trajectory (Fig. 2B). Repeated-measures ANOVA revealed that there was no change over the 10 days for all participants in morning pain (Greenhouse-Geisser test: F=.51, P=.79) or afternoon pain (Greenhouse-Geisser test: F=.51, P=.78). In addition, there was no difference in morning pain or afternoon pain over the 10 days between the subacute and the chronic therapy group participants (morning pain, Greenhouse-Geisser test: F=.53, P=.79; afternoon pain, Greenhouse-Geisser test: F=.53, P=.77).

The average scores tended to be higher for afternoon pain in the subacute therapy group and lowest for morning pain in the chronic therapy group. There was no difference between the subacute and the chronic therapy groups for average daily morning pain or afternoon pain (Tab. 2). Additional analyses failed to reveal a change in joint pain scores within groups before CI therapy and after CI therapy for either the subacute (t=.51, df=17, P>.05) or the chronic (t=.94, df=13, P>.05) therapy group.

The relationships between daily pain and assessments of joint pain (scored by the evaluator) before and after the administration of CI therapy also were examined. Assessments of joint pain were related to self-reported average daily pain during therapy in the chronic therapy group (before therapy: r=-.84, P<.001; after therapy: r=-.76, P=-.001) but not in the subacute therapy group (before therapy: r=.32, P>.05; after therapy: r=-.04, P>.05).

Discussion

Although results from previous studies indicated that pain may affect a patient's ability to participate in therapy, (18,21.36) the participants in this study had relatively low levels of pain throughout the CI therapy protocol. Furthermore, pain did not increase over the 2-week therapy period. These results are somewhat unexpected, on the basis of the high intensity and multiple practice hours of CI therapy. This limited complaint of pain is likely a function of several factors: the inclusion criteria (see minimal movement criteria described by Winstein et al (12)), which restricted participation to minimally to moderately impaired patients with stroke; the exclusion of patients who had sufficient complaints of pain that would interfere with daily activities; and the careful monitoring of symptoms during training activities. These encouraging results indicate that with cautious screening, pain should not be a concern for therapists who use CI therapy for their patients.

Fatigue resulting from many hours of intensive therapy is another reason that patients and therapists may be reluctant to use CI therapy. (37) In both subacute and chronic therapy group participants, fatigue level scores during CI therapy remained low over the course of therapy and were not related to upper-extremity functional capabilities, before or after training. This finding suggests that the level of fatigue should not increase over the course of this intensive therapy.

However, the magnitude of improvement in upper-extremity function experienced by the chronic therapy group participants was related to the participants' reports of pain and fatigue scores during therapy, suggesting that chronic therapy group participants may have experienced some pain and fatigue as upper-extremity function improved. Impressively, participants in the chronic therapy group showed as much improvement in upper-extremity function as did participants in the subacute therapy group, although they had not been forced to use their affected extremity for over 1 year.

Thus, low levels of pain and fatigue may not interfere with a patient's capability to maximize improvement in functional status if the therapy is started later, in the chronic phase of recovery. Both groups showed significant improvement in upper-extremity motor function after CI therapy training, a result that is consistent with those of other CI therapy studies involving patients in the acute, (38) subacute, (24,39) and chronic (7,13,40) phases of recovery after stroke.

Both subacute and chronic therapy group participants achieved the same intensity of therapy, about 4.5 hours of the scheduled 6 hours of contact each day. For the subacute therapy group, we found that participants with better upper-extremity function tolerated more time in therapy. However, there was no relationship between intensity of practice and joint pain or daily pain. A relationship between lower intensity of practice and higher fatigue during therapy was as expected, although not significant. Therefore, starting intensive therapy earlier in the recovery process was beneficial and did not have adverse effects.

One obvious limitation of this study involved the small number of participants in each group and the possibility of a type II error. Although the sample was small, strengths of the EXCITE clinical trial include the strict eligibility criteria to help control through homogeneity of the sample, random assignment to groups, and rigorous standardization of trainers and evaluators to control threats to internal validity. Larger samples will allow for testing of other patient attributes that may affect pain and fatigue. However, the results of this study suggest several additional avenues for exploration. Because of the specific criteria used for participants more than 3 months after stroke in this study, the levels of pain and fatigue that patients in a more acute phase and undergoing this therapy would experience are unknown. Although there were no differences in outcomes between the subacute and the chronic therapy groups for this small subset of participants, knowing at what point in the recovery trajectory CI therapy is most effective for patients with stroke would help to better direct optimal delivery of the intervention. Although participants in this study averaged about 4.5 hours of actual training, more research is needed to determine whether the optimal intensity needed to achieve maximal meaningful clinical benefit for nondistributed practice can be ascertained.

Conclusion

Although therapists always need to assess patients' pain and fatigue during therapy, patients meeting the EXCITE criteria, whether in the subacute or in the chronic phase of recovery after stroke, are likely to experience improvement in upper-extremity function after participation in an intensive 2-week protocol of CI therapy without increases in symptoms of pain and fatigue. Clinicians and researchers should continue to evaluate whether intensive therapy may increase other undesirable outcomes for patients.

This article was received November 10, 2005, and was accepted April 17, 2006.

References

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The Bottom Line

The Bottom Line is a translation of study findings for application to clinical practice. It is not intended to substitute for a critical reading of the research article. Summaries are written by members of The Bottom Line Committee.

[Underwood J, Clark PC, Blanton S, et al. Pain, fatigue, and intensity of practice in people with stroke who are receiving constraint-induced movement therapy.

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?

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?

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?

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?

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?

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

(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.

[DOI: 10.2522/ptj.20050357.bI]

* SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

Julie Underwood, Patricia C Clark, Sarah Blanton, Dawn M Aycock, Steven L Wolf

J Underwood, BSN, RN, is Clinical Research Associate, Pharmaceutical Product Development Inc, Morrisville, NC. She was a research honors nursing student at Emory University, Atlanta, Ga, when most of this work was completed.

PC Clark, PhD, RN, FAHA, FAAN, is Associate Professor, Byrdine F. Lewis School of Nursing, Georgia State University, Atlanta, Ga. She was a faculty member at Emory University when most of this work was completed.

S Blanton, PT, DPT, NCS, is Physical Therapist and Associate Director of Research Projects, Center for Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Ga.

DM Aycock, MSN, APRN-BC, is Clinical Instructor, Byrdine F. Lewis School of Nursing, Georgia State University. She was a senior research nurse at Emory University when most of this work was completed.

SL Wolf, PT, PhD, FAPTA, is Professor, Center for Rehabilitation Medicine, Emory University School of Medicine, 1441 Clifton Rd NE, Atlanta, GA 30332 (USA). Address all correspondence to Dr Wolf at: [e-mail].

Dr. Blanton and Dr Wolf provided concept/idea/research design. Ms Underwood, Dr Clark, Dr Blanton, and Dr Wolf provided writing. Ms Underwood and Dr Blanton provided data collection, and Ms Underwood, Dr Clark, Ms Aycock, and Dr Wolf provided data analysis. Dr Wolf provided project management, fund procurement, and facilities/equipment. Dr Blanton provided subjects. Dr Clark provided consultation (including review of manuscript before submission).

The institutional review boards at all sites, including Emory University, approved the study protocol.

This research was supported, in part, by the following grants: EXCITE-National Clinical Trial for Extremity Constraint-Induced Therapy Evaluation, the National Center for Medical Rehabilitation Research (NCMRR), and the National Institute of Neurological Disorders and Stroke (NINDS) (RO1 HD37606) to Dr Wolf and Family Function, Stroke Recovery, & Caregiver Outcomes, National Institute of Nursing Research (NINR) (1 RO1 NR07612-01) to Dr Clark.

An abstract of this research was presented at the annual conference of the Southern Nursing Research Society; February 4, 2005; Atlanta, Ga.

DOI: 10.2522/ptj.20050357

Table 1.

Differences in Wolf Motor Function Test Times (in Seconds) Before
and After Constraint-Induced Movement Therapy (CI Therapy) in
Subacute and Chronic Therapy Groups (a)

           [bar.X] [+ or -] SD for Time

Therapy    Before CI              After CI
Group      Therapy                Therapy

Subacute   25.45 [+ or -] 26.39   17.56 [+ or -] 21.95

Chronic    33.65 [+ or -] 24.59   24.24 [+ or -] 22.25

Therapy
Group      t      df   P

Subacute   3.83   17   .001

Chronic    3.61   13   .003

(a) Both the log mean Wolf Motor Function Test (WMFT) data
and the raw data were significant. The log mean WMFT data were
used in the analysis, but for the ease of comprehension, the raw
data are reported here.

Table 2.

Comparison of Subacute and Chronic Therapy Groups
With Regard to Pain, Fatigue, and Function (a)

                            [bar.X] [+ or -] SD Score

                            Subacute
                            Therapy Group
Variable                    (n=18)

Average morning pain         2.02 [+ or -] 0.83
Average afternoon pain       2.18 [+ or -] 1.07
Average morning fatigue      2.81 [+ or -] 1.26
Average afternoon fatigue    3.31 [+ or -] 1.29
Pretest joint pain          20.06 [+ or -] 3.15
  (Fugl-Meyer Assessment)
Posttest joint pain          20.39 [+ or -] 2.93
  (Fugl-Meyer Assessment)
Pretest log WMFT (s)          2.68 [+ or -] 1.14
Posttest log WMFT (s)         2.25 [+ or -] 1.13
WMFT change score             0.43 [+ or -] 0.48
Intensity of practice       250.96 [+ or -] 23.33
  (average total minutes
  each day over 10 days)

                            [bar.X] [+ or -] SD Score

                            Chronic
                            Therapy Group
Variable                    (n=14)

Average morning pain          1.72 [+ or -] 1.11
Average afternoon pain        1.87 [+ or -] 1.00
Average morning fatigue       1.87 [+ or -] 1.08
Average afternoon fatigue      2.8 [+ or -] 1.35
Pretest joint pain           22.57 [+ or -] 2.50
  (Fugl-Meyer Assessment)
Posttest joint pain          22.29 [+ or -] 3.05
  (Fugl-Meyer Assessment)
Pretest log WMFT (s)          3.14 [+ or -] 1.04
Posttest log WMFT (s)         2.75 [+ or -] 1.03
WMFT change score             0.39 [+ or -] 0.40
Intensity of practice       260.66 [+ or -] 26.46
  (average total minutes
  each day over 10 days)

Variable                    t (b)     P

Average morning pain
Average afternoon pain      0.88     .388
Average morning fatigue     0.82     .417
Average afternoon fatigue   2.23     .034
Pretest joint pain          1.08     .290
  (Fugl-Meyer Assessment)   2.44     .021
Posttest joint pain
  (Fugl-Meyer Assessment)   1.78     .085
Pretest log WMFT (s)
Posttest log WMFT (s)       1.18     .246
WMFT change score           1.30     .203
Intensity of practice       0.27     .790
  (average total minutes    1.10     .280
  each day over 10 days)

(a) Joint pain and Wolf Motor Function Test (WMFT) scores were rated
by the evaluator. Pain and fatigue during therapy were self-reported
by participants. Intensity of practice was documented by the trainer.

(b) df = 30 for all t tests.

Table 3.

Relationships Between Log Wolf Motor Function Test [WMFT])
and Pain, Fatigue, and Intensity of Practice in Subacute
and Chronic Therapy Groups (a)

                              Correlation for:

                              Subacute Therapy
                              Group      (n=18)

                              Pretest    Posttest
Variable                      WMFT       WMFT

Pretest joint pain            -.21
Posttest joint pain                      -.24
Fatigue during constraint-     .32        .26
  induced therapy
Pain during constraint-       -.05       -.06
  induced therapy
Intensity of practice (min)   -.51 (b)    .46 (c)

                              Chronic Therapy
                              Group (n=14)

                              Pretest    Posttest
Variable                      WMFT       WMFT

Pretest joint pain            -.24
Posttest joint pain                       .05
Fatigue during constraint-     .08       -.22
  induced therapy
Pain during constraint-        .09       -.12
  induced therapy
Intensity of practice (min)    .06        .01

(a) Joint pain and WMFT scores were rated by the evaluator.
Pain and fatigue during therapy were self-reported by participants.
Intensity of practice was documented by the trainer. Correlations
for intensity of practice and subacute therapy group motor function
differed, as determined by nonparametric tests: intensity of practice
and pretest WMFT ([r.sub.s] = -.40, P = .11) and intensity of
practice and posttest WMFT ([r.sub.] = -.44, P = .07).

(b) P < .05.

(c) P = .05.