Research Report

Constraint-Induced Therapy With

Trunk Restraint for Improving
Functional Outcomes and Trunk-Arm
Control After Stroke: A Randomized
Controlled Trial
Ching-yi Wu, Yi-an Chen, Keh-chung Lin, Ching-ping Chao, Yu-ting Chen

Background. Studies have suggested that constraint-induced therapy combined

with trunk restraint (CIT-TR) improves arm movement and reduces trunk compensation. Whether participants who receive CIT-TR can translate the benefits to real-life
circumstances awaits further investigation.

Objective. The effects of distributed CIT-TR (dCIT-TR) on motor function, daily

function, quality of life (QOL), and arm-trunk control were investigated.

Design. The study was a single-blind, randomized controlled trial.

Setting. The study took place at 4 hospitals.
Participants. Participants were 57 people who had had a stroke 6 to 55 months
earlier.

Intervention. Participants received a dose-matched intervention (2 hours per

day, 5 days per week, for 3 weeks) of dCIT-TR, distributed constraint-induced therapy
(dCIT), or control therapy.
Measurements. The Action Research Arm Test (ARAT), Motor Activity Log,
Frenchay Activities Index (FAI), and Stroke Impact Scale (SIS) were used to evaluate
motor function, daily function, and QOL. Data for reaching kinematics were
recorded.
Results. Participants receiving dCIT-TR and dCIT exhibited higher overall scores
on the ARAT, FAI, and hand function domain of the SIS and better quality of
movement and larger amount of use (of the affected arm) on the Motor Activity Log
than participants in the control group. Participants receiving dCIT-TR further demonstrated greater improvements on the ARAT grip subscale and FAI outdoor activities
scale than participants receiving dCIT or participants in the control group. However,
participants receiving dCIT showed greater improvements on the strength domain of
the SIS after training than participants receiving dCIT-TR or participants in the control
group.

Limitations. Research with a larger sample size is needed.

Conclusions. Participants who received dCIT-TR were able to translate gains in
arm-trunk control into functional performance and QOL, specifically in grip function
and outdoor activities. A long-term study to examine the recovery course for force
output may be needed to evaluate peoples perception of less improvement in
strength after dCIT-TR.

April 2012

C. Wu, ScD, OTR, Department of

Occupational Therapy and Graduate Institute of Behavioral Sciences, Chang Gung University,
Taoyuan, Taiwan.
Y. Chen, MS, Department of
Occupational Therapy and Graduate Institute of Behavioral Sciences, Chang Gung University.
K. Lin, ScD, OTR, School of Occupational Therapy, College of
Medicine, National Taiwan University, Taipei, Taiwan, and Division of Occupational Therapy,
Department of Physical Medicine
and Rehabilitation, National Taiwan University Hospital, 17, F4,
Xu Zhou Rd, Taipei, Taiwan.
Address all correspondence to Dr
Lin at: kehchunglin@ntu.edu.tw.
C. Chao, MS, School of Occupational Therapy, College of Medicine, National Taiwan University.
Y. Chen, MS, Department of
Occupational Therapy and Graduate Institute of Behavioral Sciences, Chang Gung University.
[Wu C, Chen Y, Lin K, et al.
Constraint-induced therapy with
trunk restraint for improving
functional outcomes and trunkarm control after stroke: a randomized controlled trial. Phys
Ther. 2012;92:483 492.]
2012 American Physical Therapy
Association
Published Ahead of Print:
January 6, 2012
Accepted: December 23, 2011
Submitted: July 6, 2011

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Effects of dCIT With Trunk Restraint on Function and Quality of Life

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

Given that restricting excessive

trunk movement can improve arm
movement and reduce trunk compensation during reaching,1215
Woodbury et al10 incorporated trunk
restraint (TR) into CIT (CIT-TR) and
reported reduced UE deficits, less
trunk displacement, and greater
range of motion in elbow and shoulder joints.
Although training with CIT-TR10 or
TR only1214 improves motor control
of the arm and trunk, whether
patients who receive CIT-TR can
translate this benefit into UE function and activities of daily living
(ADL) has not been studied.10,15
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Physical Therapy

Patients return to functional independence in basic and instrumental

ADL is an important goal during
stroke
neurorehabilitation.16 18
Constraint-induced therapy involves
the practice of functional tasks and is
focused primarily on the ability to
accomplish a task, whereas TR is
focused on reducing compensatory
movement strategies and normalizing motor control through practice
of movements in a specific and less
functional way solely with the UE.
Furthermore, a previous study suggested that improved motor performance may not be related to
improved
functional
independence.16 The therapeutic gains of
CIT-TR in real-life circumstances
await further investigation.
Previous studies also failed to underscore patients perceptions about
the value of their more normal performance, as indicated by evaluators
and biomechanical instruments.10
Because patients are the final arbiters
of how well or poorly a delivered
intervention is working,19 their perception about quality of life (QOL),
which is related to their goals and
expectations,20 is the core of rehabilitation and a valuable outcome.16 18
Further study is needed to determine
whether improvements in movement control after CIT-TR contribute
to patients perceptions about QOL.
This study was conducted to investigate the effects of distributed CIT-TR
(dCIT-TR) on motor function and
daily function, including instrumental ADL and health-related QOL, as
well as arm-trunk control. We chose
distributed CIT (dCIT) rather than
CIT because dCIT is effective5,6 and
was more feasible and acceptable
than the signature CIT at the participating sites. The CIT consisted of
6 hours of functional training per
day with the more affected arm for
10 days, along with restraint of the
less affected arm for almost 1 full
day.1 The term distributed indi-

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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Effects of dCIT With Trunk Restraint on Function and Quality of Life

demographic and baseline clinical
characteristics of the 3 groups (participants who received dCIT-TR, participants who received dCIT, and
participants who received standard
therapy [control group]).

Table 1.
Demographic and Clinical Characteristics of Study Participantsa
dCIT-TR
Group
(n20)

Variable

The intervention took place in an

occupational therapy clinic, and all
other routine rehabilitation, including physical therapy or speech therapy, proceeded as usual. The treating
therapists were trained by the investigators in the administration of the
3 intervention protocols to ensure
consistency. The outcome measures
were administered before and after
a 3-week intervention by 3 certified
occupational therapists who were
unaware of group allocation. Rater
competence was assessed by a
senior occupational therapist.

Women

April 2012

16

14

14

12

13

Statistic

Pb

0.23

.89

4.36

.11

Side of brain lesion

Right

12

Age, y, X (SD)

Left

54.0 (9.7)

56.3 (12.2)

58.6 (11.6)

0.79

.46

Months since stroke, X (SD)

15.7 (13.5)

13.7 (7.3)

17.7 (13.4)

0.55

.58

Fugl-Meyer Assessment score,

X (SD)

43.0 (9.6)

39.1 (11.3)

36.7 (13.2)

1.48

.24

Mini-Mental State Examination

score, X (SD)

27.2 (2.0)

27.1 (3.5)

26.1 (3.5)

0.71

.50

Values are reported as number of participants unless otherwise indicated. dCIT-TRdistributed

constraint-induced therapy with trunk restraint, dCITdistributed constraint-induced therapy.
b
P value associated with the 2 test for categoric variables and with the analysis of variance test for
continuous variables.

based on the participating site

(Fig. 1). All treatments were dose
matched (2 hours per day, 5 days per
week, for 3 weeks) and administered
with 1-to-1 supervision.
dCIT-TR group. Training of the
affected UE with dCIT-TR included
shaping skills and repetitive practice
of functional tasks.26 Shaping skills
involved practicing parts of tasks for

a successive approximation of the

task goal, and each part of a task was
practiced for 20 to 30 minutes
within 1 training session. In repetitive task practice, the functional
tasks appropriate for a participant
were used in their entirety, and
each was practiced for 20 to 30 minutes within 1 training session. Verbal
feedback and physical assistance
were applied to help participants

Eligible participants (n=220)

Excluded (n=163)
Did not meet inclusion criteria (n=142)
Refused to participate (n=21)

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

It was suggested that at least 15

participants in each group would
be needed in a demonstration-ofconcept trial aimed at finding compelling evidence or an argument for
the possible efficacy of a novel intervention (ie, CIT-TR).25 Previous studies provided preliminary evidence
of the effects of CIT-TR10 and TR
only1214 on motor control. There is
limited research investigating the
effects of CIT-TR on daily function
and QOL. The present study was
considered to be a demonstration-ofconcept randomized controlled trial
with the aim of showing the potential effects of CIT-TR on daily function and QOL. Accordingly, the sample size recruited for the present
study was 19 or 20 participants in
each group; this sample size was
considered to be appropriate for a
randomized, controlled trial at the
demonstration-of-concept stage.

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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Effects of dCIT With Trunk Restraint on Function and Quality of Life

ity. Possible unilateral tasks involved
moving the pegs on a vertical tower
or putting chessmen into the holes
on a board, and possible bilateral
tasks involved picking up cones with
the hands clasped or scooping beans
from a bowl with one hand while the
other hand stabilized the bowl.

Figure 2.
Trunk-restraint harness used for participants who received distributed constraintinduced therapy with trunk restraint.

regain task skills and performance.

Daily treatment content included
practice of, for example, 3 parts of
tasks (eg, grasping and releasing
blocks, using a tablecloth to wipe a
table with elbow flexion and extension, and opening and closing a
clothespin) and 2 whole functional
tasks (eg, simulated tea-making activity and picking up coins from a bag).
Therapists adjusted the difficulty of
the tasks according to the capability
of the participants (eg, relative distance between the participant and
the target and the weight, size,
shape, or texture of the target). Participants were required to wear a
mitt on the unaffected hand and
wrist (6 hours per day for 3 weeks)
and report the time wearing the mitt
outside clinic sessions in daily logs.
To facilitate participants engagement in active problem solving,
therapists also discussed with them
the possible difficulties encountered
while performing daily activities
with hand restraint and the possible
solutions for those problems.
The TR harness that participants
wore during the training sessions
has Velcro straps (Velcro USA Inc,
Manchester, New Hampshire) that
secure the trunk to the chair back
486

Physical Therapy

and restrain anterior trunk and

rotation movements (Fig. 2). The
harness was adjusted individually so
that it did not interfere with arm
movements.
dCIT group. Participants in the
dCIT group received an intervention
that was similar to the dCIT-TR intervention but did not include TR.
Control group. Participants in the
control group received usual and
customary care, which primarily
consisted of treatment based on neurodevelopmental principles, emphasizing stretching and weight bearing
by the affected UE, improving fine
motor dexterity, and practicing functional activities when possible. Practicing functional or dexterity activities involved unilateral and bilateral
tasks with the affected UE and both
UEs, with assistance from the unaffected UE. Daily treatment content
included, for example, passive range
of motion, stretching of the affected
limb, or facilitatory and inhibitory
techniques for 10 minutes and unilateral and bilateral task training for
50 minutes each. For each type of
task training, about 2 therapeutic
activities were required, with 20 to
30 minutes of practice of each activ-

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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Effects of dCIT With Trunk Restraint on Function and Quality of Life

Likert scale is used to rate each item;
higher scores indicate better function. The strength, ADL, mobility,
and hand function domains were
used to evaluate physical function
only.
Secondary outcome measures:
trunk and arm movement kinematics. The
kinematic
task
required the participant to use the
index finger of the affected arm to
press a bell (3 cm long, 3 cm wide,
and 0.5 cm tall). The bell was placed
along the participants midsagittal
plane at a distance corresponding to
90% of his or her arm length, as measured from the acromion to the third
fingertip. During the kinematic trial,
each participant sat on a heightadjustable chair with the seat height
set to 100% of the lower leg length,
as measured from the lateral knee
joint to the floor. Adjacent to the
chair was a table with the height
adjusted to 5 cm below the elbow
while the participant sat on the
chair. The initial position of the hand
was on the edge of the table with the
elbow flexed at 90 degrees. After 1
practice trial, the participant performed reaching to press the bell as
fast as possible for 3 data-producing
trials. Only the reaching phase was
analyzed.
Reference markers were placed on
the seventh cervical vertebra (C7),
fourth thoracic vertebra (T4), bilateral clavicles, midsternum, affected
side of the acromion, middle of the
humerus, lateral epicondyle, styloid
process of the ulna and radius,
thumb nail, and index nail. A VICON
MX 7-camera motion analysis system
(Oxford Metrics Inc, Oxford, United
Kingdom) was linked to a personal
computer to capture the movement
of the markers. LabVIEW (National
Instruments Inc, Austin, Texas) software was used to process the kinematic data.

April 2012

Movement onset was defined for

each trial on the basis of the time at
which the tangential index velocity
was 5% above its peak value; it began
as a bell was pressed and was indicated by a digital signal connected
to the computer. Movements were
recorded at 120 Hz and digitally filtered with a low-pass filter at 5 Hz by
use of a second-order Butterworth
filter with dual passes.
Kinematic variables were chosen
to indicate trunk movement and
recruitment of UE joints. The variable of the slope (the ratio of trunk
to UE displacement in the sagittal
plane) represented trunk movement
to the total end point of motion.
Because of the characterized displacement of the trunk and arm in
the early and late phases of reaching,9 the slope was calculated separately for 3 phases of reaching (start,
middle, and end phases) to determine the proportions contributed
by the trunk and the arm. The larger
the slope, the less the trunk was
involved. In people who are healthy,
a significant contribution of the
trunk occurs only at the end phase of
reaching.8 The variables of the joint
recruitment contained the recruitment of shoulder and elbow joints
during reaching. Because the task
distance varied across participants,
the recruitment of shoulder and
elbow joints was normalized to correct for variations in task distance.
Data Analysis
Data were analyzed with SPSS 14.0
software (SPSS Inc, Chicago, Illinois). An analysis of covariance
(ANCOVA) was applied to examine
the relative effects of the treatments
for each variable. The pretest score
was the covariate, group was the
independent variable, and the posttest score was the dependent variable. Separate ANCOVAs were used
for the subscales of the outcome
measures. The least significant difference was used to determine the

post hoc significance of pair-wise

comparisons. The level of statistical
significance (alpha) was set at .05.
Bonferroni correction was not used
for multiple comparisons because
such a correction is actually wasteful
of statistical power,35 likely leading
to a type II error.36 It would have
increased the possibility of nonsignificant findings that were actually
significant (ie, false-negative findings). More importantly, low statistical power would have had a
negative impact on the development
of the knowledge base to guide clinical rehabilitation practice.37 Adopting a conservative Bonferroni correction in the present study might
have decreased the chance to demonstrate the potential effects of
dCIT-TR and dCIT on specific outcomes. To index the magnitude of
group differences in performance,
we calculated 2SSbetween/SStotal,
where SS is sum of squares, for each
outcome variable.38 A large effect
was represented by an 2 value of at
least 0.14, a moderate effect was represented by an 2 value of 0.06, and
a small effect was represented by an
2 value of 0.01.39
Role of the Funding Source
This work was supported by the
National Health Research Institutes
(NHRI-EX100-9920PI and NHRIEX100-10010PI), the National Science Council (NSC-99-2314-B-182014-MY3 and NSC-97-2314-B-002008-MY3), and Healthy Ageing
Research Center at Chang Gung University (EMRPD1A0891) in Taiwan.
The funding sources had no influence on analysis, interpretation, or
manuscript writing.

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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Effects of dCIT With Trunk Restraint on Function and Quality of Life

Table 2.
Effects of Interventions on Functional Measuresa
Before Intervention

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)

1.35 .27 .05

.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)

4.45 .02 .14

.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)

2.54 .09 .09

.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)

2.91 .06 .10

.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)

4.12 .02 .14

.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)

4.41 .02 .14

.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)

1.71 .19 .06

.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)

1.03 .37 .04

.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)

3.79 .03 .13

.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)

3.78 .03 .13

.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)

4.57 .02 .15

.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)

0.56 .58 .02

.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)

0.14 .87 .01

.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)

4.43 .02 .14

.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

durations of restraint and good

adherence for both groups.

groups improved more than the control group.

Primary Outcome Measures:

Functional Performance and QOL
Motor function. The ANCOVA
showed significant differences in
ARAT grip subscale and total scores
among the groups but no significant
differences in the scores on the
other subscales (Tab. 2). Post hoc
analyses revealed that the dCIT-TR
group had more improvements in
grip function than the dCIT (P.02)
and control (P.01) groups. In total
motor function performance, the
dCIT-TR (P.02) and dCIT (P.04)

Daily function. The ANCOVA

showed significant group effects on
AOU and QOM, as assessed with the
MAL (Tab. 2). Post hoc analyses
revealed that the dCIT-TR (P.03)
and dCIT (P.01) groups had
greater QOM with the affected arm
than the control group after 3 weeks
of training. Compared with participants in the control group, participants in the dCIT group (P.01) but
not those in the dCIT-TR group used
the affected hand with a higher frequency. The differences between

488

Physical Therapy

the dCIT-TR group and the dCIT

group in AOU and QOM were not
significant.
The ANCOVA showed significant
and moderate group effects on FAI
outdoor activities and total scores
(Tab. 2). Post hoc analyses revealed
that the dCIT-TR group (P.01) but
not the dCIT group had a significantly higher frequency of participation in outdoor activities than the
control group. The dCIT-TR (P.01)
and dCIT (P.04) groups exhibited
significantly higher FAI total scores
than the control group. There were

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Effects of dCIT With Trunk Restraint on Function and Quality of Life

Table 3.
Effects of Interventions on Kinematic Tasksa
Before Intervention

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.

no significant differences in other

FAI subscale scores.
QOL. Significant and large group
effects on the hand function and
strength domains of the SIS were
observed (Tab. 2). Post hoc analyses
revealed that the dCIT-TR (P.01)
and dCIT (P.01) groups had less
difficulty with the hand function
domain than the control group. Participants in the dCIT group perceived less difficulty with the
strength domain than participants in
the dCIT-TR (P.01) and control
(P.02) groups. The results for the
ADL and mobility domains were not
significantly different.
Secondary Outcome Measures:
Trunk and Arm Movement
Kinematics
There was a significant and moderate
effect on the start phase of reaching
among the groups in the kinematic
task (Tab. 3). Only the dCIT-TR
group showed significantly less
trunk compensation during the start
phase of reaching than the control
group (P.02). The differences in
slopes for the other phases were not
significant.

April 2012

The normalized shoulder flexion represented a significant and large effect

in the kinematic task (Tab. 3). Post
hoc analyses revealed that the
dCIT-TR group showed larger active
shoulder movement in the affected
UE during reaching than the dCIT
group (P.02). There was no significant difference in the normalized
elbow flexion in the kinematic task.

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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Effects of dCIT With Trunk Restraint on Function and Quality of Life

of movement of the trunk through
trunk restraint, participants receiving dCIT-TR had to engage in an
implicit learning process of reorganizing the required degrees of freedom in the UE and finding a more
efficient way to coordinate multijoint UE movement in a more normal
coordinative structure.10,41 Grasping
control was consequently improved.
Another possible explanation is that
hand reaching movement was
closely associated with postural control.42 Restraining abnormal trunk
movement during reaching to grasp
might have elicited better trunk control, as evidenced in the present
study by less trunk displacement during the early stage of reaching.
Appropriate trunk control might
have ensured successful hand movement toward the target to be
grasped. Compared with the items in
the grasp and pinch subscales,
which also were related to fine
motor movements, the items in the
grip subscale involved tasks with
greater functional relevance (eg,
pouring water from one glass to
another) and without high accuracy
demands (eg, displacing a 1- or
2.25-cm tube). The augmented
effects of dCIT-TR on grip function
suggested that dCIT-TR might have
specifically benefited grip capability
during functional tasks with
medium-sized targets.
Similarly, participants in both the
dCIT-TR group and the dCIT group
perceived greater QOM, as assessed
with the MAL, than those in the control group. The perceived greater
QOM might have resulted from different fundamental qualities of the
relearned movement. The use of
dCIT-TR might have minimized compensatory movement strategies and
permitted the motor system to reexperience previously learned movement, inducing enhanced movement
quality, whereas the use of dCIT
alone might have helped participants

490

Physical Therapy

become familiar with performing

functional tasks, possibly through
various adaptive and maladaptive
However,
further
behaviors.10
research analyzing movement kinematics when people perform the
testing tasks of the MAL is needed.
The findings that dCIT-TR and dCIT
both facilitated movement quality
and that dCIT enhanced the frequency of use of the affected hand
(AOU) were consistent with the findings of previous studies of dCIT5,6
but were inconsistent with the findings of a previous study of CIT-TR,10
perhaps because of differences in
the treatment protocols used.
Moreover, there was a discrepancy
between our study results and the
results of some previous studies in
the magnitude of changes on the
MAL. Our results showed an
improvement of approximately 1
point on the MAL, whereas the
results of some previous studies43,44
demonstrated a larger improvement,
of approximately 2 points. This discrepancy in improvement on the
MAL might have been associated
with the different participant characteristics in these studies. Specifically,
the interval since stroke in our study
(15.7 months) was much shorter
than the interval in the study by Gauthier et al43 (36 months). However, a
study with a relatively large sample
size (n222)45 reported improvements of 1.03 points for AOU and
0.91 for QOM, similar to our
findings.
Although the participants who
received dCIT-TR and dCIT exhibited better overall scores on the FAI,
only participants who received
dCIT-TR showed a higher frequency
of participation in outdoor activities
than participants in the control
group. Ustinova et al46 indicated that
patients with stroke showed abnormal patterns of armtrunk interactions, with standing balance being
destabilized during bilateral arm

swinging, possibly because of

greater involvement of the trunk.
Trunk restraint could block excessive trunk motion, as evidenced by
the present study and previous studies,10,1215 and break the abnormal
arm-trunk linkage during reaching
tasks. The restoration of more normal movement, with better independent control of the trunk and the
arm, might transfer to improve the
arm-trunk linkage for balance and
walking with arm swinging. Thus,
participants who received dCIT-TR
might have had a high motivation to
participate in outdoor activities,
which often require mobility (eg,
walking, driving, and taking a bus),
in daily living.
There were no significant group differences in the domestic chores and
leisure/work subscales of the FAI.
These findings might be related to
the short-term, 3-week intervention
administered in the present study
and the 3- or 6-month performance
required for rating FAI scores. A longer period of time might be needed
to detect significant changes in some
aspects of daily function. Future
studies with 3 or 6 months of
follow-up are warranted to investigate the effects of dCIT-TR or dCIT
on daily function.
Participants who received dCIT-TR
reported less improvement in
strength than participants who
received dCIT. Because dCIT-TR
includes constraint of trunk movement and recomposition of UE
movement patterns, it might require
more effort for performance of
tasks10 and, thus, might result in
more difficultly in specifically
improving force output. It might
have resulted in participants perceiving less improvement in strength.
Furthermore, this finding could be
related to the short-term, 3-week
intervention, which might have been
insufficient to detect changes in the
strength aspect of QOL. A follow-up

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Effects of dCIT With Trunk Restraint on Function and Quality of Life

study might be warranted to understand whether self-perception of
strength recovery shifts over time in
participants receiving dCIT-TR. The
equal gains in self-reported hand
function in participants receiving
dCIT-TR and dCIT suggested that
reacquisition of hand function might
result primarily from intensive,
repetitive training protocols and
might not be affected by whether
the practice context is a natural one
or a restricted condition.
Consistent with the results of previous studies,10,1215 the dCIT-TR
group showed less trunk compensation during the start phase of reaching and more shoulder joint recruitment than the dCIT and control
groups in the kinematic task. The
uniqueness of the present study is
that it demonstrated that participants improvements after dCIT-TR
occurred not only in motor control
and compensatory movement but
also in functional gains and patientreported outcomes of functional performance and QOL. To address the
limitations of the present study
regarding small sample size and lack
of follow-up, future research to confirm our study findings through the
incorporation of TR into a dCIT program with a large sample size and
follow-up would be of value.

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

examine the recovery course of

force output may be required to evaluate peoples perception of less
improvement in strength after
dCIT-TR.
Dr Wu and Dr Lin provided concept/idea/
research design, project management, fund
procurement, and facilities/equipment. Dr
Wu, Mr Yi-an Chen, and Dr Lin provided
writing. Mr Chao and Ms Yu-ting Chen provided data collection. Mr Yi-an Chen, Mr
Chao, and Ms Yu-ting Chen provided data
analysis.
This work was supported by the National
Health Research Institutes (NHRI-EX1009920PI and NHRI-EX100-10010PI), the
National Science Council (NSC-99-2314B-182-014-MY3 and NSC-97-2314-B-002008-MY3), and Healthy Ageing Research
Center at Chang Gung University
(EMRPD1A0891) in Taiwan.
Trial registration: ClinicalTrials.gov Identifier:
NCT00564005.
DOI: 10.2522/ptj.20110213

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