Constraint-Induced Movement Therapy Reduced Shoulder Pain and Improved Function in Subacute and Chronic Stroke: A Cohort Study

Annika Sefastsson^1,2Therése Brändström²Håkan Littbrand³Per Wester^4,5Per Liv⁶Britt-Marie Stålnacke²Ann Sörlin²Xiaolei Hu^2*

• ¹Liljeholmskliniken, Stockholm, Sweden
• ²Umeå University, Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå, Sweden
• ³Umeå University, Dep. of Community and Rehabilitation Medicine, Geriatric Medicine, Umeå University, Dep. of Community and Rehabilitation Medicine, Geriatric medicine, Umeå, Sweden
• ⁴Umeå University, Dep. of Public Health and Clinical Medicine, Umeå, Sweden
• ⁵Department of Clinical Science, Karolinska Institute Danderyd Hospital, Stockholm, Sweden
• ⁶Umeå University, Department of Public Health and Clinical Medicine, Umeå, Sweden

INTRODUCTION: The objective of this study was to evaluate the effects of Constraint-Induced Movement Therapy (CIMT) on hemiplegic shoulder pain (HSP), shoulder range of motion (ROM) and upper extremity motor function in stroke patients. METHODS: This longitudinal intervention cohort study was performed in an outpatient clinic without a control group. Participants underwent individually tailored CIMT with a patient therapist ratio of 4:1 for 6 hours/day, 5 days/week for 2 consecutive weeks, including daily shoulder strength and joint motion training. A total of 221 (101 with and 120 without pre-CIMT HSP) middle-aged (median 54 years) persons at sub-acute or chronic phases after stroke were included in the study. The Fugl-Meyer Assessment (FMA) subscale for pain was used for defining and scoring HSP at passive motion (sum of four directions of movement, maximum 8 points indicating no pain). Passive and active shoulder ROM (sum of flexion and abduction) were assessed. Upper extremity motor function was assessed with B. Lindmark Motor Assessment. Assessments were done pre-and post-CIMT and at 3-month follow-up. Comparisons were stratified by subgroups with-and without HSP. RESULTS: In the subgroup with pre-CIMT HSP, median HSP score at passive movement was reduced (FMA shoulder pain score increased) from pre-to post-CIMT from 5 points to 7 points post-CIMT, p<0.001, Effct size (ES) 0.68). Median active ROM increased from 230° to 308° (p<0.001, ES 0.72) and median passive ROM increased from 350° to 360° (p<0.001, ES 0.44). Median motor function improved from 42 to 49 points (p<0.001, ES 0.92). In the subgroup without pre-CIMT HSP no statistically significant increase of HSP was seen and no clinically significant changes observed for active or passive ROM after CIMT. Median motor function improved from 52 to 56 points (p<0.001, ES 0.71). All improvements persisted at 3-month follow-up. CONCLUSION: CIMT in an outpatient clinical setting may be a feasible treatment to decrease HSP and to improve shoulder ROM and upper extremity motor function among middle-aged persons in the subacute and chronic phases after stroke. Results need to be confirmed in an RCT setting.