Effect of Acupressure and Trigger Points in Treating Headache

15 Pages·2010·0.09 MB·English

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TheAmericanJournalofChineseMedicine,Vol.38,No.1,1–14
©2010WorldScientificPublishingCompany
InstituteforAdvancedResearchinAsianScienceandMedicine
Effect of Acupressure and Trigger
Points in Treating Headache: A
Randomized Controlled Trial
LisaLi-ChenHsieh,∗,§Horng-HueiLiou,‡,∗∗Liang-HueiLee,†
TonyHsiu-HsiChen¶,//andAmyMing-FangYen¶,//
∗DepartmentofRehabilitation,CollegeofHealthScience
KaohsiungMedicalUniversity,Kaohsiung,Taiwan
†KaohsiungChangGangMemorialHospital
Kaohsiung,Taiwan
‡DepartmentofNeurology,NationalTaiwanUniversityHospital
Taipei,Taiwan
§InstituteofPreventionMedicine
¶DivisionofBiostatistics,GraduateInstituteofPreventiveMedicine
//CentreofBiostatisticsConsultation,CollegeofPublicHealth
∗∗DepartmentofPharmacology,CollegeofMedicine
NationalTaiwanUniversity,Taipei,Taiwan
Abstract: Theefficacyofacupressure inrelievingpainhasbeendocumented; however, its
effectivenessforchronicheadachecomparedtothemusclerelaxantmedicationhasnotyet
beenelucidated. Toaddressthis,arandomized, controlledclinicaltrialwasconducted ina
medicalcenterinSouthernTaiwanin2003.Twenty-eightpatientssufferingchronicheadache
wererandomlyassignedtotheacupressuregroup(n=14)orthemusclerelaxantmedication
group (n = 14). Outcome measures regarding self-appraised pain scores (measured on a
visualanaloguescale;VAS)andratingsofhowheadachesaffectedlifequalitywererecorded
atbaseline,1monthaftertreatment,andata6-monthfollow-up.Painareaswererecordedin
ordertoestablishtriggerpoints.ResultsshowedthatmeanscoresontheVASatpost-treatment
assessmentweresignificantlylowerintheacupressuregroup(32.9±26.0)thaninthemuscle
relaxant medicationgroup (55.7±28.7) (p = 0.047). Thesuperiorityof acupressure over
muscle relaxant medication remained at 6-month follow-up assessments (p = 0.002). The
qualityofliferatingsrelatedtoheadacheshowedsimilardifferencesbetweenthetwogroups
intheposttreatmentandatsix-monthassessments.TriggerpointsBL2,GV20,GB20,TH21,
and GB5 were used most commonly for etiological assessment. In conclusion, our study
Correspondenceto:Dr.TonyHsiu-HsiChen,DivisionofBiostatistics,GraduateInstituteofEpidemiology/Centre
ofBiostatisticsConsultation,CollegeofPublicHealth,NationalTaiwanUniversity,Room533,No.17,Hsuchow
Road,Taipei,Taiwan.Tel:[phone],Fax:[phone],E-mail:[email protected]
1
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2 L.L.-C.HSIEHetal.
suggeststhat1monthofacupressuretreatmentismoreeffectiveinreducingchronicheadache
than1monthofmusclerelaxanttreatment,andthattheeffectremains6monthsaftertreatment.
Triggerpointshelpdemonstratethetreatmenttechniquerecommendedifalarger-scalestudy
isconductedinthefuture.
Keywords:Acupressure;AlternativeMedicine;Headache;Pain;RandomizedControlledTrial;
TriggerPoint.
Introduction
Headachedisordersareremarkablycommon.Aheadacheisasymptomwithabroadrange
of possible causes. The diagnosis of primary headache disorders depends on systematic
exclusionofsecondarydisordersandsystematicidentificationofthespecificfeaturesofthe
primarydisorders(AlbertEinsteinCollegeofMedicine,1999).About40%ofpeopleinthe
populationexperience a severe headacheannually (Rowland, 1995).Chronic headache is
oneofthe predominantcomplaintspresentedin primarycare clinics.Ofthese, 95.5%are
tension-typeheadaches,and4.5%arecommonmigraineheadaches(Sebit,1996).The1-year
prevalencerateforchronicheadacheisabout3%inwomenand1.5%inmen(Rasmussen
andOlesen,1994;Schwartzetal.,1998).InTaiwan,thelifetimeprevalenceofstress-related
headachesamonguniversitystudentsis about4.5%(6.5%in femalesand3.5%in males;
Liaw,1997).Tensionheadachesoftenoccureverydayornearlyeverydayinindividualswho
seektreatment(Holroydetal.,2000;JensenandSandrini,2000;SchoenenandWang,1997).
Tension headaches can be classified as episodic or chronic. The International Headache
Society’s diagnostic criteria for a chronic (rather than an episodic) tension headache are
that the headache occurs on 15 or more days per month for at least 6 months (Olesen,
1998).
A meta-analysis reviewing 78 articles with 175 treated and non-treated conditions
revealedthattheoutcomesforheadachestreatedwithcognitivetherapy,relaxation,orelec-
tromyelographicbiofeedbackaloneorincombinationwithrelaxationweresuperiortono
treatmentand/ortopseudo/placebotherapy.Pharmacologicalandothertherapiesweremore
effectivethannotreatment(BogaardsandterKuile,1994).Variousstudiesreportedthatmus-
cle relaxantswereeffectivein reducingheadaches(FriedelandFitton,1993;Saperetal.,
2001;Spira and Beran, 2003).Alternative medicine, relaxationtechniques, and cognitive
traininghavealsobeenshowntobehelpful(Ludin,1997).Onestudyshowedthatadding
a muscle relaxant to a compound analgesic achieved satisfactory pain relief (Atkinson,
1979).
Extensivestudieshave investigatedtheuse ofacupunctureand relatedtechniquesthat
involvethestimulationofanatomicallocationsontheskinfortreatingchronicpainofthe
head,neck,andface.Acupuncturehasperformedfavorablyincomparisontrialstothestan-
dardtherapy,shamacupuncture,ormocktranscutaneouselectricalnervestimulationforthe
treatmentoftensionheadaches,migraine,andheadachesarisingfromvariousothercauses,
(Ahonen,1983;Chen, 1997;Dowsonet al., 1985l;Kubiena,1992;Liu, 1997;Lohet al.,
1984; Tavola et al., 1992; Vincent, 1989; Weinschutz, 1994; Xu, 1993). A randomized,
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ACUPRESSUREINTREATINGHEADACHE 3
placebo-controlled study showed that needle acupuncture was an effective treatment but
only provideda weak improvementin quality of life (Karst et al., 2001).Acupressure, a
techniquederivedfrom acupuncture,is anothertreatmentmodality of traditionalChinese
medicineandhasbeenusedforcenturiesinAsianareasincludingChina,Japan,andKorea
andothercountriesforrelievingpain,illness,andinjury(Mills,2001).Acupressure,which
uses fingers instead of needles at the acupoints, is an effective, non-invasive, supportive
treatmentformultipleclinicalcomplaints,andhaslimitedsideeffects.Itseffectivenessin
reducinglowerbackpainhasbeendocumented(Hsiehetal.,2004).However,theefficacy
of acupressure in reducing headache has never been demonstrated by a randomized con-
trolledclinicaltrial.Therefore,theaimofthisstudywastocomparetheefficacyofacupres-
surewiththatofamusclerelaxanttogetherwithanalgesicmedicationinreducingchronic
headache.
MaterialsandMethods
Participants
Thestudywasconductedfrom12March2003to10May2003atKaoshiungChangGung
MemorialHospital,amedicalcenterinSouthernTaiwan.Participantswererecruitedfrom
outpatients seeking clinical management of chronic headache, as diagnosed by a senior
neurologicalspecialist.Eligibilitycriteriaforparticipantsinthisstudywereasfollows:(1)
patientswereaged18yearsorolder;(2)patientshadexperiencedchronicheadacheforover
6months,withanepisodefrequencyofmorethan4amonth;(3)thechronicheadachewas
not caused by systematic or organic disease; (4) the headache was not caused by cancer
or psychiatric diseases; (5) female participants were not pregnant; (6) patients were not
experiencingacutesevereheadachethatrequiredimmediatetreatment;(7)patientshadno
contraindicationstoacupressure;and(8)patientswerenotallergictothemusclerelaxant.
We screened 79 patients and found 28 subjects, aged between 24 and 83 years, who met
oureligibilityrequirementsandagreedtogiveinformedconsentandfollowthetreatment
protocol.Thisnumberwasdeterminedtobesufficientinlightofthesamplesizedescribed
below.
Randomization
Uponrecruitment,anindependentresearchassistantusedapre-determinedrandomtableto
assign14participantstotheacupressuregroupandtheother14tothemusclerelaxantmed-
icationgroup.ThediagraminFig.1illustratestherandomizationandfollow-upprocedure.
Intheacupressuregroup,13patientsreceivedacupressureasallocated,butonerefusedthe
traditionaltreatment.Similarly,inthemusclerelaxantgroup,13patientsreceivedpharma-
ceuticaltherapyasallocated,butonerefusedthemedication.Attheendofthetreatmentand
atthesix-monthfollow-upassessment,all13patientsintheacupressuregroupand10of13
patientsinthemusclerelaxantgroupwerestillavailablefortheoutcomemeasurementpart
ofthestudy.
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4 L.L.-C.HSIEHetal.
Patients screened
(n = 79)
Patients met the eligible
criteria (n = 33)
Patients agree to participate in the
study, complete SEMG, and are
randomly assigned to groups (n = 28)
Patients allocated to Patients allocated to
acupressure group (n = 14) pharmaceutical therapy
group (n = 14)
Received acupressure as Received pharmaceutical
allocated (n = 13) therapy as allocated (n = 13)
Did not receive acupressure Did not receive pharmaceutical
as allocated (n = 1) therapy as allocated (n = 1)
Followed up after 8 treatments Followed up after a 6–8 week
or in 6–8 weeks, whichever period (n = 10)
came earlier (n = 13) Lost to follow-up (n = 3)
Lost to follow-up (n = 0) Pain assessment (n = 10)
Pain assessment (n = 13)
Followed up after a 6-month Followed up after a 6-month
period (n = 13) period (n = 10)
Pain assessment (n = 13) Pain assessment (n = 10)
Figure1.Flowdiagramofrandomized,controlledclinicaltrialonchronicheadache.
SampleSizeDetermination
Todeterminetheappropriatesamplesizeforthisstudy,wesearchedtherelevantliterature
toestimatethepretreatmentmeansandstandarddeviationsofpainscoresassessedbyvisual
analoguescale (VAS) (D’Andreaet al., 1995;Franke et al., 2000;Irnich etal., 2002).In
ordertodetectthedifferencebetweentwomeansof4.50and2.04withacommonstandard
January20,2010 14:38 WSPC WS-AJCM SPI-J000 00763
ACUPRESSUREINTREATINGHEADACHE 5
deviation(2.48)bymeansofanindependentt-test, fourteenparticipantswererequiredin
eacharmtoachieve80%statisticalpower,giventypeIerrorof5%.
Interventions
Thedurationofeachinterventionwassetat1month.Duringthisperiod,participantsinthe
musclerelaxantmedicationgroupreceivedDorsiflex(Mephenoxalone,amusclerelaxant)
plusanalgesicsifneeded,atthediscretionoftheseniorneurologist,for1month.Participants
in the acupressure groupreceived eight sessions of acupressuretreatment plus vitamin B
complexasaplacebomedicationinplaceofmusclerelaxantfor1month.ThedoseofB2
(riboflavin)intheBcomplexvitaminwas15mg/day.Patientswererequestedtomaintain
good medication compliance. The neurologist was responsible for administering the trial
andmanagingcomplaintsfrompatients.Theinterventionwasfurtherarrangedasfollows.
Inphase1,afterrandomization,participantsintheacupressuregroupreceivedsix10-min
treatments,spreadacross4weeksandperformedbythesamesenioracupressuretherapist
in order to render uniform technique and to ensure consistent experience for all patients.
The muscle relaxantmedicationgroup was prescribed a single type and standard dose of
Dorsiflexfor2–4weeks.Inphase2,afterthefirsttwoweeks,patientsineithergroupwho
experiencednopainreliefreceivedtheothertreatmentforanothertwoweeks,witha3day
breakbetweenthetwoformsoftreatments(3daysreflectsthehalflifeoftheDorsiflex;the
effectoftheacupressurenormallylastsforlessthantwodays);theothersremainedintheir
originalgroupsuntiltheyweresatisfiedthattheyrequirednomoretreatment.
BlindingtoPre-TreatmentScore
InordertoreducetheHawthorneeffect(wherebyknowledgeofpainscorespriortointer-
vention might influence the degree of effort made by the therapist), the neurologist and
acupressuretherapistwere blindto pre-treatmentassessment results,butwere requiredto
write down the dates of medication or treatment given to each participant. Patients were
requestedtoassesstheirpost-treatmentpainandratetheimpacttheirheadachehadontheir
lifequalitywithoutreferencetotheirpre-treatmentassessmentresults.Theydidthisaftera
1-monthperiodinthemusclerelaxantmedicationgrouporuponcompletionofsixtreatment
sessionsora1-monthperiod,whichevercamesooner,intheacupressuregroup.Patientswho
wereunabletocometothehospitalforpost-treatmentassessmentwerefollowedupbytele-
phone.Theresearchassistantwhoconductedtheposttreatmentandthe6-monthfollow-up
interviewswasalsoblindtopre-treatmentassessmentresultsandwasinstructedbeforehand
nottoasktheparticipantsfordetailsabouttheinterventiontheyhadreceived.
OutcomesMeasures
Participantswereaskedtoprovidebaselineinformationandtocompletethe‘headachequal-
ity of life’ questionnaire when they enrolled in the study. Baseline information included
dateofbirth,gender,maritalstatus,levelofeducation,occupation,income,andVASpain
January20,2010 14:38 WSPC WS-AJCM SPI-J000 00763
6 L.L.-C.HSIEHetal.
score.Theywerealsoaskedaboutthenatureoftheirheadacheexperience;theserelatedto
sleep quality,neck pain,and eye pain.The ‘headachequalityof life’ questionnaire,com-
monlyused in the centerfor evaluatingthe effectivenessof pharmaceuticalinterventions,
was used to rate the impact of patients’ headaches on their life quality both before and
aftertreatment.The‘headachequalityoflife’questionnaireconsistsof14items.Eachitem
is rated on a 6-point scale from ‘not a problem’ to ‘a continuous problem.’ Items cover
familyandsocialactivities,dailylifeactivities,workdaysandworking,assistancefromoth-
ers,andpsychophysicalexperiences.Freshcopiesofthequestionnairewereusedforthepre
andpost-treatmentassessmentsandthe6-monthfollow-up,andonlyparticipants’namesand
referencenumberswerecarriedovertoeachnewformtoavoidrevealingthepre-treatment
painassessmentscoresonlaterassessments.
StatisticalAnalysis
Analysisofdatafollowedtheintention-to-treatprinciple.TheWilcoxonranksumtestwas
usedtocomparecontinuousvariablesbetweenthetwogroups,andFisher’sexacttestwas
used to compare categorical variables. To assess the efficacy of the two treatments, two
sets of questions were used to examine differences in VAS pain score, headache related
symptoms,andratingsonthe‘headachequalityoflife’questionnaire.Thefirstsetofques-
tionswas used to compareoutcomesbetweenthe two groupsat the end of treatmentand
at 6-monthfollow-up.The second was used to assess the change in these outcomesfrom
the baseline after treatment and at the 6-month follow-up between the two groups. All
statistical analyses were performed with standard statistical software, SAS for Windows
version9.
Results
Table1showsthebaselinecharacteristicsoftheparticipantsinthetwogroups.Nosignifi-
cantdifferenceswereobservedbetweenthetwogroupswithrespecttoanyofthebaseline
variables.
Acomparisonbetweenthetwogroupspost-treatmentandthe6-monthfollow-upassess-
ment in terms of VAS pain score is shown in Table 2. The mean VAS pain score at 1
month after treatmentwas significantly lower in the acupressure group(32.9) than in the
muscle relaxant group (55.7) (p = 0.047). The mean change of score from the baseline
was also statistically remarkablein the acupressure group(−31.1)compared to the mus-
cle relaxant group (−8.1) (p = 0.033). The acupressure group also showed substantial
improvementsfrom baseline in two headache related symptoms, namely sleeping distur-
bance(p = 0.045)andneckpain(p < 0.001),howevernosignificantreductionintheeye
pain(p=0.088).Theimprovementineyepainwasofborderlinesignificance(p<0.001).
At the 6-month follow-upassessments, the mean value of VAS scores in the acupressure
groupwasstillsignificantlylowerthanthatinthemusclerelaxantmedicationgroup(11.5vs.
57.5,p=0.002).Asimilartrendwasfoundforthemeanchangeofscorefromthebaseline
(p=0.007).
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ACUPRESSUREINTREATINGHEADACHE 7
Table1. BaselineComparisonbetweenMuscleRelaxantGroupandAcupressureGroup
Variable MuscleRelaxantnnn===111444 Acupressurennn===111444 p-Value∗
Age 0.627
Rangey/o 27–83 24–64
Mean(SD)y/o 48.5(16.4) 44.1(12.6)
Sex 0.440
Male 4 7
Female 10 7
Marriage 0.724
Single 2 3
Married 11 9
Divorced 1 2
Education 1.000
(cid:1)College 10 10
(cid:2)Highschool 4 4
Occupation 0.385
Labor 2 5
Non-Labor 12 9
Income 0.596
HighIncome 11 13
LowIncome 3 1
SleepingQuality 0.695
Well 8 10
Poor 6 4
NeckPainInvolved 0.326
No 1 4
Yes 13 10
EyePainInvolved 1.000
No 7 8
Yes 7 6
VASPainScore(0–100) 0.963
Range 10–100 3–100
Mean(SD) 63.8(29.2) 64.1(27.1)
∗
Wilcoxonrank-sumtestwasappliedtothecomparisonofcontinuousvariablesbetweenthe
twogroups,andFisher’sexacttesttocategoricalvariables.
Table3 showsthedifferencesbetweenthe twogroupsinratingson14itemsfromthe
‘headachequalityoflife’questionnaire.Atbaseline,nosignificantdifferencewasobserved
betweenthetwogroupsintermsoftheimpactofheadachesontheirqualityoflife.Inthe
post-treatmentassessment,responsestosixofthefourteenitems,mainlyrelatingtowork
and activities, had improved more in the acupressure group than in the muscle relaxant
group.At the 6-monthfollow-upassessments, all 14 items showed more improvementin
theacupressuregroupthaninthemusclerelaxantgroup.
Whencomparingchangesfromthebaseline,subjectsintheacupressuregroupshowed
a significant improvementin post-treatmentin items related to daily and social activities
(Table4).Forsomeitems,thechangesfromthebaselinebecameinsignificantbythetime
ofthe6-monthfollow-up.
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8 L.L.-C.HSIEHetal.
Table 2. Comparison of Post-Treatment and 6-Month Follow-Up Assessments
betweenMuscleRelaxantGroupandtheAcupressureGroup
∗
VASPainScale(0-100) MuscleRelaxant Acupressure p-Value
Post-TreatmentAssessments n=14 n=14
TotalVASPainScore 0.047
Range 10–100 4–85
Mean(SD) 55.7(28.7) 32.9(26.0)
ChangeinVASPainScore 0.033
Range –64–0 –84–12
Mean(SD) −8.1(17.7) −31.1(29.7)
SleepingQuality 0.045
Well 7 12
Poor 7 2
NeckPainInvolved <0.001
No 1 11
Yes 13 3
EyePainInvolved 0.088
No 8 12
Yes 6 2
Six-MonthFollow-UpAssessments n=10 n=13
TotalVASPainScore 0.002
Range 0–90 0–60
Mean(SD) 57.5(31.7) 11.5(17.6)
ChangeinVASPainScore 0.007
Range –70–30 –100–2
Mean(SD) −11.5(28.9) −53.6(31.5)
∗
ByWilcoxontwo-sampletest.
Table 5 compares pain areas, trigger points used, and etiological causes by acupres-
sure in each patient. Among the etiologicalcauses, there were three cases resulting from
trauma,threefromtemporal-mandibularjointdisorder,andonefromboth.Inthese seven
cases, patients reported a history of previous injury. Etiological causes for another four
casesresultedfromprolongedmuscletension;chronicneckover-flexion,neckstiffness,and
persistentmentalstressandrelatedacheweremuchrelievedafteracupressuretreatment.
Discussion
ThisstudydemonstratedthatacupressureismoreefficaciousthanthemusclerelaxantDor-
siflexcombinedwithanalgesicsinreducingchronicheadache.ThemeanreductioninVAS
painscoreintheacupressuregroup(31.1)wassignificantlygreaterthanthatinthemuscle
relaxantmedicationgroup(8.1)(p=0.033).Thescoresforsustainedeffects6monthsafter
treatmentwerealsomoresubstantialintheVASpainscoresfortheacupressuregroup(11.5)
thanthoseinthemusclerelaxantmedicationgroup(57.5)(p=0.007).
VitaminBgiventopatientsintheacupressuregroupwasintendedasacounterparttothe
analgesicsprovidedtothoseinthemusclerelaxantgroup,toreduceanypossiblenegative
January20,2010 14:38 WSPC WS-AJCM SPI-J000 00763
ACUPRESSUREINTREATINGHEADACHE 9
ents p∗Value 0.0070.0040.011 0.0040.0030.010 0.0070.0010.002 0.0020.0040.0050.003 0.003
m
s
s
w-UpAsse upressure===n13n13n13 1.311.381.62 1.541.461.92 1.541.231.31 1.231.151.311.15 1.15
ps Follo Ac
ntbyGrou 6-Month Muscle Relaxant===n10n10n10 2.702.803.20 3.403.603.70 3.203.703.50 3.302.703.302.90 2.80
e
m
st-Treat ments p∗Value 0.0950.0100.014 0.0230.0070.049 0.0720.2340.365 0.0230.0790.0780.324 0.142
o
andP Assess ssure141414 469 661 434 1471 3
ment ment cupre===nnn 1.61.81.7 1.81.82.2 2.11.91.6 1.71.62.01.7 1.4
Treat Treat A
ngsPre- Post- Muscle Relaxant===n14n14n14 2.363.293.07 3.003.363.14 3.212.792.21 3.142.863.072.29 2.14
ati
R
ofLife’ ents p∗Value 0.7421,0000.655 0.4050.2000.811 0.2700.9260.307 0.9811.0000.8330.559 0.586
y m
Qualit Assess ssure141414 940 400 699 0001 0
he nt pre=== 2.73.63.0 3.13.03.5 2.82.72.7 3.03.03.52.7 2.0
ac me cunnn
ad at A
e e
risonof‘H Pre-Tr Muscle Relaxant===n14n14n14 2.573.573.21 3.433.793.29 3.362.932.29 3.073.003.362.43 2.36
a
p
m s
Table3.Co eQualityItems(1–14) AffectingfamilygatheringsAffectingleisureactivitiesDifficultywithdailyactivities UnabletoperformusualtasksHavinglimitedconcentrationFeelingtootiredtocompletetask LimitingworkingdaysCuttingworkingdaysNeedinghelpwithdailytasks StoppingworkinprogressUnabletojoininsocialmeetingsFeelingboredandsetbackBecomingaburden Disappointingothers yWilcoxonranksumtest.
Lif 1.23. 4.5.6. 7.8.9. 10.11.12.13. 14. ∗B
January20,2010 14:38 WSPC WS-AJCM SPI-J000 00763
10 L.L.-C.HSIEHetal.
d p∗Value 0.0580.0610.071 0.0190.0790.006 0.1540.0210.011 0.0200.0310.0080.013 0.020
n
ntaents
em
ost-TreatmUpAssess cupressure===n13n13n13 −.146−.231−.138−.162−.154−.162−.131−.154−.154−.185−.192−.231−.162−.092
Pw- A
nnairebyGroups Changesbetween6-MonthFollo cleRelaxant===n10n10n10 .010−.100.010.010−.040.050−.030.040.100.010−.050−.020.030.050
o s
sti Mu
e
u
Q
e’
yofLif p∗Value 0.0350.0090.020 0.0510.1380.015 0.1330.1240.021 0.0070.0200.0200.034 0.258
on‘HeadacheQualit betweenPre-andmentAssessments Acupressure===n14n14n14 −.114−.179−.121−.129−.114−.129−.071−.086−.114−.129−.136−.143−.100−.057
risonofChanges ChangesPost-Treat uscleRelaxant===n14n14n14 −.021−.029−.014−.043−.043−.014−.014−.014−.007.007−.014−.029−.014−.021
pa M
m
o
C
4. s
Table eQualityItems(1–14) AffectingfamilygatheringsAffectingleisureactivitiesDifficultywithdailyactivities UnabletoperformusualtasksHavinglimitedconcentrationFeelingtootiredtocompletetask LimitingworkingdaysCuttingworkingdaysNeedinghelpwithdailytasks StoppingworkinprogressUnabletojoininsocialmeetingsFeelingboredandsetbackBecomingaburden Disappointingothers yWilcoxonranksumtest.
Lif 1.2.3. 4.5.6. 7.8.9. 10.11.12.13. 14. ∗B