paper publications

31

Functional Outcome between Ischemic and Hemorrhagic Stroke Patients after Inpatient RehabilitationChandan KumarM.M. Institute of Physiotherapy and Rehabilitation, Mullana, Ambala

Abstract

PurposeThe goal of this study is to clarify whether

rehabilitation results are different between ischemic and hemorrhagic stroke patients matched for several other factors or different only in stroke origin.

MethodologyThis was a case control study of 70 inpatients

with result of first stroke who were enrolled in identical subgroup and matched for basal stroke severity evaluated by Canadian Neurological Scale, basal disability by Barthel Index, and Rivermead Mobility Index, age, and same duration of admission (within 3 days), who were different only in terms of stroke etiology hemorrhagic or ischemic.

We compare the efficiency and effectiveness of treatment, risk factors for stroke and changes in common component of Barthel and Rivermead Mobility Index score.

ResultsHemorrhagic patients showed better neurological

and functional prognosis when compared with ischemic patients. Hemorrhagic had significantly higher Canadian Neurological Scale score, higher barthel index score and higher Rivermead Mobility Index scores at discharge as compared to ischemic group. Rivermead mobility index, Barthel index and their mobility components were statically analyzed to obtain any co-relation between these two scales. It was found that there was not any statistically significant co-relation present between both the scales and their mobility components.

ConclusionsFrom this study, it can be concluded that hemorrhagic

patients showed faster recovery than ischemic patients did. Hemorrhagic stroke patients had better chance to make complete recovery from stroke.

Key wordsHemorrhagic, ischemic, rehabilitation, stroke

IntroductionStroke is one of the oldest recognized diseases, but

remains one of the least understood. Stroke is the third

most common cause of death and single largest cause of neurological disability worldwide1. Worldwide, 3 million women and 2.5 million men die from stroke every year2-4.

The generally accepted definition of stroke originates with the World Health Organization (WHO) and dates back to 1980 (1): which states that “Rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin”5.

A transient ischemic attack (TIA) is generally accepted as consisting of the same symptoms, but lasting for up to 24 hours.

Strokes can be classified into two major categories: ischemic and hemorrhagic

Ischemic StrokeIschemic stroke is a common form of stroke

accounting for approximately 80-85% of all strokes.6-8It occurs when a blood vessel becomes occluded and the blood supply to part of the brain is totally or partially blocked.

Hemorrhagic StrokeHemorrhagic stroke is more deadly and occurs

when a vessel in the brain suddenly ruptures and blood begins to leak directly into brain tissue and or into the clear cerebrospinal fluid that surrounds the brain and fills its central cavities (ventricles) account for 12-24% of strokes9-11.

Regarding recovery, it is generally believed that hemorrhagic stroke survivors have better neurological and functional prognosis than non-hemorrhagic stroke survivors do, but currently available data do not definitively answer all questions. In past, very few studies were done regarding outcome after hemorrhagic stroke compare with cerebral infarction12.

In other outcome studies, other prognostic factors such as stroke severity, age, and onset-admission interval (OAI) showed to be relevant prognostic factors in functional outcome13-14.

In a case-control study, hemorrhagic stroke patients showed functional gains, somewhat faster than ischemic patients but their data were not support with those of a prior study15-18. In other outcome studies, other prognostic factors such as stroke severity, age, and onset-admission interval (OAI) showed to be relevant prognostic factors in functional outcome18-21.

Therefore, to obtain a clear characterization of the

Chandan Kumar / Indian Journal of Physiotherapy & Occupational Therapy. April-June 2011, Vol. 5, No. 2

32

role of a potential prognostic factor on functional outcome, it should be necessary to perform a case-control study, with groups matched by a large number of variables, to avoid, minimize, or control for the role of several well-recognized risk factors.

The aim of the present study was to clarify whether rehabilitation results were different between ischemic and hemorrhagic patients matched for several other factors or Different only in stroke origin.

MethodologyTotal 70 patients selected from stroke patients

admitted to YCM Hospital, Pune for rehabilitation of sequel of their first stroke. For patient’s selection purposive sampling was done. On admission, patients were submitted to clinical, neurological and functional examination. All patients must have CT scan because it is consider the most sensitive and specific test to evaluate intracerebral hemorrhage. In several cases, MRI was also available.

Inclusion Criteria1. Individuals with first episode of stroke.2. Admitted within 3 days.3. Must have neuro-radiological reports.4. All patients who were medically stable.5. Age group between 40-70 years.6. Any sex.

Exclusion Criteria1. Individuals who had secondary hemorrhage.2. Patients who had neurological deficits after surgical

decompression of hemorrhage. 3. Patients had other chronic disabling neuropathology

e.g. Parkinsonism, polyneuropathy, severe cardiac, liver or renal failure and cancer.

4. Patients with absence of brain lesion on CT scan or MRI were excluded to avoid enrolling transient ischemic attack (TIA).

5. Any orthopedic complications (fracture, scoliosis) associated with stroke.

6. Cognitive deficits

MatchingFrom the results of neuroradiological result at the

time of Admission, stroke patients were divided into 2 groups, ischemic and hemorrhagic, matched by basal stroke severity (same CNS score), basal disability (same BI score and same rivermead mobility index), age (within 1 year), sex, and OAI (within 3 days).

Neurological and Functional EvaluationTo measure severity of stroke revised and validated

version of the Canadian neurological scale (CNS) was used ranging from 0 to 1522.

Functional data included rehabilitation length of stay (LOS), degree of independence evaluated by barthel index, mobility status evaluated by Rivermead mobility index (RMI).

Barthel index is widely used ADL Scale with ranging score from 0to100.23

The Rivermead mobility scale is short, simple scale validated for research analysis. That assesses 15 common daily activities. The scale gives a score ranging from 0 to 15.24

Each patient was evaluated by Canadian neurological scale, barthel index, and Rivermead mobility scale at the time of admission and discharge. All score were noted down.

Matching from the result of neuro-radiological report at the time of evaluation, stroke patients were divided into two groups ischemic and hemorrhagic matched by basal stroke severity, basal disability, age, and same duration of admission within three days.

Same physiotherapist for all patients designed exercise. Physiotherapy session was performed once a day for six days a week.

Physiotherapy started within 24 hours of admission. Same therapist treated each patient. Physiotherapy continued throughout the hospital stay.

Ethical clearance for the study was obtained from the ethical clearance committee of department of Physical Medicine and Rehabilitation, College of Physiotherapy, Nigdi, Pune.

Treatment (Physiotherapy)The rehabilitation plan, essentially conventional physical therapy based on ADL skills included:• Passive range of motion exercises• Active assistive exercises• Active exercises• Resistive exercises• Exercises in different functional positions• Weight bearing exercises• Weight shifting exercises• Reaching exercises in sitting, kneeling and standing. • ADL activities (Brushing, Combing, Cutting, Drinking,

Eating etc)• Gait training

These exercises prevent complications of immobilization and improve ADL skill at the earliest. This helps in preventing contractures and development of abnormal postures25-26. These exercises start with simple movements and subsequently complex movements and actions are tried.

Data and Statistical AnalysesWe compared demographic, clinical neuro-

radiological and functional data of the age-matched subgroups was using parametric or non-parametric analysis.

Comparison was performed between both the groups first at baseline level. Then again, comparisons were done at discharge level as well as from baseline to discharge level and results were noted.

Data analysis was performed with the SPSS10.0 statistical package.


33

ResultsWe successfully matched 70 ischemic patients with

hemorrhagic patients for stroke severity, age, basal disability, risk factor and sex.

Clinical characteristics of the subgroups are shown in Table I. As shown, characteristics of the 2 groups were the same except for hypertension (significantly more frequent in hemorrhagic patients), diabetes, and heart diseases (significantly more frequent in ischemic patients).

Table I: Baseline Characteristics of the 2 Subgroups After Matching

Ischemic Hemorrhagic P valueNo of patients 35 35

Age 64.8±5.49 64.29±4.416 NS

Sex (male) 68.5% 60% Ns

Stroke left 23 21 NS

CNS Score at admission 4.75 4.74 NS

BI Score at admission 17.28 16.00 NS

RMI Score at admission 1.22 1.02 NS

Hypertensive% 37.14% 74.28%

Diabetes % 11.42% 14.2%

Heart disease% 51.42% 11.42%

Both the groups were compared at the time of discharge by using non-parametric test of Mann Whitney in, which it was found that hemorrhagic patients had statistically significant, gain on all three scales.

DiscussionThe controversy about recovery after hemorrhagic

and ischemic stroke still exists.There are few studies on functional outcome of

hemorrhagic stroke patients. In total stroke population, only 15% are hemorrhagic in which 59-72% dies within three months making it difficult to compare it with same no of ischemic population.

In this study it was observed that hemorrhagic patients had a better prognosis but only in the absence of other more powerful prognostic factor like age, sex and same duration of admission. This is an impact of type of lesion on rehabilitation that is clearly significant in this study and earlier studies also show the same results16-22. If two patients at the beginning of rehabilitation had the same basal neurological severity (evaluated by Canadian Neurological Scale), same basal functional disability, same age, and same duration of admission as shows in table (I) Hemorrhagic patients showed better neurological and functional prognosis when compared

with ischemic patients as it shows in Table II, III and IV and graph I, II, II and IV.

This better functional recovery in hemorrhagic patients is probably due to a better neurological recovery, which is visible as the hemorrhagic patients had higher CNS scores at discharge as shows in table II and graph II. Neurological status evaluated by CNS is considered to reflect recovery from the stroke lesion itself12. It may depend on the mechanism of injury.

In hemorrhagic strokes, bleeding in the brain causes hematoma. Hematoma irritates the brain tissue, disrupting the delicate chemical balance and if the bleeding continues, it can cause increased intracranial pressure. This physically impinges on brain tissue and restricts blood flow to the brain.

In these respects, hemorrhagic strokes are more fatal than their counterpart ischemic strokes. But if patient survives after having cross the initial period of high risk for fatality the recovery seen in hemorrhagic patients as the hemorrhage can be treated medically or surgically, this leads to early healing, early neurological recovery and thus resulting into better neurological and functional status.

In case of ischemic stroke the area affected within the ischemic cerebrovascular bed, there are two major zones of injury, the core ischemic zone and the “ischemic penumbra” (the term generally used to define surrounding area of core infarct cerebral tissue). In the core zone, which is an area of severe ischemia (blood flow below 10% to 25%), the loss of supply of oxygen and glucose for more than 60-90 seconds brain tissue ceases to function resulting rapid depletion of energy stores. Severe ischemia can result in necrosis of neurons and of supporting cellular elements (glial cells) within the severely ischemic area. Brain cells within the penumbra, a rim of mild to moderately ischemic tissue lying between tissue that is normally perfused and the area in which infarction is evolving, may remain viable for several hours.

After treatment when recovery occurs, it is seen only in surrounding area (ischemic penumbra) but not in the dead tissues or core area of infarct.

So in case of ischemic stroke affected part dies and there is irreversible injury but in case of hemorrhagic stroke hematoma irritates brain tissues rather than damaging it9-13. That’s why it is possible for patients to make a better neurological recovery from a hemorrhagic stroke. Functional and mobility status is improved due to neurological recovery.

Thus, this study supports the previous literature, and is seen in Indian population, as well. This data is useful in improving knowledge on rehabilitation outcome of stroke survivors.

Table II: Admission and discharge score of both the groups

Hemorrhagic IschemicAt admission At discharge At admission At discharge

Canadian neurological score 4.74 8.11 4.75 7.30

Rivermead mobility index score 1.02 5.71 1.22 5.22

Barthel index score 16.00 50.00 17.28 47.28


34

Limitations of a StudyLength of stay could not be included as an

independent variable in this study as sample size was selected from acute care hospital setup and physiotherapist were not consulted if it was appropriate for the patients to be discharged.

Future Scope of StudyStudy to be carried out like the said methodology,

but can be a prospective study for a longer period and therapist should be able to decide upon discontinuation of treatment so that length of stay or days of physiotherapy treatment can be included as an independent variable.

Conclusion From this study it can be concluded that hemorrhagic

patients showed faster recovery than ischemic patients in Indian population as well. Hemorrhagic stroke patients had better chance to make complete recovery from stroke.

References 1. Bonita R. Epidemiology of stroke. The Lancet1992; 339:342-42. World Health Organization. WHO Burden of Diseases and

Injury (Dataset - 2002).3. World Health Organization. 2003. Geneva, Switzerland,

World Health Organization. 20034. World Health Organization. The WHO stroke surveillance...

2004. World Health Organization. 29-7-2004.

5. Aho K, Harmsen P, Hatano S, et al. Cerebrovascular disease in the community: results of a WHO collaborative study. Bull WHO 1980; 58:113 – 130.

6. Sudlow CL,. Warlow CP. Comparable studies of the incidence of stroke and Its pathological types: results from an international collaboration.International StrokeIncidence Collaboration. Stroke.28 (3):491-9, 1997.

7. National Institute of Neurological Disorders and Stroke (NINDS) (1999). Stroke: Hope through Research. National Institutes of Health.

8. Ay H; Furie KL; Singhal A; Smith WS; Sorensen AG; Koroshetz WJ (2005). “An evidence-based causative classification system for acute ischemic Stroke”. Ann Neurol 58 (5): 688-97

9. Labovitz DL, Sacco RL. Intracerebral hemorrhage: update. Curr Opinion Neurol. 2001; 14:103–108.

10. Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF. Spontaneous intracerebral hemorrhage. N Engl J Med. 2001; 344:1450–1460.

11. Vermeer SE, Algra A, Franke CL, Koudstaal PJ, Rinkel GJ. Long-term Prognosis after recovery from primary intracerebral hemorrhage. Neurology. 2002; 59:205–209.

12. Jorgensen HS, Nakayama H, Raaschou HO, Olsen TS. Intracerebral Hemorrhage versus infarction: stroke severity, risk factors, and prognosis. Ann Neurol. 1995; 38:45–50.

13. Shah S, Vanclay F, Cooper B. Predicting discharge status at commencement of stroke rehabilitation. Stroke. 1989; 20:766–769.

14. Ween JE, Alexander MP, D’Esposito M, Roberts M. Factors predictive of Stroke outcome in a rehabilitation setting. Neurology. 1996; 47:388–392.

16. Bomford J. et al:a prospective study of acute cerebrovascular disease in the Community; the oxford community stroke project 1981-86.incidence case Fatality rates and over all outcomes at one year of cerebral infarction, Primary Intracerebral and subarchnoid hemorrage. J Neural Neurosurg Psychiatry 1990; 53:16-22.

17. Anderson C.J. et al Predicting survival for one year among different subtypes of stroke.Results from the Pearth community stroke study. Stroke 1994; 25:1935-44.

18. Chae J, Zorowitz RD, Johnston MV. Functional outcome of hemorrhagic And non- hemorrhagic stroke patients after in-patient rehabilitation. Am J Phys Med Rehabil. 1996; 75: 177–182

19. Franke CL, van Swieten JC, Algra A, van Gijn J. Prognostic factors in Patients with intracerebral hematoma. J Neurol Neurosurg Psychiatry.1992; 55:653–657.

20. Kelly P.J., Furie LK, Shafqat S. Rallis N, Chang Y. Stein J. Functional Recovery Following Rehabilitation after Hemorrhagic and Ischemic Stroke. Arch Phy Med Rahabil Vol 84; July 2003, 968-72.

21. Ghatak RK, Ballav A Mukherjee SC. Comparison of outcome of stroke Patients– cerebral ischemic versus cerebral hemorrhagic from the standpoint of a physiatrist.

22. Lin JH. Hsich CL, Lo SK, Hsiao SF, Hyang MH. Prediction of functional Outcomes in stroke inpatients receiving rehabilitation.

23. Cote, R; Battista, R; Wolfson, C; Boucher, J; Adam, J; Hachinski, V. The Canadian Neurological Scale: Validation and Reliability Assessment. Neurology 1989; 39:638- 643.

24. Mahoney FI, Barthel DW. Functional Evaluation: The Barthel Index. Maryland State Medical Journal 1965; 14:61-65.

25. Scand J Rehabil Med. 2000 Sep; 32(3): 140-2. Validity and responsiveness of the rivermead mobility index in stroke patients.

26. Lord JP, Hall K: Neuromuscular reeducation versus traditional programmed for stroke rehabilitation. Arch Phys Med Rehabil 1985; 67: 88 – 91.

27. Dickstein R. Hocherman S. Pillar T el at: Stroke rehabilitation. Three exercise Therapy approaches. Phys Therapy: 1986; 66: 1233 – 1238.

Graph I:Comparison of Admission and Discharge Values

4.7

1

16

4.71.2

17

8.15.7

50

7.35.2

47

0

10

20

30

40

50

60

CNS RMI BI CNS RMI BI

Haemorrhagic Ischemic

Me

dia

n

Admission Discharge

The graph shows the scores of both the groups ischemic and hemorrhagic at the time of admission and after rehabilitation at the time of discharge on all three scales.

Graph II:

Admission

Discharge

Admission

Discharge

4

4.5

5

5.5

6

6.5

7

7.5

8

8.5

Admission Discharge

Scale

Neurological Status (CNS Score)

at Admission and Discharge

Haemorrhagic Ischemic

Above Mentioned graph shows that the hemorrhagic patients had higher scores on the Canadian neurological scale as compared to ischemic patients, in spite of same treatment program. Hemorrhagic group showed statistically significant higher Canadian neurological scale score discharge time. Statistically significance was at the level of (P.<. 001).


35

The Efficacy of Bilateral Training on Functional Recovery of Upper Extremity After StrokeChandan Kumar, Mukesh KumarM.M. Institute of Physiotherapy and Rehabilitation, Mullana, Ambala

Abstract

PurposeThe goal of this study is to find out that how much

bilateral training is more effective as compare to the unilateral training on functional recovery of upper extremity in stroke rehabilitation.

MethodologyThis was a experimental study of 30 stroke patients

with unilaterally stroke had paresis or plegia of upper limb. All the subjects are enrolled in identical subgroup and divided into two equal group (15 patient in each group) one experimental and another control group. Experimental group contain bilateral activities training and control group contain unilateral activities training.

We assessed the Functional recovery of upper extremity and functional independence of all patients by Fugl-Meyer scale for upper extremity and Functional independence measure for self care and tried to find out the additional effect of bilateral activity training on stroke patients.

ResultsResult shows that, both the group improved

significantly but bilateral training group improved much better than unilateral training group

ConclusionsThis study suggests that bilateral activities training

is more effective as compare to the unilateral activities training for the functional recovery of upper extremity in stroke patients.

Key wordsUnilateral training, bilateral training, stroke

rehabilitation, upper extremity.

IntroductionStroke is an increasing public health concern

throughout the world; it is the second commonest cause of death and the leading cause of long term disability1. Stroke is a major cause of long term neurological disability in adults and has Implication for patents, caregivers, health professional and general society2.

The generally accepted definition of stroke originates with the World Health Organization (WHO) and dates

back to 1980 (1): which states that “Rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin”3.

The Common Neurological Impairments Due T0 Stroke Are

Motor impairments are most prevalent of all deficits seen after stroke, usually with involvement of the face, arm and leg (Hemiparesis) alone or in various combinations, which include involvement of cranial nerves, muscle power and tone, reflexes, balance, gait, co ordination and apraxia4.

Sensory deficits range from loss of primary sensation to more complex loss of perception; it can cause visual and perceptual impairments, homonymous hemianopia or cortical blindness5.

Common speech disorder that are seen include aphasia, dysphasia. Dysphasia may be exhibited by disturbances in comprehension, naming, repetition, fluency, reading or writing6.

Hemiparesis represent the dominant functionally limiting symptoms in 80% of patients with acute stroke within 2-5 months after stroke; patients recover a Variable degree of function, depending on the magnitude of the initial deficit7.

Arm recovery after stroke is typically poor; with 20% to 80% of patients showing incomplete recovery depends on the initial impairment. Upper limb dysfunction in stroke is characterized by paresis, loss of manual dexterity, and movement abnormalities that may impact considerably on the performance of ADLs8.

Grasping, holding, and manipulation objects are daily functions that remain Deficient in 55% to 75% of patient 3 to 6 months poststroke9.

Physiotherapy Treatment for Recovery of Upper Extremity

In physiotherapy a variety of movement therapy approaches are available for retraining motor skill in adult patients with hemiplegia. Certain approaches like Proprioceptive neuromuscular facilitation, Rood, Brunnstrom, and Bobath relay on reflex and hierarchical theories of motor control and motor learning as well as the principles of neural plasticity10.

Bilateral TrainingBilateral training is a new class of interventions aimed


36

at increasing the efficiency of movement in the context of using both hands together11-12. Previous research has typically focused on motor learning approach involving unilateral training of the hemiplegic arm. Recently bilateral training, in which patients practice identical activities with both upper limbs simultaneously, has been proposed as a strategy to improve hemiplegic upper limb control and function13. but currently available data do not definitively answer all questions. Therefore, to obtain a clear characterization of effectiveness of bilateral training a research study was required.

The purpose of this study to find out that how much bilateral training is effective as compare to the Unilateral training on functional recovery of upper extremity in stroke rehabilitation.

MethodologyTotal 30 patients of stroke from M.M hospital

Mullana, Ambala and Yamunanagar hospitals who met the inclusion criteria included in this study. For patient selection purposive sampling was done. The total 30 patient were divided into two equal group (15 patient in each group) one experimental and another control group. Experimental group contain bilateral training and control group contain unilateral training

Inclusion Criteria1. Individuals with first episode of unilateral stroke. 2. All patients who were medically stable3. Paresis of upper limb.4. Mini-Mental stage examination score of at least 24/30.5. Fugl-Meyer score between 11 and 40.6. No clinical evidence of limited passive joint range of

motion.7. Age 46 to 80 years both male and female.8. Able and willing to participate in a 4 weeks study.9. Ability and willingness to sign the consent form.

Exclusion Criteria1. Multiple clinical stroke patients.2. Subject had other neurological, orthopedic or pain

condition that might limit arm movement.3. Clinical evidence of shoulder subluxation. 4. Any type of Cognitive deficit.

ProcedureThirty patients of stroke who fulfill the inclusion criteria

were included in this study. Total numbers of patients were divided into two equal groups, one experimental group and another control group. Each group contained 15 patients. The bilateral training for upper extremities had given to the experimental group and unilateral training for upper extremity had given to the control group. All participants were evaluated by Fugl-Meyer scale for upper extremity, Functional independence measure scale for self care and Mini-Metal status scale to know the mental status.

Fugl-Meyer scale shown to valid and reliable,12 has a top score 66. All the Fugl-Meyer scale for upper

extremity was used for assessment of motor function of upper extremity in all stroke patients.

Functional independence measure scale was used for the assessment of functional recovery of upper extremity in all stroke patients. This scale has been shown to valid and reliable13.

Mini mental status scale is a reliable and valid scale to asses the mental status of subjects used in this study14.

At the first, the patients were informed about the purpose, procedure, possible discomforts, risks and benefits of the study prior to obtaining an informed written consent from the patient.

All patients were first assessed by Mini-Metal status scale to know the mental status.

After that all patients were assessed by Fugl-Meyer scale, Functional independence measure before and after giving intervention.

The subjects were asked not to participate in any other study or physiotherapy treatment for upper extremity from for the duration of the study and to follow the designated protocol.

Treatment (Physiotherapy)Patients of the bilateral training group were made

to start of exercise from passive/ active movements of all the joints of upper extremities including shoulder joint, elbow joint, wrist joint, metacarpophalangeal joints and interphalangeal joints with the use of both upper extremities together.

After active movements patients were made to start weight bearing and supportive reaction with the use of both upper extremity (e.g. seated weight bearing), after that reaching activities (e.g. forward supported reach with both upper extremities and shoulder in elevation, wrist and elbow in extension) than grasping, holding and releasing activities and at last patients were performed ADL activities (e.g. dressing and self feeding activities)15.

Subjects of unilateral training group performed the same activities with the use of only the effected upper extremity.

All the exercises were performed in 45 minutes. There was no subdivision of time for each activity. Patients were performed exercises on the bases of their motor control for 45 minutes in a day and 5 days in a week for 4 weeks.

Data and Statistical AnalysesComparison was performed between both the

groups first at baseline level. Then again, comparisons were done at discharge level as well as from baseline to discharge level and results were noted.

Paired T test was used for analyzed the pre to post changes within the groups. Unpaired T test was used for analyzed the changes between the two groups. Data were analyzed using SPSS 13.0.

ResultsWe successfully matched 30 patients of both control

and experimental group for upper extremity recovery


37

and functional independence. First we compared demographic and functional data of the age matched subgroup. Analysis comparison was done between both the groups first at base line and then at the end of intervention and again comparison was done between baseline score and after intervention score and result were noted.

Baselines characteristics of both the group are shown in table 1. cheracteristic of both the groups were same at the base line level prior to intervention.

Table 1: Baseline Characteristics of the 2 groups After Matching

Bilateral group

Unilateral group

P value

No of patients 15 15

Age 59.20±8.326 58.80±7.193 NS

Sex (male) 9 9 – 1

Stroke left 13 13 NS

Stroke right 2 2 NS

Mini-Mental scalescore

27.13 27.40 o.5886

Fugl-Meyer score before intervention

25.60 25.80 .910

Functional independence measure score before intervention

20.13 19.80 .670

This table shows that before intervention there was no significant difference of Fugl Meyer score between the groups (p value- .910) and functional independence score of both the groups ( p value.670).

Table 2: Fugl-Meyer Scores of both the group before and after intervention

Group Fugl-Meyer score before intervention

Fugl-Meyer score after intervention

P value

Bilateral group

25.60 49.13 .001

Unilateral group

25.80 37.53

Above table shows that after intervention there was significant difference between both the groups (p value- .001).

Table 3: Functional independence measure score of both the group before and after intervention

Group F I M score before

Intervention

FIM score after intervention

P value

Bilateral group

20.13 36.93 .001

Unilateral group

19.80 30.67

Above table shows that after the intervention there was significant difference between the groups ( p value - .001).

Table 4: Fugl-Meyer scale and FIM score of both the group after intervention

Fugl-Meyer score after

intervention

P value FIM score after

intervention

P value

Bilateral group

49.13 .001 36.93 .001

Unilateral group

37.53 30.67

Above table is showing the score of both groups on Fugl-Meyer scale and FIM score after given the treatment. Independent sample test was used showed significant changes between both the group both the scales. On Fugl-Meyer scale p value is .001 and same for FIM score.

Above Mentioned graph and table show that the bilateral group patients had higher scores on the Fugl- Mayer score and FIM score as compared to unilateral group patients in spite of same base line score. Bilateral group showed statistically significant higher Fugl- Mayer and FIM score at the end of intervention. Statistically significance was at the level of (P.<. 001).

DiscussionIn this experimental design study, result shows the

effects of Bilateral training as compare to the unilateral training on functional recovery of upper extremity in stroke patients. The results support the hypothesis that bilateral training is more effective for functional Recovery of upper extremity in stroke patients as compare to the unilateral training. Although both groups (bilateral training group and unilateral training group) improved,

Graph 1:

Graph 2:

0

5

10

15

20

25

Fugl-Meyerscore

Mean S.D

Fugl-Meyer score change before to after given

intervention

Bilateral group

Unilateral group

Above graph showing the changes score on FIM is more in bilateral training group than the unilateral training group.

Above graph showing the changes in the bilateral training group and unilateral training group on Fugl-Meyer score before and after treatment.

0

5

10

15

20

Mean S.D

FIM score

FIM score changes before to after given

intervention

Bilateral group

Unilateral group


48 Gagandeep Kaur / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Relationship Between Motor Impairments of Hand and ManualAbility in Spastic Cerebral Palsy ChildrenGagandeep Kaur1, Poonam Mehta2, Chandan Kumar3

1Student, 2,3Lecturer, M M IPR, M M University, Mullana, Ambala, Haryana, India

Abstract

Introduction

Cerebral palsy is a static neurologic condition resultingfrom brain injury that occurs before cerebral developmentincomplete. Hand impairments are related to the manual ability.Hand impairments are not rare in the cerebral palsy but theyare not considered significantly. We assessed the handimpairments in relation to manual ability amongst Cerebral palsychildren who were spastic diplegics and quadriplegics.

Material and Methods

Thirty cerebral palsy children were assessed. Handimpairments included grip strength, fine finger dexterity, grossmanual dexterity and these were assessed by hydraulic handhandle dynamometer, pegboards and box and block testrespectively. Manual ability was assessed by

Abilhand kid’s questionnaire. All the subjects according tothe inclusion criteria were included in the study. One timeassessment was taken. For the grip strength and fine fingerdexterity three readings were taken and average of these threereadings was taken as the final score. For box and block testsingle reading was taken. Spasticity was assessed by theModified Ashworth Scale. Results were calculated by usingPearson’s correlation.

Results

There is a significant correlation between grip strength,fine finger dexterity, gross manual dexterity and manual ability.Grip strength has correlation of -0.459(P=<0.05) with the manualability, fine finger dexterity has the correlation of -.732(P=<0.05)with the manual ability and gross manual dexterity has thecorrelation of -0.781(P=<0.05) with the manual ability.

Key Words

Cerebral palsy, impairments, manual ability.

Introduction

Cerebral palsy is an umbrella term encompassing a groupof non progressive, non contagious motor condition that causesphysical disability in human development, chiefly in various areasof body1.Martin Bax defined “Cerebral palsy as a disorder ofposture and movement that occurs secondary to damage to theimmature brain before, during or after birth. This disorder is calleda static encephalopathy because it represents a problem withbrain structure and function2.The birth prevalence of cerebralpalsy ranged from 1.18 to1.97 per 1000 live birth each year,with a mean of 1.51 per 1000 live births3.

Address for correspondence:Gagandeep KaurM.P.T. Pediatrics StudentContact number+91-09896429194.E-Mail: [email protected]

Cerebral palsy is a static neurologic condition resulting frombrain injury that occurs before cerebral development incomplete.Because brain development continues during the first two yearsof life, cerebral palsy can result from brain injury occurring duringthe prenatal, perinatal or post natal periods. Etiology of cerebralpalsy include problems in intrauterine development (e.g.exposure to radiation, infection),asphyxia before birth, hypoxiaof the brain and birth trauma during labor and delivery,complications in the perinatal period or duringchildhood1.Braindevelopment continues during the first two years of life, cerebralpalsy can result from brain injury occurring during the prenatal,perinatal or post natal periods4.

According to tone classification includes spastic, athetoidi.e. hypotonic/floppy or atonic. Spastic type of cerebral palsy isthe commonest type. Spastic Cerebral palsy associated withdamage to cortical motor areas and underlying white matter,choreoathetotic cerebral palsy associated with damage to basalganglia, ataxic cerebral palsy is associated with damage tocerebellar structures7 Spastic cerebral palsy consists of hypertonicity of clasp-knife variety, abnormal postures, weakness ininitiation of motion. Changes in hypertonous and posture mayoccur with excitement, fear or anxiety. Intelligence is impairedthan athetoid Impairments include motor impairments andsensory impairments. Motor impairments include abnormalreflexes, disturbances in balance, locomotion, propulsion ofobjects and sensory impairments include tactile pressurestereognosis, proprioception4, cerebral palsy. Perceptualproblems, sensory loss, epilepsies, poor ribcage abnormalitiesand poor respiration4,5.

The aim of physiotherapy is to make patient maximumindependent. Physical therapy includes muscle strengtheningand fitness programs as popular interventions for cerebral palsy;however advocates of neuro developmental treatment adviseagainst the use of resistive exercises because it is believed toincrease spasticity18.It is also shown that resistive exercise couldbe beneficial in strengthening when muscle weakness causesdysfunction19. Stretching exercises, sensory stimulation, PNF,Biofeedback are also used4,5. Orthotic devices such as anklefoot orthosis are often prescribed to minimize gait irregularities20.AFO’s have been found to improve several measures ofambulation, including reducing energy expenditure andincreasing speed and stride length20.21.

Previous studies show that hand impairments and manualability are correlated to each other. In previous studies, gripstrength was measured by Jamar dynamometer, gross manualdexterity was measured by box and block test, fine fingerdexterity was measured by Purdue pegboard. But in presentstudy, the grip strength is measured by Hydraulic hand handledynamometer which measures the strength in kgs, gross manualdexterity is measured by box and block test, in which one woodenbox is there having six inches partition in it with 150 blocks ofone inch and fine finger dexterity is measured by pegboards(square pegboard and fine finger test).The square pegboard istwelve inches in length and twelve inches in width. It consists of25 pegs and 25 holes. The fine finger dexterity test consists of

49

two square wooden boards, one is having 49 holes in it andother is having one cup which consists of 49 pins in it and oneforcep in it.

Manual ability is a major component of daily living activities.Hand impairments are related to the manual ability. Handimpairments are not rare in the cerebral palsy but they are notconsidered significantly. There are very few studies done toassess the hand impairments and to measure the manual ability.Because there is lack of instrumentation to assess theseimpairment and manual ability. This study will help to measurethe hand impairments and manual ability. And will also help tofind the relation between these impairment and manual ability.

The objective of this study is to find the relationship betweenhand impairments (Grip strength, gross manual dexterity andmanual ability) and manual ability in children with spastic cerebralpalsy (diplegics and quadriplegics).

Objective of the Study

To evaluate hand impairments i.e. grip strength, fine fingerdexterity and gross manual dexterity in relation to manual ability.

Hypothesis

Alternate Hypothesis

There is a significant correlation between hand impairmentsand manual ability.

Null Hypothesis

There is no significant correlation between handimpairments and manual ability.

Methodology

This chapter contains cerebral palsy children’s handimpairments and their relation with the manual ability.

Study Design

Correlation.

Sample Size

A convenience sample of total 30 subjects with alreadydiagnosed cerebral palsy were included in the study.

Study Population

Subjects were taken from the M.M.I.P.R Mullana and M.M.Hospital Mullana.

Inclusion Criteria

Children who fulfilled the following criteria were taken intothe study.1. Children diagnosed with cerebral palsy (Diplegics and

Quadriplegics).2. Age between 5-13y (Both boys and girls).3. Children with no major intellectual deficits.

Exclusion Criteria

1. Children with learning disabilities.2. Children undergone surgical procedures (for upper limb)3. Children with major intellectual deficits.

Outcome Measures

In the study the following outcome measures were taken.1. Abilhand kids questionnaire.2. Grip strength.3. Gross manual dexterity.4. Fine finger dexterity

Instrumentation

Following instruments were used in the study.1. Hydraulic Hand Handle Dynamometer.2. Box and Block Test.3. Pegboard Test.

Procedure

30 subjects were selected on the basis of inclusion criteria.A thorough assessment was done. The procedure of the studywas explained to parents/guardian and written consent wastaken. The children were tested individually and instructions thathow to perform each test were given to them. Three motorimpairments i.e. Grip strength, Gross manual dexterity and finefinger dexterity were assessed on both hands, starting withdominant hand. Handedness was determined by writing handpreference. Grip strength was measured with Hydraulic Handhandle dynamometer. The grip strength score was determinedas the average of maximum force exerted on dynamometeracross three trials. According to standard position for testingwhich was recommended by American Society of Hand therapist,the readings were taken. The child sat in a straight backed chair,feet flat on the floor ,shoulders adducted in a neutral, armsunsupported, elbows flexed at 900,forearm rotation neutral, wrist0-300dorsiflexion and 0-150 ulnar deviation. Gross manualdexterity was measured by Box and Block test. The child satstraight on the chair and box was kept in front of the child andinstructions were given to him that how to perform the test. Thescore was determined as the maximum number of blockstransported from one compartment to another in one minute.Fine finger dexterity was measured by the pegboard test. Thechild sat on the chair and pegboard was kept in front of the childand instructions how to perform the test were given to him. Thechild was instructed to do 2 times practice before performingthe final test. The fine finger dexterity score was determined bythe number of pegs picked up from a cup and placed into holesof a board in one minute. Manual ability was assessed byAbilhand kids questionnaire. This questionnaire measures thechild’s capacity to manage daily activities requiring the use ofhand and upper limb. Twenty one mostly bimanual activitieswere rated by children’s parents on a 3-level scale (0-impossible,1-difficult, 2-easy) by providing their child’s perceived difficultyin performing each activity.

Data Analysis

A Pearson correlation coefficient was calculated to examinethe relationship between grip strength, fine finger dexterity, grossmanual dexterity and manual ability. P value was set at<.05.SPSS version statistical software was used for analysis.

Results

All (30) subjects meeting inclusion criteria were invited toparticipate in the study. All 30 subjects consented and completedall observation. Subjects included were both boys and girls.Subjects included in the study were diplegics and quadriplegics.All the subjects include in the study were of age between 5-13y. Subjects were taken from out patients departments.

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50 Gagandeep Kaur / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Table 1: Mean and standard deviation of grip strength, fine finger dexterity, gross manual dexterity and manual ability.

Mean for RT grip strength is 2.303 ± 0.712 and for LT gripstrength is 1.913 ± 0.224.

Mean for RT fine finger dexterity is 12.777 ± 1.926 and forLT fine finger dexterity is 10.000 ± 2.777.

Mean for RT gross manual dexterity is 22.867 ± 3.711 andfor LT gross manual dexterity is 16.933 ± 2.852

Mean for manual ability is 27.833 ± 8.073.

GRIP FINE FINGER GROSS MANUAL MANUAL ABILITYSTRENGTH DEXTERITY DEXTERITY

RT LT RT LT RT LTMEAN 2.303 1.913 12.777 10.000 22.867 16.933 27.833

S.D 0.712 0.224 1.926 2.777 3.711 2.852 8.073

Table 2: Correlation for grip strength, fine finger dexterity, gross manual dexterity with manual ability (Lf & Rt).

The correlation is significant with p value <0.05Correlation with manual ability for grip strength is -0.407(RT)

& -0.567(LT).Correlation with manual ability for fine finger dexterity is -

0.728(RT) & -0.567(LT).Correlation with manual ability for gross manual dexterity

is -0.766(RT) & -0.773(LT).Correlation of grip strength with manual ability is -0.459.Correlation of fine finger dexterity with manual ability is -

0.732.Correlation of gross manual dexterity with manual ability is

-0.781.

GRIP FINE FINGER GROSS MANUALSTRENGTH DEXTERITY DEXTERITY

RT LT RT LT RT LT

Correlationwith manual -0.407 -0.567 -0.728 -0.567 -0.766 -0.773 ability

Table 3: Correlation for grip strength, fine finger dexterity, gross manual dexterity with manual ability.

GRIP FINE FINGER GROSS MANUAL Correlation STRENGTH DEXTERITY DEXTERITY

with manual ability -0.459 -0.732 -0.781

Fig. 1: Correlation b/w grip strength (Rt) and manual ability.

Fig 2: Correlation b/w grip strength (Lf) and manual ability.

Fig. 3: Correlation b/w fine finger dexterity (Rt) and manualability

Fig. 4: Correlation b/w fine finger dexterity (Lf) and manualability

51Gagandeep Kaur / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Fig. 5: Correlation B/W gross manual dexterity (Rt) and manualability

Fig. 6: Correlation B/W gross manual dexterity (Lf) and manualability

Discussion

This chapter deals with the results of the study. In this study,results showed that there is a significant relationship betweenthe hand impairments and manual ability. We found that handimpairments has significant correlation with manual ability. Gripstrength has significant relationship with manual ability whenmeasured with hydraulic hand handle dynamometer andAbilhand kid’s questionnaire respectively. Correlation of gripstrength with manual ability is -0.459.There was a significantrelationship between fine finger dexterity and manual ability whenmeasured with pegboards and Abilhand kid’s questionnairerespectively. Correlation of fine finger dexterity with manual abilityis -0.732. There was a significant relationship between grossmanual dexterity and manual ability when measured with boxand block tests and kid’s questionnaire. Correlation of grossmanual dexterity with manual ability is -0.781.

Results of our study show that the capacity of upper limband completion of ADL’s of upper limb had a significantcorrelation. A study done by Carlyne Arnould et al suggestedthat manual ability was significantly correlated with motorimpairment and stereognosis, while no significant relationshipwas found with tactile pressure detection and proprioception.Melanie Ziebell et al suggested that the children with diplegiaperformed at lower levels in all gross and fine motor assessmentsas compared to children without diplegia.

Massimo Penta et al concluded that grip strength, dexterity,motricity, depression were significantly correlated with Abilhandmeasures which was used to measure manual ability in thestroke patients. Gonca Bumin et al showed that there wassignificant correlation between handwriting parameters andupper extremity speed and dexterity, propioception. bilateralcoordination, visual and spatial perception and visual motororganisation in children with cerebral palsy. Julie Duquesuggested that there is a correlation between impaired dexterityand corticospinal tract dysgenesis in congenital hemiplegiabetween .Jetty Van Meeteren et al suggested that correlationsbetween grip strength parameters and activity limitations wererelatively weak.

Our study suggests that impaired grip strength, fine fingerdexterity and gross manual dexterity, interfere with the activitiesof daily living i.e. manual ability and quality of life. This studyalso suggests that the effect of maturation and hand dominanceand gender is also there. Age and hand dominance and genderalso affects the grip strength, five finger dexterity, gross manualdexterity and so as manual ability. Both impairment and upperlimb activity i.e. manual ability showed a correlation and influenceon activities of daily living.

Clinical Implications

Hand impairments i.e. grip strength, fine finger dexterity

and gross manual dexterity were rarely correlated with manualability. Therefore our study suggests that the other parametersof upper limb are also important to stress upon. So, thisknowledge can assist clinician in making specific treatmentinterventions for improving condition of cerebral palsy children.

Future Research

1. The study can be conducted with a heterogeneous genderbias (either males or females).

2. Subjects included were only spastic diplegic andquadriplegics. The study can be done on any type ofcerebral palsy.

Limitations of the Study

1. Small sample size.2. No gender differentiation.3. Subjects with age group 5-13y.4. Influence of external factors.

Conclusion

There is a significant correlation between the grip strength,fine finger dexterity, gross manual dexterity and manual ability.

Bibliography

1. Kesler Martin Neurological Caonditions 1st Edition,page345.

2. Beukelman et al. Augmentative and AlternativeCommunication: Management of Severe communicationdisorders in children and adults. Baltimore: Paul H BrookersPublishing Co.1999;2:246-2494.

3. P.O. Pharoah et al Trends in birth prevalence of cerebralpalsy. Arch Dis Child.1987 April;62(4):379-384

4. Bass N.Cerebral palsy and neurodegenerative disease CurrOpin Pediatr 1999; 11: 4-7.

5. Sophie Levitt : Treatment of Cerbral palsy and motordelay.3rd Edition,Page 3-12.

6. Ann Thomson et al. Tidy’s Physiotherapy. Twelth EditionPage 361- 366.

7. Joans MW et al.Cerebral palsy:Introduction andDiagnosis(part 1).J Pediatr Health Care. May-June2007;21(3):146-52.

8. Paul D.Cheney.Pathophysiology of the corticospinal systemand basal ganglia in cerebral palsy1998 Dec,volume 3 Issue2.Pages 153-167.

9. Palisano R et al.Development and reliability of a system toclassify gross motor function in children with cerebral palsy.Dev Med Child Neurol.1997; 39: 214-23.

10. Bohannon RW, Smith MB. Interrater reliability of a modified

52

Asworth Scale of muscle spasticity Phy Ther. 1987;67:206.11. Palisano RJ et al. Validation of model of gross motor

function for children with cerebral palsy.Phys Ther2000;80:974-85.

12. Falio M et al.Peabody Development Motor Scales,2nd

Edition examiner Manual,Austin, TX Pro-ED,Inc,200013. Falio M et al.Peabody Development Motor Scales, 2nd

Edition examiner Manual,Austin, TX Pro- ED,Inc,200014. Felters et al.” Discriminate Power of the Alberta Infant Motor

Scale and the movement Assessment of Infants forPrediction of Peabody Gross Motor Scale Scores of InfantsExposed in Utero to Cocaine.”Pediatric Physical Therapy12,no.1(spring 2000):16-23.

15. Mayer NH et al.Common patterns of clinical motordysfunction.Muscle Nerve Suppl.1997;20:S 21-35.

16. Haultram J et al.Botulinum toxin type A in management ofequinus in children with cerebral palsy:an evidence basedeconomic evaluation.Euro J Neurol.2001;8 Suppl 5: S194202.

17. Butler C,Campbell S,for the AACPDM Treatment OutcomesCommittee Review Panel. Evidence of the effects ofintrathecal baclofen for spastic and dystonic cerebral palsy.Dev Med Child Neurol.2000;42:634-45.

18. V.A.Fassano et al.Surgical Treatment of spasticity incerebral palsy.Childs Brain 1978;4:289-305.

19. Mclaughlin J,et al.Selective dorsal rhizotomy:Meta Analysisof three randomised controlled Trials.Dev Med ChildNeurol.2002;44:17-25.

20. Fowler EG et al.The effect of quadriceps femoris musclestrengthening exs.on spasticity in children with cerbralpalsy.Phys Ther.2001;81:1215-23.

21. Dodd KJ et al. A syatematic review of the effectiveness ofstrength training programs for people with cerebralpalsy.Arch Phys Med Rehabil.2002;83:1157-64.

22. Balaban B et al.”The effect of hinged ankle foot orthosis ongait and energy expenditure in hemiplegic cerebralpalsy”.Disability and rehabilitation 29(2):139-44.

23. White H et al.”Clinically prescribed orthoses demonstratean increase in velocity of gait in children with cerebralpalsy”:a retrospective study”. Develpomental medicine andchild Neurology 44(4):227-32.

24. Uvebrant P.Hemiplegic cerebral palsy. Aetiology andoutcome.Acta Paediatr Scand Suppl 1988;345:1-100.

25. Carlyne Arnould et al.Hand Impairments and theirrelationship with manual ability in children with cerebralpalsy.J.Rehabil Med 2007;39:708-714.

26. Fedrizzi E et al.Hand function in children with hemiplegiccerebral palsy:Prospective follow up and functional outcomein adolescence.Dev Med Child Neurol 2003;45:85-91.

27. Ostensjo S et al.Everyday functioning in children withcerebral palsy:functional skill, caregiver assistance andmodifications of the environment. Dev Med Child Neurol2003;45:603-612.

28. Arnould C et al.ABILHAND-Kids:a measure of manualability in children with cerebral palsy. Neurology2004;63:1045-1052.

29. Pagliano E et al.Evolution of upper limb function in childrenwith congenital hemiplegia.Neurol Sci 2001;22:371-375.

30. Penta M et al The ABILHAND questionnaire as a measureof manual ability in chronic stroke patients. Rasch-basedvalidation and relationship to upper limb impairementsstroke 2001;32:1627-1634.

31. Brown JK et al A neurological study of hand function ofhemiplegic children.Dev Med Child Neurol 1987;29:287-304.

32. Krumlinde-Sundholm L,Eliasson A-C.Comparing tests oftactile sensibility:aspects relevant to testing children withspastic hemiplegia.Dev Med Neurol 2002;44:604-612.

33. Julie Duque et al.Correlation between impaired dexterityand corticospinal tracts dysgenesis in congenitalhemiplegia.Brain March 2003 Vol.126,No.3,732-747.

34. Tiffin J.Asher EJ.The purdue Pegboard:norms and studiesof reliability and validity.J Appl Psychol 1948;32:234-247.

35. Mathiowetz V et al.Adult norms for Box and Block Test ofmanual dexterity.Am J Occup

Ther 1985;39:386-391.36. Gonca Bumin and Sermin Tukel Kavak “An investigation of

the factors affecting handwriting performance in childrenwith hemiplegic cerebral palsy.Disability & rehabilitation2008 Vol 30,No.18;1374-1385.

37. Massimo Penta et al “The Abilhand Questionnaire as ameasure of manual ability in chronic stroke patients“.American Heart Association 2001,Vol 32 :1627.

38. Blank R & Hermsdorfer J.”Basic motor capacity in relationto object manipulation and general manual ability in youngchildren with spastic cerebral palsy”.NeurosciLett.2009:23,450(1):65-69.

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INTRODUCTION

Stroke affects 15 million people in the world eachyear and approximately one-third will live with thesequel of this disease1.After coronary heart disease(CHD) and cancer of all types, stroke is the thirdcommonest cause of death worldwide. Howeverunlike the Caucasians, Asians have a lower rate ofCHD and a higher prevalence of stroke2. Stroke is oneof the 10 highest contributors of Medicare costs andamong elderly, stroke and transient ischemic attacksare leading causes of hospitalization3.

The definition of stroke originates with the WorldHealth Organization (WHO) and dates back to 1980(1): which states that “Rapidly developing clinical signsof focal (at times global) disturbance of cerebralfunction, lasting more than 24 hours or leading to deathwith no apparent cause other than that of vascularorigin”4.

The Effect of Task Oriented Training on Hand Functions inStroke Patients- A Randomized Control Trial

Chandan Kumar1, Ruchika Goyal2,1(PT) Assistant Professor M. M. Institute of Physiotherapy & Rehabilitation Mullana, Ambala,

3M.P.T (Neurology-Student) M. M. Institute of Physiotherapy and Rehabilitation, Mullana, Ambala

ABSTRACT

Purpose: The goal of this study is to find out the effect of task oriented training on hand functions instroke patients.

Methodology: This was an experimental study of 30 stroke patients with unilateral involvement,with paresis of hand. All the subjects were enrolled in identical subgroup and divided into two equalgroups (15 patient in each group) one control group (A) and another experimental group(B).Experimental group receive task oriented training and control group receive conventionalphysiotherapy training.

We assessed the hand functions (Gross and Fine manual dexterity) by Box and Block test and Ninehole peg test respectively and tried to find out the additional effect of task oriented training on handfunctions .

Results: Result shows that, both the group improved significantly but task oriented training groupimproved much better than conventional training group.

Conclusions: This study suggests that task oriented is more effective as compare to the conventionaltraining for the hand functions in stroke patients.

Key words: Task Oriented Training, Gross Manual Dexterity, Fine manual Dexterity.

THE COMMON NEUROLOGICALIMPAIRMENTS DUE TO STROKE ARE

Motor impairments are most prevalent of all deficitsseen after stroke, usually with involvement of the face,arm and leg (hemiparesis) alone or in variouscombinations, which include involvement of cranialnerves, muscle power and tone, reflexes, balance, gait,co ordination and apraxia.5 Most common sensorylosses include asterognosis, agraphia, barognosis,kinesthesia, tactile extinction and two pointdiscrimination6.

The stroke causes the inability to understand andexpress emotions. Common speech disorder that areseen include aphasia, dysphasia. Dysphasia may beexhibited by disturbances in comprehension, naming,repetition, fluency, reading or writing7.

Hemiparesis represent the dominant functionallylimiting symptoms in 80% of patients with acute stroke

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94 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

within 2-5 months after stroke; patients recover aVariable degree of function, depending on themagnitude of the initial deficit. Arm recovery afterstroke is typically poor; with 20% to 80% of patientsshowing incomplete recovery depends on the initialimpairment.

Upper limb dysfunction in stroke is characterizedby paresis, loss of manual dexterity, and movementabnormalities that may impact considerably on theperformance of ADLs.8

Grasping, holding, and manipulation objects aredaily functions that remain Deficient in 55% to 75% ofpatient 3 to 6 months poststroke.8

After rehabilitation 9% of patients with severe UEweakness at onset may gain good recovery of handfunction. As many as 70% of patients showing somemotor recovery in the hand by 4 weeks make a full orgood recovery8.

Grasping, holding, and manipulation objects aredaily functions that remain Deficient in 55% to 75% ofpatient 3 to 6 months poststroke.9

VARIOUS TREATMENT APPROACHESFOR HEMIPARESIS

In physiotherapy a variety of movement therapyapproaches are available for retraining motor skill inadult patients with hemiparesis. Certain approacheslike proprioceptive neuromuscular facilitation, Rood,Brunnstrom, and Bobath relay on reflex andhierarchical theories of motor control and motorlearning as well as the principles of neural plasticity.11

TASK ORIENTED TRAINING

Task oriented training is newer approach. Task-oriented training involves practicing real-life tasks,with the intention of acquiring or reacquiring a skill(defined by consistency, flexibility and efficiency).12The tasks should be challenging and progressivelyadapted and should involve active participation (Wolf& Winstein, 2009). Previous studies done on taskoriented training has advocated the different effectsof it in stroke patients13. But currently available datado not definitively answer all the questions. Therefore,to obtain a clear characterization of effectiveness of taskoriented training a research study was required.

CONVENTIONAL PHYSIOTHERAPYTRAINING

These exercises prevent complications of

immobilization and improve ADL skill at the earliest.This helps in preventing contractures anddevelopment of abnormal postures.14 The purpose ofthis study is to find out that how much task orientedtraining is effective as compared to the conventionaltraining in functional recovery of hand in strokerehabilitation.

METHODOLOGY

Total 30 patients of stroke were selected from M.Mhospital Mullana and nearby areas. For patientselection purposive sampling was done. The total30 patient were divided into two equal groups(15 patients in each group), one experimental andanother control group. Experimental group receivedtask oriented training and control group receivedconventional physiotherapy training.

INCLUSION CRITERIA

1. Age group=40-70 years.2. Both males and females included.3. Duration of stroke within 30 – 150 days

(1-5 months), prior to start of study.4. Paresis in upper extremity and Hand5. First time stroke survivors.6. Able and willing to participate in the study of 6

weeks and to sign consent form.

EXCLUSION CRITERIA

1. Any associated medical and high riskcardiovascular diseases.

2. Any musculoskeletal impairment of upperextremity.

3. Any neurological pain or disorder limiting themovement.

4. MMSE less than 23.5. Still enrolled in any form of physiotherapy

treatment.

PROCEDURE

Thirty patients of stroke who fulfill the inclusioncriteria were included in this study. Total numbers ofpatients were divided into two equal groups, oneexperimental group and another control group.Each group contained 15 patients. The task orientedtraining for upper extremities had given to theexperimental group and conventional training forupper extremity had given to the control group. Allparticipants were evaluated by Box and Block test andNine Hole Peg test for gross and fine manual dexterityrespectively.


Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 95

Box and Block test (BBT)

This instrument is designed to measure the grossmanual dexterity of hand in stroke patients. Itconsists of a wooden/cardboard box having twocompartments and some small wooden blocks in it.The number of blocks displaced from onecompartment to another in one minute is recorded asreading/score/value15.

Nine Hole peg test (9HPT)

This instrument is designed to measure the finemanual dexterity of hand in stroke patients. It consistsof a wooden base having nine holes in it and ninedowels/pegs are provided separately with it. Time toplace nine dowels in holes and then removing them isnoted in seconds and is recorded as reading/score/value15.

Mini mental status scale is a reliable and valid scaleto asses the mental status of subjects used in thisstudy.16

At the first, the patients were informed about thepurpose, procedure, possible discomforts, risks andbenefits of the study prior to obtaining an informedwritten consent from the patient.

All patients were first assessed by Mini-Metalstatus scale to know the mental status.

After that all patients were assessed by Box andblock test and Nine hole peg test. The subjects wereasked not to participate in any other study orphysiotherapy treatment for hand functions from forthe duration of the study and to follow the designatedprotocol.

Treatment protocol

Experimental Group

All subjects in this group performed task orientedexercises which contain both simple and complex taskprograms with attending therapist. The task orientedtraining protocol was inspired by Gad Alon et al.13 wasa standardized protocol .Components of task orientedprotocol included were – range of motion exercises,weight bearing and supporting reactions, reachingholding and releasing activities and activities of dailyliving involving use of hand.

Control Group

All subjects in this group performed exercises basedon conventional physiotherapy. Patients of theconventional PT training group were made to start ofexercise from passive/ active movements of all thejoints of upper extremities including shoulder joint,

elbow joint, wrist joint, metacarpophalangeal jointsand interphalangeal joints with the use of upperextremities.

After active movements patients were made to startweight bearing, strength training reaching activitieswith the use of upper extremity and at last patientswas performed ADL activities (e.g. dressing and selffeeding activities).

These exercises start with simple movements andsubsequently complex movements and actions aretried.

All the exercises were performed in 90 minutes.There was no subdivision of time for each activity.Patients were performed exercises on the bases of theirmotor control for 90 minutes in a day and 3 days in aweek for 6 weeks.

Data and Statistical Analyses

Comparison was performed between both thegroups first at baseline level. Then again, comparisonswere done at discharge level as well as from baselineto discharge level and results were noted. Paired T testwas used for analyzed the pre to post changes withinthe groups. Unpaired T test was used to analyze thechanges between the two groups. Data was analyzedusing SPSS 17.

RESULTS

We successfully matched 30 patients of both controland experimental group for hand functions. First wecompared demographic and functional data of the agematched subgroup. Analysis comparison was donebetween both the groups first at base line and then atthe end of intervention.

Baselines characteristics of both the group areshown in table1.cheracteristic of both the groups weresame at the base line level prior to intervention.

Table 1. Baseline Characteristics of both the Group.

Group A BAge Mean ± S.D 55.93 ± 9.08 56.67 ± 9.05

Values t=0.22 P=0.82Gender M 9(60%) 8(53.3%)

F 6(40%) 7(46.6%)SideAffected L 8(53.3%) 7(46.6%)

R 7(46.6%) 8(53.3%)Typeof Stroke I 5(33.3%) 9(60%)

H 10(66.6%) 6(40%)

M-Male, F-Female, L-Left, R-Right, I-Ischemic, H-Hemorrhagic



This table shows that before intervention there wasno significant difference of Box and block test score(p=0.59) and nine hole peg test score (p=0.87) betweenthe groups.

Table 2. Box and block test Scores of both the groupbefore and after intervention

Group Before treatment After treatment p value

A 6.00 8.00 0.0001

B 5.67 10.33 0.0001

Above table shows that after intervention there wassignificant difference in both the groups.

TABLE 3. Nine hole peg test score of both the groupbefore and after intervention

Group before after PIntervention intervention value

A 73.40 72.87 0.00610.B 74.47 71.93 0001

Above table shows that after the intervention therewas significant difference between the groups ( p value- .001).

TABLE 4. BBT and 9HPT scores of both thegroup after intervention

Group BBT score after P value 9HPT after P valueintervention intervention

A 8.00 0.0007 72.87 0.89

B 10.33 71.93

Above table is showing the BBT and 9HPT scoresafter treatment in both the groups. Independent t testwas to analyses data in between the groups anddependent t test was used to analyze the data withinthe groups.

The evaluated data suggest that the gross manualdexterity has been more improved in task orientedgroup (experimental group=0.0007).whereas finemanual dexterity has been improved clinically but notstatistically in between group comparison (p=0.89) butwithin group results are statistically significant.

DISCUSSION

In this experimental design study, result shows theeffects of task oriented training as compare to theconventional training on hand functions in strokepatients. The results support the hypothesis that taskoriented training is more effective for hand functionsin stroke patients as compare to the conventionaltraining. Although both the groups task orientedtraining and conventional training improvedsignificantly post intervention, but task oriented

training group improved much better than taskoriented training. The overall evaluation of datasuggests that the gross manual dexterity has beenimproved more in task oriented training group(experimental group), whereas fine manual dexterityhas been improved clinically but not statistically inbetween group comparison post intervention, butwithin group results are statistically significant.

The results of the study are consistent withthe previous studies done on task orientedtraining.11-13 & 17.

The task oriented training is based on the motorprogramming theory of motor control and systemtheory. The former theory puts an emphasis on thespecial neural circuits known as central patterngenerators (CPJ). The practice play important role instrong engrams formation in the brain. The taskoriented training focuses on the intention of acquiringor reacquiring a skill (defined by consistency, flexibilityand efficiency) important to a functional task ratherthan educating the specific muscles in isolation henceit is a functional approach. In this approach, movementis organized around a behavioral goal; thus multiplesystems are organized according to the inherentrequirements of the task being performed. In thisapproach, the patient is working on functional tasksrather than on movement patterns for movement aloneas compared to conventional physiotherapy.

The significant results in task oriented traininggroup also may be due to more motor unit recruitmentbeing activated as the patient is practicing the samefunctional task again and again. Task orientedapproach leads to acquisition of new skills as patientgets feedback simultaneously which leads to betterlearning of activities of daily living. The results for finemanual dexterity are clinically significant at postintervention level but are not statistically significant.The gain in changes was small and also may be due tothe fact that nine whole peg test is not a very sensitivemeasure to analyze such small changes of fine manualdexterity in hemiparetic patients. Moreover the testused the time values that too in seconds which isfurther a very specific count.

CLINICAL IMPLICATION

This treatment will help the patients to enhance thefunctional recovery of hand in stroke patients andincreased functional recovery will provide theimprovement in quality of life. So, task orientedapproach can be used clinically as it will be much easierto perform, safer and convenient for patients.



Limitations of a Study

The sample size used in this study was small sothat result is not generalized. There is no follow upperiod after 6 weeks, so it may be another limitationof the study. The measure of fine manual dexterity wasnot appropriate.

Future Scope of Study

Follow-ups can be done to see the long term effectsof training. The initial degree of level of deficit can betaken. More sensitive measure can be used todetermine fine manual dexterity. Study can bereplicated by molding the treatment protocol and largesample size can be taken.

CONCLUSION

This study suggests that task oriented training ismore effective as compare to the conventional trainingfor the functional recovery of hand in stroke patients.

REFERENCES

1. World Health Organization. The WHO strokesurveillance... 2004. World

2. Health Organization. 29-7-2004.3. Shyamal K. Das, Tapes K. Banrejee.

Epidemiology of stroke in India. Neurology Asia2006; 11:1-4.

4. Judith h. Lichtman, EricaC.Leifheit-Limson, SaraB, ones Michael, S. Phipps, L.B. Goldstein.Predictors of hospital readmissions after stroke2010; 41: 2525-2533.

5. Aho K, Harmsen P, Hatano S, et al.Cerebrovascular disease in the community:results of a WHO collaborative study. Bull WHO1980; 58: 113 – 130.

6. C. Collin and D. Wade. Asessory Motorimpairment after stroke Journal of Neural,Neurosurgery and psychiatry. 1990; 53 (7): 576-579.

7. Lee Anne M. Carey et al. Frequency ofDiscriminative sensory loss in the hand afterstroke in a rehabilitation setting. J Rehab Med 2010;43:82-88.

8. Sherry H. Post stroke speech disorders; 2011.9. Alexander w. Dromerisk, Catherine G. Lang,

Robecca. Brikenmeirer, Michael G. Hahn.Relationships between upper limb functionallimitation and self. Reported disability 3 monthsafter stroke. Journal of Rehabilitation Researchand development 2006; 43: 401-405.

10. Gad Alan, Alon F. Leritt, Patricia A. Mc Corthy.Functional electric stimulation enhancement ofupper extremity functional recovery duringstroke Rehabilitation: A pilot study. NeurorehabilNeural Repair 2007; 21 (3): 1-9.

11. Dickstein R: Contemporary exercise therapyapproaches in stroke Rehabilitation riticalReviews in Physical and Rehabilitation Medicine1989; 1:161 – 181.

12. NorineFoley , Robert Teasell , Jeffrey Jutai ,SanjitBhogal , Elizabeth Kruger , Cauraugh andKim(2003). Upper Extremity InterventionsTheEvidence-BasedReview of StrokeRehabilitation reviews current practices in strokerehabilitation.2011;24-28

13. Winstein CJ, Rose DK, Tan SM, Lewthwaite R,Chui HC, Azen SP. (2004). A randomizedcontrolled comparison of upper-extremityrehabilitation strategies in acute stroke: A pilotstudy of immediate and long-term outcomes.Arch Phys Med Rehabil, 85(4), 620-628.

14. Gad Alon, F. Levitt et al. Functional electricalstimulation enhancement of upper extremityduring stroke rehabilitation – A Pilot study.Neuro Rehabilitation and Neural Repair 2007;21:207.

15. Dickstein R. Hocherman S. Pillar T el at: Strokerehabilitation. Three exercise Therapyapproaches. Phys Therapy: 1986; 66: 1233 – 1238.

16. Mathiowetz et al. Box and block test informationand nine hole peg test information 1985.

17. Folstein MF, Folstein SE, McHugh PR (1975).“”Mini-mental state”. A practical method forgrading the cognitive state of patients for theclinician”. Journal of psychiatric research 12 (3):189–198.

18. Higgins J, Salbach NM, Wood-Dauphinee S,Richards CL, Cote R, Mayo NE. (2006). The effectof a task-oriented intervention on arm functionin people with stroke: a randomized controlledtrial. Clin Rehabil, 20(4), 296-310.


INTRODUCTION

Skilled handwriting is an essential activity forschool aged children that allows them to write withina reasonable time and to create a readable productthrough which thoughts and ideas can becommunicated.1-3 Handwriting is often judged andseen as reflection of an individual’s intelligence andcapabilities as illustrated by several studies in whichlower marks are consistently assigned to children withpoor handwriting and higher marks are given to thosewith legible handwriting despite similar content.4

The effect of sex is also an important considerationin handwriting development..4 Girl’s handwriting ismore legible than boy’s handwriting and also the girlswrite faster. Right hander’s are also faster than the lefthander’s.5

Factors that affect the handwriting performancecan be intrinsic i.e. because of lack of fine motor control,improper visual-motor integration or may be extrinsiclike sitting position, chair-desk height, blackboardposition, environmental lighting etc.6

Effectiveness of Physiotherapy for the HandwritingProblem of School Going Children

Chandan Kumar1, Poonam Mehta2, Sobika Rao3

1Neurology-Assistant Prof, 2Paediatrics- Assistant Prof, 3 MPT StudentM.M Institute of Physiotherapy and Rehabilitation, Mullana, Ambala

ABSTRACT

Purpose: The purpose of the study is to see the effectiveness of a 12 week physiotherapeuticintervention to improve the handwriting quality of school going children.

Methodology: This study is a randomized clinical trial of 60 school going children who havehandwriting problem as diagnosed with Handwriting Proficiency Screening Questionnaire (HPSQ).The 60 subjects are than randomly divided into 2 groups, Group A (Intervention Group) whichconsists of a set of Physiotherapeutic Exercises and Group B (Ergonomic Advice) . The Handwritingquality was evaluated using Minnesota Handwriting Assessment (MHA).

Results: The results of the present study showed that both the groups showed significant improvementbut the group receiving 12 week physiotherapeutic intervention showed more significantimprovement.

Conclusion: Finally it can be concluded that a well planned physiotherapeutic program can help toimprove the handwriting quality of school going children over a short period of time and thus helpthe child to improve his self-confidence and his academic results.

Key words: Handwriting Skills, Physiotherapy Intervention, Assessment Scales.

Writing difficulties have been documented inchildren with and without disabilities. Legiblehandwriting constitutes to be an important skill forchildren to develop in elementary school and difficultywith this area can affect any child’s proficiency at work.Proficiency is the quality of having great facility andcompetence at school work.7 Those children who donot succeed in developing proficient handwriting aredefined by some authors as “poor hand writers” andby the others as dysgraphic.8

In addition to legibility and timing deficits,observations by clinicians have revealed that childrenwith dysgraphia erase more, complain more aboutfatigue and hand pain, and are unwilling to write anddo their homework.1 All of these signs may beconsidered to represent a category of physical andemotional well-being.9

The teacher is an important source of informationabout a child’s handwriting.6The perceptions of regulareducation teachers on problems with handwriting canprovide valuable information to practioner’s whenproviding consultation and direct services related to

24 chandan kumar 29th aug 11 (117-121).pmd 10/16/2012, 2:41 PM117


handwriting in school.10

Besides this various handwriting assessment toolsare available. Judith E. Riesman developed theMinnesota Handwriting Test (MHT) which has beenused in the present study. This tool is norm referencedand measures changes in handwriting performance offirst and second graders. The interrater reliability ofthe Minnesota Handwriting Test has a strong range of0.87-0.98.11

When consulted , physicians most often choosephysiotherapy as the preferred method to help.The physiotherapeutic interventions help to improvethe intrinsic factors related to handwriting skills. But,little is known about the effectiveness ofphysiotherapy in treating children with suchdisorder.

Methodology: A total of 200 HandwritingProficiency Screening Questionnaires (HPSQ) weredistributed in 3 schools. The questionnaires were filledby the teachers of teaching grade 1 and 2. A total of 60children were selected to participate in this study withthe aid of the standardized and validated HPSQ. These60 children were then randomly assigned to 2 groups.Simple random sampling was used to randomlyallocate the children into 2 groups.

INCLUSION CRITERIA

1) The child is a non-proficient writer as assessed bythe HPSQ.

2) The child attends a regular elementary school.

3) The child is in grade 1 and 2.

4) Age b/w 5-7 years.

5) Both boys and girls were included in the study.

6) Has no neurological problem.

7) Has no orthopedic problem.

8) Has no developmental delay.

9) Has no physical impairment of the upper limb.

10)Should not have received any physiotherapeutictreatment before.

Exclusion Criteria:

1) Developmental delay.

2) Physical impairment of upper extremity

3) Hearing deficit.

4) Has good handwriting.

5) Gross motor impairments.

6) Any recent trauma to upper limb.

7) Has poor intelligence.

8) Neurological deficit.

9) Visual problem.

PROCEDURE

The students selected by the teacher on the basis ofthe HPSQ who fulfilled the inclusion criteria wererandomly assigned to 2 groups. Simple randomsampling was used to randomly allocate 30 studentsin group A and 30 students in group B.

Group A (Intervention group): n=30.

Group B (Ergonomic advice): n=30

Pre-Intervention measurement was taken for boththe groups using the MHA. The students were askedto copy a sample from near point. The student sat onthe desk opposite to the blackboard. The wordsutilized were a derivative of the sentence, “The quickbrown fox jumped over the lazy dogs.” The quality ofthe sample was determined by assessing legibility,form, spacing, alignment, and size.

Following this students in Group A (InterventionGroup) were given a set of physiotherapeutic exercises.The student’s received 4 sessions of physiotherapy perweek, for 1 hour on alternate days for 3 months. Thestudents in the Group B (Ergonomic Advice) receivedergonomic advice on handwriting and were taughtappropriate writing posture by their parents andteachers. After a period of 3 months, again theHandwriting Proficiency Screening Questionnaire(HPSQ) were filled by the school teachers and the postintervention measurements were taken for both thegroups using MHA.

Group A (Intervention Group) n=30

1) Exercises to improve proximal stability of the upperlimb (5 repitions each).

2) Fine motor exercises for handwriting (5 repetitionseach

3) Exercises to improve visual-motor development(5 repetitions each)i) Exercises to improve Ocular motor control:ii) Exercises to improve eye-hand coordination:



Group B (Ergonomic Advice): n=30

Students in the Group B were taught appropriatewriting posture and were given ergonomic adviceonly.

Data Analysis:The data was tested parametrically.To determine the possible differences within andbetween the groups on the pre-test and post-testmeasures paired “t” test and “z” test were usedrespectively. p value was set at <0.05 level ofsignificance and SPSS software was used for analysis.

Results: In the present study 200 HPSQ weredistributed to the school teachers of teaching grade 1and 2. On the basis of this subjective assessment 90students were diagnosed by the teachers as non-proficient hand writers and were included in the study.Next MHA was filled by the students and 40 studentshaving a score of e”30 on MHA were excluded fromthe study.

Table 5.1. Demographic data for the 2 groups.

GroupA GroupBIntervention Group Ergonomic Advice

Females n = 09 n = 10Males n = 21 n = 20Age = 6years n = 05 n = 00Age = 6+years n = 12 n = 14Age = 7 years n = 13 n = 16Handedness n = 30 n = 30Class I n = 17 n = 20Class II n = 13 n = 10

The baseline data shows that the 2 gps did not differregarding Gender, Age, Handedness, Class

Table (5.2). Mean and S.D for HPSQ, Total MHA, andMHA Subscale for Group APre – Test Post – Test t value p valued”0.05

HPSQ 56.50 ± 7.28 42.33 ± 7.65 8.413

MHA Total 135.33 ± 5.51 155.60 ± 4.56 42.17

MHA Subscale

Legibility 29.03 ± 0.96 32.63 ± 0.96 18.42 Not Significant

Form 26.77 ± 1.85 30.47 ± 1.22 15.09

Alignment 26.73 ± 2.21 31.53 ± 1.77 18.78

Size 25.33 ± 2.10 30.27 ± 2.11 13.63

Spacing 27.47 ± 1.99 30.70 ± 1.46 9.47

Above table is showing the scores of the HPSQ,Total MHA and MHA Subscales. It was interpretedthat there is a statistically significant improvement inthe scores at the 0.05 level of significance.

Table (5.3). Mean and S.D for HPSQ, Total MHA, andMHA Subscale for Group B.Pre – Test Post – Test t value p valued”0.05

Mean ± S.D Mean ± S.D

HPSQ 48.33 ± 7.65 44.67 ± 7.10 6.71

MHA Total 136.73 ± 6.97 144.13 ± 6.88 34.00

MHA Subscale

Legibility 29.23 ± 1.13 30.83 ± 0.98 12.99

Form 27.47 ± 1.57 28.80 ± 1.66 15.23

Alignment 27.30 ± 1.89 28.67 ± 1.82 11.19

Size 24.63 ± 2.22 25.97 ± 2.20 13.35

Spacing 28.00 ± 2.01 29.77 ± 2.04 15.45

Above table is showing the scores of the HPSQ,Total MHA and MHA Subscale.

It was interpreted that there is a significantimprovement in the scores at 0.05 level of significance.

Table (5.4): Comparison of the Mean and S.D for theHPSQ, Total MHA Score between Group A

(Intervention Group) and Group B(Ergonomic Advice).

Group A Group B Mean diff. Zvalue p

b/w group valued”0.05

Mean ± S.D Mean ± S.D

HPSQ 14.17 ± 0.08 3.67 ± 0.55 10.50 ± 0.43 5.932 significant

MHA Total 20.27 ± 2.59 7.40 ± 1.19 12.86 ± 1.40 24.64

Above table is showing the scores of the HPSQ andTotal MHA Score. It was interpreted that there is astatistically significant improvement in the scores at0.05 level of significance.

Table (5.5) : Comparison of the mean change in theMHA Subscale Scores between Group A (Intervention

Group) and Group B (Ergonomic Advice).

MHA Group A Group B Mean diff. z value p valuedSubscale Mean ± S.D Mean ± S.D b/w group. ”0.05

Legibility 3.60 ± 1.07 1.60 ± 0.67 2.00 ± 0.39 8.66

Form 3.70 ± 1.34 1.33 ± 0.47 2.36 ± 0.97 9.09

Alignment 4.80 ± 1.40 1.37 ± 0.66 3.43 ± 0.73 12.12 significant

Size 4.93 ± 1.98 1.33 ± 0.54 3.60 ± 1.44 9.59

Spacing 3.32 ± 1.87 1.77 ± 0.62 1.46 ± 1.25 4.07

Above table is showing the scores of the MHASubscale. It was interpreted that there is a statisticallysignificant improvement in the scores between the2 groups at 0.05 level of significance.

DISCUSSION

In this study it was observed that a 12 weekphysiotherapeutic intervention had a significant effecton improving the handwriting quality and the earlier



studies also show the same result.12 The positiveresults found in this study can be supported bythe sufficient evidence in the literature thatintervention to improve handwriting would resultin greater gains than no intervention at all.8,9,16,17.

The intervention was so structured that it directlytargeted the intrinsic components which are requiredfor good handwriting. The intervention consisted ofexercises to improve proximal stability of upper limb,fine motor exercises for handwriting, and exercises toimprove the visual- motor control.2 The interventiontargeted primarily at improving the proximal musclestabilization of the upper extremity. This is supportedby the “proximal-distal” muscle principle which statesthat the proximal muscle stability is a pre-requisite formanipulative hand use.18

Next the in-hand manipulation skills whichincluded activities like rolling the balls of clay betweenthe tips of the thumb, middle and index finger ;pinching and sealing a zip-lock ; twisting open a smalltube of toothpaste with thumb, index and middlefingers while holding the tube with the ulnar digits;and ball squeezing exercises. All these exercises makeuse of the muscles of the thener-eminence which isconsidered as the “skilled triad” of the hand. So, thein-hand manipulation skills helped to improve the finemotor skills.. 18, 13, 19Previous studies in this field haverevealed that the visual-motor integration i.e. theability to see and copy moderately to strongly relateto handwriting skills. So, the exercises to improve theocular-motor control and eye-hand co-ordinationhelped to improve this skill.2, 20, 21

Another important factor was the intensity andduration of the intervention used for this study. Theintervention lasted for a period of 12 weeks and wasadministered 4 times a week for 1 hour. This durationof intervention for improving the handwriting qualityhas been supported by various studies in which similarduration of intervention resulted in improving thehandwriting.7, 12, 19 Lastly all the activities which wereincluded were of playful nature which the childrenmight have enjoyed and thus led to their maximumparticipation and thus resulted in significantimprovement in the group which receivedintervention.

The children in Group B were taught appropriatewriting posture and were given ergonomic adviceprovided by the physiotherapist to their parent’s andteacher’s. The ergonomics and the writing posture arethe extrincic factors related to handwriting.Ergonomics 6,1,14 play an important role. Body posture

is generally considered to have an important influenceon the efficiency of writing process and product.614,22

So, students in group B also showed improvement intheir handwriting quality.

After a period of 3 months both the groups showedan improvement in their handwriting quality but incomparison the students in group A (InterventionGroup) showed more significant improvement ascompared to the students in group B (ErgonomicAdvice).Finally it can be concluded that a well plannedphysiotherapeutic program can help to improve thehandwriting quality of the children and help improvetheir academic results and confidence.

Clinical Implication

The findings of the present study can be used inthe schools by the teachers to improve the handwritingquality of the students who have poor handwriting.

Limitations of the study:

1. The inclusion criteria is subjective based on HPSQ.2. Purposive Sampling was used leading to decreased

generalizability.3. No individual attention was given.

Future Research:

1. To see the effectiveness of the intervention inchildren with cerebral palsy, hyperactivitydisorder, developmental co-ordination disorder.

2. Comparing the effectiveness with the otheravailable handwriting programs: “Handwritingwithout Tears”; “Log Handwriting Program” etc.

3. Effectiveness of the intervention in improving thespeed of writing.

REFERRENCES

1. Rosenblum, Sara. Handwriting performance,self- reports and perceived self-efficacy amongchildren with dysgraphia. American Journal ofOccupational Therapy, 2009 March.

2. Rhoda P. Erhardt and Vickie Meade. Improvinghandwriting without teaching handwriting. Theconsultative clinical reasoning process. AmericanJournal of Occupational Therapy 2005; 52:199-210.

3. Sara Rosenblum; Shula Parush and Patrice L.Weiss. Computerized temporal handwritingCharacteristics of Proficient and Non-Proficienthand-writers. The American Journal ofOccupational Therapy; 57(2): 129-138.

4. Sasson R. Handwriting: A new perspective.Cheltenham, UK: Stanley Thornes 1990.



5. Steve Graham. Development of handwritingspeed and legibility grade 1- 9.The Journal ofEducational Research 1998; 92(1): 42-52.

6. Feder, Majnemer. Handwriting development,competency and intervention Review.Developmental medicine and child neurology2007; 49: 312-317.

7. Centre for child development. Child.support.in.8. Graham, Harris. Is handwriting causally related

to learning to write? Treatment of handwritingproblems in beginning writers. Journal ofEducational Psychology 2000; 92: 620-633.

9. Rosenblum, Sara. Development, reliability, andvalidity of the Handwriting Proficiency ScreeningQuestionnaire (HPSQ). . American Journal ofOccupational Therapy 2008; 62 : (298-307).

10. Hammerschmidt, Sandra L. Teacher’s Survey onProblems with Handwriting: Referral,Evaluation, and Outcomes. American Journal ofOccupational Therapy 2004.

11. Wendy Collins, MOTS, Evidence Topic:Handwriting Assessment 2008.

12. Smits-Engelsman et. al. Physiotherapy forchildren’s writing problems. An EvaluationStudy. Handwriting and Drawing Research:Basic and Applied Issues. 1996; (227-240)

13. Christopher M. Boyle. An analysis of the efficacyof a motor skills training programme for youngpeople with moderate learning difficulties.

14. Jill G. Zwicker. Cognitive vs Multisensoryapproach to handwriting Intervention. A RCT.The American Journal of Occupational Therapy2009: (25)1.

15. Handwriting Resource Handbook: A TeacherResource Manual. Occupational and PTDepartment, Student support service division.Nov 4, 2008.

16. Tseng and Cermak. The influence of ergonomicfactors and perceptual– motor abilities onhandwriting performance. American Journal ofOccupational Therapy 199347: 919-926.

17. Kline, T.J.B. Psychological Testing. London Sage2005 ; 202-203.

18. Naider et al. Analysis of proximal and distalmuscle activity during handwriting tasks.American Journal of Occupational Therapy 2007;61(4): 392-398.

19. Nandine Mackay et al: The Log HandwritingProgram Improved Children’s writingLegibility: A pretest-posttest study. 2010 January;64(1) : 30-36

20. Cornhill & Case-Smith. Factors that relate to goodand poor handwriting. American Journal ofOccupational Therapy 1996; 50: 732-739.

21. Arpita S Desai. Correlation betweenDevelopmental Test for Visuomotor Integrationand Handwriting Difficulties in Cerebral PalsyChildren. The Indian journal of occupationaltherapy 2005: 2.

22. Handwriting Resource Handbook: A TeacherResource Manual. Occupational and PTDepartment, Student support service division.Nov 4 2008


Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 21

Effect of Neuromuscular Electrical Stimulation Combinedwith Cryotherapy on Spasticity and Hand Function in

Patients with Spastic Cerebral Palsy

Chandan Kumar1, Vinti2

1Assistant Professor, M. M. Institute Of Physiotherapy & Rehabilitation, Mullana, Ambala, 2M.p.t (Neurology-student)), M. M. Institute OfPhysiotherapy And Rehabilitation, Mullana, Ambala

ABSTRACT

Purpose: To determine the effectiveness of Neuromuscular electrical stimulation combined withCryotherapy on spasticity and hand function in patients with spastic Cerebral Palsy. Children with CPoften demonstrate poor hand function due to spasticity in wrist and finger flexors.

Methodology: This was an experimental study of 30 spastic CP patients aged 5-15 yr with mild tomoderate spasticity. All the subjects were divided into two groups (A & B) with equal subject number ineach group. Group A were treated with passive stretching, cryotherapy followed by NeuromuscularElectrical Stimulation (NMES) and Group B treated with passive stretching and cryotherapy, 3 times aweek on alternate days for 6 weeks. Spasticity and hand function were assessed pretreatment and posttreatment using the Modified Ashworth Scale (MAS) and Manual Ability Classification System (MACS).We tried to find out the additional effect of NMES on spastic CP patients.

Results: Showed that both the group improved significantly but group A improved much better thangroup B.

Conclusions: This study suggests that NMES combined with cryotherapy is more effective as comparedto cryotherapy alone in reducing spasticity and improving hand function in spastic CP patients.

Keywords: Spasticity, Cerebral Palsy, Neuromuscular Electrical Stimulation, Cryotherapy.

INTRODUCTION

Cerebral palsy is a well-recognizedneurodevelopmental condition beginning in childhood& persisting throughout the lifespan. Cerebral palsy isa group of permanent disorders of the development ofmovement and posture, causing activity limitation, thatare attributed to non-progressive disturbances thatoccurred in the developing fetal or infant brain. Themotor disorders of cerebral palsy are often accompaniedby disturbances of sensation, perception, cognition,communication, and behavior; by epilepsy, and bysecondary musculoskeletal problems.1 Cerebral palsyis the commonest physical disability in childhood,occurring in 2.0 to 2.5 per 1000 live births.2 The causesare congenital, genetic, inflammatory, infections, anoxic,traumatic & metabolic. The injury to the developingbrain may be prenatal, natal or postnatal.3 Causes ofCP were prenatal in 50% of the cases, perinatal in 33%,postnatal in 10%, and mixed in 7%.4 75% of childrenwith CP have spastic cerebral palsy.3 Spasticity isclassically defined as a tonal abnormality of skeletalmuscle characterized by a velocity-dependent

resistance to passive stretch.5 Studies done to find outdevelopment of spasticity with age shown that thedegree of muscle tone increased upto 4 year of age. After4 year of age the muscle tone decreased each year upto12 year of age.6

Physiotherapy Treatment For Spasticity

Various treatment approaches & modalities tomanage spasticity associated with spastic cerebral palsyinclude the use of oral neuropharmacological agentsor injectable materials such as botulinum-A toxin7,surgical treatment through tendon transfer8 or selectiverhizotomy9. The other treatment approaches areapplication of cryotherapy10, progressive resistiveexercises to improve muscle strength, repetitive passiverange of motion exercises to improve & maintain jointmobility. Passive, static, gentle stretches are performedon individual joints to decrease & prevent jointcontractures. Neurodevelopmental treatment (NDT),sensory integration, electrical stimulation, constrainedinduced therapy & orthosis are also used inmanagement of cerebral palsy.11, 12

5. chandan kumar 17TH april-21-25.pmd 1/24/2013, 5:10 PM21

22 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1

CRYOTHERAPY

Cold application has been used for some time toreduce spasticity clinically. Decrease in resistance topassive stretch lasts from a few minutes up to 24 hours.Cold anesthesia of peripheral sensory end-organschanges the balance of facilitatory-inhibitory influencesplaying on the anterior horn cell in favor of inhibition.Unmasking of spasticity permits strengthening ofvoluntary mechanisms normally snowed under byundesired reflexes.10

Neuromuscular Electrical Stimulation

Neuromuscular electrical stimulation has gainedsupport since its inception as a treatment for cerebralpalsy in the 1970s. With neuromuscular electricalstimulation, electrical stimulation of sufficient intensitygenerally to produce visible muscle contraction isapplied at the muscle motor point. Electrical stimulationis thought to improve strength, reduce spasticity of theantagonist muscle, reduce co-contraction, and createsoft-tissue changes permitting increased range ofmotion.13 There are few studies that report theeffectiveness of NMES and cryotherapy on reduction ofspasticity & improvement of hand function in patientswith spastic cerebral palsy and found that both themodalities used are effective and none of the twomodalities is superior to other.14 Therefore, aim of thisstudy is to determine the effectiveness ofNeuromuscular electrical stimulation combined withCryotherapy on spasticity and hand function inpatients with spastic Cerebral Palsy.

In present study, hand function is measured usingthe Manual Ability Classification System (MACS)instead of Zancolli system14 because a review ofclassification systems of upper limb function &deformity in cerebral palsy supports the use of MACSto classify upper limb function and Zancolli system isrecommended to classify thumb, hand &wristdeformity.15

METHODOLOGY

30 subjects were selected by means of conveniencesampling based on inclusion and exclusion criteria.All the parents received a written explanation of thetrial before entry into the study and then gave signedconsent to participate their children in the study. Thepatients were randomly allocated into 2 groups.

INCLUSION CRITERIA

1. Patient diagnosed with spastic cerebral palsy(quadriplegic and hemiplegic).

2. Patient having wrist flexor spasticity upto Grade 3according to Modified Ashworth Scale.

3. Age 5-15 yr, both male & female.

4. Patient who can comprehend and comply withinstructions.

5. Normal skin sensation of upper limb.

EXCLUSION CRITERIA

1. Dermatological problems

2. Seizures

3. Patients on muscle relaxing medications

4. Patient having contracture or deformity of upperlimb

5. Patient undergone any surgery for upper limb

PROCEDURE

Thirty patients of CP who fulfill the inclusion criteriawere included in this study. Total numbers of patientswere equally divided into two groups (A & B). Eachgroup contained 15 patients. All participants wereevaluated by modified ashworth scale for wrist flexorspasticity and manual ability classification system forhand function.

Modified Ashworth Scale measure spasticity and isapplied manually to determine the resistance of muscleto passive stretching. This scale has been shown toovalid and reliable.16 Manual Ability Classificationsystem describes how children with cerebral palsy (CP)use their hands to handle objects in daily activities.MACS describe five levels. The levels are based on thechildren’s self-initiated ability to handle objects andtheir need for assistance or adaptation to performmanual activities in everyday life. The objects referredto are those that are relevant and age-appropriate forthe children, used when they perform tasks such aseating, dressing, playing, drawing or writing.17 MACShas shown to be valid and reliable.18 All patients wereassessed by modified ashworth scale and manualability classification system before and after givingintervention.



The technique for application of passive stretchingwas based on passive range of motion (PROM)therapeutic exercises described by Kisner and Colby.19

The PROM consists of moving the elbow, wrist, fingersand thumb passively and holding it in position for 60seconds. This procedure was repeated 5 times givingduration of 5 minutes bout. The procedure of passivestretching was given prior to every treatment session inall the subjects, both in group A & B.

Treatment procedure for group A subjects

The subject was placed in sitting position. The entireforearm from elbow to the fingers was carefully anddecently exposed. The area was cleaned with cottonwool and with methylated spirit. The upper limb of thesubject was positioned on a pillow on the plinth withthe shoulder in mild abduction. The forearm was alsopositioned in mid flexion and supination with thefingers and thumb in anatomical position .The icelollipop was applied to the flexor compartment of theforearm and gently massaged using stroking techniquefrom the proximal to the distal end of the forearm. Thiswas applied continuously for 20 minutes. The sequenceof treatment was 3 times a week on alternate days for 6uninterrupted weeks.

After cryotherapy, subjects received electricalstimulation to the dorsum of the forearm. The electricalstimulation was consist of a dual channel devise withcurrent outcome between 0 and 100 MA , pulse widthof 200 microseconds and the pulse set between 30 and40 Hz to produce tolerable muscle contraction. Theelectrical stimulation was applied for duration of30minutes, 3 times in a week on alternate days for aperiod of 6 uninterrupted weeks.

Treatment procedure for group B subjects

Following the application of passive stretching, thesubjects received Cryotherapy as describe for thesubjects in group A.

Data and Statistical Analyses

Comparison was performed between the groups firstat baseline level. Then again, comparisons were doneafter treatment at 6 week as well as from baseline to 6week and results were noted. Wilcoxon signed ranktest and Mann Whitney U test was used to analyze thepre and post treatment values of MAS scores and MACSscores within the groups and between the groupsrespectively. The level of significance was set at p<0.05.Data were analyzed using SPSS 17.0.

RESULTS

Patients in both the groups were assessed at baselinelevel for spasticity with modified ashworth scale &hand function with manual ability classification scaleprior to the commencement of the treatment sessions.Post-test measurements were taken after 6 weeks aftercompletion of treatment sessions. There were no dropouts in the study. A total of 16 female and 14 malesubjects participated in the study.

Demographic characteristics of both the group areshown in table 1.

Table: 1 Demographic characteristic of the subjects

VARIABLES GROUP A GROUP B

Sex F:M 7:8 9:6

Mean Age 7.53 ± 1.35 7.66 ± 1.63

Spastic CP (Type)

Quadriplegic (%) 8 (53%) 7 (46%)

Right Hemiplegic (%) 5 (33.3%) 5 (33.3%)

Left Hemiplegic (%) 2 (13.3%) 3 (20%)

Dominating hand (number)

Right hand 15 15

Above table showing that subjects in both the groupsare matched for baseline level

Table: 2 Baseline score of MAS and MACS ofboth the group

MAS MACS

A B A B

Mean± S.D 2.46±0.611 2.33±0.587 4.60±0.632 4.53±0.639

P value (<0.05) 0.59 0.77

Above table showing mean value of baseline scoresof MAS & MACS of both groups. After analysis, the pvalue is >0.05 which is statistically non-significant.

Table: 3 Pre and Post value of MAS and MACS ofgroup A

GROUP A

Variables Mean ± S.D p value (<0.05)

Pre value Post value

MAS 2.466±0.611 1.333±0.408 0.0003

MACS 4.60±0.632 2.53±0.833 0.0003

Above Table showing mean value of pre MAS andpost MAS & pre MACS and post MACS of group A.After analysis, p value is <0.05 which is statisticallysignificant.


24 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1

Table: 4 Pre & post value of MAS andMACS of group B

GROUP A

Variables Mean ± S.D p value (<0.05)

Pre value Post value

MAS 2.333±0.587 1.666±0.308 0.0008

MACS 4.53±0.639 3.46±0.828 0.0005

Above Table showing mean value of pre MAS andpost MAS & pre MACS and post MACS of group B.After analysis, p value is <0.05 which is statisticallysignificant.

Table: 5 Post intervention MAS and MACS value ofgroup A & B

MAS MACS

A B A B

Mean ± S.D 1.33±0.408 1.66±0.308 2.53±0.833 3.46±0.828

P value (<0.05) 0.02 0.01

Above Table showing mean value of postintervention scores of MAS & MACS of both groups.

The result obtained from the study data showed thatthere was significant difference within group A and Bin reducing spasticity and improving hand function.Group A showed more significant difference in outcomemeasures in comparison to group B.

DISCUSSION

In this experimental design study, result showedthe combined effect of neuromuscular electricalstimulation and cryotherapy on spasticity and handfunction in patients with spastic cerebral palsy. Theresults support the hypothesis that NMES along withcryotherapy produce good results as compared tocryotherapy alone. Cold facilitates alpha-motor neuronactivity and decreases gamma motor neuron firingthrough stimulation of cutaneous afferents. There isalso a decrease in the afferent-spindle discharge bydirect cooling of the muscle. When nerves are cooled,synaptic transmission are impeded or blocked byaltering the transmembrane ionic flow. The possibleexplanation of the mechanism of relief of spasticity canbe that cold anesthesia of peripheral sensory end-organs changes the balance of the sum of facilitatory-inhibitory influences playing on the anterior horn cellin favor of inhibition. Unmasking of spasticity permitsstrengthening of voluntary mechanisms normallysnowed under by undesired reflexes.10

The results of this study are supported by previousstudies which tell that the neuromuscular electricalstimulation is helpful in increasing muscle strength byincreasing cross sectional area of the muscle & byincreasing recruitment of Type 2 muscle fibers.12 WithNMES, unused muscles can be stimulated when neededand the sensory input from NMES can give addedsensory awareness of what is happening in the handto allow motor learning to occur and to permit motorcontrol.20 Neuromuscular electrical stimulation, whenapplied to the peripheral muscles has a direct effect onthe cerebral cortex.21 In group A as we have givencryotherapy first and after that NMES, combined effectof both the modalities leads to significant improvementin experimental group.

Result of this study showed that improvement ismore significant in subjects of group A treated withcryotherapy followed by neuromuscular electricalstimulation when compared with subjects of group Btreated with cryotherapy alone (table 5). This showedthat additional improvement in group A is because ofneuromuscular electrical stimulation. First cryotherapyhas reduced spasticity in wrist flexors and then NMESapplied to wrist extensors has further reduced spasticityin wrist flexors via reciprocal inhibition and increasedstrength in wrist extensors. Few studies have been doneon neuromuscular electrical stimulation andcryotherapy in isolation which shows their effectivenessbut the result obtained from this study is novel thatproves the combined efficacy of neuromuscularelectrical stimulation and cryotherapy on spasticity.Neuromuscular electrical stimulation is a non-invasivetherapy and offers a better clinical outcome.

CLINICAL IMPLICATION

The results of the present study enlighten the use ofcombination therapy approach (NMES+Cryotherapy)as an more effective approach than the eitherintervention alone in the clinical settings for themanagement of spasticity and hand function in patientswith spastic cerebral palsy.

Limitations of the study

Subjective measures used for measuring spasticityand hand function challenges the results obtained. Nofollow up was taken to see the long term effects.Dominating hand was only treated in quadriplegics toavoid collecting paired data.



Future Research Suggestion

Future research can be done using objectivemeasures for measuring spasticity and hand function.There should be long term follow up of the patient todetermine the sustained effects of combination therapy(NMES+Cryotherapy).

CONCLUSION

This study describes the management of spasticcerebral palsy patients with hand functionimpairments, who responded favorably to anintervention program focused NMES and cryotherapy.

REFERENCES

1. R peter, P. Nigel, G murray, G martin. The Definitionand classification of cerebral palsy. DevelopmentalMedicine & Child Neurology. 2007; 49(109):8–14.

2. Reddihough Dinah S, Collins Kevin J. theepidemiology and causes of cerebral palsy.Australian Journal of Physiotherapy. 2003; 49:7-12.

3. S. chitra, M nandani. Cerebral palsy-definition,classification, etiology and early diagnosis. Indianjournal of pediatric. 2005: 865-868.

4. Holm Vanja A. the Causes of Cerebral Palsy. JAMA.1982; 247:1473-1477.

5. R Susan, G Joan T. Non operative management ofspasticity in children. Child nervous system. 2007;23:943-956.

6. H Gunnar, W philippe. Development of spasticitywith age in a total population of children withcerebral palsy. BMC Musculoskeletal Disorder.2008; 9:150-159.

7. Patel Dilip R, S olufemi. Pharmacologicalintervention for reducing spasticity in cerebralpalsy. Indian journal of pediatrics. 2005; 72:896-872.

8. Das Shakti P, Mohanthy Ram N, Das Sanjay K.Management of upper limb in cerebral palsy-roleof surgery. IJPMR. 2002 April; 13:15-18.

9. F Jean P, J abdulrehman. Selective dorsal rhizotomyin the treatment of spasticity related to cerebralpalsy. Child nervous system. 2007 July 21; 23:991-1002.

10. Mead Sedwick, Knott Margaret. TopicalCryotherapy: Use for Relief of Pain and Spasticity.California Medicine. 1966; 105(3):179-181

11. Sharan Deepak. Recent advances in managementof cerebral palsy. Indian journal of pediatric. 2005;72:969-973.

12. Patel Dilip R. Therapeutic intervention in cerebralpalsy. Indian journal pediatrics. 2005; 72:979-983.

13. Kemper Derek G, Yasukawa Audyer M. Effects ofneuromuscular electrical stimulation treatment ofcerebral palsy on potential impairmentmechanism. Pediatric physical therapy. 2006;18:31-38.

14. Akinbo S R A, Tella B A, Otunla A. Comparison ofthe effect of neuromuscular electrical stimulationand cryotherapy on spasticity and hand functionin patient with spastic cerebral palsy. Nigerianmedical practitioner. 2007; 51:128-132.

15. K McConnell, L Johnston, C Kerr. Upper limbfunction and deformity in cerebral palsy: a reviewof classification systems. Dev Med Child Neurol.2011; 53(9): 799-805.

16. Bohannon Richard W, Smith Melissa B. InterraterReliability of a Modified Ashworth Scale of MuscleSpasticity. Physical Therapy 1987 Feb; 67(2):206-207.

17. Kuijper M. A, Ketelaar M. Manual abilityclassification system for children with cerebralpalsy in a school setting and its relationship tohome self-care activities. American Journal ofOccupational therap. 2010; 64:614-620.

18. Eliasson Ann-Christin, Krumlinde-SundholmLena, Rosblad Birgit, Beckung Eva, ArnerMarianne, Ohrvall Ann-Marie, Rosenbaum Peter.The Manual Ability Classification System (MACS)for children with cerebral palsy: scale developmentand evidence of validity and reliability.Developmental Medicine & Child Neurology 2006;48(7):549-554. DOI: 10.1017/S0012162206001162

19. Kisner C, Colby L. A. Therapeutic Exercise:Foundation and Techniques. 4thed. New Delhi:Jaypee Brothers, Medical Publishers (P) Ltd; 2003.

20. Scheker L R, Ramirez S. Neuromuscular electricalstimulation and dynamic bracing as a treatmentfor upper extremity spasticity in children withcerebral palsy. Journal of hand surgery. 1999;24:226 -232.

21. Han BS, Jang SH, Chang Y, Byun WM, Lim SK,Kang DS. Functional magnetic resonance imagefinding of cortical activation by neuromuscularelectrical stimulation on wrist extensor muscles.Am J Phys Med Rehabil. 2003 Jan; 82(1):17-20.


Indian Journal of Physiotherapy & Occupational Therapy. April-June 2013, Vol. 8, No. 2 27

Effect of Obstacle Ambulation Training on WalkingAbility for Ambulant Stroke Subjects

Chandan Kumar1, Salam Anita Devi2

1Assistant Professor, 2M.P.T (Neurology-Student) M. M. Institute of Physiotherapyand Rehabilitation, Mullana, Ambala

ABSTRACT

Purpose: To find out the effect of obstacle ambulation training on walking ability for ambulant strokesubjects.

Methodology: This was an experimental study of 30 stroke patients having first ever unilateral stroke.All the subjects were enrolled in identical subgroup and divided into two equal group one experimentaland another control group. Experimental group did balance training with obstacle ambulation trainingand control group performed balance training.

We assessed the Dynamic balance with Dynamic Gait Index and walking endurance with Six MinuteWalk Test (6MWT) and tried to find out the additional effect of obstacle ambulation training onwalking ability for ambulant stroke subjects.

Results: Result shows that, both the group improved significantly but obstacle ambulation traininggroup improved much better than balance training group

Conclusions: Balance training with obstacle ambulation training is more effective as compare to thebalance training on walking ability for stroke patients.

Keywords: Stroke, Obstacle Ambulation Training, Balance Training

INTRODUCTION

Stroke is one of the most common neurologicaldisorders leading to chronic disability. It remains thethird leading cause of the death, a leading cause ofpermanent disability and a major contributor of lifeconsequences. 1.2% of total deaths in India occur dueto stroke1. WHO estimated that in 1999, out of 9.4million deaths in India, 619000 deaths were due tostroke giving a mortality rate of 73/ 100000population2.

Stroke refers to a vascular syndrome characterizedby “ rapidly developing signs of focal or globaldisturbance of cerebral functions lasting more than 24hrs or leading to death with no apparent cause otherthan vascular origin”.( WHO 1989)3.

The Common Neurological Impairments Due ToStroke Are

Depending on the site and extent of the lesion,stroke can result in impairment of motor, sensory and/or cognitive abilities, swallowing and communicationproblems and incontinence. While each can have

debilitating effect independently, impairment in onearea will affect performance in another4. Impairmentof motor may include I) alterations on tone. Flaccidityis present immediately after stroke and is due tocerebral shock. It is short lived, lasting hours, days, orweeks. Spasticity emerges in about 90% of cases andoccurs on the side of the body opposite the lesionpredominantly in antigravity muscles. ii) Abnormalsynergy patterns, iii) abnormal reflexes, IV) motorprogramming deficits etc5.

Somatosensory impairments range frominvolvement of just one type of sensation, such as lighttouch, to all somatosensory abilities being impaired.The most common types of cognitive deficits arisingfrom stroke are disturbances of attention, languagesyntax, delayed recall and executive dysfunctionaffecting the ability to analyze, interpret, plan,organize, and execute complex information5.

Walking after stroke is characterized by slow gaitspeed, slow poor endurance and changes in the qualityand adaptability of walking pattern. Although 60% ofstroke survivors regain walking independence after 3

6. chandan kumar-27-32.pmd 4/25/2013, 11:26 PM27

28 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2013, Vol. 8, No. 2

months, many have continuing problems withmobility due to impaired balance, motor weakness anddecreased walking velocities6.

Physiotherapy Treatment for Walking Recovery

In physiotherapy training methods to improvewalking patterns of individuals with post strokepatients involve therapists giving verbal cues andmanual support during overground walking and usingequipment such as parallel bars, mirrors, and stairs7.

Obstacle Ambulation Training

Stepping over obstacles (obstacle ambulationtraining) as an alternative training to improve walkingin individuals with post stroke patients.Obstacleambulation training lead to improvements in variousmeasures of walking ability (gait velocity, step length,ability to step over obstacles and walking endurance)7.

However, due to the controversial reports about theeffectiveness of obstacle ambulation training onwalking ability, this study has been designed toinvestigate the effect of obstacle ambulation trainingon walking ability in ambulant stroke patient.

METHODOLOGY

Total 30 patients of stroke from M.M hospitalMullana, Ambala who met the inclusion criteriaincluded in this study. For patient selection randomsampling was done. The total 30 patient were dividedinto two equal groups (15 patients in each group) oneexperimental (Group B) and another control group(Group A). Experimental group did balance trainingwith obstacle ambulation training and control groupcontain balance training.

Inclusion Criteria

1. Age: 40-60 years

2. Gender : both male and female

3. Subjects having first ever unilateral stroke (3-6months) after stroke

4. Capable of walking independently withoutassistance for a distance of 5m walkway.

5. Cognitively sound subject with mini mental stateexamination score of at least 24/30.

Exclusion Criteria

1. Transient ischemic stroke.

2. Any associated cognitive and perceptualneurological conditions.

3. Blindness or severe field deficit affecting balanceand gait

4. Musculoskeletal disorders of lower extremityleading to inability in walking and pain e.g.contractures, deformities

5. Inability to provide informed consents.

PROCEDURE

The total 30 patient were divided into two equalgroups. Each group contained 15 patients. The balancetraining with obstacle ambulation training was givento the experimental group and balance training wasgiven to the control group. All participants wereevaluated by Dynamic Gait Index for dynamic balanceand Six Minute Walk Test for walking endurance.Dynamic Gait Index and Six Minute Walk Test shownto valid and reliable8-9, 10-11.All patients were assessedby Dynamic Gait Index and Six Minute Walk Testbefore and after intervention.

Treatment (Physiotherapy)

Group A

All subjects in this group performed balancetraining exercises.

Balance training exercises

1. Sit to stand

2. All four position

3. Alternate leg and arm raise in all four position

4. Kneel standing

5. Half kneeling

6. Standing

7. Bilateral calf raises

8. Unilateral standing with 90 degree knee flexion

9. Unilateral standing with hip in abduction

10. Bilateral mini squats



11. Lunges

12. Walking

13. Spot marching

All the exercises were performed 5 times each for40 minutes.

Group B

All subjects in this group performed balancetraining along with obstacle ambulation training. Afterperforming the balance training protocol for 40 minutethe subjects were provided 25min extra in which thesubjects were instructed to take rest for 1 minute thenunder supervision the patient were made to crossobstacles made from cardboard which were of variousheights (6.5cm, 13cm, 27cm) and widths (6.5cm, 13cm,27cm) with either affected limb or unaffected limbbeing the lead limb. Subject had to cross the obstacleswhich were placed randomly in 3 sets on a walk way.In each set, the placement of obstacles were changedand asked the subject to perform 5 times each of sets.Random placement was done to avoid any learningeffect of the sequence in which the obstacles wereplaced. Safety measures were taken so that the patientdid not hurt himself during the training.

Both the groups received therapy for 5 days a weekfor 8 weeks.

Data and Statistical Analysis

Comparison was performed between both thegroups first at baseline level then analyzed frombaseline to the end of 8th week for each group, andfinally at the end of 8 weeks. Paired‘t’ test was usedto analyze within group analysis for 6MWT.Unpaired‘t’ was used to analyze between groupanalysis for 6MWT. Wilcoxon was used for withingroup analysis for DGI and DGI stepping components.Mann Whitney U test was used to analyze betweengroup analysis for DGI and DGI stepping components.Data analysis was performed with SPSS statisticalpackage version 13. The results were statisticallysignificant if the p-value d” 0.05.

RESULTS

Patients in both the groups were assessed atbaseline level for dynamic balance with DGI andwalking endurance with 6MWT prior to thecommencement of the treatment sessions. First we

compared demographic and functional data of the agematched subgroup. Post test measurements were takenafter 8 weeks after completion of treatment sessions.There was no drop out in the study.

Baselines characteristics of both the group areshown in table 1.characteristic of both the groups weresame at the base line level prior to intervention.

Table 1. Baseline Characteristics of the both the groups

Balance Balance p valuetraining group training with

obstacle ambulation

training group

No of patients 15 15

Age 48.06±6.74 47.86±6.027 NS

Sex 10(M), 5(F) 9(M), 6(F)

Side affected 6(Rt), 9(Lt) 7(Rt), 8(Lt)

DGI score before 11.8±0.86 12±1.25 1.00intervention

6MWT value before 124.09±58.87 125.09±57.62 1.00intervention

This table shows that before intervention there wasno significant difference of DGI score between thegroups (p value- 1.00) and 6MWT value of both thegroups ( p value- 1.00).

Table 2. DGI score of both the groups beforeand after intervention

Group Balance p value Balance training p valuetraining group with obstacle

ambulationtraining group

DGI score before 11.8±0.86 0.001 12±1.25 0.002intervention

DGI score after 16.06 17.8±2.62intervention

Above table shows the pre and post scores of DGIof both groups. Analysis revealed that there was asignificant improvement in post treatment scores ofDGI.

TABLE 3. 6MWT value of both the groups before andafter intervention

Group Balance p value Balance training p valuetraining group with obstacle

ambulationtraining group

6MWT value 124.09±58.8 0.001 125.09±57.62 0.00beforeIntervention

6MWT value 164.81±65.53 211.33±57.62after Intervention

Above table shows the pre and post values of6MWT of both groups. Analysis revealed that therewas a significant improvement in post treatment valueof 6MWT.


30 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2013, Vol. 8, No. 2

TABLE 4. DGI score and 6MWT value of both thegroups after intervention

DGi score after p value 6MWT value p valueintervention after intervention

Balance 16.06 0.04 164.81±65.53 0.04training group

Balance training 17.8±2.62 211.33±57.62with obstacleambulationtraining group

Above table is showing the score of both groupson DGI and 6MWT after given the treatment.Independent sample test showed significant changesbetween both the groups for both the variables. OnDGI test p value was 0.04and for 6MWT also p valuewas 0.04.

TABLE 5. Baseline measurement of Dynamic gaitindex (DGI) stepping components (component 6,7,8)

in group A and Group B.


obstacle ambulation

training groupDGI stepping 1.06±0.79 1.2±0.77 0.67components scorebefore intervention

Table shows the Mean ±SD of DGI steppingcomponents ( 6,7,8) in both groups A and B. There wasno significant difference between the groups.

TABLE 6. Post intervention scores of DGI steppingcomponent(6,7,8) of Group A & Group B.


obstacle ambulation

training groupDGI stepping 2.7±1.03 3.6±1.24 0.02component scoreafter intervention

The above table showing the post interventionscores of DGI stepping component (6,7,8) of Group A& Group B with p-value 0.02 (statistically significant).

DISCUSSION

In this experimental design study, result shows theeffectiveness of balance training with obstacleambulation training on walking ability of strokepatients. The results support the hypothesis thatbalance training with obstacle ambulation training ismore effective than that of balance training.

Both the groups showed significant improvementat the end of intervention when compared frombaseline which shows that balance training is effective

in treating stroke patients who have balancedifficulties. This suggests that balance trainingprovides increased postural and trunk control thusimproving balance in both the groups. Improvedpostural and trunk control allows the body to remainupright, to adjust to weight shifts, to control movementagainst the constant pull of gravity12.

The result of this study is supported by previousstudies which shown that balance recoverycharacterized by reduction in postural sway andinstability and reduction in visual dependencyparticularly with regard to frontal plane enhancesrelearning of independent standing and walkingabilities13.

The stroke patients due to impaired balance includean increase in postural sway, decreased area of stabilityin stance, an uneven weight distribution on stance withless weight placed on the weaker leg. Moreover theirability to walk is affected by various neurologicaldeficits including impaired neuromuscular control,sensation loss, abnormal tone (spasticity of lower limb),and loss of sensory and anticipatory postural controletc4.

When analysis was done between the group at postintervention level it was found that the group receivingbalance training combined with obstacle ambulationtraining had better recovery compared to balancetraining group alone. During obstacle ambulationtraining, while crossing the obstacles there is need ofgreater motion of body segments which results ingreater excursion of the whole body’s centre of mass(COM) and perturbs balance maintenance and alsoleads to linearly increase in flexion angles of the hip,knee and the maximum dorsiflexion movement at theankle joint during late stance. The maximum extensionmoment at the hip joint during late stance decreasedlinearly with obstacle height when the toe of thetrailing limb was over the obstacles which showedclinically meaningful changes in gait velocity, stridelength, walking endurance and obstacle clearancecapacity as a result of stepping over obstacles 14-15.While crossing the obstacle with the help of sound leg,there is increase in stance phase of weight bearing limbwhich further increases the weight bearing of affectedlimb. That is the reason behind better improvement ofGroup B receiving balance training with obstacleambulation training.



The findings of this study does not correlate withresults of the study done by Smita Agarwal et al inwhich stroke patients were given balance training inone group while balance training with obstacle trainingwere given to another group4. This could be attributedto the total duration of the intervention (2 weeks) intheir study. Where as in this study the total durationof intervention is 8 weeks and since the study was toinvestigate the additive effect of obstacle trainingfurther analysis of stepping components of DGI whichone having direct relationship or similar task relativeto obstacle training e.g.( stepping over obstacles,crossing around the obstacles and stairs) from baselinelevel to post intervention level was done andsignificant improvement was seen at the end ofintervention on walking ability. So after obstacleambulation training resulting improvement is DGIstepping component. That is the reason whyexperimental group had significant better recovery atthe end of intervention.

Limitation of study

In term of study limitations the sample size usedin this study was small so that result is not generalized.In this study there is no follow up after 8 weeks, so itmay be another limitation of the study. Other gaitvariables like step length, stride length and temporalsymmetry index was not considered.

Future scope of study

Similar exercise protocol can be used to verify theeffect of balance training with obstacle ambulationtraining in chronic stroke subjects.

Future research can be carried out using moreobjective outcome measures like gait analyzer whichwill pick up changes in the gait parameters andobstacle ambulation meticulously.

Clinical implication

Obstacle ambulation training can be used toenhance the efficacy and efficiency of physiotherapytreatment for stroke patients. This treatment will helpthe patients to increase the walking competency andenabling the patients to ambulate in the communityagain. Increased walking competency will enhance thequality of life of stroke patients. This treatment can be

used clinically as it will be much convenient, safer andeasy to perform by the patients

CONCLUSION

This study suggests that balance training withobstacle ambulation training is more effective ascompare to the balance training on walking ability forambulant stroke patients.

REFERENCES

1. O’ Sullivan S.B, Schmitz T.Z. PhysicalRehabilitation Assessment and Treatment 4th

edition: ch-17 stroke:p-509.2. Stroke—1999. Recommendations on stroke

prevention, diagnosis, and therapy. Report of theWHO Task Force on Stroke and otherCerebrovascular Disorders. Journal of theAmerican Heart Association. Stroke 1989;20:1407

3. Goldstein M, Barnett H, Orgogozo JM, Sartorius.Stroke -1989 Recommendations on strokeprevention, diagnosis, and therapy. Report of theWHO Task Force on Stroke and otherCerebrovascular Disorders. Journal of theAmerican Heart Association. 1989; 20:1470-31.

4. Agarwal S, Joshua MA, Kumar V. Efficacy ofobstacle ambulation training on functionalmobility in ambulant stroke subjects. The Journalof Indian Association of Physiotherapists. 2010;15:35-40.

5. Bayouk JF, Jean P, Leroux A. Balance trainingfollowing stroke: effects of task –orientedexercises with and without altered sensory input.International Journal of Rehabilitation Research2006; 29: No1.

6. Babalola JF, Taiwo O. Effects of endurancewalking training programme on functionalambulation recovery of stroke survivors.Research Journal of International Studies 2011;19:5-12.

7. David LJ, David A. Brown CD, Pierson C, Ellie L.Stepping over obstacles to improve walking inindividuals with post stroke hemiplegia.Journalof Rehabilitation Research and Development.2004; 41; 283-292.

8. Jonsdottir J, Cattaneo D. Reliability and validityof the Dynamic Gait Index in persons with


ONLINE FIRST International Journal of Physiotherapy and Research Provisional Article

ISSN 2321-1822 IJPR-A-2013- 313 (14-06-2013)

Manoj Kumar Deshmukh et al. Effectiveness of transcutaneous electrical stimulation on acupoints combined with task-related training to

improve lower limb function in subjects after sub-acute stroke. 1

Original Article:

EFFECTIVENESS OF TRANSCUTANEOUS ELECTRICAL STIMULATION ON ACUPOINTS COMBINED WITH TASK-RELATED

TRAINING TO IMPROVE LOWER LIMB FUNCTION IN SUBJECTS AFTER SUB-ACUTE STROKE

Manoj Kumar Deshmukh1, Chandan Kumar2, Manu Goyal3

M.P.T. (Neurology) student, M.M Institute of Physiotherapy & Rehabilitation, M.M.University, Mullana, Ambala, Haryana, India 1. Assistant professor, M.M Institute of Physiotherapy & Rehabilitation, M.M.University, Mullana, Ambala, Haryana, India 2 & 3. Address for correspondence: Manoj Deshmukh,

34/2-C Risali sector Bhilai nagar ,Durg. Chattisgarh. Email: [email protected] Abstract Background: There is increasing evidence of neural plastic changes associated with specific training that is goal-directed and requires special attention with practice. Transcutaneous electrical stimulation (TENS) has been used to treat pain and also hemiplegia. Sensory input by TENS on acupoints and task related training (TRT) induces recovery of lower limb function in patients after sub-acute stroke. There are very few studies which show the combined effectiveness of sensory stimulation through acupoints and TRT, therefore the purpose of the current study is to evaluate the effectiveness of TENS on acupuncture points combined with TRT over conventional physiotherapy on reducing spasticity and improving lower limb function in subjects after sub-acute stroke. Materials and Methods: Thirty subjects with sub-acute stroke of either side including both male and female participated in randomised clinical trial. Both group received TRT along with conventional physiotherapy program. TENS on acupoints was given in subjects of experimental group along with TRT to evaluate the effectiveness of TENS. Measurement of spasticity was done by Modified Ashworth Scale (MAS), functional ability was measured by Dynamic Gait index (DGI) and Timed up & Go (TUG) test. All the measurements were done before and after 5 weeks intervention. Result: A significant reduction in spasticity measured by MAS (p=0.03) and relevant improvement in functional ability measured by DGI (p=0.03) and TUG (p=0.04) were observed in experimental group after five weeks intervention. Conclusion: Present study provides an evidence to support the use of TENS on acupoints as an adjunctive with task related training and other rehabilitation program. KEY WORDS: Transcutaneous Electrical Stimulation (TENS); Acupoints; Task-related Training (TRT); Stroke. INTRODUCTION Stroke is the leading cause of adult disability and inpatient rehabilitation admissions1. It is the second commonest cause of death and fourth leading cause of disability world wide2. Approximately 20 million people each year will suffer from stroke and of these 5 million will not survive3. In India, the ICMR estimates in 2004 indicated that stroke contributed 41% of deaths and 72% of disability adjusted life years amongst the non-communicable diseases. Ambulation and locomotion is an essential part of daily activity in life. After stroke, about 65% of survivors have reduced ambulatory capacity4 and after 6 months 50% still have impaired muscle function.5 Damage of motor and sensory pathways results in altered motor function6 and, over time, intramuscular changes7 which leads to impaired locomotion and functional capacity.


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In patients after stroke because of spasticity ankle dorsiflexors of affected limb become weak and it leads to some compensation in normal gait pattern such as foot slap, toe dragging, and step gait. Weak dorsiflexors are one of the most common causes to loss of joint coordination & gait dysfunction8. Motor weakness, poor motor control, and spasticity result in an altered gait pattern, poor balance, risk of falls, and increased energy expenditure during walking. Ineffective ankle dorsiflexion during swing (drop foot) and failure to achieve heel strike at initial contact are common problems that disturb gait pattern after stroke. Voluntary ankle dorsiflexion in the lower extremity is a stand point indicating the achievement of selective motor control9. There are a number of different approaches to physiotherapy treatment following stroke. Prior to the 1940s these primarily consisted of corrective exercises based on orthopaedic principles related to the contraction and relaxation of muscles, with emphasis placed on regaining function by compensating with the unaffected limbs. In the 1950s and 1960s techniques based on available neurophysiological knowledge were developed, including the methods of Bobath, Brunnstrom, Rood and the Proprioceptive Neuromuscular Facilitation approach. In the 1980s the potential importance of neuropsychology and motor learning was highlighted and the motor learning, or re-learning, approach was proposed. This suggests that active practice of context-specific motor tasks with appropriate feedback would promote learning and motor recovery10. Task-related training (TRT) is a rehabilitation strategy that involves the practice of goal-directed, functional movements in a natural environments11 to help patients derive optimal control strategies for alleviating movement disorder12. Task-specific physiotherapy involving repetitive practice of meaningful daily activities can lead to increased activation of the affected sensorimotor cortex13. Studies also demonstrate that movement and experience-dependent reorganization patterns occurs in both the damaged hemisphere and the contralateral hemisphere14,15. There is strong evidence that task-specific gait training improves gait post-stroke16,17. There is increasing evidence of neural plastic changes associated with training. Cortical representation areas can be increased by training that is specific, requires attention, and is repeated over time and also by sensory input18. Sensory information to the brain is provided by sensory tracts via various modalities. One way to maximize the amount of sensory input is via sensory amplitude electrical stimulation (SES), which, unlike NMES, is not limited by muscle fatigue. In one study, when SES was delivered to the hand of subjects without neurological impairments, functional MRI showed increased blood flow in the areas of the primary and secondary motor cortices as well as the primary sensory cortex. In other studies, the application of SES to patients following a stroke resulted in improvements in skin sensation and somato-sensory evoked potential19, a reduction in abnormally high “muscle tone” (as measured by joint stiffness20, reflex torque onset21, and modified Ashworth Scale22), and reduced inattention and neglect23. Transcutaneous electrical nerve stimulation (TENS) has been used to treat pain and also chronic hemiplegia since the last decade24. In the only study incorporating placebo-TENS up to mid-1990s, Levin found that 60 minutes of TENS, applied to the common peroneal nerve 5 times a week for 3 weeks, significantly decreased ankle plantarflexor spasticity and hyperactive stretch reflex, and markedly increased maximal voluntary contraction of the ankle dorsiflexors in chronic spastic hemiparetic subjects25. This placebo-controlled study demonstrated that the decreased spasticity


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in planterflexor and increase in peak dorsiflexor torque were evident after TENS but not after placebo stimulation. In clinical practice, the TENS electrodes are commonly placed at 4 broad categories of anatomical sites, including over the painful areas, along the peripheral nerves, along spinal nerve roots, or other specific points. A number of studies have also demonstrated considerable effectiveness in applying TENS over acupuncture points25. Wong and co-workers demonstrated that 2 weeks of transcutaneous electrical stimulation (TES) over 4 acupuncture points each in the affected upper and lower limbs produced a shorter hospital stay and better functional outcome than standard rehabilitation (SR) alone26. However, according to the review by Park and co-workers, there was insufficient evidence to support the use of acupuncture for stroke rehabilitation27. Numerous studies have revealed that cortical representation areas are constantly modified by sensory inputs and motor experiences, which play a major role in the subsequent physiological reorganization that occurs in the adjacent intact brain tissues after brain injuries28,29. A recent study showed that TENS excites large diameter Aα & Aβ afferents, which would include sensory and motor fibres. Because increased sensory input could facilitate cortical synaptic reorganization and motor output, and since the acupuncture points are located subcutaneously and intramuscularly, with many closely related to the nerves,30,31 stimulation over it induces greater response. However, sensory input by TENS on acupuncture points and TRT induces and facilitates plastic changes of brain and recovery of lower limb function in patients with stroke, it was hypothesized that combination of both treatment approach will induce greater summative effect on lower limb function in subjects after sub-acute stroke. MATERIALS AND METHODOLOGY The sample of 30 subjects between 40-47 year aged were assessed and selected by the means of simple random sampling from MMIMSR, Mullana, Ambala. Subjects were randomly allocated in the two groups using sealed yellow and green coloured envelopes containing the treatment allocation for each participant. Both male and female participants with unilateral stroke on either side, having the spasticity score between 2 to 4 in MAS were included. All the participants were able to walk 10 m unassisted with or without walking aids. Exclusion criteria for the study were subjects with psychological and cognitive disorders, chronic and secondary stroke, significant visual & auditory impairment, brainstem lesions and cerebellar lesions. 30 subjects were randomly allocated by means of simple random sampling into Control (group A) and Experimental group (group B). The procedure of study was explained to all subjects and written consent was taken. All subjects in both Groups actively participated in the study and received standard conventional physiotherapy treatment approaches that were aimed at promoting the recovery of postural control (balance during the maintenance of a posture, restoration of a posture or movement between postures). Interventions that had a more generalized stated aim, such as improving functional ability of lower limb and upper limb were also given. Protocol: In Control group, all participants received Task-related training for 60 minutes and conventional physiotherapy program. In Experimental group, all participants received 60 minutes of TENS on acupoints followed by Task-related training and conventional physiotherapy.


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Stimulator applied with 0.2 ms pulses, at 100 Hz in the constant mode within the subject’s tolerance level, via (5 × 3.5 cm) electrodes attached to the following acupuncture points on the affected lower extremity: St 36, Lv 3, GB 34, and Bl 60. Transcutaneous electrical stimulation on acupoints (TENS) The patient received 60 minutes of TENS (100 Hz, 0.2 ms square pulses at 2-3 times sensory threshold) from TENS stimulator. The choice of parameters of TENS were based on result of previous study.30,32,33 The electrode were carefully positioned over the 4 acupuncture points of affected leg (Fig.-1). The acupuncture points are commonly used in traditional Chinese medicine and have been used in previous studies.32,33 Task-related training (TRT) Task-related training program was adapted by previous study32 which was modified from that recommended by Carr and Shepherd. The program was conducted for 60 minutes per session. It included 40 minutes of 4 lower limb task specific exercises with wooden blocks of 10-15 cm in height. The wooden blocks was used for loading, stepping and heel-lift exercise. The total duration of treatment protocol was 5 days a week for 5 week. The patients attended instruction session in first week for two times.

Fig.1- Location of acupoints

1. St 36 is 7 to 8 cm below the tibial tuberosity and on the lateral aspect of the tibialis anterior muscle.

2. GB 34 is on the antero-inferior aspect of the capitulum of fibula bone. 3. BI 60 is in the depressed area lateral to tendon of the calcaneus, posterior to the lateral

malleolus. 4. Lv 3 is on the dorsum of foot between the first and second metatarsal bones.

Outcome measures: Measurements were taken prior and after 5 weeks of intervention in both groups, that was consisted with following measures. Modified Ashworth Scale (MAS) The objective measurement of spasticity of planterflexor was done by using MAS scale34. The test has recently been validated and shown to be reliable measurement of spasticity on lower limb in


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subjects with stroke35,36. The patients was examined on a couch in relaxed position in supine lying. The affected extremity was moved passively. Resistance encountered by the therapist to passive movement of ankle was then recorded by MAS. Timed up and Go test (TUG) The timed up and go test is a simple, quick and reliable functional mobility test that is used to examine the functional mobility and balance in community dwelling, frail older adults and individual with stroke37,38. A recent study demonstrate the reliability and validity of TUG test in stroke population39,40. The patients was asked to stand up from chair, walks 3 meters, turn around, return to chair and sit down. The time taken to complete the task was recorded in second with help of stopwatch. Dynamic Gait Index (DGI) The Dynamic Gait Index (DGI) was developed by Shumway-Cook and Woollacott to evaluate functional stability during gait activities in older people and to evaluate their risk of falling.41 The DGI is an 8-item tool with which the examiner rates an individual’s gait performance on an ordinal scale that ranges from 0 to 3. It takes approximately 10 minutes or less to complete and score the DGI. Reliability and validity of DGI for people with stroke has been established.42,43 Test was performed on distance of 20 foot. The patients were instructed to walk on marked surface with different task. Results Data analysis was done by using SPSS version 16.0 software. Descriptive statistics were used for subject’s demographic characteristics. Non-parametric data were analysed with Man-Whitney U test and Wilcoxon test. Student t-test was used for parametric data. The p-value was set at 0.05. The mean age of group A was 63.2(4.0) years and that of group B was 62.8(4.5). There was no significant reduction in spasticity in control group after treatment. Functional improvement was observed in both groups after 5 week intervention (table-1). The subjects, who received TENS and TRT shows significant reduction in spasticity compare to control group (p=0.03). The experimental group was also superior in DGI score (p=0.03) and time taken to complete the task in TUG test (p=0.04). The result of the study shows significant reduction and relevant improvement in functional capacity after 5 week intervention in the subjects who received TENS and TRT (table-2). DISCUSSION In the present study it was found that spasticity of planterflexor was reduced significantly after application of TENS on acupoints in group B. The finding of present study is similar to study done by Wong and co-worker which found that application of TENS on aupoints by surface electrode 5 times a week is effective therapy for better neurological and functional outcomes26. Another study done by Levin, demonstrated that 60 minutes of TENS applied over peroneal nerve is effective in reducing spasticity25.

When TENS is applied over acupoints by surface electrode the area stimulated were much larger than those of acupuncture needles. Study by Gladys and co-workers states that application of TENS on acupoints at 4 Hz; and 0.2ms pulse duration at the tolerable intensity increases negative peak latency (NPL) which indicates that the conduction velocity of nerve had decreased.44 An increase in H/M ratio and reduction in H-reflex latency in the affected limb in patients with stroke,


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this indicates that individual suffering from spasticity presents high excitability in pathways involving stretch reflex. The mechanism underlying the improvement in motor function reduction in spasticity could be enhancement of pre-synaptic inhibition of hyperactive stretch reflex in spastic muscle and disinhibition of descending voluntary commands to motor neuron of paretic muscle and decrease in co-contraction of spastic planterflexor following application of TENS over peroneal nerve30,45. Berbo and co-workers stated that plasticity can be influenced by sensory stimulation and training. Acupuncture and electrostimulation have physiological effects that can influence the brain plasticity46; as the present study also included the acupoints for electrical stimulation.

Gladys investigated that similar effect were found during stimulation by TENS on peripheral and acupoints. However the effect was somewhat greater in acupoints. The effects may be due to specific characteristic that occur at acupuncture points included large peripheral nerve, cutaneous nerves, blood vessels, and motor points. The acupoints are the loci of type II and type III afferents fibres which can be stimulated by TENS44.

The another hypothesis by Jackonssen et al showed that 20 session of TENS on acupoints over the 10 weeks period had no beneficial effect in patients 5-10 days after acute stroke. However their measurement tool was mainly clinical scale such as Barthel index which may not be sensitive to detect the spasticity47. In present study there was significant improvement in TUG and DGI parameters after intervention in both group and however group B was superior to control group. These findings were similar to study by Catherinel et al which stated that 4 weeks of TRT intervention improves sit to stand performance and reduced time to complete the TUG task16. The possible mechanism behind this as suggested by Sung et al may be that brain plasticity occurs after physical intervention which involves repetition of task. The study demonstrated that the 4 week TRT program can induce functional recovery and sensory cortical reorganization in chronic hemiplegic population48. Cortical representation area of the paretic muscle was found to be reduced in subjects after stroke; this can be due to limited use of paretic muscle and limb28. Joachim et al found that after 12 weeks of CIMT in hand, the cortical reorganization of affected limb significantly occurred. The possible mechanism may be increase in excitability of neuron already involved in innervations of affected muscle or increase in excitable neuronal tissue in infarcted hemisphere. The task specific training involving the functional activity of limb induces new anatomic connection by means of sprouting unlikely because clear evidence has not been found after lesion28. The present study also provides the evidence of improvement in functional characteristics associated with significant reduction in spasticity of planterflexors when TENS was combined with TRT exercise which was specific to lower limb function. The another study support the hypothesis that combined effect of TENS and TRT induces greater improvement in motor function in subjects after chronic stroke49,32,33.

It was found that electrically stimulated sensory inputs could enhance brain plasticity. The sensory motor cortices are intimately involved with receiving and transmitting sensory information to other cortical area including premotor and motor cortices46. In present study the subjects were asked to practice the task specific exercise after sensory stimulation for 60 minutes. The above


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mechanism might be involved in improvement of lower extremity functions in relation to spasticity, TUG and walking function. However spasticity of other muscle group was not taken into consideration. One of the limitations of study is that, Quantitative measurement of spasticity and relevant improvement in Dorsiflexors strength was not done. Conclusion In conclusion, the present study provides an evidence to support the use of TENS on acupoints as an adjunctive with task related training and other rehabilitation program. The clinical and statistical improvements were observed after the 5 week intervention. Therefore, TENS on acupoints can be incorporated with task-related training for effective reduction of spasticity and associated lower limb function improvement in subjects after sub-acute stroke. Although present study was done on small sample size, the finding of study may be generalized to stroke patients with larger population. REFERENCES

1. Dejong,G., Horn, S.D., Conroy, B., Nichols, D., Healton, E.B. Opening the black box of post stroke rehabilitation: stroke rehabilitation patients, processes, and outcomes. Archv. Physic. Med. Rehab. 2005; 86 (12 suppl): 1-7.

2. Strong K., Mathers C, Bonita R. Preventing stroke: saves lives around the world. Lancet neurol. 2007; 6:182-7.

3. Dalal P, Bhattacharjee M, and Vairale J, Bhat P. Un millennium development goals: can we halt the stroke epidemic in india? Ann indian acad neurol. 2007; 10: 130-6.

4. H. S. Jorgensen, H. Nakayama, H. O. Raaschou, and T. S. Olsen, Recovery of walking function in stroke patients:the copenhagen stroke study. Archives of physical medicine and rehabilitation.1995; 76(1):27–32.

5. M. Kelly-Hayes, A. Beiser, C. S. Kase, A. Scaramucci, R. B. D’agostino, and P. A. Wolf. The influence of gender and age on disability following ischemic stroke: the framingham study. Journal of stroke and cerebrovascular diseases. 2003; 12(3): 119–126.

6. K. S. Sunnerhagen, U. Svantesson, I. L¨onn, M. Krotkiewski, and G. Grimby. Upper motor neuron lesions: their effect on muscle performance and appearance in stroke patients with minor motor impairment. Archives Of Physical Medicine And rehabilitation. 1999 ; 80(2): 155–161.

7. F. M. Lvey, R. F. Macko, A. S. Ryan, and C. E. Hafer-macko, Cardiovascular health and fitness after stroke. Topics in stroke rehabilitation. 2005; 12(1): 1–16.

8. Susan B. O’sullivan. Physical Rehabilitation, 5th ed.2007,Jaypee publisher. 9. De Quervain IA, Simon S.R., Leurgans S, Pease W.S., Mcallister D. Gait pattern in the early

recovery period after stroke. J bone joint surg am. 1996; 78: 1506-14. 10. Pollock A, Baer G, Pomeroy VM, Langhornen P. Physiotherapy treatment approaches for

the recovery of postural control and lower limb function following stroke, Cochrane review.2009.

11. Carr JH, Shepherd RB. Neurological rehabilitation: optimizing motor performance. Oxford: Butterworth-Heinemann; 1998.


ISSN 2321-1822 IJPR-A-2013- 313 (14-06-2013)



12. Gentile AM. Skill acquisition: action, movement and neuromotor processes. In: carr jh, shepherd RB, EDs. Movement sciences: foundation for physical therapy in rehabilitation. 2nd ed. Gaithersburg: aspen; 2000:111–187.

13. Jang Sh, Kim YH, Cho SH. Cortical reorganization induced by task-oriented training in chronic hemiplegic stroke patients. Neuroreport. 2003; 14: 137-141.

14. Johansen-Berg H., Dawes H, Guy C., Smith S.M., Wade D.T. & Matthews P.M. Correlation between motor improvements and altered fmri activity after rehabilitative therapy. Brain.2007; 125(pt 12), 2731–2742.

15. Ward N.S. Future perspectives in functional neuroimaging in stroke recovery. Europa medicophysica.2007; 43(2), 285–294.

16. Dean CM Richards Cl, Malouin F. Task-related circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial. Arch phys med rehabil. 2000; 81: 409-417.

17. Salbach NM, Mayo N.E, Wood-Dauphinee S, Hanley JA, Richards CL, Cote R. A task-orientated intervention enhances walking distance and speed in the first year post stroke: A randomized controlled trial. Clinical rehabilitation. 2004; 18: 509-519.

18. Byl N, Roderick J, Mohamed O. Effectiveness of sensory and motor rehabilitation of the upper limb following the principles of neuroplasticity: patients stable poststroke. Neurorehabil neural repair. 2003; 17: 176–191.

19. Peurala Sh, Pitklinen K, Sivenius J, Tarkka IM. Cutaneous electrical stimulation may enhance sensorimotor recovery in chronic stroke. Clin rehabil. 2002; 16: 709–716.

20. Seib TP, Price R, Reyes MR, lehmann JF. The quantitative measurement of spasticity: effect of cutaneous electrical stimulation. Arch phys med rehabil. 1994; 75: 746–750.

21. Dewald JP, Given JD, Rrymer WZ. Long-lasting reductions of spasticity induced by skin electrical stimulation. Leee trans rehabil eng.1996; 4: 231–242.

22. Sonde L, Kalimo H, Viitanen M. Stimulation with high-frequency tens: effects on lower limb spasticity after stroke. Advances in physiotherapy. 2000; 2:183–187.

23. Vallar G, Rusconi ML, bernardini B. Modulation of neglect hemianesthesia by transcutaneous electrical stimulation. J int neuropsychol soc.1996; 2 :452–459.

24. Walsh DM, editor. Tens: clinical applications and related theory. New york: Churchil Livingstone; 1997.

25. Levin M.F. and Hui-Chan CWY. Relief of hemiparetic spasticity by tens is associated with improvement in reflex and voluntary motor functions. Electroencephalogr clin neurophysiol 1992; 85: 131-42.

26. Wong Amk, Su Ty, Tang FT, Cheng Pt, Liaw MY. Clinical trials of electrical acupuncture on hemiplegic stroke patients. Am j phys med rehabil. 1999; 78: 117–122.

27. Park J, Hopwood V, White AR, Ernst E. Effectiveness of acupuncture for stroke: a systematic review. J neurol 2001; 248: 558–563.

28. Liepert J, Bauder H, Miltner WHR, Taub E, Weiller C. Treatment induced cortical reorganization after stroke in humans. Stroke. 2000; 31: 1210–1222.

29. Nudo RJ, Milliken GW. Reorganization of movement representations in primary motor

cortex following focal ischemic infarcts in adult squirrel monkeys. J neurophysiol. 1996; 75: 2144 –2149.


ISSN 2321-1822 IJPR-A-2013- 313 (14-06-2013)



30. Levin MF, Hui-chan CWY. Conventional and acupuncture-like transcutaneous electrical nerve stimulation excites similar afferent fibers. Arch phys med rehabil. 1993; 74: 54–60.

31. Chen M, Shen H, Lin B, Gian J, Luo Q, Liu W, editors. Atlas of cross sectional anatomy of human 14 meridians and acupoints. Beijing: science press. 1996, p. 305–306.

32. Tiebin Yan,and Christina W. Y. Transcutaneous electrical stimulation on acupuncture points improves muscle function in subjects after acute stroke: a randomized controlled trial. J rehabil med 2009; 41: 312–316.

33. Shamay S.M. Ng and Christina. Transcutaneous electrical stimulation combined with TRT improves lower limb function in subjects with chronic stroke. Stroke. 2007, 38:2953-2959.

34. R.W. Bohannon and M.B. Smithz. Interrater reliability of Modified Ashworth Scale of muscle spasticity. Physical Therapy. 1987;67: 207.

35. Gregson JM, Leathley M, Moore AP. Reliability of the tone assessment scale and the modified ashworth scale as clinical tools for assessing poststroke spasticity. Arch phys med rehabil. 1999 sep;80(9):1013-6.

36. Blackbum M van Vliet P, Mockett Sp. Reliability of measurements obtained with the modified ashworth scale in the lower extremities of people with stroke. Phys therapy. 2002 jan;82(1):25-34.

37. Podsiadlo D, Richaedson S. The time “up & go”:A Test Of Basic Functional Mobility For Frail Elderly Person. Journal of the American Geriatrics Society. 1991; 39(2):142-148.

38. Shumway Cook A, Brauser S. Woollacott M. Predicting the Probability for falls in community dwelling older adults using the timed “up & go” test. The physical therapy. 2000;80:896-903.

39. Ng SS, Hui-chan CW. The timed up & go test: its reliability and association with lower-limb impairments and locomotor capacities in people with chronic stroke. Arch phys med rehabil. 2005 aug;86(8):1641-7.

40. Flansbjer UM, Holmbäck AM, Downham D. Reliability of gait performance tests in men and women with hemiparesis after stroke. J rehabil med. 2005 mar;37(2):75-82.

41. Shumway-Cook A, Woollacott M. Motor control: theory and practical applications. Baltimore: Williams & Wilkins; 1995.

42. Jonsson IR, kristensen MT. Intra- and interrater reliability and agreement of the danish version of the dynamic gait index in older people with balance impairments. Arch phys med rehabil. 2011 oct;92(10):1630-5.

43. Jonsdottir J, Cattaneo D. Reliability and validity of the dynamic gait index in persons with chronic stroke. Arch phys med rehabil. 2007 nov;88(11):1410-5.

44. Gladys L. Y. Cheing, and Winnie W. Y. Chan. Influence of choice of electrical stimulation site on peripheral neurophysiological and hypoalgesic effects; J Rehabil Med. 2009; 41: 412–417.

45. Fabio L. Martins,Luis C. Carvalho, Immediate effects of TENS and cryotherapy in the reflex and voluntary activity in hemiparetic subjects: a randomized control trial;Rev Bras Fisioter.2012;16(4):337-44.

46. Barbro B. Johansson. Acupuncture and transcutaneous nerve stimulation in stroke rehabilitation:a randomized controlled trial. Stroke 2001; 32: 707-713.

47. A,Ursing D, Asplund K. Acupuncture and transcutaneous nerve stimulation in stroke rehabilitation: a randomized, controlled trial. Stroke. 2001; 32: 707–713.


ISSN 2321-1822 IJPR-A-2013- 313 (14-06-2013)



48. Sung Ho Jang, Yun-Hee Kim. Cortical reorganization induced by task-oriented training in chronic hemiparetic stroke patients.Lippincott Williams and Williams. 2003;14(1):137-141.

49. Michelle N. McDonnell, Influence of Combined Afferents stimulation and Task specific training following stroke: a pilot randomized controlled trial. Neurorehabil Neural Repair.2007;21:435.

Table -1:- comparison of pre and post values within Group A and B.

pre post pre post pre post pre post pre post pre post Mean 3 2.7 3.3 2.2 7.1 9.13 7.1 11.4 25.2 23.4 24 20.9

S.D. 0.7 0.5 0.6 0.7 0.9 2.92 0.9 3.1 3.2 3.6S.E.M. - - - - - - - - 0.79 0.82 0.67 0.93

Median 3 3 3 2 7 10 7 12

IQR 2 1 1 1 2 6 2 2

Maximum 4 3 4 4 9 14 9 16

Minimum 2 1.5 2 1.5 6 5 6 8

Test value

p-value

-

MAS DGI TUG(sec.)Group A Group B Group A Group B Group A Group B

2.2 2.6

- - -

- -

- - - -

-1.47 -3.41

- -

- - - -

-2.98

(z-value)

-2.42

(z-value)

2.41

(t-value)

3.29

(t-value)-0.14 (0.003)*

(z-value)(z-value)(0.03)* (0.005)*(0.01)* (0.001)*

* Significant difference between pre and post value within Group A and B. MAS= Modified Ashworth Scale, DGI = Dynamic Gait Index, TUG = Timed Up and Go test, S.D=

standard deviation, IQR= Inter Quartile Range, SEM= standard Error of Measurement. Table-2:- comparison of pre and post values between Group A and B

A B A B A B A B A B A B

S.E.M. 0.79 0.67 0.82 0.99Median 3 3 3 2 7 7 10 12

Maximum 4 4 3 4 9 10 14 16

Minimum 2 2 1.5 1.5 6 6 5 8

Test value

MAS DGI TUG(sec.)Pre Post pre post pre post

2.2 3.08 3.1

1.98

(t-value)

-1.249

(U-value)

-2.14

(U-value)

-0.22

(U-value)

(0.03)* (0.04)*p-value

Mean 3 3.3 2.7 2.2

-0.21 (0.03)* -0.82 -0.26

-2.11

(U-value)

1.147

(t-value)

S.D.

23.4 20.9

3.62.632.90.9

7.1 7.06 9.1 11.4 25.2 24.1

0.7 0.90.50.60.7

2 6 2IQR 2 1 1 1 2

* Significant difference between Group A and B.

MAS= Modified Ashworth Scale, DGI = Dynamic Gait Index, TUG = Timed Up and Go test, S.D= standard deviation, IQR= Inter Quartile Range, SEM= standard Error of Measurement.

-End- *Original Article will be Published on 11th of August 2013 in Our 3rd Issue

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