Paper Publications

Functional Outcome between Ischemic and Hemorrhagic Stroke Patients after Inpatient Rehabilitation
Chandan Kumar M.M. Institute of Physiotherapy and Rehabilitation, Mullana, Ambala
Abstract Purpose
The 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.
Methodology
This 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.
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 origin5. 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 Stroke
Ischemic stroke is a common form of stroke accounting for approximately 80-85% of all strokes.68It occurs when a blood vessel becomes occluded and the blood supply to part of the brain is totally or partially blocked.
Results
Hemorrhagic 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.
Hemorrhagic Stroke
Hemorrhagic 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 31
Conclusions
From 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 words
Hemorrhagic, ischemic, rehabilitation, stroke
Introduction
Stroke is one of the oldest recognized diseases, but remains one of the least understood. Stroke is the third
Chandan Kumar / Indian Journal of Physiotherapy & Occupational Therapy. April-June 2011, Vol. 5, No. 2
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 wellrecognized 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.
Methodology
Total 70 patients selected from stroke patients admitted to YCM Hospital, Pune for rehabilitation of sequel of their first stroke. For patients 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 Criteria
1. 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.
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.
Exclusion Criteria
1. 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
Matching
From 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).
Data and Statistical Analyses

We compared demographic, clinical neuroradiological 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.
Neurological and Functional Evaluation

To 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). 32
Results
We 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 No of patients Age Sex (male) Stroke left CNS Score at admission BI Score at admission RMI Score at admission Hypertensive% Diabetes % Heart disease% 35 64.85.49 68.5% 23 4.75 17.28 1.22 37.14% 11.42% 51.42% Hemorrhagic P value 35 64.294.416 60% 21 4.74 16.00 1.02 74.28% 14.2% 11.42% NS Ns NS NS NS NS
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.
Discussion
The 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
Table II: Admission and discharge score of both the groups Hemorrhagic At admission Canadian neurological score Rivermead mobility index score Barthel index score 4.74 1.02 16.00
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. Thats 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.
Ischemic At admission 4.75 1.22 17.28 7.30 5.22 47.28 At discharge
At discharge 8.11 5.71 50.00
33
Graph I:
Comparison of Admission and Discharge Values
60 50 50 40
Median
47
30 20 10 0 CNS RMI Haemorrhagic

Admission Discharge
16 8.1 4.7 1 BI CNS 5.7 7.3 1.2 RMI Ischemic
17
4.7
5.2
BI
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:
Neurological Status (CNS Score) at Admission and Discharge Scale 8.5 8 7.5 7 6.5 6 5.5 5 4.5 4 Admission
Haemorrhagic
Discharge Discharge
Admission
Discharge
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).
Limitations of a Study Length 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 Study Study 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; 339:342-4 2. World Health Organization. WHO Burden of Diseases and Injury (Dataset - 2002). 3. World Health Organization. 2003. Geneva, Switzerland, World Health Organization. 2003 4. 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; 14:103108. 10. Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF. Spontaneous intracerebral hemorrhage. N Engl J Med. 2001; 344:14501460. 11. Vermeer SE, Algra A, Franke CL, Koudstaal PJ, Rinkel GJ. Long-term Prognosis after recovery from primary intracerebral hemorrhage. Neurology. 2002; 59:205209. 12. Jorgensen HS, Nakayama H, Raaschou HO, Olsen TS. Intracerebral Hemorrhage versus infarction: stroke severity, risk factors, and prognosis. Ann Neurol. 1995; 38:4550. 13. Shah S, Vanclay F, Cooper B. Predicting discharge status at commencement of stroke rehabilitation. Stroke. 1989; 20:766769. 14. Ween JE, Alexander MP, DEsposito M, Roberts M. Factors predictive of Stroke outcome in a rehabilitation setting. Neurology. 1996; 47:388392. 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: 177182 19. Franke CL, van Swieten JC, Algra A, van Gijn J. Prognostic factors in Patients with intracerebral hematoma. J Neurol Neurosurg Psychiatry.1992; 55:653657. 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.
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The Efficacy of Bilateral Training on Functional Recovery of Upper Extremity After Stroke
Chandan Kumar, Mukesh Kumar M.M. Institute of Physiotherapy and Rehabilitation, Mullana, Ambala
Abstract Purpose
The 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.
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 origin3. 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.
Methodology
This 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.
Results
Result shows that, both the group improved significantly but bilateral training group improved much better than unilateral training group
Conclusions
This 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 words
Unilateral training, bilateral rehabilitation, upper extremity. training, stroke
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.
Introduction
Stroke 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
Bilateral Training
Bilateral training is a new class of interventions aimed 35
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.
Methodology
Total 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
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.
Inclusion Criteria
1. Individuals with first episode of unilateral stroke. 2. All patients who were medically stable 3. 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 Criteria
1. 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.
Procedure
Thirty 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 36
Data and Statistical Analyses

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. 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.
Results
We successfully matched 30 patients of both control and experimental group for upper extremity recovery
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 No of patients Age Sex (male) Stroke left Stroke right Mini-Mental scalescore Fugl-Meyer score before intervention Functional independence measure score before intervention 15 59.208.326 9 13 2 27.13 25.60 20.13 Unilateral group 15 58.807.193 9 13 2 27.40 25.80 19.80 NS 1 NS NS o.5886 .910 .670 P value
Table 4: Fugl-Meyer scale and FIM score of both the group after intervention Fugl-Meyer score after intervention Bilateral group Unilateral group 49.13 37.53 P value FIM score after intervention 36.93 30.67 P value .001
.001
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).
Discussion
In 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:
Fugl-Meyer score change before to after given intervention
25 20
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 25.60 25.80 Fugl-Meyer score after intervention 49.13 37.53 P value .001
Bilateral group Unilateral group
15
Fugl-Meyer score
10 5 0 Mean S.D
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 20.13 19.80 FIM score after intervention 36.93 30.67 P value
Above graph showing the changes in the bilateral training group and unilateral training group on Fugl-Meyer score before and after treatment. Graph 2:
FIM score changes before to after given intervention
20
.001
15
FIM score 10 Bilateral group Unilateral group
5 0 Mean S.D
Above table shows that after the intervention there was significant difference between the groups ( p value - .001).
Above graph showing the changes score on FIM is more in bilateral training group than the unilateral training group.
37
Relationship Between Motor Impairments of Hand and Manual Ability in Spastic Cerebral Palsy Children
Gagandeep Kaur1, Poonam Mehta2, Chandan Kumar3
1
Student,
2,3
Lecturer, M M IPR, M M University, Mullana, Ambala, Haryana, India
Abstract Introduction
Cerebral palsy is a static neurologic condition resulting from brain injury that occurs before cerebral development incomplete. Hand impairments are related to the manual ability. Hand impairments are not rare in the cerebral palsy but they are not considered significantly. We assessed the hand impairments in relation to manual ability amongst Cerebral palsy children who were spastic diplegics and quadriplegics.
Material and Methods

Thirty cerebral palsy children were assessed. Hand impairments included grip strength, fine finger dexterity, gross manual dexterity and these were assessed by hydraulic hand handle dynamometer, pegboards and box and block test respectively. Manual ability was assessed by Abilhand kids questionnaire. All the subjects according to the inclusion criteria were included in the study. One time assessment was taken. For the grip strength and fine finger dexterity three readings were taken and average of these three readings was taken as the final score. For box and block test single reading was taken. Spasticity was assessed by the Modified Ashworth Scale. Results were calculated by using Pearsons 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 manual ability, fine finger dexterity has the correlation of -.732(P=<0.05) with the manual ability and gross manual dexterity has the correlation 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 group of non progressive, non contagious motor condition that causes physical disability in human development, chiefly in various areas of body1.Martin Bax defined Cerebral palsy as a disorder of posture and movement that occurs secondary to damage to the immature brain before, during or after birth. This disorder is called a static encephalopathy because it represents a problem with brain structure and function2.The birth prevalence of cerebral palsy 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 Kaur M.P.T. Pediatrics Student Contact number+91-09896429194. E-Mail: physiogagan@yahoo.com
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Cerebral palsy is a static neurologic condition resulting from brain injury that occurs before cerebral development incomplete. Because brain development continues during the first two years of life, cerebral palsy can result from brain injury occurring during the prenatal, perinatal or post natal periods. Etiology of cerebral palsy include problems in intrauterine development (e.g. exposure to radiation, infection),asphyxia before birth, hypoxia of the brain and birth trauma during labor and delivery, complications in the perinatal period or duringchildhood1.Brain development continues during the first two years of life, cerebral palsy can result from brain injury occurring during the prenatal, perinatal or post natal periods4. According to tone classification includes spastic, athetoid i.e. hypotonic/floppy or atonic. Spastic type of cerebral palsy is the commonest type. Spastic Cerebral palsy associated with damage to cortical motor areas and underlying white matter, choreoathetotic cerebral palsy associated with damage to basal ganglia, ataxic cerebral palsy is associated with damage to cerebellar structures7 Spastic cerebral palsy consists of hyper tonicity of clasp-knife variety, abnormal postures, weakness in initiation of motion. Changes in hypertonous and posture may occur with excitement, fear or anxiety. Intelligence is impaired than athetoid Impairments include motor impairments and sensory impairments. Motor impairments include abnormal reflexes, disturbances in balance, locomotion, propulsion of objects and sensory impairments include tactile pressure stereognosis, proprioception 4, cerebral palsy. Perceptual problems, sensory loss, epilepsies, poor ribcage abnormalities and poor respiration4,5. The aim of physiotherapy is to make patient maximum independent. Physical therapy includes muscle strengthening and fitness programs as popular interventions for cerebral palsy; however advocates of neuro developmental treatment advise against the use of resistive exercises because it is believed to increase spasticity18.It is also shown that resistive exercise could be beneficial in strengthening when muscle weakness causes dysfunction19. Stretching exercises, sensory stimulation, PNF, Biofeedback are also used4,5. Orthotic devices such as ankle foot orthosis are often prescribed to minimize gait irregularities20. AFOs have been found to improve several measures of ambulation, including reducing energy expenditure and increasing speed and stride length20.21. Previous studies show that hand impairments and manual ability are correlated to each other. In previous studies, grip strength was measured by Jamar dynamometer, gross manual dexterity was measured by box and block test, fine finger dexterity was measured by Purdue pegboard. But in present study, the grip strength is measured by Hydraulic hand handle dynamometer which measures the strength in kgs, gross manual dexterity is measured by box and block test, in which one wooden box is there having six inches partition in it with 150 blocks of one inch and fine finger dexterity is measured by pegboards (square pegboard and fine finger test).The square pegboard is twelve inches in length and twelve inches in width. It consists of 25 pegs and 25 holes. The fine finger dexterity test consists of
Gagandeep Kaur / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4
two square wooden boards, one is having 49 holes in it and other is having one cup which consists of 49 pins in it and one forcep in it. Manual ability is a major component of daily living activities. Hand impairments are related to the manual ability. Hand impairments are not rare in the cerebral palsy but they are not considered significantly. There are very few studies done to assess the hand impairments and to measure the manual ability. Because there is lack of instrumentation to assess these impairment and manual ability. This study will help to measure the hand impairments and manual ability. And will also help to find the relation between these impairment and manual ability. The objective of this study is to find the relationship between hand impairments (Grip strength, gross manual dexterity and manual ability) and manual ability in children with spastic cerebral palsy (diplegics and quadriplegics).
Outcome Measures
1. 2. 3. 4. In the study the following outcome measures were taken. Abilhand kids questionnaire. Grip strength. Gross manual dexterity. Fine finger dexterity
Instrumentation
Following instruments were used in the study. Hydraulic Hand Handle Dynamometer. 2. Box and Block Test. 3. Pegboard Test. 1.
Procedure
30 subjects were selected on the basis of inclusion criteria. A thorough assessment was done. The procedure of the study was explained to parents/guardian and written consent was taken. The children were tested individually and instructions that how to perform each test were given to them. Three motor impairments i.e. Grip strength, Gross manual dexterity and fine finger dexterity were assessed on both hands, starting with dominant hand. Handedness was determined by writing hand preference. Grip strength was measured with Hydraulic Hand handle dynamometer. The grip strength score was determined as the average of maximum force exerted on dynamometer across three trials. According to standard position for testing which 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, arms unsupported, elbows flexed at 900,forearm rotation neutral, wrist 0-300dorsiflexion and 0-15 0 ulnar deviation. Gross manual dexterity was measured by Box and Block test. The child sat straight on the chair and box was kept in front of the child and instructions were given to him that how to perform the test. The score was determined as the maximum number of blocks transported from one compartment to another in one minute. Fine finger dexterity was measured by the pegboard test. The child sat on the chair and pegboard was kept in front of the child and instructions how to perform the test were given to him. The child was instructed to do 2 times practice before performing the final test. The fine finger dexterity score was determined by the number of pegs picked up from a cup and placed into holes of a board in one minute. Manual ability was assessed by Abilhand kids questionnaire. This questionnaire measures the childs capacity to manage daily activities requiring the use of hand and upper limb. Twenty one mostly bimanual activities were rated by childrens parents on a 3-level scale (0-impossible, 1-difficult, 2-easy) by providing their childs perceived difficulty in performing each activity.
Objective of the Study

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

There is a significant correlation between hand impairments and manual ability.
Null Hypothesis
There is no significant correlation between hand impairments and manual ability.
Methodology
This chapter contains cerebral palsy childrens hand impairments and their relation with the manual ability.
Study Design
Correlation.
Sample Size
A convenience sample of total 30 subjects with already diagnosed 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.
Data Analysis
A Pearson correlation coefficient was calculated to examine the relationship between grip strength, fine finger dexterity, gross manual dexterity and manual ability. P value was set at <.05.SPSS version statistical software was used for analysis.
Inclusion Criteria
Children who fulfilled the following criteria were taken into the 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.
Results
All (30) subjects meeting inclusion criteria were invited to participate in the study. All 30 subjects consented and completed all 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 5-13 y. Subjects were taken from out patients departments.
Exclusion Criteria
1. 2. 3. Children with learning disabilities. Children undergone surgical procedures (for upper limb) Children with major intellectual deficits.
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Table 1: Mean and standard deviation of grip strength, fine finger dexterity, gross manual dexterity and manual ability. GRIP STRENGTH RT 2.303 0.712 LT 1.913 0.224 FINE FINGER DEXTERITY RT 12.777 1.926 LT 10.000 2.777 GROSS MANUAL DEXTERITY RT 22.867 3.711 LT 16.933 2.852 MANUAL ABILITY
MEAN S.D
27.833 8.073
Mean for RT grip strength is 2.303 0.712 and for LT grip strength is 1.913 0.224. Mean for RT fine finger dexterity is 12.777 1.926 and for LT fine finger dexterity is 10.000 2.777.
Mean for RT gross manual dexterity is 22.867 3.711 and for LT gross manual dexterity is 16.933 2.852 Mean for manual ability is 27.833 8.073.
Table 2: Correlation for grip strength, fine finger dexterity, gross manual dexterity with manual ability (Lf & Rt). GRIP STRENGTH RT Correlation with manual ability LT FINE FINGER DEXTERITY RT LT GROSS MANUAL DEXTERITY RT LT
-0.407
-0.567
-0.728
-0.567
-0.766
-0.773
The correlation is significant with p value <0.05 Correlation 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.
Table 3: Correlation for grip strength, fine finger dexterity, gross manual dexterity with manual ability. Correlation with manual ability GRIP STRENGTH -0.459 FINE FINGER DEXTERITY -0.732 GROSS MANUAL DEXTERITY -0.781
Fig. 1: Correlation b/w grip strength (Rt) and manual ability.
Fig. 3: Correlation b/w fine finger dexterity (Rt) and manual ability
Fig 2: Correlation b/w grip strength (Lf) and manual ability.
Fig. 4: Correlation b/w fine finger dexterity (Lf) and manual ability
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Fig. 5: Correlation B/W gross manual dexterity (Rt) and manual ability
Fig. 6: Correlation B/W gross manual dexterity (Lf) and manual ability
Discussion
This chapter deals with the results of the study. In this study, results showed that there is a significant relationship between the hand impairments and manual ability. We found that hand impairments has significant correlation with manual ability. Grip strength has significant relationship with manual ability when measured with hydraulic hand handle dynamometer and Abilhand kids questionnaire respectively. Correlation of grip strength with manual ability is -0.459.There was a significant relationship between fine finger dexterity and manual ability when measured with pegboards and Abilhand kids questionnaire respectively. Correlation of fine finger dexterity with manual ability is -0.732. There was a significant relationship between gross manual dexterity and manual ability when measured with box and block tests and kids questionnaire. Correlation of gross manual dexterity with manual ability is -0.781. Results of our study show that the capacity of upper limb and completion of ADLs of upper limb had a significant correlation. A study done by Carlyne Arnould et al suggested that manual ability was significantly correlated with motor impairment and stereognosis, while no significant relationship was found with tactile pressure detection and proprioception. Melanie Ziebell et al suggested that the children with diplegia performed at lower levels in all gross and fine motor assessments as compared to children without diplegia. Massimo Penta et al concluded that grip strength, dexterity, motricity, depression were significantly correlated with Abilhand measures which was used to measure manual ability in the stroke patients. Gonca Bumin et al showed that there was significant correlation between handwriting parameters and upper extremity speed and dexterity, propioception. bilateral coordination, visual and spatial perception and visual motor organisation in children with cerebral palsy. Julie Duque suggested that there is a correlation between impaired dexterity and corticospinal tract dysgenesis in congenital hemiplegia between .Jetty Van Meeteren et al suggested that correlations between grip strength parameters and activity limitations were relatively weak. Our study suggests that impaired grip strength, fine finger dexterity and gross manual dexterity, interfere with the activities of daily living i.e. manual ability and quality of life. This study also suggests that the effect of maturation and hand dominance and gender is also there. Age and hand dominance and gender also affects the grip strength, five finger dexterity, gross manual dexterity and so as manual ability. Both impairment and upper limb activity i.e. manual ability showed a correlation and influence on activities of daily living.
and gross manual dexterity were rarely correlated with manual ability. Therefore our study suggests that the other parameters of upper limb are also important to stress upon. So, this knowledge can assist clinician in making specific treatment interventions for improving condition of cerebral palsy children.
Future Research
1. 2. The study can be conducted with a heterogeneous gender bias (either males or females). Subjects included were only spastic diplegic and quadriplegics. The study can be done on any type of cerebral palsy.
Limitations of the Study

1. 2. 3. 4. Small sample size. No gender differentiation. Subjects with age group 5-13y. Influence of external factors.
Conclusion
There is a significant correlation between the grip strength, fine finger dexterity, gross manual dexterity and manual ability.
Bibliography
Kesler Martin Neurological Caonditions 1st Edition,page 345. 2. Beukelman et al. Augmentative and Alternative Communication: Management of Severe communication disorders in children and adults. Baltimore: Paul H Brookers Publishing Co.1999;2:246-2494. 3. P.O. Pharoah et al Trends in birth prevalence of cerebral palsy. Arch Dis Child.1987 April;62(4):379-384 4. Bass N.Cerebral palsy and neurodegenerative disease Curr Opin Pediatr 1999; 11: 4-7. 5. Sophie Levitt : Treatment of Cerbral palsy and motor delay.3rd Edition,Page 3-12. 6. Ann Thomson et al. Tidys Physiotherapy. Twelth Edition Page 361- 366. 7. Joans MW et al.Cerebral palsy:Introduction and Diagnosis(part 1).J Pediatr Health Care. May-June 2007;21(3):146-52. 8. Paul D.Cheney.Pathophysiology of the corticospinal system and basal ganglia in cerebral palsy1998 Dec,volume 3 Issue 2.Pages 153-167. 9. Palisano R et al.Development and reliability of a system to classify 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 1.
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Clinical Implications
Hand impairments i.e. grip strength, fine finger dexterity
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 Ther 2000;80:974-85. 12. Falio M et al.Peabody Development Motor Scales,2nd Edition examiner Manual,Austin, TX Pro-ED,Inc,2000 13. Falio M et al.Peabody Development Motor Scales, 2nd Edition examiner Manual,Austin, TX Pro- ED,Inc,2000 14. Felters et al. Discriminate Power of the Alberta Infant Motor Scale and the movement Assessment of Infants for Prediction of Peabody Gross Motor Scale Scores of Infants Exposed in Utero to Cocaine.Pediatric Physical Therapy 12,no.1(spring 2000):16-23. 15. Mayer NH et al.Common patterns of clinical motor dysfunction.Muscle Nerve Suppl.1997;20:S 21-35. 16. Haultram J et al.Botulinum toxin type A in management of equinus in children with cerebral palsy:an evidence based economic evaluation.Euro J Neurol.2001;8 Suppl 5: S194 202. 17. Butler C,Campbell S,for the AACPDM Treatment Outcomes Committee Review Panel. Evidence of the effects of intrathecal 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 in cerebral palsy.Childs Brain 1978;4:289-305. 19. Mclaughlin J,et al.Selective dorsal rhizotomy:Meta Analysis of three randomised controlled Trials.Dev Med Child Neurol.2002;44:17-25. 20. Fowler EG et al.The effect of quadriceps femoris muscle strengthening exs.on spasticity in children with cerbral palsy.Phys Ther.2001;81:1215-23. 21. Dodd KJ et al. A syatematic review of the effectiveness of strength training programs for people with cerebral palsy.Arch Phys Med Rehabil.2002;83:1157-64. 22. Balaban B et al.The effect of hinged ankle foot orthosis on gait and energy expenditure in hemiplegic cerebral palsy.Disability and rehabilitation 29(2):139-44. 23. White H et al.Clinically prescribed orthoses demonstrate an increase in velocity of gait in children with cerebral palsy:a retrospective study. Develpomental medicine and child Neurology 44(4):227-32. 24. Uvebrant P.Hemiplegic cerebral palsy. Aetiology and outcome.Acta Paediatr Scand Suppl 1988;345:1-100.
25. Carlyne Arnould et al.Hand Impairments and their relationship with manual ability in children with cerebral palsy.J.Rehabil Med 2007;39:708-714. 26. Fedrizzi E et al.Hand function in children with hemiplegic cerebral palsy:Prospective follow up and functional outcome in adolescence.Dev Med Child Neurol 2003;45:85-91. 27. Ostensjo S et al.Everyday functioning in children with cerebral palsy:functional skill, caregiver assistance and modifications of the environment. Dev Med Child Neurol 2003;45:603-612. 28. Arnould C et al.ABILHAND-Kids:a measure of manual ability in children with cerebral palsy. Neurology 2004;63:1045-1052. 29. Pagliano E et al.Evolution of upper limb function in children with congenital hemiplegia.Neurol Sci 2001;22:371-375. 30. Penta M et al The ABILHAND questionnaire as a measure of manual ability in chronic stroke patients. Rasch-based validation and relationship to upper limb impairements stroke 2001;32:1627-1634. 31. Brown JK et al A neurological study of hand function of hemiplegic children.Dev Med Child Neurol 1987;29:287304. 32. Krumlinde-Sundholm L,Eliasson A-C.Comparing tests of tactile sensibility:aspects relevant to testing children with spastic hemiplegia.Dev Med Neurol 2002;44:604-612. 33. Julie Duque et al.Correlation between impaired dexterity and corticospinal tracts dysgenesis in congenital hemiplegia.Brain March 2003 Vol.126,No.3,732-747. 34. Tiffin J.Asher EJ.The purdue Pegboard:norms and studies of reliability and validity.J Appl Psychol 1948;32:234-247. 35. Mathiowetz V et al.Adult norms for Box and Block Test of manual 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 children with hemiplegic cerebral palsy.Disability & rehabilitation 2008 Vol 30,No.18;1374-1385. 37. Massimo Penta et al The Abilhand Questionnaire as a measure of manual ability in chronic stroke patients .American Heart Association 2001,Vol 32 :1627. 38. Blank R & Hermsdorfer J.Basic motor capacity in relation to object manipulation and general manual ability in young children with spastic cerebral palsy.Neurosci Lett.2009:23,450(1):65-69.
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The Effect of Task Oriented Training on Hand Functions in Stroke Patients- A Randomized Control Trial
Chandan Kumar1, Ruchika Goyal2, (PT) Assistant Professor M. M. Institute of Physiotherapy & Rehabilitation Mullana, Ambala, 3 M.P.T (Neurology-Student) M. M. Institute of Physiotherapy and Rehabilitation, Mullana, Ambala
1
ABSTRACT Purpose: The goal of this study is to find out the effect of task oriented training on hand functions in stroke 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 equal groups (15 patient in each group) one control group (A) and another experimental group(B). Experimental group receive task oriented training and control group receive conventional physiotherapy training. We assessed the hand functions (Gross and Fine manual dexterity) by Box and Block test and Nine hole peg test respectively and tried to find out the additional effect of task oriented training on hand functions . Results: Result shows that, both the group improved significantly but task oriented training group improved much better than conventional training group. Conclusions: This study suggests that task oriented is more effective as compare to the conventional training for the hand functions in stroke patients. Key words: Task Oriented Training, Gross Manual Dexterity, Fine manual Dexterity.
INTRODUCTION Stroke affects 15 million people in the world each year and approximately one-third will live with the sequel of this disease1.After coronary heart disease (CHD) and cancer of all types, stroke is the third commonest cause of death worldwide. However unlike the Caucasians, Asians have a lower rate of CHD and a higher prevalence of stroke2. Stroke is one of the 10 highest contributors of Medicare costs and among elderly, stroke and transient ischemic attacks are leading causes of hospitalization3. The 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 origin4.
THE COMMON NEUROLOGICAL IMPAIRMENTS DUE TO 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 apraxia.5 Most common sensory losses include asterognosis, agraphia, barognosis, kinesthesia, tactile extinction and two point discrimination6. The stroke causes the inability to understand and express emotions. Common speech disorder that are seen include aphasia, dysphasia. Dysphasia may be exhibited by disturbances in comprehension, naming, repetition, fluency, reading or writing7. Hemiparesis represent the dominant functionally limiting symptoms in 80% of patients with acute stroke
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within 2-5 months after stroke; patients recover a Variable degree of function, depending on the magnitude of the initial deficit. 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 ADLs.8 Grasping, holding, and manipulation objects are daily functions that remain Deficient in 55% to 75% of patient 3 to 6 months poststroke.8 After rehabilitation 9% of patients with severe UE weakness at onset may gain good recovery of hand function. As many as 70% of patients showing some motor recovery in the hand by 4 weeks make a full or good recovery8. Grasping, holding, and manipulation objects are daily functions that remain Deficient in 55% to 75% of patient 3 to 6 months poststroke.9 VARIOUS TREATMENT APPROACHES FOR HEMIPARESIS In physiotherapy a variety of movement therapy approaches are available for retraining motor skill in adult patients with hemiparesis. 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 plasticity.11 TASK ORIENTED TRAINING Task oriented training is newer approach. Taskoriented training involves practicing real-life tasks, with the intention of acquiring or reacquiring a skill (defined by consistency, flexibility and efficiency).12 The tasks should be challenging and progressively adapted and should involve active participation (Wolf & Winstein, 2009). Previous studies done on task oriented training has advocated the different effects of it in stroke patients13. But currently available data do not definitively answer all the questions. Therefore, to obtain a clear characterization of effectiveness of task oriented training a research study was required. CONVENTIONAL PHYSIOTHERAPY TRAINING These exercises prevent complications of
immobilization and improve ADL skill at the earliest. This helps in preventing contractures and development of abnormal postures.14 The purpose of this study is to find out that how much task oriented training is effective as compared to the conventional training in functional recovery of hand in stroke rehabilitation. METHODOLOGY Total 30 patients of stroke were selected from M.M hospital Mullana and nearby areas. For patient selection purposive sampling was done. The total 30 patient were divided into two equal groups (15 patients in each group), one experimental and another control group. Experimental group received task oriented training and control group received conventional 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 Hand 5. 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 risk cardiovascular diseases. 2. Any musculoskeletal impairment of upper extremity. 3. Any neurological pain or disorder limiting the movement. 4. MMSE less than 23. 5. Still enrolled in any form of physiotherapy treatment. PROCEDURE Thirty 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 task oriented training for upper extremities had given to the experimental group and conventional training for upper extremity had given to the control group. All participants were evaluated by Box and Block test and Nine Hole Peg test for gross and fine manual dexterity respectively.
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 gross manual dexterity of hand in stroke patients. It consists of a wooden/cardboard box having two compartments and some small wooden blocks in it. The number of blocks displaced from one compartment to another in one minute is recorded as reading/score/value15. Nine Hole peg test (9HPT) This instrument is designed to measure the fine manual dexterity of hand in stroke patients. It consists of a wooden base having nine holes in it and nine dowels/pegs are provided separately with it. Time to place nine dowels in holes and then removing them is noted in seconds and is recorded as reading/score/ value15. Mini mental status scale is a reliable and valid scale to asses the mental status of subjects used in this study.16 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 Box and block test and Nine hole peg test. The subjects were asked not to participate in any other study or physiotherapy treatment for hand functions from for the duration of the study and to follow the designated protocol. Treatment protocol Experimental Group All subjects in this group performed task oriented exercises which contain both simple and complex task programs with attending therapist. The task oriented training protocol was inspired by Gad Alon et al.13 was a standardized protocol .Components of task oriented protocol included were range of motion exercises, weight bearing and supporting reactions, reaching holding and releasing activities and activities of daily living involving use of hand. Control Group All subjects in this group performed exercises based on conventional physiotherapy. Patients of the conventional PT 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 upper extremities. After active movements patients were made to start weight bearing, strength training reaching activities with the use of upper extremity and at last patients was performed ADL activities (e.g. dressing and self feeding activities). These exercises start with simple movements and subsequently complex movements and actions are tried. 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 their motor control for 90 minutes in a day and 3 days in a week for 6 weeks. Data and Statistical Analyses 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. Paired T test was used for analyzed the pre to post changes within the groups. Unpaired T test was used to analyze the changes between the two groups. Data was analyzed using SPSS 17. RESULTS We successfully matched 30 patients of both control and experimental group for hand functions. 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. Baselines characteristics of both the group are shown in table1.cheracteristic of both the groups were same at the base line level prior to intervention.
Table 1. Baseline Characteristics of both the Group.
Age Gender Side Affected Type of Stroke Group Mean S.D Values M F L R I H A 55.93 9.08 t=0.22 9(60%) 6(40%) 8(53.3%) 7(46.6%) 5(33.3%) 10(66.6%) B 56.67 9.05 P=0.82 8(53.3%) 7(46.6%) 7(46.6%) 8(53.3%) 9(60%) 6(40%)
M-Male, F-Female, L-Left, R-Right, I-Ischemic, HHemorrhagic
This table shows that before intervention there was no significant difference of Box and block test score (p=0.59) and nine hole peg test score (p=0.87) between the groups.
Table 2. Box and block test Scores of both the group before and after intervention
Group A B Before treatment 6.00 5.67 After treatment 8.00 10.33 p value 0.0001 0.0001
training group improved much better than task oriented training. The overall evaluation of data suggests that the gross manual dexterity has been improved more in task oriented training group (experimental group), whereas fine manual dexterity has been improved clinically but not statistically in between group comparison post intervention, but within group results are statistically significant. The results of the study are consistent with the previous studies done on task oriented training.11-13 & 17. The task oriented training is based on the motor programming theory of motor control and system theory. The former theory puts an emphasis on the special neural circuits known as central pattern generators (CPJ). The practice play important role in strong engrams formation in the brain. The task oriented training focuses on the intention of acquiring or reacquiring a skill (defined by consistency, flexibility and efficiency) important to a functional task rather than educating the specific muscles in isolation hence it is a functional approach. In this approach, movement is organized around a behavioral goal; thus multiple systems are organized according to the inherent requirements of the task being performed. In this approach, the patient is working on functional tasks rather than on movement patterns for movement alone as compared to conventional physiotherapy. The significant results in task oriented training group also may be due to more motor unit recruitment being activated as the patient is practicing the same functional task again and again. Task oriented approach leads to acquisition of new skills as patient gets feedback simultaneously which leads to better learning of activities of daily living. The results for fine manual dexterity are clinically significant at post intervention level but are not statistically significant. The gain in changes was small and also may be due to the fact that nine whole peg test is not a very sensitive measure to analyze such small changes of fine manual dexterity in hemiparetic patients. Moreover the test used the time values that too in seconds which is further a very specific count. CLINICAL IMPLICATION This treatment will help the patients to enhance the functional recovery of hand in stroke patients and increased functional recovery will provide the improvement in quality of life. So, task oriented approach can be used clinically as it will be much easier to perform, safer and convenient for patients.
Above table shows that after intervention there was significant difference in both the groups.
TABLE 3. Nine hole peg test score of both the group before and after intervention
Group A B before Intervention 73.40 74.47 after intervention 72.87 71.93 P value 0.00610. 0001
Above table shows that after the intervention there was significant difference between the groups ( p value - .001).
TABLE 4. BBT and 9HPT scores of both the group after intervention
Group A B BBT score after intervention 8.00 10.33 P value 0.0007 9HPT after intervention 72.87 71.93 P value 0.89
Above table is showing the BBT and 9HPT scores after treatment in both the groups. Independent t test was to analyses data in between the groups and dependent t test was used to analyze the data within the groups. The evaluated data suggest that the gross manual dexterity has been more improved in task oriented group (experimental group=0.0007).whereas fine manual dexterity has been improved clinically but not statistically in between group comparison (p=0.89) but within group results are statistically significant. DISCUSSION In this experimental design study, result shows the effects of task oriented training as compare to the conventional training on hand functions in stroke patients. The results support the hypothesis that task oriented training is more effective for hand functions in stroke patients as compare to the conventional training. Although both the groups task oriented training and conventional training improved significantly post intervention, but task oriented
Limitations of a Study The sample size used in this study was small so that result is not generalized. There is no follow up period after 6 weeks, so it may be another limitation of the study. The measure of fine manual dexterity was not appropriate. Future Scope of Study Follow-ups can be done to see the long term effects of training. The initial degree of level of deficit can be taken. More sensitive measure can be used to determine fine manual dexterity. Study can be replicated by molding the treatment protocol and large sample size can be taken. CONCLUSION This study suggests that task oriented training is more effective as compare to the conventional training for the functional recovery of hand in stroke patients.
8. 9.
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11.
12.
13. REFERENCES 1. 2. 3. World Health Organization. The WHO stroke surveillance... 2004. World Health Organization. 29-7-2004. Shyamal K. Das, Tapes K. Banrejee. Epidemiology of stroke in India. Neurology Asia 2006; 11:1-4. Judith h. Lichtman, EricaC.Leifheit-Limson, Sara B, ones Michael, S. Phipps, L.B. Goldstein. Predictors of hospital readmissions after stroke 2010; 41: 2525-2533. 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. C. Collin and D. Wade. Asessory Motor impairment after stroke Journal of Neural, Neurosurgery and psychiatry. 1990; 53 (7): 576579. Lee Anne M. Carey et al. Frequency of Discriminative sensory loss in the hand after stroke in a rehabilitation setting. J Rehab Med 2010; 43:82-88.
14.
4.
15.
5.
16. 17.
6.
7.
18.
Sherry H. Post stroke speech disorders; 2011. Alexander w. Dromerisk, Catherine G. Lang, Robecca. Brikenmeirer, Michael G. Hahn. Relationships between upper limb functional limitation and self. Reported disability 3 months after stroke. Journal of Rehabilitation Research and development 2006; 43: 401-405. Gad Alan, Alon F. Leritt, Patricia A. Mc Corthy. Functional electric stimulation enhancement of upper extremity functional recovery during stroke Rehabilitation: A pilot study. Neurorehabil Neural Repair 2007; 21 (3): 1-9. Dickstein R: Contemporary exercise therapy approaches in stroke Rehabilitation ritical Reviews in Physical and Rehabilitation Medicine 1989; 1:161 181. NorineFoley , Robert Teasell , Jeffrey Jutai , SanjitBhogal , Elizabeth Kruger , Cauraugh and Kim(2003). Upper Extremity Interventions TheEvidence-BasedReview of Stroke Rehabilitation reviews current practices in stroke rehabilitation.2011;24-28 Winstein CJ, Rose DK, Tan SM, Lewthwaite R, Chui HC, Azen SP. (2004). A randomized controlled comparison of upper-extremity rehabilitation strategies in acute stroke: A pilot study of immediate and long-term outcomes. Arch Phys Med Rehabil, 85(4), 620-628. Gad Alon, F. Levitt et al. Functional electrical stimulation enhancement of upper extremity during stroke rehabilitation A Pilot study. Neuro Rehabilitation and Neural Repair 2007; 21:207. Dickstein R. Hocherman S. Pillar T el at: Stroke rehabilitation. Three exercise Therapy approaches. Phys Therapy: 1986; 66: 1233 1238. Mathiowetz et al. Box and block test information and nine hole peg test information 1985. Folstein MF, Folstein SE, McHugh PR (1975). Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. Journal of psychiatric research 12 (3): 189198. Higgins J, Salbach NM, Wood-Dauphinee S, Richards CL, Cote R, Mayo NE. (2006). The effect of a task-oriented intervention on arm function in people with stroke: a randomized controlled trial. Clin Rehabil, 20(4), 296-310.
Effectiveness of Physiotherapy for the Handwriting Problem of School Going Children

Chandan Kumar1, Poonam Mehta2, Sobika Rao3 Neurology-Assistant Prof, 2Paediatrics- Assistant Prof, 3 MPT Student M.M Institute of Physiotherapy and Rehabilitation, Mullana, Ambala ABSTRACT Purpose: The purpose of the study is to see the effectiveness of a 12 week physiotherapeutic intervention to improve the handwriting quality of school going children. Methodology: This study is a randomized clinical trial of 60 school going children who have handwriting problem as diagnosed with Handwriting Proficiency Screening Questionnaire (HPSQ). The 60 subjects are than randomly divided into 2 groups, Group A (Intervention Group) which consists of a set of Physiotherapeutic Exercises and Group B (Ergonomic Advice) . The Handwriting quality was evaluated using Minnesota Handwriting Assessment (MHA). Results: The results of the present study showed that both the groups showed significant improvement but the group receiving 12 week physiotherapeutic intervention showed more significant improvement. Conclusion: Finally it can be concluded that a well planned physiotherapeutic program can help to improve the handwriting quality of school going children over a short period of time and thus help the child to improve his self-confidence and his academic results. Key words: Handwriting Skills, Physiotherapy Intervention, Assessment Scales.
INTRODUCTION Skilled handwriting is an essential activity for school aged children that allows them to write within a reasonable time and to create a readable product through which thoughts and ideas can be communicated.1-3 Handwriting is often judged and seen as reflection of an individuals intelligence and capabilities as illustrated by several studies in which lower marks are consistently assigned to children with poor handwriting and higher marks are given to those with legible handwriting despite similar content.4 The effect of sex is also an important consideration in handwriting development..4 Girls handwriting is more legible than boys handwriting and also the girls write faster. Right handers are also faster than the left handers.5 Factors that affect the handwriting performance can be intrinsic i.e. because of lack of fine motor control, improper visual-motor integration or may be extrinsic like sitting position, chair-desk height, blackboard position, environmental lighting etc.6
Writing difficulties have been documented in children with and without disabilities. Legible handwriting constitutes to be an important skill for children to develop in elementary school and difficulty with this area can affect any childs proficiency at work. Proficiency is the quality of having great facility and competence at school work.7 Those children who do not succeed in developing proficient handwriting are defined by some authors as poor hand writers and by the others as dysgraphic.8 In addition to legibility and timing deficits, observations by clinicians have revealed that children with dysgraphia erase more, complain more about fatigue and hand pain, and are unwilling to write and do their homework. 1 All of these signs may be considered to represent a category of physical and emotional well-being.9 The teacher is an important source of information about a childs handwriting.6The perceptions of regular education teachers on problems with handwriting can provide valuable information to practioners when providing consultation and direct services related to
handwriting in school.10 Besides this various handwriting assessment tools are available. Judith E. Riesman developed the Minnesota Handwriting Test (MHT) which has been used in the present study. This tool is norm referenced and measures changes in handwriting performance of first and second graders. The interrater reliability of the Minnesota Handwriting Test has a strong range of 0.87-0.98.11 When consulted , physicians most often choose physiotherapy as the preferred method to help. The physiotherapeutic interventions help to improve the intrinsic factors related to handwriting skills. But, little is known about the effectiveness of physiotherapy in treating children with such disorder. Methodology: A total of 200 Handwriting Proficiency Screening Questionnaires (HPSQ) were distributed in 3 schools. The questionnaires were filled by the teachers of teaching grade 1 and 2. A total of 60 children were selected to participate in this study with the aid of the standardized and validated HPSQ. These 60 children were then randomly assigned to 2 groups. Simple random sampling was used to randomly allocate the children into 2 groups. INCLUSION CRITERIA 1) The child is a non-proficient writer as assessed by the 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 physiotherapeutic treatment 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 of the HPSQ who fulfilled the inclusion criteria were randomly assigned to 2 groups. Simple random sampling was used to randomly allocate 30 students in 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 both the groups using the MHA. The students were asked to copy a sample from near point. The student sat on the desk opposite to the blackboard. The words utilized were a derivative of the sentence, The quick brown fox jumped over the lazy dogs. The quality of the sample was determined by assessing legibility, form, spacing, alignment, and size. Following this students in Group A (Intervention Group) were given a set of physiotherapeutic exercises. The students received 4 sessions of physiotherapy per week, for 1 hour on alternate days for 3 months. The students in the Group B (Ergonomic Advice) received ergonomic advice on handwriting and were taught appropriate writing posture by their parents and teachers. After a period of 3 months, again the Handwriting Proficiency Screening Questionnaire (HPSQ) were filled by the school teachers and the post intervention measurements were taken for both the groups using MHA. Group A (Intervention Group) n=30 1) Exercises to improve proximal stability of the upper limb (5 repitions each). 2) Fine motor exercises for handwriting (5 repetitions each 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 appropriate writing posture and were given ergonomic advice only. Data Analysis:The data was tested parametrically. To determine the possible differences within and between the groups on the pre-test and post-test measures paired t test and z test were used respectively. p value was set at <0.05 level of significance and SPSS software was used for analysis. Results: In the present study 200 HPSQ were distributed to the school teachers of teaching grade 1 and 2. On the basis of this subjective assessment 90 students were diagnosed by the teachers as nonproficient hand writers and were included in the study. Next MHA was filled by the students and 40 students having a score of e30 on MHA were excluded from the study.
Table 5.1. Demographic data for the 2 groups.
GroupA Intervention Group n = 09 n = 21 n = 05 n = 12 n = 13 n = 30 n = 17 n = 13 GroupB Ergonomic Advice n = 10 n = 20 n = 00 n = 14 n = 16 n = 30 n = 20 n = 10
Table (5.3). Mean and S.D for HPSQ, Total MHA, and MHA Subscale for Group B.
Pre Test Mean S.D HPSQ MHA Total MHA Subscale Legibility Form Alignment Size Spacing 29.23 1.13 27.47 1.57 27.30 1.89 24.63 2.22 28.00 2.01 30.83 0.98 28.80 1.66 28.67 1.82 25.97 2.20 29.77 2.04 12.99 15.23 11.19 13.35 15.45 48.33 7.65 Post Test Mean S.D 44.67 7.10 6.71 34.00 t value p valued0.05
136.73 6.97 144.13 6.88
Above table is showing the scores of the HPSQ, Total MHA and MHA Subscale. It was interpreted that there is a significant improvement in the scores at 0.05 level of significance.
Table (5.4): Comparison of the Mean and S.D for the HPSQ, Total MHA Score between Group A (Intervention Group) and Group B (Ergonomic Advice).
Group A Mean S.D HPSQ MHA Total 14.17 0.08 20.27 2.59 Group B Mean S.D 3.67 0.55 7.40 1.19 10.50 0.43 12.86 1.40 5.932 24.64 significant Mean diff. b/w group Zvalue p valued0.05
Females Males Age = 6years Age = 6+years Age = 7 years Handedness Class I Class II
Above table is showing the scores of the HPSQ and Total MHA Score. It was interpreted that there is a statistically significant improvement in the scores at 0.05 level of significance.
Table (5.5) : Comparison of the mean change in the MHA Subscale Scores between Group A (Intervention Group) and Group B (Ergonomic Advice).
MHA Subscale Legibility Form Alignment Size Spacing Group A Mean S.D 3.60 1.07 3.70 1.34 4.80 1.40 4.93 1.98 3.32 1.87 Group B Mean S.D 1.60 0.67 1.33 0.47 1.37 0.66 1.33 0.54 1.77 0.62 Mean diff. b/w group. 2.00 0.39 2.36 0.97 3.43 0.73 3.60 1.44 1.46 1.25 z value 8.66 9.09 12.12 9.59 4.07 significant p valued 0.05
The baseline data shows that the 2 gps did not differ regarding Gender, Age, Handedness, Class
Table (5.2). Mean and S.D for HPSQ, Total MHA, and MHA Subscale for Group A
Pre Test HPSQ MHA Total MHA Subscale Legibility Form Alignment Size Spacing 29.03 0.96 26.77 1.85 26.73 2.21 25.33 2.10 27.47 1.99 32.63 0.96 30.47 1.22 31.53 1.77 30.27 2.11 30.70 1.46 18.42 15.09 18.78 13.63 9.47 Not Significant 56.50 7.28 135.33 5.51 Post Test 42.33 7.65 155.60 4.56 t value 8.413 42.17 p valued0.05
Above table is showing the scores of the MHA Subscale. It was interpreted that there is a statistically significant improvement in the scores between the 2 groups at 0.05 level of significance. DISCUSSION In this study it was observed that a 12 week physiotherapeutic intervention had a significant effect on improving the handwriting quality and the earlier
Above table is showing the scores of the HPSQ, Total MHA and MHA Subscales. It was interpreted that there is a statistically significant improvement in the scores at the 0.05 level of significance.
studies also show the same result.12 The positive results found in this study can be supported by the sufficient evidence in the literature that intervention to improve handwriting would result in greater gains than no intervention at all.8,9,16,17. The intervention was so structured that it directly targeted the intrinsic components which are required for good handwriting. The intervention consisted of exercises to improve proximal stability of upper limb, fine motor exercises for handwriting, and exercises to improve the visual- motor control.2 The intervention targeted primarily at improving the proximal muscle stabilization of the upper extremity. This is supported by the proximal-distal muscle principle which states that the proximal muscle stability is a pre-requisite for manipulative hand use.18 Next the in-hand manipulation skills which included activities like rolling the balls of clay between the tips of the thumb, middle and index finger ; pinching and sealing a zip-lock ; twisting open a small tube of toothpaste with thumb, index and middle fingers while holding the tube with the ulnar digits; and ball squeezing exercises. All these exercises make use of the muscles of the thener-eminence which is considered as the skilled triad of the hand. So, the in-hand manipulation skills helped to improve the fine motor skills.. 18, 13, 19Previous studies in this field have revealed that the visual-motor integration i.e. the ability to see and copy moderately to strongly relate to handwriting skills. So, the exercises to improve the ocular-motor control and eye-hand co-ordination helped to improve this skill.2, 20, 21 Another important factor was the intensity and duration of the intervention used for this study. The intervention lasted for a period of 12 weeks and was administered 4 times a week for 1 hour. This duration of intervention for improving the handwriting quality has been supported by various studies in which similar duration of intervention resulted in improving the handwriting.7, 12, 19 Lastly all the activities which were included were of playful nature which the children might have enjoyed and thus led to their maximum participation and thus resulted in significant improvement in the group which received intervention. The children in Group B were taught appropriate writing posture and were given ergonomic advice provided by the physiotherapist to their parents and teachers. The ergonomics and the writing posture are the extrincic factors related to handwriting. Ergonomics 6,1,14 play an important role. Body posture
is generally considered to have an important influence on the efficiency of writing process and product.614,22 So, students in group B also showed improvement in their handwriting quality. After a period of 3 months both the groups showed an improvement in their handwriting quality but in comparison the students in group A (Intervention Group) showed more significant improvement as compared to the students in group B (Ergonomic Advice).Finally it can be concluded that a well planned physiotherapeutic program can help to improve the handwriting quality of the children and help improve their academic results and confidence. Clinical Implication The findings of the present study can be used in the schools by the teachers to improve the handwriting quality 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 in children with cerebral palsy, hyperactivity disorder, developmental co-ordination disorder. 2. Comparing the effectiveness with the other available handwriting programs: Handwriting without Tears; Log Handwriting Program etc. 3. Effectiveness of the intervention in improving the speed of writing. REFERRENCES 1. Rosenblum, Sara. Handwriting performance, self- reports and perceived self-efficacy among children with dysgraphia. American Journal of Occupational Therapy, 2009 March. Rhoda P. Erhardt and Vickie Meade. Improving handwriting without teaching handwriting. The consultative clinical reasoning process. American Journal of Occupational Therapy 2005; 52: 199-210. Sara Rosenblum; Shula Parush and Patrice L. Weiss. Computerized temporal handwriting Characteristics of Proficient and Non-Proficient hand-writers. The American Journal of Occupational Therapy; 57(2): 129-138. Sasson R. Handwriting: A new perspective. Cheltenham, UK: Stanley Thornes 1990.
2.
3.
4.
5.
6.
7. 8.
9.
10.
11. 12.
13.
14.
Steve Graham. Development of handwriting speed and legibility grade 1- 9.The Journal of Educational Research 1998; 92(1): 42-52. Feder, Majnemer. Handwriting development, competency and intervention Review. Developmental medicine and child neurology 2007; 49: 312-317. Centre for child development. Child.support.in. Graham, Harris. Is handwriting causally related to learning to write? Treatment of handwriting problems in beginning writers. Journal of Educational Psychology 2000; 92: 620-633. Rosenblum, Sara. Development, reliability, and validity of the Handwriting Proficiency Screening Questionnaire (HPSQ). . American Journal of Occupational Therapy 2008; 62 : (298-307). Hammerschmidt, Sandra L. Teachers Survey on Problems with Handwriting: Referral, Evaluation, and Outcomes. American Journal of Occupational Therapy 2004. Wendy Collins, MOTS, Evidence Topic: Handwriting Assessment 2008. Smits-Engelsman et. al. Physiotherapy for childrens writing problems. An Evaluation Study. Handwriting and Drawing Research: Basic and Applied Issues. 1996; (227-240) Christopher M. Boyle. An analysis of the efficacy of a motor skills training programme for young people with moderate learning difficulties. Jill G. Zwicker. Cognitive vs Multisensory approach to handwriting Intervention. A RCT. The American Journal of Occupational Therapy 2009: (25)1.
15.
16.
17. 18.
19.
20.
21.
22.
Handwriting Resource Handbook: A Teacher Resource Manual. Occupational and PT Department, Student support service division. Nov 4, 2008. Tseng and Cermak. The influence of ergonomic factors and perceptual motor abilities on handwriting performance. American Journal of Occupational Therapy 199347: 919-926. Kline, T.J.B. Psychological Testing. London Sage 2005 ; 202-203. Naider et al. Analysis of proximal and distal muscle activity during handwriting tasks. American Journal of Occupational Therapy 2007; 61(4): 392-398. Nandine Mackay et al: The Log Handwriting Program Improved Childrens writing Legibility: A pretest-posttest study. 2010 January; 64(1) : 30-36 Cornhill & Case-Smith. Factors that relate to good and poor handwriting. American Journal of Occupational Therapy 1996; 50: 732-739. Arpita S Desai. Correlation between Developmental Test for Visuomotor Integration and Handwriting Difficulties in Cerebral Palsy Children. The Indian journal of occupational therapy 2005: 2. Handwriting Resource Handbook: A Teacher Resource Manual. Occupational and PT Department, 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 Combined with Cryotherapy on Spasticity and Hand Function in Patients with Spastic Cerebral Palsy
Chandan Kumar1, Vinti2 Assistant Professor, M. M. Institute Of Physiotherapy & Rehabilitation, Mullana, Ambala, 2M.p.t (Neurology-student)), M. M. Institute Of Physiotherapy And Rehabilitation, Mullana, Ambala ABSTRACT Purpose: To determine the effectiveness of Neuromuscular electrical stimulation combined with Cryotherapy on spasticity and hand function in patients with spastic Cerebral Palsy. Children with CP often 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 to moderate spasticity. All the subjects were divided into two groups (A & B) with equal subject number in each group. Group A were treated with passive stretching, cryotherapy followed by Neuromuscular Electrical Stimulation (NMES) and Group B treated with passive stretching and cryotherapy, 3 times a week on alternate days for 6 weeks. Spasticity and hand function were assessed pretreatment and post treatment 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 than group B. Conclusions: This study suggests that NMES combined with cryotherapy is more effective as compared to 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-recognized neurodevelopmental condition beginning in childhood & persisting throughout the lifespan. Cerebral palsy is a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior; by epilepsy, and by secondary musculoskeletal problems.1 Cerebral palsy is the commonest physical disability in childhood, occurring in 2.0 to 2.5 per 1000 live births.2 The causes are congenital, genetic, inflammatory, infections, anoxic, traumatic & metabolic. The injury to the developing brain may be prenatal, natal or postnatal.3 Causes of CP were prenatal in 50% of the cases, perinatal in 33%, postnatal in 10%, and mixed in 7%.4 75% of children with CP have spastic cerebral palsy.3 Spasticity is classically defined as a tonal abnormality of skeletal muscle characterized by a velocity-dependent
resistance to passive stretch.5 Studies done to find out development of spasticity with age shown that the degree of muscle tone increased upto 4 year of age. After 4 year of age the muscle tone decreased each year upto 12 year of age.6 Physiotherapy Treatment For Spasticity Various treatment approaches & modalities to manage spasticity associated with spastic cerebral palsy include the use of oral neuropharmacological agents or injectable materials such as botulinum-A toxin7, surgical treatment through tendon transfer8 or selective rhizotomy 9. The other treatment approaches are application of cryotherapy10, progressive resistive exercises to improve muscle strength, repetitive passive range of motion exercises to improve & maintain joint mobility. Passive, static, gentle stretches are performed on individual joints to decrease & prevent joint contractures. Neurodevelopmental treatment (NDT), sensory integration, electrical stimulation, constrained induced therapy & orthosis are also used in management of cerebral palsy.11, 12
22 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1
CRYOTHERAPY Cold application has been used for some time to reduce spasticity clinically. Decrease in resistance to passive stretch lasts from a few minutes up to 24 hours. Cold anesthesia of peripheral sensory end-organs changes the balance of facilitatory-inhibitory influences playing on the anterior horn cell in favor of inhibition. Unmasking of spasticity permits strengthening of voluntary mechanisms normally snowed under by undesired reflexes.10 Neuromuscular Electrical Stimulation Neuromuscular electrical stimulation has gained support since its inception as a treatment for cerebral palsy in the 1970s. With neuromuscular electrical stimulation, electrical stimulation of sufficient intensity generally to produce visible muscle contraction is applied at the muscle motor point. Electrical stimulation is thought to improve strength, reduce spasticity of the antagonist muscle, reduce co-contraction, and create soft-tissue changes permitting increased range of motion. 13 There are few studies that report the effectiveness of NMES and cryotherapy on reduction of spasticity & improvement of hand function in patients with spastic cerebral palsy and found that both the modalities used are effective and none of the two modalities is superior to other.14 Therefore, aim of this study is to determine the effectiveness of Neuromuscular electrical stimulation combined with Cryotherapy on spasticity and hand function in patients with spastic Cerebral Palsy. In present study, hand function is measured using the Manual Ability Classification System (MACS) instead of Zancolli system 14 because a review of classification systems of upper limb function & deformity in cerebral palsy supports the use of MACS to classify upper limb function and Zancolli system is recommended to classify thumb, hand &wrist deformity.15 METHODOLOGY 30 subjects were selected by means of convenience sampling based on inclusion and exclusion criteria. All the parents received a written explanation of the trial before entry into the study and then gave signed consent to participate their children in the study. The patients 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 3 according to Modified Ashworth Scale. 3. Age 5-15 yr, both male & female. 4. Patient who can comprehend and comply with instructions. 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 upper limb 5. Patient undergone any surgery for upper limb PROCEDURE Thirty patients of CP who fulfill the inclusion criteria were included in this study. Total numbers of patients were equally divided into two groups (A & B). Each group contained 15 patients. All participants were evaluated by modified ashworth scale for wrist flexor spasticity and manual ability classification system for hand function. Modified Ashworth Scale measure spasticity and is applied manually to determine the resistance of muscle to passive stretching. This scale has been shown too valid and reliable.16 Manual Ability Classification system 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 the childrens self-initiated ability to handle objects and their need for assistance or adaptation to perform manual activities in everyday life. The objects referred to are those that are relevant and age-appropriate for the children, used when they perform tasks such as eating, dressing, playing, drawing or writing.17 MACS has shown to be valid and reliable.18 All patients were assessed by modified ashworth scale and manual ability classification system before and after giving intervention.
The technique for application of passive stretching was based on passive range of motion (PROM) therapeutic exercises described by Kisner and Colby.19 The PROM consists of moving the elbow, wrist, fingers and thumb passively and holding it in position for 60 seconds. This procedure was repeated 5 times giving duration of 5 minutes bout. The procedure of passive stretching was given prior to every treatment session in all the subjects, both in group A & B. Treatment procedure for group A subjects The subject was placed in sitting position. The entire forearm from elbow to the fingers was carefully and decently exposed. The area was cleaned with cotton wool and with methylated spirit. The upper limb of the subject was positioned on a pillow on the plinth with the shoulder in mild abduction. The forearm was also positioned in mid flexion and supination with the fingers and thumb in anatomical position .The ice lollipop was applied to the flexor compartment of the forearm and gently massaged using stroking technique from the proximal to the distal end of the forearm. This was applied continuously for 20 minutes. The sequence of treatment was 3 times a week on alternate days for 6 uninterrupted weeks. After cryotherapy, subjects received electrical stimulation to the dorsum of the forearm. The electrical stimulation was consist of a dual channel devise with current outcome between 0 and 100 MA , pulse width of 200 microseconds and the pulse set between 30 and 40 Hz to produce tolerable muscle contraction. The electrical stimulation was applied for duration of 30minutes, 3 times in a week on alternate days for a period of 6 uninterrupted weeks. Treatment procedure for group B subjects Following the application of passive stretching, the subjects received Cryotherapy as describe for the subjects in group A. Data and Statistical Analyses
RESULTS Patients in both the groups were assessed at baseline level for spasticity with modified ashworth scale & hand function with manual ability classification scale prior to the commencement of the treatment sessions. Post-test measurements were taken after 6 weeks after completion of treatment sessions. There were no drop outs in the study. A total of 16 female and 14 male subjects participated in the study. Demographic characteristics of both the group are shown in table 1.
Table: 1 Demographic characteristic of the subjects
VARIABLES Sex F:M Mean Age Spastic CP (Type) Quadriplegic (%) Right Hemiplegic (%) Left Hemiplegic (%) Dominating hand (number) Right hand 15 15 8 (53%) 5 (33.3%) 2 (13.3%) 7 (46%) 5 (33.3%) 3 (20%) GROUP A 7:8 7.53 1.35 GROUP B 9:6 7.66 1.63
Above table showing that subjects in both the groups are matched for baseline level
Table: 2 Baseline score of MAS and MACS of both the group
MAS
A Mean S.D P value (<0.05) 2.460.611 0.59 B 2.330.587 A 4.600.632
MACS
B 4.530.639
0.77
Above table showing mean value of baseline scores of MAS & MACS of both groups. After analysis, the p value is >0.05 which is statistically non-significant.
Table: 3 Pre and Post value of MAS and MACS of group A
GROUP A
Comparison was performed between the groups first at baseline level. Then again, comparisons were done after treatment at 6 week as well as from baseline to 6 week and results were noted. Wilcoxon signed rank test and Mann Whitney U test was used to analyze the pre and post treatment values of MAS scores and MACS scores within the groups and between the groups respectively. The level of significance was set at p<0.05. Data were analyzed using SPSS 17.0.
Variables
Mean S.D Pre value Post value 1.3330.408 2.530.833
p value (<0.05)
MAS MACS
2.4660.611 4.600.632
0.0003 0.0003
Above Table showing mean value of pre MAS and post MAS & pre MACS and post MACS of group A. After analysis, p value is <0.05 which is statistically significant.
24 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 Table: 4 Pre & post value of MAS and MACS of group B
GROUP A Variables Mean S.D Pre value MAS MACS 2.3330.587 4.530.639 Post value 1.6660.308 3.460.828 0.0008 0.0005 p value (<0.05)
Above Table showing mean value of pre MAS and post MAS & pre MACS and post MACS of group B. After analysis, p value is <0.05 which is statistically significant.
Table: 5 Post intervention MAS and MACS value of group A & B
MAS
A Mean S.D P value (<0.05) 1.330.408 0.02 B 1.660.308 A 2.530.833
The results of this study are supported by previous studies which tell that the neuromuscular electrical stimulation is helpful in increasing muscle strength by increasing cross sectional area of the muscle & by increasing recruitment of Type 2 muscle fibers.12 With NMES, unused muscles can be stimulated when needed and the sensory input from NMES can give added sensory awareness of what is happening in the hand to allow motor learning to occur and to permit motor control.20 Neuromuscular electrical stimulation, when applied to the peripheral muscles has a direct effect on the cerebral cortex.21 In group A as we have given cryotherapy first and after that NMES, combined effect of both the modalities leads to significant improvement in experimental group. Result of this study showed that improvement is more significant in subjects of group A treated with cryotherapy followed by neuromuscular electrical stimulation when compared with subjects of group B treated with cryotherapy alone (table 5). This showed that additional improvement in group A is because of neuromuscular electrical stimulation. First cryotherapy has reduced spasticity in wrist flexors and then NMES applied to wrist extensors has further reduced spasticity in wrist flexors via reciprocal inhibition and increased strength in wrist extensors. Few studies have been done on neuromuscular electrical stimulation and cryotherapy in isolation which shows their effectiveness but the result obtained from this study is novel that proves the combined efficacy of neuromuscular electrical stimulation and cryotherapy on spasticity. Neuromuscular electrical stimulation is a non-invasive therapy and offers a better clinical outcome. CLINICAL IMPLICATION The results of the present study enlighten the use of combination therapy approach (NMES+Cryotherapy) as an more effective approach than the either intervention alone in the clinical settings for the management of spasticity and hand function in patients with spastic cerebral palsy. Limitations of the study Subjective measures used for measuring spasticity and hand function challenges the results obtained. No follow up was taken to see the long term effects. Dominating hand was only treated in quadriplegics to avoid collecting paired data.
MACS
B 3.460.828 0.01
Above Table showing mean value of post intervention scores of MAS & MACS of both groups. The result obtained from the study data showed that there was significant difference within group A and B in reducing spasticity and improving hand function. Group A showed more significant difference in outcome measures in comparison to group B. DISCUSSION In this experimental design study, result showed the combined effect of neuromuscular electrical stimulation and cryotherapy on spasticity and hand function in patients with spastic cerebral palsy. The results support the hypothesis that NMES along with cryotherapy produce good results as compared to cryotherapy alone. Cold facilitates alpha-motor neuron activity and decreases gamma motor neuron firing through stimulation of cutaneous afferents. There is also a decrease in the afferent-spindle discharge by direct cooling of the muscle. When nerves are cooled, synaptic transmission are impeded or blocked by altering the transmembrane ionic flow. The possible explanation of the mechanism of relief of spasticity can be that cold anesthesia of peripheral sensory endorgans changes the balance of the sum of facilitatoryinhibitory influences playing on the anterior horn cell in favor of inhibition. Unmasking of spasticity permits strengthening of voluntary mechanisms normally snowed under by undesired reflexes.10
Future Research Suggestion Future research can be done using objective measures for measuring spasticity and hand function. There should be long term follow up of the patient to determine the sustained effects of combination therapy (NMES+Cryotherapy). CONCLUSION This study describes the management of spastic cerebral palsy patients with hand function impairments, who responded favorably to an intervention program focused NMES and cryotherapy. REFERENCES 1. R peter, P. Nigel, G murray, G martin. The Definition and classification of cerebral palsy. Developmental Medicine & Child Neurology. 2007; 49(109):814. 2. Reddihough Dinah S, Collins Kevin J. the epidemiology 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. Indian journal 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 of spasticity in children. Child nervous system. 2007; 23:943-956. 6. H Gunnar, W philippe. Development of spasticity with age in a total population of children with cerebral palsy. BMC Musculoskeletal Disorder. 2008; 9:150-159. 7. Patel Dilip R, S olufemi. Pharmacological intervention for reducing spasticity in cerebral palsy. 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-role of surgery. IJPMR. 2002 April; 13:15-18. 9. F Jean P, J abdulrehman. Selective dorsal rhizotomy in the treatment of spasticity related to cerebral palsy. Child nervous system. 2007 July 21; 23: 991-1002. 10. Mead Sedwick, Knott Margaret. Topical Cryotherapy: Use for Relief of Pain and Spasticity. California Medicine. 1966; 105(3):179-181
11.
12. 13.
14.
15.
16.
17.
18.
19.
20.
21.
Sharan Deepak. Recent advances in management of cerebral palsy. Indian journal of pediatric. 2005; 72:969-973. Patel Dilip R. Therapeutic intervention in cerebral palsy. Indian journal pediatrics. 2005; 72:979-983. Kemper Derek G, Yasukawa Audyer M. Effects of neuromuscular electrical stimulation treatment of cerebral palsy on potential impairment mechanism. Pediatric physical therapy. 2006; 18:31-38. Akinbo S R A, Tella B A, Otunla A. Comparison of the effect of neuromuscular electrical stimulation and cryotherapy on spasticity and hand function in patient with spastic cerebral palsy. Nigerian medical practitioner. 2007; 51:128-132. K McConnell, L Johnston, C Kerr. Upper limb function and deformity in cerebral palsy: a review of classification systems. Dev Med Child Neurol. 2011; 53(9): 799-805. Bohannon Richard W, Smith Melissa B. Interrater Reliability of a Modified Ashworth Scale of Muscle Spasticity. Physical Therapy 1987 Feb; 67(2): 206-207. Kuijper M. A, Ketelaar M. Manual ability classification system for children with cerebral palsy in a school setting and its relationship to home self-care activities. American Journal of Occupational therap. 2010; 64:614-620. Eliasson Ann-Christin, Krumlinde-Sundholm Lena, Rosblad Birgit, Beckung Eva, Arner Marianne, Ohrvall Ann-Marie, Rosenbaum Peter. The Manual Ability Classification System (MACS) for children with cerebral palsy: scale development and evidence of validity and reliability. Developmental Medicine & Child Neurology 2006; 48(7):549-554. DOI: 10.1017/S0012162206001162 Kisner C, Colby L. A. Therapeutic Exercise: Foundation and Techniques. 4thed. New Delhi: Jaypee Brothers, Medical Publishers (P) Ltd; 2003. Scheker L R, Ramirez S. Neuromuscular electrical stimulation and dynamic bracing as a treatment for upper extremity spasticity in children with cerebral palsy. Journal of hand surgery. 1999; 24:226 -232. Han BS, Jang SH, Chang Y, Byun WM, Lim SK, Kang DS. Functional magnetic resonance image finding of cortical activation by neuromuscular electrical 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 Walking Ability for Ambulant Stroke Subjects
Chandan Kumar1, Salam Anita Devi2 Assistant Professor, 2M.P.T (Neurology-Student) M. M. Institute of Physiotherapy and Rehabilitation, Mullana, Ambala ABSTRACT Purpose: To find out the effect of obstacle ambulation training on walking ability for ambulant stroke subjects. 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 experimental and another control group. Experimental group did balance training with obstacle ambulation training and control group performed balance training. We assessed the Dynamic balance with Dynamic Gait Index and walking endurance with Six Minute Walk Test (6MWT) and tried to find out the additional effect of obstacle ambulation training on walking ability for ambulant stroke subjects. Results: Result shows that, both the group improved significantly but obstacle ambulation training group improved much better than balance training group Conclusions: Balance training with obstacle ambulation training is more effective as compare to the balance training on walking ability for stroke patients. Keywords: Stroke, Obstacle Ambulation Training, Balance Training INTRODUCTION Stroke is one of the most common neurological disorders leading to chronic disability. It remains the third leading cause of the death, a leading cause of permanent disability and a major contributor of life consequences. 1.2% of total deaths in India occur due to stroke1. WHO estimated that in 1999, out of 9.4 million deaths in India, 619000 deaths were due to stroke giving a mortality rate of 73/ 100000 population2. Stroke refers to a vascular syndrome characterized by rapidly developing signs of focal or global disturbance of cerebral functions lasting more than 24 hrs or leading to death with no apparent cause other than vascular origin.( WHO 1989)3. The Common Neurological Impairments Due To Stroke Are Depending on the site and extent of the lesion, stroke can result in impairment of motor, sensory and/ or cognitive abilities, swallowing and communication problems and incontinence. While each can have debilitating effect independently, impairment in one area will affect performance in another4. Impairment of motor may include I) alterations on tone. Flaccidity is present immediately after stroke and is due to cerebral shock. It is short lived, lasting hours, days, or weeks. Spasticity emerges in about 90% of cases and occurs on the side of the body opposite the lesion predominantly in antigravity muscles. ii) Abnormal synergy patterns, iii) abnormal reflexes, IV) motor programming deficits etc5. Somatosensory impairments range from involvement of just one type of sensation, such as light touch, to all somatosensory abilities being impaired. The most common types of cognitive deficits arising from stroke are disturbances of attention, language syntax, delayed recall and executive dysfunction affecting the ability to analyze, interpret, plan, organize, and execute complex information5. Walking after stroke is characterized by slow gait speed, slow poor endurance and changes in the quality and adaptability of walking pattern. Although 60% of stroke survivors regain walking independence after 3
28 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2013, Vol. 8, No. 2
months, many have continuing problems with mobility due to impaired balance, motor weakness and decreased walking velocities6. Physiotherapy Treatment for Walking Recovery In physiotherapy training methods to improve walking patterns of individuals with post stroke patients involve therapists giving verbal cues and manual support during overground walking and using equipment such as parallel bars, mirrors, and stairs7. Obstacle Ambulation Training
Exclusion Criteria 1. Transient ischemic stroke.
2. Any associated cognitive and perceptual neurological conditions. 3. Blindness or severe field deficit affecting balance and gait 4. Musculoskeletal disorders of lower extremity leading to inability in walking and pain e.g. contractures, deformities 5. Inability to provide informed consents.
Stepping over obstacles (obstacle ambulation training) as an alternative training to improve walking in individuals with post stroke patients.Obstacle ambulation training lead to improvements in various measures of walking ability (gait velocity, step length, ability to step over obstacles and walking endurance)7. However, due to the controversial reports about the effectiveness of obstacle ambulation training on walking ability, this study has been designed to investigate the effect of obstacle ambulation training on walking ability in ambulant stroke patient. METHODOLOGY Total 30 patients of stroke from M.M hospital Mullana, Ambala who met the inclusion criteria included in this study. For patient selection random sampling was done. The total 30 patient were divided into two equal groups (15 patients in each group) one experimental (Group B) and another control group (Group A). Experimental group did balance training with obstacle ambulation training and control group contain balance training. Inclusion Criteria 1. Age: 40-60 years 2. Gender : both male and female 3. Subjects having first ever unilateral stroke (3-6 months) after stroke 4. Capable of walking independently without assistance for a distance of 5m walkway. 5. Cognitively sound subject with mini mental state examination score of at least 24/30.
PROCEDURE The total 30 patient were divided into two equal groups. Each group contained 15 patients. The balance training with obstacle ambulation training was given to the experimental group and balance training was given to the control group. All participants were evaluated by Dynamic Gait Index for dynamic balance and Six Minute Walk Test for walking endurance. Dynamic Gait Index and Six Minute Walk Test shown to valid and reliable8-9, 10-11.All patients were assessed by Dynamic Gait Index and Six Minute Walk Test before and after intervention. Treatment (Physiotherapy) Group A All subjects in this group performed balance training 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 for 40 minutes. Group B All subjects in this group performed balance training along with obstacle ambulation training. After performing the balance training protocol for 40 minute the subjects were provided 25min extra in which the subjects were instructed to take rest for 1 minute then under supervision the patient were made to cross obstacles made from cardboard which were of various heights (6.5cm, 13cm, 27cm) and widths (6.5cm, 13cm, 27cm) with either affected limb or unaffected limb being the lead limb. Subject had to cross the obstacles which were placed randomly in 3 sets on a walk way. In each set, the placement of obstacles were changed and asked the subject to perform 5 times each of sets. Random placement was done to avoid any learning effect of the sequence in which the obstacles were placed. Safety measures were taken so that the patient did not hurt himself during the training. Both the groups received therapy for 5 days a week for 8 weeks. Data and Statistical Analysis Comparison was performed between both the groups first at baseline level then analyzed from baseline to the end of 8th week for each group, and finally at the end of 8 weeks. Pairedt test was used to analyze within group analysis for 6MWT. Unpairedt was used to analyze between group analysis for 6MWT. Wilcoxon was used for within group analysis for DGI and DGI stepping components. Mann Whitney U test was used to analyze between group analysis for DGI and DGI stepping components. Data analysis was performed with SPSS statistical package version 13. The results were statistically significant if the p-value d 0.05. RESULTS Patients in both the groups were assessed at baseline level for dynamic balance with DGI and walking endurance with 6MWT prior to the commencement of the treatment sessions. First we
compared demographic and functional data of the age matched subgroup. Post test measurements were taken after 8 weeks after completion of treatment sessions. There was no drop out in the study. Baselines characteristics of both the group are shown in table 1.characteristic of both the groups were same at the base line level prior to intervention.
Table 1. Baseline Characteristics of the both the groups
Balance training group Balance training with obstacle a mbulation training group 15 47.866.027 9(M), 6(F) 7(Rt), 8(Lt) 121.25 125.0957.62 1.00 1.00 NS p value
No of patients Age Sex Side affected DGI score before intervention 6MWT value before intervention
15 48.066.74 10(M), 5(F) 6(Rt), 9(Lt) 11.80.86 124.0958.87
This table shows that before intervention there was no significant difference of DGI score between the groups (p value- 1.00) and 6MWT value of both the groups ( p value- 1.00).
Table 2. DGI score of both the groups before and after intervention
Group Balance training group p value Balance training with obstacle ambulation training group 121.25 17.82.62 p value
DGI score before intervention DGI score after intervention
11.80.86 16.06
0.001
0.002
Above table shows the pre and post scores of DGI of both groups. Analysis revealed that there was a significant improvement in post treatment scores of DGI.
TABLE 3. 6MWT value of both the groups before and after intervention
Group Balance training group p value Balance training with obstacle ambulation training group 125.0957.62 p value
6MWT value before Intervention 6MWT value after Intervention
124.0958.8
0.001
0.00
164.8165.53
211.3357.62
Above table shows the pre and post values of 6MWT of both groups. Analysis revealed that there was a significant improvement in post treatment value of 6MWT.
30 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2013, Vol. 8, No. 2 TABLE 4. DGI score and 6MWT value of both the groups after intervention
DGi score after intervention Balance training group Balance training with obstacle ambulation training group 16.06 17.82.62 p value 0.04 6MWT value after intervention 164.8165.53 211.3357.62 p value 0.04
in treating stroke patients who have balance difficulties. This suggests that balance training provides increased postural and trunk control thus improving balance in both the groups. Improved postural and trunk control allows the body to remain upright, to adjust to weight shifts, to control movement against the constant pull of gravity12. The result of this study is supported by previous studies which shown that balance recovery characterized by reduction in postural sway and instability and reduction in visual dependency particularly with regard to frontal plane enhances relearning of independent standing and walking abilities13. The stroke patients due to impaired balance include an increase in postural sway, decreased area of stability in stance, an uneven weight distribution on stance with less weight placed on the weaker leg. Moreover their ability to walk is affected by various neurological deficits including impaired neuromuscular control, sensation loss, abnormal tone (spasticity of lower limb), and loss of sensory and anticipatory postural control etc4. When analysis was done between the group at post intervention level it was found that the group receiving balance training combined with obstacle ambulation training had better recovery compared to balance training group alone. During obstacle ambulation training, while crossing the obstacles there is need of greater motion of body segments which results in greater excursion of the whole bodys centre of mass (COM) and perturbs balance maintenance and also leads to linearly increase in flexion angles of the hip, knee and the maximum dorsiflexion movement at the ankle joint during late stance. The maximum extension moment at the hip joint during late stance decreased linearly with obstacle height when the toe of the trailing limb was over the obstacles which showed clinically meaningful changes in gait velocity, stride length, walking endurance and obstacle clearance capacity 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 limb which further increases the weight bearing of affected limb. That is the reason behind better improvement of Group B receiving balance training with obstacle ambulation training.
Above table is showing the score of both groups on DGI and 6MWT after given the treatment. Independent sample test showed significant changes between both the groups for both the variables. On DGI test p value was 0.04and for 6MWT also p value was 0.04.
TABLE 5. Baseline measurement of Dynamic gait index (DGI) stepping components (component 6,7,8) in group A and Group B.
Balance training group Balance training with obstacle a mbulation training group
1.20.77
p value
DGI stepping components score before intervention
1.060.79
0.67
Table shows the Mean SD of DGI stepping components ( 6,7,8) in both groups A and B. There was no significant difference between the groups.
TABLE 6. Post intervention scores of DGI stepping component(6,7,8) of Group A & Group B.
Balance training group Balance training with obstacle a mbulation training group
3.61.24
p value
DGI stepping component score after intervention
2.71.03
0.02
The above table showing the post intervention scores 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 the effectiveness of balance training with obstacle ambulation training on walking ability of stroke patients. The results support the hypothesis that balance training with obstacle ambulation training is more effective than that of balance training. Both the groups showed significant improvement at the end of intervention when compared from baseline which shows that balance training is effective
The findings of this study does not correlate with results of the study done by Smita Agarwal et al in which stroke patients were given balance training in one group while balance training with obstacle training were given to another group4. This could be attributed to the total duration of the intervention (2 weeks) in their study. Where as in this study the total duration of intervention is 8 weeks and since the study was to investigate the additive effect of obstacle training further analysis of stepping components of DGI which one having direct relationship or similar task relative to obstacle training e.g.( stepping over obstacles, crossing around the obstacles and stairs) from baseline level to post intervention level was done and significant improvement was seen at the end of intervention on walking ability. So after obstacle ambulation training resulting improvement is DGI stepping component. That is the reason why experimental group had significant better recovery at the end of intervention. Limitation of study In term of study limitations the sample size used in this study was small so that result is not generalized. In this study there is no follow up after 8 weeks, so it may be another limitation of the study. Other gait variables like step length, stride length and temporal symmetry index was not considered. Future scope of study Similar exercise protocol can be used to verify the effect of balance training with obstacle ambulation training in chronic stroke subjects. Future research can be carried out using more objective outcome measures like gait analyzer which will pick up changes in the gait parameters and obstacle ambulation meticulously. Clinical implication Obstacle ambulation training can be used to enhance the efficacy and efficiency of physiotherapy treatment for stroke patients. This treatment will help the patients to increase the walking competency and enabling the patients to ambulate in the community again. Increased walking competency will enhance the quality of life of stroke patients. This treatment can be
used clinically as it will be much convenient, safer and easy to perform by the patients CONCLUSION This study suggests that balance training with obstacle ambulation training is more effective as compare to the balance training on walking ability for ambulant stroke patients. REFERENCES 1. O Sullivan S.B, Schmitz T.Z. Physical Rehabilitation Assessment and Treatment 4 th edition: ch-17 stroke:p-509. Stroke1999. Recommendations on stroke prevention, diagnosis, and therapy. Report of the WHO Task Force on Stroke and other Cerebrovascular Disorders. Journal of the American Heart Association. Stroke 1989;20:1407 Goldstein M, Barnett H, Orgogozo JM, Sartorius. Stroke -1989 Recommendations on stroke prevention, diagnosis, and therapy. Report of the WHO Task Force on Stroke and other Cerebrovascular Disorders. Journal of the American Heart Association. 1989; 20:1470-31. Agarwal S, Joshua MA, Kumar V. Efficacy of obstacle ambulation training on functional mobility in ambulant stroke subjects. The Journal of Indian Association of Physiotherapists. 2010; 15:35-40. Bayouk JF, Jean P, Leroux A. Balance training following stroke: effects of task oriented exercises with and without altered sensory input. International Journal of Rehabilitation Research 2006; 29: No1. Babalola JF, Taiwo O. Effects of endurance walking training programme on functional ambulation recovery of stroke survivors. Research Journal of International Studies 2011; 19:5-12. David LJ, David A. Brown CD, Pierson C, Ellie L. Stepping over obstacles to improve walking in individuals with post stroke hemiplegia.Journal of Rehabilitation Research and Development. 2004; 41; 283-292. Jonsdottir J, Cattaneo D. Reliability and validity of the Dynamic Gait Index in persons with
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International Journal of Physiotherapy and Research ISSN 2321-1822 Provisional Article IJPR-A-2013- 313 (14-06-2013)
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: manojdeshmukh619@gmail.com Abstract

Background: There is increasing evidence of neural plastic changes associated with specific training that is goaldirected 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.
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.
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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 relearning, 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 A & A 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 subjects 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 individuals 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 subjects 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):2732. 5. M. Kelly-Hayes, A. Beiser, C. S. Kase, A. Scaramucci, R. B. Dagostino, 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): 119126. 6. K. S. Sunnerhagen, U. Svantesson, I. Lonn, 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): 155161. 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): 116. 8. Susan B. Osullivan. 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.
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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; 2000:111187. 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), 27312742. 15. Ward N.S. Future perspectives in functional neuroimaging in stroke recovery. Europa medicophysica.2007; 43(2), 285294. 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 taskorientated 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: 176191. 19. Peurala Sh, Pitklinen K, Sivenius J, Tarkka IM. Cutaneous electrical stimulation may enhance sensorimotor recovery in chronic stroke. Clin rehabil. 2002; 16: 709716. 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: 746750. 21. Dewald JP, Given JD, Rrymer WZ. Long-lasting reductions of spasticity induced by skin electrical stimulation. Leee trans rehabil eng.1996; 4: 231242. 22. Sonde L, Kalimo H, Viitanen M. Stimulation with high-frequency tens: effects on lower limb spasticity after stroke. Advances in physiotherapy. 2000; 2:183187. 23. Vallar G, Rusconi ML, bernardini B. Modulation of neglect hemianesthesia by transcutaneous electrical stimulation. J int neuropsychol soc.1996; 2 :452459. 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: 117122. 27. Park J, Hopwood V, White AR, Ernst E. Effectiveness of acupuncture for stroke: a systematic review. J neurol 2001; 248: 558563. 28. Liepert J, Bauder H, Miltner WHR, Taub E, Weiller C. Treatment induced cortical reorganization after stroke in humans. Stroke. 2000; 31: 12101222. 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.
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30. Levin MF, Hui-chan CWY. Conventional and acupuncture-like transcutaneous electrical nerve stimulation excites similar afferent fibers. Arch phys med rehabil. 1993; 74: 5460. 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. 305306. 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: 312316. 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, Holmbck 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: 412417. 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: 707713.
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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.
MAS Group A Group B pre post pre post 3 2.7 3.3 2.2 0.7 3 2 4 0.5 3 1 3 0.6 3 1 4 0.7 2 1 4 DGI Group A pre post 7.1 9.13 0.9 7 2 9 2.92 10 6 14 Group B pre post 7.1 11.4 0.9 7 2 9 2.2 12 2 16 TUG(sec.) Group A Group B pre post pre post 25.2 23.4 24 20.9 3.1 0.79 3.2 0.82 2.6 0.67 3.6 0.93 -
Mean S.D. S.E.M. Median IQR Maximu m Minimu m Test value p-value
2 -1.47
1.5
2 -2.98
1.5
6 -2.42
6 -3.41
2.41 (t-value) (0.03)*
3.29 (t-value) (0.005)*
(z-value) -0.14
(z-value) (0.003)*
(z-value) (0.01)*
(z-value) (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
MAS Pre A Mean S.D. S.E.M. Median IQR Maxim um Minimu m Test value p-value 3 0.7 3 2 4 2 -1.249 (U-value) -0.21 B 3.3 0.6 3 1 4 2 A 2.7 0.5 3 1 3 1.5 -2.14 (U-value) (0.03)* Post B 2.2 0.7 2 1 4 1.5 A 7.1 0.9 7 2 9 6 -0.22 (U-value) -0.82 pre B 7.06 0.9 7 2 10 6 A 9.1 2.9 10 6 14 5 -2.11 (U-value) (0.03)* DGI post B 11.4 2.2 12 2 16 8 1.147 (t-value) -0.26 1.98 (t-value) (0.04)* A 25.2 3.08 0.79 pre B 24.1 2.63 0.67 A 23.4 3.1 0.82 TUG(sec.) post B 20.9 3.6 0.99
* 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 www.ijmhr.org/ijpr.html ISSN 2321-1822
For More details contact us: editor_physiotherapy@hotmail.com IJMHR.ORG Publications
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Functional Outcome between Ischemic and Hemorrhagic Stroke Patients after Inpatient Rehabilitation

Chandan Kumar M.M. Institute of Physiotherapy and Rehabilitation, Mullana, Ambala

Data and Statistical Analyses

Neurological and Functional Evaluation

Ischemic At admission 4.75 1.22 17.28 7.30 5.22 47.28 At discharge

At discharge 8.11 5.71 50.00

30 20 10 0 CNS RMI Haemorrhagic

16 8.1 4.7 1 BI CNS 5.7 7.3 1.2 RMI Ischemic

Physiotherapy Treatment for Recovery of Upper Extremity

Data and Statistical Analyses

Bilateral group Unilateral group

Bilateral group Unilateral group

Bilateral group Unilateral group

Lecturer, M M IPR, M M University, Mullana, Ambala, Haryana, India

Material and Methods

Objective of the Study

Hypothesis Alternate Hypothesis

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

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

Limitations of the Study

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

Effectiveness of Physiotherapy for the Handwriting Problem of School Going Children

136.73 6.97 144.13 6.88

Mean S.D Pre value Post value 1.3330.408 2.530.833

Exclusion Criteria 1. Transient ischemic stroke.

15 48.066.74 10(M), 5(F) 6(Rt), 9(Lt) 11.80.86 124.0958.87

DGI score before intervention DGI score after intervention

6MWT value before Intervention 6MWT value after Intervention

DGI stepping components score before intervention

DGI stepping component score after intervention

Email: manojdeshmukh619@gmail.com Abstract

2.41 (t-value) (0.03)*

3.29 (t-value) (0.005)*

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