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THE EFFECTS OF BIT VERSUS MCIMT ON FUNCTIONAL PERFORMANCE OF UPPER EXTREMITY IN CHRONIC HEMIPARESIS
Dr. Bhatri Pratim Dowarah, MPT(Neurology)*

ABSTRACT Aim of the study was to evaluate the effectiveness of Bilateral Isokinematic training versus Modified Constraint Induced Movement therapy in improving the functional performance of the upper extremity in chronic hemiparetic subjects. METHOD: In mCIMT group, training was administered intensively for 2 hours per day for 6 days per week for 12 weeks with restraining of the unaffected upper extremity in sling and splint. In BIT group, 2 hour session containing 5 exercise each with minimum 5 trails of every task and maximum the patient can perform with BIT. SUBJECTS: The population of 30 patients was included in the study which was divided by random allocation into two groups. The features of each group was as mentioned under 15 minutes of therapy was spent on stretching and weight bearing exercises for normalization of muscle tone of the affected limb as needed in both the group. RESULTS: Subjects in mCIMT group Confirmed that they were largely using their affected limb for ADL following intervention with significant changes in MAL and ARAT score suggesting increased use of the affected limb, whereas subjects in the BIT group showed nominal MAL and ARAT changes and reported the pattern of use similar to those that they reported before intervention. KEY WORDS: Modified CIMT, BIT, MAL scale, ARAT scale

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INTRODUCTION

Most patients who survive a stroke survivors experience experience persistent impairment of arm movement
10,11 .

Many

stroke

impairments such as hemiparesis, spasticity, sensory/perceptual disorders, hemianopia,

8.

It has been suggested that

constraint- induced movement therapy or less intensive variants of constraint-induced

dysphasia or cognitive impairments

Most

patients regain their walking ability, but between 30 and 60% are no longer able to use their more affected hand after 3-6 months
4,7,19

movement therapy (i.e. modified) may be used to overcome the learned non-use phenomenon and improve functional

. Only 11% to 18% of those sustaining a

7.

performance of the affected arm of stroke patients in the acute, subacute and chronic phases 13,17,18,25. Bilateral Isokinematic Training (BIT) is used for upper limb rehabilitation in stroke patients and is based on the theory that therapy for stroke patients needs to be directed at the central nervous system because it is the brain that is damaged by a stroke, not the muscles. Quite simply, BIT trains the stroke patient to use both hands in the same way, simultaneously but separately (bilateral = both sides, iso = equal/same, kinematic = same movement of both upper limbs simultaneously) 23. Need and Significance of the study: Functional recovery of the paretic upper extremity post stroke continues to be one of the greatest challenges faced by rehabilitation professionals. Although most patients regain

severe post stroke upper extremity paresis achieve full upper extremity function The

inability to reach, to grasp and to manipulate objects limits activities and causes particular difficulties to perform daily personal care. Perceived loss of arm function has been reported as a major problem in approximately 65% of patients with stroke Thus, there is a strong need to develop effective arm-hand treatment methods in stroke rehabilitation 4. Constraint-induced movement therapy

(CIMT), also known as forced use movement therapy, is a therapeutic approach to

rehabilitation of movement after stroke. The principal therapy involves constraining

movements of the less-affected arm with a sling for 90% of waking hours for the duration of therapy, while intensively training use of the more-affected arm. 3 Chronic lack of use of the upper extremity induced in monkey by unilateral sectioning of the dorsal cervical and upper thoracic spinal nerve roots could be reversed several months to years later with a physical restraint applied to the contralateral unaffected arm 21.
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walking

ability,

30%66%

of

stroke

survivors fail to regain functional use of their arm and hand 10. The incorporation of bimanual movements into upper limb rehabilitation protocols, also

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it is considered that the BIT approach is in direct contrast to constraint- induced therapy as long as the implementation of the technique is considered 6.

week for 12 weeks with restraining of the unaffected upper extremity in sling and splint. 15 minutes of therapy was be spent on normalization of muscle tone of the affected

Hypothesis Experimental Hypothesis: There may be significant difference in the effectiveness between Movement Isokinematic Modified therapy Training Constraint and in Induced Bilateral improving

limb as needed by stretching and weight bearing exercises, patients unaffected hand and wrist was restrain with sling and splint every week days for 6 hours identified as a time of frequent arm use. 6 In BIT group, 2 hour session(training period matching to mCIMT group in duration) containing 5 exercise each with minimum 5 trails of every task and maximum the patient can perform with BIT (spatiotemporally identical movement performed bilaterally but with each limb independently).

functional performance of upper extremity in chronic hemiparesis. Null Hypothesis: There may not be any significant difference in the effectiveness between Movement Isokinematic Modified therapy Training constraint and in Induced Bilateral improving

functional performance of upper extremity in chronic hemiparesis.

Taub and Colleagues et al showed that chronic lack of use of the upper extremity induced in monkey by unilateral sectioning of the dorsal cervical and upper thoracic

Materials & Methodology: For the present comparative study a pre test and post test design was used. Population included chronic hemiparetic subjects.

spinal nerve roots could be reversed several months to years later with a physical restraint applied to the contralateral unaffected arm
2,21,22.

Subjects were assigned to two groups, Group A for mCIMT with 15 subjects and Group B for BIT with 15 subjects with equal probability In mCIMT group, training was administered intensively for 2 hours per day for 6 days per
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Wolf and Colleagues et al conducted studies on chronically brain hemiparetic injury stroke and which

traumatic

patients

involved forced use, that is, restraint of the less affected arm with sling for 2 weeks while requiring the more affected arm to conduct routine daily living activities found

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

that speed of the task execution improved for most functional task for up to a year following intervention 20. CIMT and mCIMT involve restraint of the unaffected limb for an extended period and repeated task-specific training of the affected limb. Numerous studies in stroke patients have shown that CIMT/mCIMT can enhance performance of the affected UE during unilateral and bimanual functional tasks (e.g., flipping a light switch, putting on socks) assessed, for example, using the Motor Activity Log (MAL). During the unilateral task mCIMT produce a greater increase in the amount of preplanned control of reaching movement than did TR 6. Inter-rater and retest reliability have been shown to be high (ICC > 0.98) in studies involving patients with stroke 25 Concurrent validity has been confirmed by comparison with the upper limb component of the Fugl- Meyer Assessment and the In recent years the development of new rehabilitation therapies has demonstrated that significant progressions in movement ability are achievable in chronic stroke patients many months or even years after the initial event 6,9. Motor Activity Log scale is a structured interview during which subjects used a six point scale to rate how much and how well they use their hemiparetic limb to perform common functional activities 22. It appears to captureboth how well and how much patients use their more-impairedarm to accomplish ADL, and, therefore, might simply be namedthe Arm Use scale 14.
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Action Research Arm Test (ARAT) is the valid and consistent scale for measuring recovery of arm-hand function in stroke patient. ARAT may reflect not only arm function but also upper extremity motor impairmrnt that represents the exteriorization of neurophysiological state due to

cerebrovascular diseases. The score of ARAT may also represent the degree of upper extremity impairment.

Motor Assessment Scale (MAS) 12,25.

Study settings All the patients were referred by consultant neurologist from the above mentioned

hospitals and clinics.

Research Design: It was a comparative study design, a sample of 30 subjects were included in the

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study with a pretest and post test study design. The subjects were selected by convenient sampling method based on an initial baseline assessment and diagnosis of their condition as per neurologist.

Patient with any congenital deformity of upper extremity like heterotrophic

ossification. Patients with any other neurological disability like any head trauma, dementia, learning disorder, schizophrenia, major depression before the stroke, epilepsy

Inclusion Criteria: Hemiparesis Age 45-75 years 19. Duration more than 1 year and less than 2 years Patient who can perform some active finger and wrist extension 6,11. Patient on MMSE( Mini Mental Scale Examination) more than 23/30 . Spasticity grading less than or equal to 2/5 on modified Ashworth Scale . Both gender to be included Both dominant and nondominant hemisphere lesion involvement patient will be equally included Considerable nonuse of the more affected limb (Amount of Use<2.5 on Motor activity log scale 20. Patients consent for participation. 30

brain tumor . Patients with visual impairment. Patient who had stroke more than once in the ipsilateral hemisphere or stroke in the contralateral hemisphere on imaging studies.

Population: The population of 30 patients was included in the study which was divided by random allocation into two groups. The features of each group was as mentioned under Sample Design: subjects with chronic hemiparesis

duration between 1-2 years and age group between 40-60 years were taken. The

definition of 'chronic' for the purposes of this study was defined as onset of stroke at least one year prior to the commencement of the treatment phase of this study 13,20,26. Time and Duration of the study:

Exclusion Criteria Duration of the study was 6 months & Data Patient who has any orthopaedic were collected within the period of 3 months. Protocol:
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condition like post fracture stiffness or contractures of wrist and fingers.

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

The subjects underwent the standardized assessment technique based on an initial baseline assessment which also included patients cognitive assessment by MMSE scale and assessment of the tone of the upper limb by Modified Ashworth Scale and diagnosis neurologist. In mCIMT group, training was administered intensively for 2 hours per day for 6 days per week for 12 weeks with restraining of the unaffected upper extremity with sling and splint. In mCIMT, we concentrated on use of the affected limb during functional task chosen by patients and the treating therapist. It consisted of shaping which involved 1. Selecting functional tasks tailored to address the motor deficits of the affected hand. 2. Increasing the task difficulty in small steps when performance was improved. 15 minutes of therapy was spent on normalization of muscle tone of the affected limb as needed by stretching and weight bearing exercises, patients unaffected hand and wrist was placed in restrain every week days for 6 hours identified as frequent arm use 6. In BIT group, 2 hour session(training period matching to mCIMT group in duration) containing 5 exercise each with minimum 5 trails of every task and maximum the patient
69

can perform with BIT (spatiotemporally identical movement performed bilaterally but with each limb independently). Procedure: 15 minutes of therapy was spent on stretching and weight bearing exercises for normalization of muscle tone of the affected limb as needed in both the group. All the 15 patients of Group A were given restraint using sling and splint on the unaffected extremity for 6 hours identified as a time of frequent arm use. Training had taken place during regularly scheduled physical therapy session, and all other routine interdisciplinary stroke rehabilitation was as usual. Group program was given to the patients (with 3-4 patients in a group), for 2 hours per day
6

of

their

condition

as

per

Patients were seated on the

chair with harness tied around the trunk to prevent the trunk rotation and forward flexion (only if required) and a table in front of the patient 2cm below the elbow the level or standing with support provided by the assistant as necessary6. Training in Group B had also taken place during regularly scheduled physical therapy session, and all other routine interdisciplinary stroke rehabilitation was as usual. All 15 patients were seated on the chair with harness tied around the trunk to prevent the trunk rotation and forward flexion(only if required) and a table in front of the patient 2cm below the elbow the level or standing with support

time of

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provided by the assistant as necessary. Exercise in BIT included activities with both hands doing same task separately, but at the same time and same speed. Analysis and Interpretation The data obtained using ARAT, MAL(AOU) Within Table: Group analysis within Group A and Group B of ARAT scale
ARAT
45 40 35 30 25 20 15 10 5 0 Day 0 Day 45 Day 90

scale of this study are ordinal and not interval or ratio. Since this does not adequately fulfill the conditions for parametric tests; nonparametric test is applied here. The result shows a significant improvement in both the group getting both mCIMT and BIT. group
Outcome measures Day 0 Mean SD Day 45 Mean SD Day 90 Mean SD

analysis
Repetitive measures Z P

ARAT

Group A Group B

30.60 8.34 27.67 7.32

37.73 7.76 31.07 7.22

42.47 8.14 33.20 6.12

-2.90

.000

-3.86

.000

Within group analysis

MAL (AOU)
4 3.5 3 2.5 2 1.5 1 0.5 0 Day 0 Day 45 Day 90

Outcome measures

Day 0 Mean SD

Day 45 Mea n SD 2.40 .54 1 1.73 .56 3

Day 90 Mea n SD 3.37 .51 6 2.40 .47 1

Repetitive measures Z P

MAL (AOU)

Group A

1.47. 516

-2.90

.000

Group B

1.27. 594

-3.86

.000

Table: RESULT The

Group

analysis

within

Group

and

Group

of

MAL(AOU)

scale

on the functional performance of the upper extremity of hemiparetic stroke patient. study was undertaken to Data collected through the study showed more improvement in the hand function and
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present

determine the effect of the mCIMT and BIT

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

functional

activities

in

patients

with

The study is done on an immediate basis i.e. the MAL scale was measured immediately on the use of mCIMT and BIT and no follow up was done. The lack of follow up has the drawback that sustained of this improvement and further progression value is not revealed. It is known that right sided hemiparesis usually have some perceptual disorder also which is not considered in the study, but

hemiparesis in the group A. Thus, it can be concluded that mCIMT is more beneficial in improving hand function for hemiparetic patients post stroke. There results showed that patients treated with mCIMT had their functional performance of affected upper extremity improved significantly more DISSCUSSION It has been recorded from the study that use of mCIMT and BIT produces significant

nevertheless can affect the outcome. CONCLUSION The present study showed a lasting effect of forced use therapy on the functional

improvement in functional performance of the upper extremity in patients with hemiparesis due to stroke. A positive effect was found on the subjective Amount of Use of the affected arm in ADL (measured by the MAL(AOU) scale)

performance of the affected arm, as measured by the ARA test in comparison to the Bilateral Isokinematic training. A positive effect was found on the subjective Amount of Use of the affected arm in ADL (measured by the MAL(AOU) scale)

especially in the patients with the learned nonuse.

especially in the patients with the learned nonuse. LIMITATIONS

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CORRESPONDING AUTHOR:

* PhD Scholar, Srimanta Sankardeva University of Health Sciences, Guwahati, Assam

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