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Received 19th February 2009; returned for revisions 22nd February 2009; revised manuscript accepted 14th January 2010.
Week
Measured two-point discriminatory sense, stereognosia, thermaesthesia
0 Randomized (n= 96)
(n = 32) (n= 32) (n= 32)
Experimental 1 Experimental 2
Control group Traditional therapy plus Traditional therapy plus
Traditional therapy individual therapy based individual therapy based on
on PNF method PNF method plus Butler’s
neuromobilizations
3
Measured two-point discriminatory sense, stereognosia, thermaesthesia
(n= 32) (n= 32) (n = 32)
stimulation without any pain. The tip-to-tip dis- the forearm, fourth and fifth fingers.17,23 The sub-
tance was gradually increased in steps of 1 mm jects assumed a relaxed supine position with closed
starting from 0. This procedure was repeated eyes. The task was to answer a simple question (i.e.
several times (with only short breaks to adjust whether the cylinder touching the skin is hot or
the compass) and was terminated when a clear cold). A correct response scored 1 point, a false
two-point sensation was indicated. Steps from response scored 0. The cylinders were applied in
zero to this point were repeated three times. random order three times. Two repeated responses
Normally, this is enough to reach a steady two- were recorded as the outcome. Outcomes for the
point sensation level.25–28 From these three three investigated dermatomes in the evaluation of
repeated measurements the two values closest to thermaesthesia were summarized, providing a
each other were averaged and analysed. In the sit- total outcome expressed in points (range 0–3).
uation where tip-to-tip distance was larger than
the phalanx’s width, the position of the tips was
changed to lie parallel to the long axis of the pha- Data analysis
lanx. If it was still larger than the distal phalanx’s One-way ANOVA and chi-squared test were
length, the medial, or proximal one was tested used for homogeneity testing. Mixed model of
instead. For the two-point discriminatory sense ANOVA (independent factor: group (control,
results obtained for individual fingers were aver- experimental 1, experimental 2); repeated factor:
aged their mean value characterized the global measurement (healthy limb initial, affected limb
level of the two-point discriminatory sense in initial, affected limb final)) together with a post-
both healthy and affected upper limbs. hoc Tukey test were used to evaluate inter- and
In assessing of stereognosia, the subjects were intra-group differences in the case of two-point
asked to identify up to 10 commonly used objects discriminatory sense and thermaesthesia. Results
by touch. These were: a comb, a box of matches, a obtained for the healthy extremities were regarded
coin, spectacles, a watch, scissors, a cup, a pen, a as independent groups.
button and a hammer. When independent grasp- In the case of the stereognosia evaluation, in
ing was impossible the objects were passively which it was impossible to collect data from the
healthy limbs, the mixed model of ANOVA was
placed into the subject’s hand. They were hidden
reduced to the form: independent factor: group
from the subject’s sight. Recognition was con-
(control, experimental 1, experimental 2); repeated
firmed by indicating objects on a set of pictures.
factor: measurement (affected limb initial, affected
A correct response was scored with 10 points, a
limb final).
false response with 0 points (maximal score ¼ 100
Change scores were analysed using simple one-
points).29,30 Because of a considerable learning way ANOVA with independent factor: group
effect it was not possible to use the same set of (control, experimental 1, experimental 2).
objects for the opposite extremity, therefore no The level of significance (P-value) was set at
data on the healthy limb were recorded in the 0.05. Comparison of initial and final inter-group
case of stereognosia. differences was used to answer our research ques-
Thermaesthesia was assessed using two identical tions. For the two-point discriminatory sense and
measurement cylinders: one filled with ice, the thermaesthesia healthy limbs were regarded as
other with hot water. During the initial measure- additional reference points.
ment the forearm and fingers of the healthy upper
limb were tested first. No data on the healthy limb
were recorded in the final measurement. Three Results
dermatomes were assessed: C6 dermatome com-
prising the radial aspect of the forearm, first and Characteristics and homogeneity of the groups
second fingers; C7 dermatome comprising the The groups were equivalent regarding distribu-
dorsal aspect of the forearm, second and third fin- tion of gender, stroke aetiology, affected side
gers; C8 dermatome comprising the ulnar aspect of of the body, age, body height and body mass.
816 T Wolny et al.
*Chi-squared test.
**One-way ANOVA.
Exp 1, experimental group 1; Exp 2, experimental group 2.
The characteristics of the three groups and out- registered. Detailed data on the two-point discrim-
comes of homogeneity testing are presented in inatory sense are presented in Table 2.
Table 1.
Stereognosia
Two-point discriminatory sense The statistical power of ANOVA was 0.25 in
With 32-subject groups we achieved statistical this case. A mean progression of 4.6 points (95%
power of ANOVA of 0.97 for two-point discrimi- CI 0.53 to 7.59) was noted in experimental group 1
natory sense (power ¼ 1–beta (probability of com- and of 9.37 points (95% CI 1.24 to 17.51) in exper-
mitting the statistical error of the second kind). imental group 2 (P50.01, Tukey test) (Table 3).
Initial measurement showed a similar level of the In the control group we registered insignificant
two-point discriminatory sense in the three groups deterioration of –0.62 points on average (95%
(P40.05 for all groups, Tukey test). Healthy limbs CI –1.90 to 0.65). No data on the healthy limb
were significantly better (P50.001 for all groups, were available for stereognosia. No significant
Tukey test). After the intervention, experimental inter-group differences were registered. Because
group 2 subjects were on average 4.17 mm better of the low power of our statistical test a probabil-
than experimental group 1 subjects (95% CI 2.64 ity of 75% of committing type 2 statistical error
to 5.7) and 3.84 mm better than control group sub- should be considered here.
jects (95% CI 3.02 to 4.67). The affected limb out-
come in experimental group 2 was even 1.72 mm Thermaesthesia
(95% CI 0.20 to 3.23) better than for the healthy In the case of thermaesthesia the statistical power
limb (P40.05, Tukey test). Intra-group difference of ANOVA was 0.85. In the control group no ther-
for affected upper extremity was also significant apeutic effect was observed. In experimental group
(P50.001, Tukey test). In experimental group 1 1 one subject increased their score from 0 to 1 point.
this difference was still negative, –3.88 mm (95% The difference between the affected and the healthy
CI –5.89 to –1.87) and significant (P50.001, limb was always significant in these groups
Tukey test) and so it was in control group (mean (P50.001 for both the initial and final measure-
3.22 mm; 95% CI –4.52 to –1.93; P50.001). ments, Tukey test). In experimental group 2 the
No significant inter-group differences were mean difference between the affected and the
Butler’s method in late-stage stroke subjects 817
Table 2 Mean SD (min–max) of groups, mean (95% CI) inter-group differences and mean (95% CI) intra-group differences
for the two-point discriminatory sense (mm)
ILI 4.56 1.50 4.22 1.23 5.66 4.88 0.34 –1.1 –1.44
(2.00–8.00) (2.40–7.80) (2.60–31.20) (0.23 to 0.43) (–2.31 to 0.11) (–2.74 to –0.12)
ALI 8.09 4.14 8.61 6.16 8.59 4.77 –0.52 –0.50 0.02
(2.00–18.60) (2.60–37.60) (3.60–26.40) (–1.25 to 0.20) (–0.73 to –0.28) (–0.48 to 0.52)
ALF 7.78 3.77 8.11 5.73 3.94 1.48 –0.33 3.84 4.17
(2.80–18.4) (2.40–34.60) (1.80–8.60) (–1.03 to 0.38) (3.02 to 4.67) (2.64 to 5.7)
Intra-group
ILI minus ALI –3.53* –4.38* –2.94*
(–4.92 to –2.14) (–6.56 to –2.20) (–4.10 to –1.77)
ILI minus ALF –3.22* –3.88* 1.72
(–4.52 to –1.93) (–5.89 to –1.87) (0.20 to 3.23)
ALF minus ALI –0.31 –0.50 –4.66*
(–0.57 to –0.04) (–0.86 to –0.13) (–6.06 to –3.25)
Table 3 Mean SD (min–max) of groups, mean (95% CI) inter-group differences and mean (95% CI) intra-group differences
for stereognosia [points]
ALI 57.19 49.46 58.12 46.45 62.19 43.68 –0.93 –5.00 –4.07
(0–100) (0–100) (0–100) (–2.03 to 0.18) (–7.09 to –2.92) (–5.06 to –3.07)
ALF 56.56 50.07 62.19 45.49 71.56 41.43 –5.63 –15.00 –9.37
(0–100) (0–100) (0–100) (–7.28 to –3.98) (–18.11 to –11.89) (–10.83 to –7.91)
Intra-group
ALF minus ALI –0.62 4.06 9.37*
(–1.90 to 0.65) (0.53 to 7.59) (1.24 to 17.51)
healthy extremity was reduced from 0.56 points (ALF minus ALI). In the case of the two-point
(95% CI 0.25 to 0.88; P50.01, Tukey test) to discriminatory sense experimental group 2 was
0.34 points (95% CI 0.13 to 0.56; P40.05, Tukey significantly better than the two other groups
test). No significant inter-group differences were (P50.001 in each case, Tukey test). A similar situ-
revealed (Table 4). ation was registered for thermaesthesia (experimen-
tal 2 versus experimental 1 P50.01; experimental 2
versus control P50.001, Tukey test). For stereo-
Change scores gnosia the only significant difference was found
Change scores for all parameters and all groups between experimental 2 and control group
may be found in the last rows of Tables 2, 3 and 4 (P50.05).
818 T Wolny et al.
Table 4 Mean SD (min–max) of groups, mean (95% CI) inter-group differences and mean (95% CI) intra-group differences
for thermaesthesia (points)
ILI 3.00 0.00 2.94 0.35 3.00 0.00 0.06 0.00 0.06
(3.00) (1.00–3.00) (3.00) (0.19 to 0.06) (–) (0.19 to 0.06)
ALI 2.31 0.10 2.06 1.16 2.44 0.88 0.25 –0.13 –0.38
(0.00–3.00) (0.00–3.00) (0.00–3.00) (0.19 to 0.31) (–0.17 to –0.08) (–0.48 to –0.27)
ALF 2.31 0.10 2.09 1.12 2.78 0.55 0.22 –0.47 –0.67(–0.89
(0.00–3.00) (0.00–3.00) (1.00–3.00) (0.17 to 0.26) (–0.62 to –0.31) to –0.48)
Intra-group
ILI minus ALI 0.69* 0.87* 0.56**
(0.33 to 1.05) (0.48 to 1.27) (0.25 to 0.88)
ILI minus ALF 0.69* 0.84* 0.22
(0.33 to 1.05) (0.44to 1.24) (0.02 to 0.42)
ALF minus ALI 0.00 0.03 0.34
(–) (–0.03 to 0.09) (0.13 to 0.56)
although the size of our sample was sufficient in synergisms, motor impairment – all these symp-
terms of statistics, it may well be too small to draw toms may result in unfavourable muscle, connec-
definite clinical conclusions. Similarly, the dura- tive and neural tissue changes, which not only
tion of the treatment may seem a bit too destroy their structure but also internal plasticity.
short for some clinicians. We also did not orga- Pathological damage can arise because of the
nize a longer follow-up, so we cannot be sure reduced ability of the nerve to slide on neighbour-
whether any effects were temporary, long-term or ing tissue.
permanent. It should be noted that the peripheral nerve is a
We would also like to draw attention to some mixed nerve containing sensory, motor and auto-
problems that may arise during the application of nomic fibres. All peripheral nerves provide the
these techniques. In the case of neuromobilization central nervous system with various data concern-
no standard, validated protocols aiming to obtain ing exteroception, proprioception, thermaesthesia,
the best outcome have been developed yet (dura- stereognosia, joint position sense, etc. This infor-
tion, number of repetitions and sets, amount of mation will only be appropriate if the function of
force, etc.). At present much depends on the the nerve remains totally unspoiled. From this
experience of the individual clinician. In the case point of view it seems that many stroke patients
of post-stroke therapy this may be even more may suffer from disturbed neuromechanics which
complicated since sensory deficit may make is followed either by impaired data transmission or
patient feedback to the clinician limited and by transmission of misleading information.
cause difficulties in adjusting the amount of force Lasting pressure exerted on the neuron and on
appropriately. surrounding connective tissue is able to introduce
Information about the effectiveness of Butler’s fibrosis followed by distorted data transmission,
neuromobilization applied as an alternative form axonal transport, vasomotor and trophic distur-
of stimulation supporting regular post-stroke bances. From this point on a short path leads to
therapy is sparse. Earlier, Davies applied neuro-
blood supply impairment which affects inter-tissue
mobilization in stroke patients31,32; he provided
chemical reactions and finally reduces the overall
technical details of the applied techniques, reported
physical capacity of the patient. The nerve may
a favourable influence on muscle tone and improve-
also receive confusing information from so-called
ment of some indicators of functional capacity, but
‘nervi nervorum’ and therefore become either a
did not mention any specific objective tools aiming
to evaluate the outcome. Rolf33 provides some source of its own symptoms or a factor cementing
information on neural tissue mobilization in pathological motion patterns and/or malalignment
stroke patients and claims its positive effects; classic of body segments.14
Butler techniques were developed by this author to The important problem of affected exterocep-
meet the demands of the neurological patient. tion, especially within the paralysed upper limb, is
Impaired neuromechanics is also addressed by the frequently neglected. It is well known that a major
proprioceptive neuromuscular facilitation method, function of the hand (besides manual motor tasks)
which allows the modification or combination of is reception of external tactile information, ther-
therapeutic techniques so that they can be used maesthesia and stereognosia. Biocybernetic
for peripheral nerve mobilization.34 models clearly indicate that only an adequate
Independent of their aetiology, hemiplegia and input information to the control system allows
hemiparesis of cerebral origin are a specific disor- for an appropriate response. Therefore, modula-
der of the locomotory system.35 Injury affecting tion of tension within all structures of the upper
the central nervous system usually has a circula- extremity may provide the central nervous system
tory background, but major dysfunctions involve with desired information, which in turn allows for
the locomotory system. Normal neuromechanics adequate motor performance. Impairments of this
may be affected by changes located either within system may burden the upper limb with severe dis-
the borders of the nervous system or outside it. ability, with modification of the motor schemes
Paralysis or paresis spreading across one side of and deregulation of spatial and time parameters
the body, spastic muscle tone, pathologic of the movement in the background.
820 T Wolny et al.
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post-stroke motor disturbances include dysfunc- facilitation; patterns and techniques, second edi-
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Weaver LE. Tactile extinction and function status
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Butler’s method in late-stage stroke subjects 821