COMPARING THE EFFICACY OF TASK SPECIFIC TRAINING AND CONVENTIONAL PHYSIOTHERAPEUTIC REHABILITATION ON MOTOR AND FUNCTIONAL ACTIVITIES OF UPPER LIMB IN POST STROKE PATIENTS Dissertation submitted in the Partial fulfillment for the degree of MASTER OF PHYSIOTHERAPY (Neurology) The Tamil Nadu Dr. M.G.R. Medical University Chennai May 2018 PSG COLLEGE OF PHYSIOTHERAPY Coimbatore
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COMPARING THE EFFICACY OF TASK SPECIFIC
TRAINING AND CONVENTIONAL PHYSIOTHERAPEUTIC
REHABILITATION ON MOTOR AND FUNCTIONAL
ACTIVITIES OF UPPER LIMB IN POST STROKE PATIENTS
Dissertation submitted in
the Partial fulfillment
for the degree of
MASTER OF PHYSIOTHERAPY
(Neurology)
The Tamil Nadu Dr. M.G.R. Medical University
Chennai
May 2018
PSG COLLEGE OF PHYSIOTHERAPY
Coimbatore
PSG COLLEGE OF PHYSIOTHERAPY
Coimbatore
CERTIFICATE
This is to certify that the research work entitled “COMPARING THE
EFFICACY OF TASK SPECIFIC TRAINING AND CONVENTIONAL
PHYSIOTHERAPEUTIC REHABILITATION ON MOTOR AND
FUNCTIONAL ACTIVITIES OF UPPER LIMB IN POST STROKE
PATIENTS” was carried out by Reg. No. 271620244, of P.S.G. College of
Physiotherapy, towards the partial fulfillment for the degree of MASTER OF
PHYSIOTHERAPY (Physiotherapy in Neurology), affiliated to The Tamil
Nadu Dr. M.G.R. Medical University, Chennai.
Internal Examiner External Examiner
Date of Evaluation:
PSG COLLEGE OF PHYSIOTHERAPY
Coimbatore
CERTIFICATE
This is to certify that the dissertation work entitled “COMPARING THE
EFFICACY OF TASK SPECIFIC TRAINING AND CONVENTIONAL
PHYSIOTHERAPEUTIC REHABILITATION ON MOTOR AND
FUNCTIONAL ACTIVITIES OF UPPER LIMB IN POST STROKE
PATIENTS” was carried out by THOMAS RICHARD. K, Reg. No. 271620244
of P.S.G. College of Physiotherapy, affiliated to The Tamil Nadu Dr. M.G.R.
Medical University, Chennai.
Prof. R.MAHESH, MPT., Principal,
P.S.G. College of Physiotherapy, Coimbatore - 641 004.
Place: Coimbatore
Date:
PSG COLLEGE OF PHYSIOTHERAPY
Coimbatore
CERTIFICATE
This is to certify that the research work entitled “COMPARING THE
EFFICACY OF TASK SPECIFIC TRAINING AND CONVENTIONAL
PHYSIOTHERAPEUTIC REHABILITATION ON MOTOR AND
FUNCTIONAL ACTIVITIES OF UPPER LIMB IN POST STROKE
PATIENTS” was carried out by THOMAS RICHARD. K, Reg. No. 271620244
of P.S.G. College of Physiotherapy, towards the partial fulfillment for the degree of
MASTER OF PHYSIOTHERAPY (Physiotherapy in Neurology), affiliated to
The Tamil Nadu Dr. M.G.R. Medical University, Chennai, under my guidance.
Dr. R. BALAKRISHNAN, MD, DM(Neuro), DNB(Neuro).,
Professor, Department of Neurology,
P.S.G Hospitals,
Coimbatore – 641 004.
Place: Coimbatore
Date:
PSG COLLEGE OF PHYSIOTHERAPY
Coimbatore
CERTIFICATE
This is to certify that the dissertation work entitled “COMPARING THE
EFFICACY OF TASK SPECIFIC TRAINING AND CONVENTIONAL
PHYSIOTHERAPEUTIC REHABILITATION ON MOTOR AND
FUNCTIONAL ACTIVITIES OF UPPER LIMB IN POST STROKE
PATIENTS” was carried out by THOMAS RICHARD. K, Reg. No. 271620244
of P.S.G. College of Physiotherapy, Coimbatore, affiliated to The Tamil Nadu Dr.
M.G.R. Medical University Chennai, under our guidance.
Guide Co-Guide
Prof. R.MAHESH, MPT., Mrs. Malarvizhi, MPT.,
Principal Assistant Professor
P.S.G. College of Physiotherapy P.S.G. College of Physiotherapy
Coimbatore - 641 004. Coimbatore - 641 004.
Place: Coimbatore
Date:
ACKNOWLEDGEMENT
It is my privilege to express my deep sense of gratitude to the GOD for
showering his blessings, who has always been my source of strength and who
guides me throughout.
For the ancestors who paved the path before me upon whose shoulders I
stand. I dedicate this study to MY FAMILY and FRIENDS for providing their
moral support and love in each and every step of my life.
With due respect, I would like to express my immense gratitude to
Professor R. Mahesh, MPT, Principal, PSG College of Physiotherapy,
Coimbatore, for his encouragement and inspiration during the course of my study.
I feel it my duty to thank Professor Dr. R. Balakrishnan, MD, DM(Neuro),
DNB(Neuro), Department of Neurology, PSG IMS&R Hospitals for his constant
and unwavering encouragement, who rendered his invaluable experience as
guidance to this project.
I also thank Professor Dr. Ramamoorthy, MD, HOD, Department of PMR,
PSG IMS& R Hospitals for his encouragement, who rendered his invaluable
experience as guidance to this project.
I am thankful to my project guides Mr. Mahesh.R, MPT and Mrs.
Malarvizhi, MPT for their encouragement, inspiration and untiring efforts given
throughout the study.
I am indebted to Mr.Raja Regan, MPT for his expertise guidance and
valuable ideas without whom the study would have not been completed.
My special thanks to Mrs V.Mahalakshmi, MPT, Post graduate
Coordinator, PSG College of physiotherapy who has moulded me in my academics
activities and made my project completion easier.
I express my gratitude to Mrs. Ashraf MPT, Ms. Shanmugapriya, MPT,
Mr. Saravanan, MPT, Mrs. Sweety Subha, MPT, Mr. Mahendiran, MPT, and
Mr.Nagaraj, MPT, for their timely help.
I am grateful to Mr. A. Parthiban, MPT, for his expert guidance and
constant support throughout the study.
My special thanks to Dr. ANIL MATHEW, Ph.D, Professor, Department
of Biostatistics, PSG Institute of Medical Science and Research who gave me a
helping hand in statistical method of data analysis.
I thank all the members of Institutional Review Committee of Research,
College of Physiotherapy and Human Ethics Committee of PSG Institute of
Medical Science and Research for their kind suggestions to complete the
dissertation.
I also thank all the staff members of the PSG College of Physiotherapy and
Department of Physiotherapy for helping me to complete this project successfully.
Finally, I thank all the patients for their kind co-operation. Without their
involvement this project would have not been possible.
ABBREVIATIONS
ARAT - Action Research Arm Test
MMSE - Mini Mental Status Examination
FMA-UE - Fugl Meyer Assessment for Upper Extremity
MAS - Modified Ashworth Scale
MCA - Middle Cerebral Artery
ADL - Activities of Daily Living
ANOVA - Analysis Of Variance
CONTENTS
CHAPTER TITLE PAGE NO
I INTRODUCTION 1
1.1Need for the Study 3
1.2 Objective 4
1.3 Hypothesis 4
1.4 Operational Definitions 4
II LITERATURE REVIEW 5
III MATERIALS AND METHODS 9
3.1 Materials 9
3.2 Study Design 9
3.3 Study Setting 9
3.4 Human Participation Protection 9
3.5 Population/Participants 10
3.6 Sampling 10
3.7 Intervention 10
3.8 Criteria for Sample Selection 10
3.8.1 Inclusion Criteria 10
3.8.2 Exclusion Criteria 10
3.9 Study Duration 10
3.10 Instrument and Tools for Data collection 11
3.11 Technique of Data Collection 11
3.12 Technique of Data Analysis and Interpretation 12
IV DATA ANALYSIS AND INTERPRETATION 14
V RESULTS AND DISCUSSION 32
VI SUMMARY AND CONCLUSION 36
BIBLIOGRAPHY 37
ANNEXURE
ABSTRACT
LIST OF ANNEXURES
Annexure Content
I Ethical Committee Clearance Letter
II Neurological Assessment Form for Stroke
III Patient Record form
IV Informed Consent (English and Tamil)
V Assessment Tool
VI Treatment Protocol
1
CHAPTER - I
INTRODUCTION
Stroke is a global health problem. It is the second commonest cause of death [13]
and
fourth leading cause of disability worldwide (Strong 2007) [15]
. Stroke is the leading cause of
disability and functional impairments [15]
; with 20% of survivors requiring institutional care after
3 months and 15%-30% being permanently disabled (Steinwarks 2000).In India the annual
incidence of stroke is about 145 per 100,000 per year during 2003-05 and 2005-06. In developed
and developing countries of the worlds. The incidence of stroke increases dramatically with age,
doubling in the decade after 65 years of age. Twenty-eight percent of strokes occur in individuals
younger than 65 years of age.
The greatest impact of stroke on both patients and families are the long-term disability,
including impairments, limitations of activities and participation restrictions in life situations. As
one of the most cause of disability, stroke imposes an economic burden in several countries.
Stroke is the most common cause of chronic disability. Of survivors, an estimated one
third will be functionally dependent after 1 year experiencing difficulty with activities of daily
living (ADL), ambulation, speech, and so forth. Stroke survivors represent the largest group
admitted to inpatient rehabilitation hospitals. Of the many arteries supplying the brain the middle
cerebral artery (MCA) is the second of the two main branches of the internal carotid artery and
supplies the entire lateral aspect of the cerebral hemisphere (frontal, temporal, and parietal lobes)
and sub cortical structures, including the internal capsule (posterior portion), corona radiata,
globuspallidus (outer part), most of the caudate nucleus, and the putamen and middle cerebral
artery most common site of occlusion in stroke [8]
.
Weakness (paresis) is found in 80 to 90 percent of all patients after stroke and is a major
factor in disability. Patients are unable to generate the force necessary for initiating and
controlling movement. The degree of weakness is related to the location and size of the brain
injury and varies from a complete inability to achieve any visible contraction to measurable
impairments in force production. Deficits on the contra lateral, side typically include hemi
paresis.
2
Owing to the high incidence of MCA strokes, the UE is frequently more affected than the
LE. About 20 percent of individuals with MCA strokes fail to regain any functional use of the
affected UE.
The effects on the upper extremities are a major cause of functional impairment. This
impairment of the upper extremity often leads to loss of independence with activities of daily
living and of important occupations. Indeed, hand function is crucial for performing delicate
movements in everyday life, such as eating meals and dressing. Identification of solutions for
hand function disorders in stroke patients is important because they restrict everyday life
activities [9]
.
There are many interventions that are intended to help people regain function and range
of motion in their hand and arm after stroke. Motor and cognitive perceptual disability could
occur in patients who have suffered brain damage from stroke, which could decrease their
capacity to perform daily activities.
Limited practice of motor activities is likely to have a negative impact upon functional
recovery and could prolong impatient rehabilitation because of the patient‟s dependency on the
unaffected upper extremity for normal functions, which results in problems such as learned
disuse, asymmetric postural patterns, contractures, and aggravated functional restrictions
involving the affected upper extremity. To improve functions of the affected upper extremity in
stroke patients, measures that maximize opportunities to use the affected upper extremity are
necessary.
Recovery and Prognosis of stroke is generally fastest in the first weeks after onset, with
measurable neurological and functional recovery occurring in the first month after stroke and
these changes are largely due to function-induced plasticity. A functional training approach that
emphasizes use of the more involved extremities and an enriched environment effectively
stimulates neural reorganization of the brain[8]
.
Functional mobility skills are impaired following stroke and vary considerably from
individual to individual. During the acute stroke phase Basic ADL skills such as feeding,
bathing, dressing, and toileting are also compromised during acute stroke, with 67 to 88 percent
of patients demonstrating partial or complete dependence.
3
Carr and Shepherd suggested task-oriented training as a treatment method to help
improve deteriorated motor skills of stroke patients and their capacity to perform daily activities,
and diverse functional activities properly applied to patients can help improve their actual motor
skills and capacity to perform daily activities [8]
. Task-oriented training refers to programs that
focus on special functional tasks that unite the muscular skeletal system and nervous system and
treatments that encourage active participation and focus on functional tasks rather than simple,
repetitive training of normal motion patterns. Research on task-oriented training has been active
lately, but application of new research results in the clinical environment is impractical because
most patients are hospitalized for short periods and programs often have long application
periods, which are usually longer than three weeks and also. There is no high quality evidence
for any interventions that are currently routine practice, and evidence is insufficient to enable
comparison of the relative effectiveness of interventions, in other words, the evidence is
insufficient to show which of the interventions are the most effective for improving upper limb
function.
Thus, the aim of this research is to determine the treatment effect of a short period of
task-oriented training (two weeks) on upper extremity function and performance of daily
activities in acute stroke patients and also majority of our daily activities require optimal function
of upper limb, therefore when its function is compromised it leads to profound activity limitation
in persons with stroke. This study is to investigate the potential benefits of task specific activities
in post stroke patients following upper limb task specific training and also to compare the effect
of task specific training and conventional physiotherapeutic rehabilitation for upper limb
performance in daily activities of stroke patient and so the Task specific training helps to restore
the preserved functional activities of the affected upper limb and to prevent non-use syndrome.
1.1 NEED FOR THE STUDY:
The majority of our daily activities require optimal function of upper limb, therefore when
its function is compromised it leads to profound activity limitation in persons with stroke [2]
.
This study is to investigate the potential benefits of task specific activities in post stroke
patients following upper limb task specific training and also to compare the effect of task
specific training and conventional physiotherapeutic rehabilitation for upper limb performance in
daily activities of stroke patients.
4
1.2 OBJECTIVE
1. To find impact of task specific training on motor changes and functional activities of
upper limb.
2. To find the effect of conventional physiotherapeutic rehabilitation on motor changes and
functional activities of upper limb.
3. To compare the effect of task specific training and conventional physiotherapeutic
rehabilitation on motor and functional activities of upper limb.
1.3 HYPOTHESIS
NULL HYPOTHESIS: There will be no significant difference after task specific
training over conventional physiotherapeutic rehabilitation on motor and functional
activities of upper limb.
ALTERNATIVE HYPOTHESIS: There will be significant difference after task
specific training over conventional physiotherapeutic rehabilitation on motor and
functional activities of upper limb.
1.4 OPERATIONAL DEFINITION:
ACTION RESEARCH ARM TEST (ARAT)
Scale used for measuring arm –hand function in stroke patients and also used to assess
activities of daily living, coordination and dexterity of hand. ARAT is found to be one of the
most valid and consistent information tests.
FUGL MEYER ASSESSMENT FOR UPPER EXTREMITY (FMA-UE)
Stroke specific, performance based impairment index. It is designed to assess motor
function, sensation and joint functioning, it is clinically used to determine disease severity,
describe motor recovery and to plan and assess treatment.
5
CHAPTER – II
REVIEW OF LITERATURE
Kimberly J.Waddell, et al., conducted a study on fifteen patients to investigate the
feasibility of high repetition, task specific training for individuals with upper extremity
paresis and the participants received 60 minutes/day of task specific training for 4
days/week during inpatient phase. With the help of ARAT(Action Research Arm Test)
and FIM(Functional Independence Measure) as additional outcome measure they
concluded that engaging patients in a high repetition task specific training improved in
all activity outcome measures and impairments.
Ching –lnhsieh, et al., conducted a study to find the inter and intra rated reliability of
action research arm test for 50 stroke patients and found that this action research arm
test is closely correlated with upper extremity motor assessment and also the study
supports the value of ARAT for measuring recovery of arm hand function in stroke.
Gui Bin Song, et al., conducted a study to investigate the effects of task-oriented
bilateral arm training and repetitive bilateral arm training on upper limb function and
activities of daily living in forty stroke patients .The task-oriented group underwent
bilateral arm training with 5 functional tasks, and the repetitive group underwent
bilateral arm training with rhythmic auditory cueing for 30 minutes/day, 5 times/week,
for 12 weeks. And found a significant difference in the task-oriented group showing a
greater improvement in upper limb function and activities of daily living and
recommend bilateral arm training as well as adding functional task training as a clinical
intervention to improve upper limb function activities of daily living.
Jannette Blennerhassett, et al., conducted a study to investigate whether additional
practice of either upper limb or mobility tasks improved functional outcome during
inpatient stroke rehabilitation in thirty stroke patients. All subjects received their usual
rehabilitation and an additional session of task-related practice using a circuit class
format. Independent assessors, blinded to group allocation, tested all subjects. Outcome
measures used were three items of the w3r636 Taylor Hand Function Test (JTHFT), two
6
arm items of the Motor Assessment Scale (MAS), and three mobility measures, the
Timed Up and Go Test (TUGT), Step Test, and Six Minute Walk Test (6MWT) and
only the Upper Limb Group made a significant improvement on the JTHFT and MAS
upper arm items. And the findings support the use of additional task-related practice
during inpatient stroke rehabilitation.
Van Der Lee JH, et al., To determine the intra- and inter rater reliability of the Action
Research Arm (ARA) test and to identify less reliable test items .Intra rater reliability of
the sum scores and of individual items was assessed by comparing (1) the ratings of the
laboratory measurements of 20 patients with the ratings of the same measurements
recorded on videotape by the original rater, and (2) the repeated ratings of videotaped
measurements by the same rater. Inter rater reliability was assessed by comparing the
ratings of the videotaped measurements of 2 raters. The resulting limits of agreement
were compared with the MCID. Stratified sample, based on the intake ARA score, of 20
chronic stroke patients (median age, 62yr; median time since stroke onset, 3.6yr; mean
intake ARA score, 29.2). Spearman's rank-order correlation coefficient (Spearman's rho);
interclass correlation coefficient (ICC); mean difference and limits of agreement, based
on ARA sum scores; and weighted kappa, based on individual items. All intra- and
interrater Spearman's rho and ICC values were higher than .98. The mean difference
between ratings was highest for the inter rater pair (.75; 95% confidence interval, .02-
1.48), suggesting a small systematic difference between raters. Intra rater limits of
agreement were -1.66 to 2.26; interrater limits of agreement were -2.35 to 3.85. Median
weighted kappas exceeded .92. The high intra- and interrater reliability of the ARA test
was confirmed, as was its ability to detect a clinically relevant difference of 5.7 points.
Park J, et al., The aim of this study was to determine the effects of task-oriented training
on upper extremity muscle activation in daily activities performed by chronic stoke
patients. In this research, task-oriented training was conducted by 2 chronic hemiplegic
stroke patients. Task-oriented training was conducted 5 times a week, 30 minutes per day,
for 2 weeks. Evaluation was conducted 3 times before and after the intervention. The
Change of muscle activation in the upper extremity was measured using a BTS Free
EMG 300. The subjects' root mean square values for agonistic muscles for the reaching
D.COORDINATION/SPEEDafteronetrialwithbotharms,blind-folded, tip of theindexfingerfromkneetonose,5timesasfastaspossible
Marked slight none
Tremor 0 1 2 Dysmetria pronouncedorunsystematic
slightandsystematic nodysmetria
0 1
2
> 5s 2- 5s <1s
Time morethan5secondsslowerthanunaffectedside 2-5secondsslowerthanunaffectedside maximumdifferenceof1secondbetweensides
0 1
2
TOTAL – (66 max)
ABSTRACT
COMPARING THE EFFICACY OF TASK SPECIFIC TRAINING AND
CONVENTIONAL PHYSIOTHERAPEUTIC REHABILITATION ON
FUNCTIONAL ACTIVITIES OF UPPER LIMB IN POST STROKE PATIENTS
BACKGROUND AND PURPOSE OF THE STUDY: The aim of this research is to determine the
treatment effect of a short period of task-oriented training (two weeks) on upper extremity function
and performance of daily activities in acute stroke patients and also to verify whether the task specific
training helps to restore the preserved functional activities of the affected upper limb and to prevent
non-use syndrome.
And the purpose of the study is to investigate the potential benefits of task specific activities in
post stroke patients following upper limb task specific training and also to compare the effect of task
specific training and conventional physiotherapeutic rehabilitation on motor and functional activities
of upper limb performance in daily activities of stroke patients.
STUDY DESIGN: Repeated Measure Study Design.
STUDY SETTING: Department of Neurology and Stroke Rehabilitation Center, PSG IMS& R
hospitals, Coimbatore.
PARTICIPANTS: 21hemiparetic patients.
INTERVENTION:
Group A: 14 patients receiving Functional Task Specific Training
Group B: 7 patients receiving Conventional Physiotherapeutic rehabilitation
STUDY PROCEDURE: Patient will be assessed for eligibility based on the inclusion and exclusion
criteria and the informed consent will be obtained. Group A received two sessions training per day for
5 days a week for two weeks [1]
with ten 5minute work stations per session, Group B received
conventional physiotherapeutic rehabilitation for two sessions per day for 5 days a week for two
weeks and then the data was collected. The measurement tool used were Action Research Arm Test
(ARAT) and Fugl Meyer Assessment for Upper Extremity (FMA-UE)
RESULTS: Analyzing the data between Group A and B there is a significant difference within the
groups with f value of 66.28, 77.12 for Group A ARAT and FMA-UE respectively and 14.76 and
133.15 for Group B ARAT and FMA-UE respectively, showing a significant difference of p<0.05.
Between group analyses shows that there is no difference laid by Group A Experimental Group and
Group B Control Group.
CONCLUSION: There is no effect of task specific training over conventional physiotherapeutic
rehabilitation on motor and functional activities of upper limb in acute post stroke patients
Keywords: Action Research Arm Test, Fugl Meyer, Upper Extremity, task specific training
Mini-Mental State Examination (MMSE)
Patient’s Name: Date:
Instructions: Score one point for each correct response within each question or activity.
MaximumScore
Patient’sScore
Questions
5 “What is the year? Season? Date? Day? Month?”
5 “Where are we now? State? County? Town/city? Hospital? Floor?”
3
The examiner names three unrelated objects clearly and slowly, thenthe instructor asks the patient to name all three of them. The patient’sresponse is used for scoring. The examiner repeats them until patientlearns all of them, if possible.
5“I would like you to count backward from 100 by sevens.” (93, 86, 79,72, 65, …)Alternative: “Spell WORLD backwards.” (D-L-R-O-W)
3 “Earlier I told you the names of three things. Can you tell me whatthose were?”
2 Show the patient two simple objects, such as a wristwatch and a pencil,and ask the patient to name them.
1 “Repeat the phrase: ‘No ifs, ands, or buts.’”
3 “Take the paper in your right hand, fold it in half, and put it on the floor.”(The examiner gives the patient a piece of blank paper.)
1 “Please read this and do what it says.” (Written instruction is “Closeyour eyes.”)
1 “Make up and write a sentence about anything.” (This sentence mustcontain a noun and a verb.)
1
“Please copy this picture.” (The examiner gives the patient a blankpiece of paper and asks him/her to draw the symbol below. All 10angles must be present and two must intersect.)
30 TOTAL
Interpretation of the MMSE:
Method Score Interpretation
Single Cutoff <24 Abnormal
Range<21
>25
Increased odds of dementia
Decreased odds of dementia
Education
21
<23
<24
Abnormal for 8th grade education
Abnormal for high school education
Abnormal for college education
Severity
24-30
18-23
0-17
No cognitive impairment
Mild cognitive impairment
Severe cognitive impairment
Interpretation of MMSE Scores:
Score Degree ofImpairment
Formal PsychometricAssessment
Day-to-Day Functioning
25-30 Questionablysignificant
If clinical signs of cognitive impairmentare present, formal assessment ofcognition may be valuable.
May have clinically significant but milddeficits. Likely to affect only mostdemanding activities of daily living.
20-25 MildFormal assessment may be helpful tobetter determine pattern and extent ofdeficits.
Significant effect. May require somesupervision, support and assistance.
10-20 Moderate Formal assessment may be helpful ifthere are specific clinical indications.
Clear impairment. May require 24-hoursupervision.
0-10 Severe Patient not likely to be testable.Marked impairment. Likely to require24-hour supervision and assistancewith ADL.
Source:• Folstein MF, Folstein SE, McHugh PR: “Mini-mental state: A practical method for grading the cognitive
state of patients for the clinician.” J Psychiatr Res 1975;12:189-198.