Keywords
hemiparesis - hand functions - arm ability training - wolf motor function and box
and block
Introduction
Stroke is a “rapidly acquired clinical symptom of focal (or global) impairment of
brain function lasting longer than 24 hours or leading to death, with no evident cause
other than vascular origin” (World Health Organization [WHO]).[1] Throughout the world, stroke is a major disease that leads to mortality.[2] The prevalence of this condition in a rural area is 84,262/100,000, whereas it is
334,424/100,000 in an urban area.[3] Approximately 85% of strokes are ischemic, and 17.8% of those over 45 years of age.[4] Pathological subtypes include ischemic and hemorrhagic stroke.[5] Ischemic strokes can be classified according to the cause, which includes large
artery atherosclerosis and cardiac emboli.[6] Atherosclerosis is a primary cause of ischemic stroke.[7] Acute hemorrhagic strokes make up 5 to 21% of all acute strokes.[8] Hypertension is a common cause of hemorrhagic strokes.[9] Hemorrhagic strokes can also be caused by vascular abnormalities.[10]
Stroke symptoms include one-sided weakness, disturbed vision, changed speech, ataxia,
and associated symptoms. This might vary according to the origin of the stroke.[11] Hemiparesis occurs when a stroke causes paresis on the body, contralateral to the
lesioned brain.[12] Mild paretic patients will move the limb normally or almost normally; however, hemiplegic
subjects cannot move at all.[13] The hemiparetic patients were aimed to restore enough sensorimotor control to the
limb.[14]
Stroke reduces mobility and can cause serious long-term disability.[15] After a stroke, over 90% of survivors experience some form of disability, which
leads to functional limits and low quality of life. It directly influences health
systems, which results in substantial costs, and is also regarded as a global public
health problem.[16] Approximately 80% of hemiparetic patients have upper limb involvement.[17]
Current treatment includes a variety of methods to improve functional ability in hemiparetic
subjects, like Bobath therapy,[18] constraint-induced movement therapy (CIMT),[19] injections,[20] electrical stimulation,[21] mental imagery,[22] and mirror box therapy.[23] Common conventional therapeutic interventions are frequent change in position and
exercise therapy technique, which relies on the therapist and the requirements.[24] Hemiparetic and hemiplegic patients have quite different motor control impairments.[25] Arm ability training (AAT) is a systematic, standardized repeating training structure
with eight training activities.[26]
Platz and Lotze[27] concluded that AAT encourages dexterity improvement after a stroke and is clinically
effective. Although this study was done with the stroke population, it did not address
functional mobility; thus, the need arises to identify the effect of AAT on functional
mobility and dexterity in hemiparetic subjects.
Materials and Methodology
Materials and Methodology
Subjects
Ethical clearance was taken from the institutional ethical committee of Krupanidhi
College of Physiotherapy (Ref. No: EC-MPT/21/PHY/015). All 42 hemiparetic subjects
were described in the study, and informed consent was taken from them. The study design
was made as a single group pre and post-test experimental study with a convenient
sampling technique. The study was conducted at the outpatient department of Krupanidhi
College of Physiotherapy, Hospitals in and around Bangalore, and home care centers.
The duration of the study was from June 2021 to June 2022. Subjects who had the ischemic
type of stroke with anterior cerebral artery involvement and who were in the subacute
phase of stroke (3 weeks to 6 months' post-stroke) were included. Hemiparetic patients
with Mini Mental State Evaluation scores more than 24 and muscle strength ⅗ for shoulder
abduction and elbow flexion, according to Medical Research Council, were included.
The subject should be able to move their fingers, and a precision grip should be preserved.[27]
[28] The study includes both genders with an age limit of 45 to 70 years. Hemorrhagic
stroke, deformities of the upper limb, epilepsy, fractures, sensory impairment, and
visual & auditory deficits patients were excluded. Participants received 40 minutes
of AAT and 20 minutes of conventional physical therapy. The treatment was given for
five sessions in a week extending for 4 weeks. Measurements were taken before and
after the treatment.
Procedure
Arm Ability Training[28]
The participants were given AAT along with conventional therapy. Patients were given
instructions regarding AAT, and a demonstration was done. AAT includes eight different
extremity tasks: (a) Aiming—To touch a given aim with maximum speed; (b) Tapping is
the alternative movement between the first, second, and third digits. (c) Cancellation:
To cancel the circles of various sizes given on paper. (d) Turning: Turning of coins
placed on a table surface. (e) Maze tracking: To track the maze printed on paper with
a pencil. (f) Bolt and nut: to screw the nuts and bolts. (g) Placing small objects:
placing small wooden blocks on top of each other. (h) Placing large objects: objects
with different weights and volumes were moved side to side.
Conventional Physiotherapy
Subjects were instructed to do the activities such as folding towels, removing bottle
caps, turning keys, turning cards upside down, holding a pencil and drawing a line,
and putting coins in the money box to increase functional mobility. Slow sustained
stretching and strengthening exercises were also given for the paretic upper extremity.[29]
Measurement Tools and Method
Wolf motor function test (WMFT)was taken to evaluate functional mobility.[30] The dexterity was measured using box and block test (BBT).[31]
Statistical Analysis
Descriptive statistics were performed to calculate the demographic variables and outcome
variables. A paired t-test was used to know the significant difference among the variables pre and post-test
BBT and WMFT. The data were analyzed using SPSS version 29.0. The level of desired
significance was kept at 5%. The samples that are collected from the subjects are
normally distributed with 95% value.
Results
The average age group of study subjects was 54.93 ± 7.819 years of 45 to 70 years.
The average body mass index of the samples was 27.34 ± 2.424 kg/m2 of 23.2 to 32.6 kg/m2. The responses obtained were 28 (66.7%) and 14 (33.3%) from males and females respectively.
Paired t-test was used to analyze the pre- and post-treatment evaluation for BBT and
WMFT. The results attained showed a significant improvement in all variables ([Table 1]); BBT pre-test mean ± standard deviation (SD; 20.31 ± 4.075) and post-test mean ± SD
(23.79 ± 4.291), which indicate dexterity improvement. Functional ability of WMFT
pre-test mean ± SD (45.38 ± 3.615) and post-test mean ± SD (54.07 ± 3.790) shows a
significant improvement in functional ability. Time (seconds) of WMFT pre-test mean ± SD
(479.29 ± 117.79) and post-test mean ± SD (434.4 ± 116.455) shows an improvement in
time. Strength (lbs.) of WMFT pre-test mean ± SD (2.95 ± 0.731) and post-test mean ± SD
(3.9 ± 0.759) shows an improvement in strength. Grip strength (kg) of WMFT pre-test
mean ± SD (2.9 ± 1.559) and post-test mean ± SD (4.21 ± 1.539) shows an improvement
in grip strength. There is a statistically significant difference for the variables
BBT and WMFT (functional ability, time [seconds], strength [lbs.], and grip strength
[kg]) and getting the p-value = 0.001 (<0.05) which indicates its highly significant.
Table 1
Outcome measures—pre- and post-treatment evaluation
|
Tests
|
Pre-test mean
|
Post-test mean
|
Mean difference
|
SD
|
t-Value
|
p-Value
|
Significance
|
|
BBT
|
20.31
|
23.79
|
−3.476
|
1.273
|
−17.692
|
0.001
|
Highly significant
|
|
Functional ability of WMFT
|
45.38
|
54.07
|
−8.690
|
1.689
|
−33.344
|
0.001
|
Highly significant
|
|
Time (seconds) of WMFT
|
479.29
|
434.40
|
44.881
|
38.139
|
7.626
|
0.001
|
Highly significant
|
|
Strength (lbs.) of WMFT
|
2.95
|
3.90
|
−0.952
|
0.216
|
−28.636
|
0.001
|
Highly significant
|
|
Grip strength (kg) of WMFT
|
2.90
|
4.21
|
−1.310
|
0.643
|
−13.189
|
0.001
|
Highly significant
|
Abbreviations: BBT, box and block test; SD, standard deviation; WMFT, wolf motor function
test.
Discussion
After a stroke, the paretic hand is a typical motor disability in which dexterity
becomes impaired, which may restrict activities of daily living performance and social
engagement and lower the quality of life for stroke patients.[32] The primary factor in determining how well the affected arm functions is the return
of use to a paretic hand. Therefore, enhancing hand functions to encourage functional
recovery is one of stroke rehabilitation's main objectives.[33] The AAT is a complicated motor training program specifically created for hemiparetic
subjects.[34] The study objective was to know the effectiveness of AAT on functional mobility
in hemiparetic patients. The efficacy of this study revealed improvement in upper
limb functional mobility, time, grip strength, strength, and dexterity in hemiparetic
patients.
In a study by Jose et al,[35] similar results were found showing good improvement in the upper limb functional
skills in Parkinson's subjects. Similarly, Ladda et al[36] demonstrated an increase in the grip force in a study of 15 participants (t = −3.02, p = 0.01). Improvements were also observed in performance level over time in fine movements
measured with Nine Hole Peg Test (NHPT; left: p = 0.01 and right: p = 0.05). There was a good improvement in hand performance over time (left: 34.1 ± 1.2
and right: 23.8 ± 1.0). Similar findings were also noticed in a study by Horn et al,[37] where all 12 patients had shown improvement in performing the task. The duration
of AAT tasks decreased by 27.7% (t =17.61, p = 0.001). The NHPT duration declined by 25.2% (t =3.28, p = 0.007). BBT (number of block) increased by 20.9% (t =8.74, p = 0.001). This study is also supportive from the study results by Lotze et al,[38] where the arm's ability showed (27.79 ± 4.70) improvement within 2 weeks, which
is a significant improvement in time (t = 20.07; p = 0.001). While the unaffected side's performance on the Test Evaluation es Membres Suprieurs de Personnes Agres (TEMPA) tasks did not change with time, the impacted side did (p = 0.001). AAT and TEMPA improvement in the paretic arm was positively correlated
(r = 0.59; p = 0.028). Platz et al[28] found that the AAT decreased the focal impairment in hemiplegic and traumatic brain
injury subjects with upper extremity paralysis. The patients showed the improvement
by reducing the time required to complete the TEMPA tasks. The effects were unaffected
significantly by knowing the outcome. At the 1-year follow-up, a functional advantage
was seen as patients' TEMPA task summary time scores improved by 51.3 seconds (p = 0.0012) over pretest scores.
AAT facilitates motor learning in terms of maintenance and generalization of training
effects.[34] Its design encourages intrinsic motivation, places premium neuroplasticity, and
significantly improves a range of sensorimotor hand and arm abilities with lasting
consequences, and also the functional reorganization of the brain with activation
of premotor cortex among hemiparetic subjects underlies training-induced recovery
of arm functions and similarly training-induced plasticity.[26] Additionally, two fundamental treatment philosophies shape conventional physiotherapeutic
methods; the first is that the adult central nervous system may adapt or reorganize
itself in some ways to restore impaired cognitive and motor functions, and the second
is that, at any point following the onset of a stroke, ongoing improvement requires
progressive skillful motor practice. Therefore, the repetition of certain tasks and
exercises, local facilitation approaches, and motor relearning procedures can all
be credited with the results.[39] With the above-discussed mechanism, it is proved that AAT and conventional physical
therapy can result in greater functional mobility and dexterity in hemi-paretic patients.
Limitation and Suggestions
Limitation and Suggestions
The study was conducted only on a single group. It can be done with CIMT for comparison.
The study findings cannot be generalized to all stroke patients. A study can be done
with chronic stroke patients and large sample size to determine the effectiveness.
The study lacks follow-up; the long-term effect of the intervention can be checked.
Conclusion
Hemiparesis can result in functional restriction due to upper extremity weakness.
It was proposed that AAT is a useful intervention for enhancing hemiparetic individuals'
upper extremity function. The results demonstrate that adding AAT to the rehabilitation
routine significantly improved stroke patients' upper extremity function, strength,
grip strength, and dexterity. The proposed AAT can be used as adjunct training to
be included with the conventional program to improve the patient's functional ability
in hemiparesis.
