EFFECTS OF BIMANUAL FUNCTIONAL PRACTICE TRAINING ON FUNCTIONAL PERFORMANCE OF UPPER EXTREMITY IN CHRONIC STROKE

Dr Jasmine Anandabai*, Dr Manish Gupta**

ABSTRACT OBJECTIVE: To study the effects of bimanual functional practice training on functional performance of upper extremity in chronic stroke. DESIGN: Pre-test and Post test design. SETTING: Inpatient and rehabilitation hospital. PARTICIPANTS: Patients were randomized to receive bimanual functional practice (n=15) at 3-4 months post-stroke onset. INTERVENTION: Supervised bimanual training for 50 minutes on 5 days week over 2 weeks using a standardized program. MAIN OUTCOME MEASURES: Upper extremity outcomes were assessed by Graded Wolf-Motor Function Test (GWMFT) and Fugl-Meyer scale (F.M.S). RESULTS: Significant differences were found within the group in mean performance time -p=0.002 and there were significant difference found in functional ability scale (GWMFT-FAS p=0.00, similarly, there were significant changes in Fugl-Meyer score p=0.00. CONCLUSION: This study suggests that 2 sessions of 25 minutes a day of bilateral training of functionally related tasks is effective for upper limb functional recovery in chronic stroke patients, regardless of the initial severity of the impairment. Further more, for recovery of functional motor performance, bimanual practices appears more beneficial. Several other studies have found benefits of bimanual training: therefore, this approach can be accepted as an upper limb intervention in stroke on the basis of finding of this study.

KEYWORDS: Stroke, Functional Performance, Bimanual Functional Practice Training

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INTRODUCTION Stroke is an acute onset of neurological dysfunction due to an abnormality in cerebral circulation with resultant signs and symptoms that corresponds to involvement of focal areas of the brain1. This can be due to ischemia (lack of blood supply) caused by thrombosis or embolism or due to a hemorrhage. As a result, the affected area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech or inability to see one side of the visual field. In the past, stroke was referred to as cerebrovascular accident or CVA, but the term "stroke" is now preferred. The traditional definition of stroke, devised by the World Health Organization in the 1970s, is a "neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours". Strokes can be classified into two major categories: ischemic and

origin); this constitutes 30-40% of all ischemic strokes. Ischemic: Ischemic stroke occurs due to a loss of blood supply to part of the brain, initiating the ischemic cascade. Brain tissue ceases to function if deprived of oxygen for more than 60 to 90 seconds and after a few hours will suffer irreversible injury possibly leading to death of the tissue, i.e., infarction. Hemorrhagic: Hemorrhagic strokes result in tissue injury by causing compression of tissue from an expanding hematoma or hematomas. This can distort and injure tissue. In addition, the pressure may lead to a loss of blood supply to affected tissue with resulting infarction. Epidemiology: Stroke is a major global health problem. It is the third most common cause of death in world and risk factors for stroke onset are high blood pressure, smoking, diabetes, heart failure, carotid artery stenosis and hyperlipidemia (SBU 1992; Gresham et al. 1995). 3 Approximately 85% of all stroke cases are ischemic, and most ischemic strokes affect one of the cerebral hemispheres by occlusion of the middle cerebral artery (MCA). In the acute stage, mechanisms such as oxygen depletion, necrosis, brain edema, excitotoxicity and inflammatory processes are at play. After the acute stage there is a phase of regeneration with neuronal plasticity and (partial) functional recovery (Dahlquist 2003).4 The effectiveness is based on

hemorrhagic. Ischemia is due to interruption of the blood supply, while hemorrhage is due to rupture of a blood vessel or an abnormal vascular structure. 80% of strokes are due to ischemia; the remainders are due to hemorrhage. Some

hemorrhages develop inside areas of ischemia ("hemorrhagic transformation"). In an ischemic

stroke, blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. There are four reasons why this might happen: thrombosis (obstruction of a blood vessel by a blood clot forming locally), embolism (idem due to an embolus from elsewhere in the body, see below), systemic hypo perfusion (general decrease in blood supply, e.g. in shock) and venous thrombosis. Stroke without an obvious explanation is termed "cryptogenic" (of unknown
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neurodevelopment techniques, repetitive unilateral or bilateral training techniques; sensoriomotor training or constraint induced movement therapy has been evaluated on motor performance of the affected arm of subjects with stroke. The Constraint induced movement therapy concept has

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been derived from basic research with monkeys and consists of a family of techniques, i.e., constraining movements of the less affected arm and intensively training of the more affected arm (Taub et al. 1993; Taub et al. 1999; Morris and Taub 2001).
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function relative to non-affected side (at least 100 of wrist extension and at least 100 of active extension of each metacarpophalengeal joint and interphalengeal joint of all digits. 5. 6. 7. No multiple infarctions. Intact cognitive functions Patients with right hand dominance with

Bilateral training activities may increase the activity of the affected hemisphere and decrease the activity of unaffected hemisphere providing a balancing effect between
5

affected left Hemispheres.

hemispheric

Exclusion Criteria: 1. Insufficient stamina to participate.

cortocomotorneuron exitibility. The practice of

bilateral

symmetrical

2. Other neurological disorders 3. Previous participation in other pharmalogical or Physical intervention studies.

movements may allow the activation of the intact hemisphere to facilitate the activation of the damaged hemisphere leading to improve

4. Any severe contractures and deformity in upper Extremity. 5. Aphasia with inability to follow 2 step commands.

movement control of impaired limb promoting neural plasticity. Bimanual practice is getting both hands to work co-operatively to hold and manipulate an object using each hand to perform different actions. Thus the objective of this study is to establish the efficacy of bimanual functional practice on functional performance of upper extremity in chronic stroke. METHODOLOGY A total of 15 subjects (12 males and 3 females), at O.P.D. of various hospitals, were included in the study. They were given bimanual practice intervention for 5 days a week for 2 weeks. Each treatment session will be of 1 hour.

On the first visit a complete neurological assessment was done. Subjects found suitable for participants in the study as per the inclusion and exclusion criteria were requested to sign the consent form. A detailed subjective examination was taken regarding type, side, duration,

occurrence of stroke, handedness and motor functions. All the selected subjects were informed in detail about the type and nature of the study and asked to sign the informed consent. After taking down the demographic data the measurement of functional performance were

Inclusion Criteria: 1. All Participants suffering from stoke for the

assessed by Fugl- Mayer assessment scale and Graded Wolf Motor Function test. Participants activity. Participants were encouraged to do the bimanual practices for 25 minutes with 10 minutes were trained for bimanual

first time. 2. 3. 4. Onset from 3-9 months Age group 40-60 yrs. Most component of movement present in affected extremity but impairment of
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Scientific Research Journal of India Volume: 2, Issue: 3, Year: 2013

rest periods. The total time period of the bimanual practice was one hour, which was divided into two training sessions (25*2=50 min) and one rest period of 10 minutes. Participants were trained for following

task was practiced for 5 minutes in two sessions. 5. Asked the patient to hold the lock with non-

affected hand and open the lock or move the key in the lock clockwise and anticlockwise for 5 minutes daily in two sessions.

bimanual task practices (15). Pouring of water from one cup to another cup with arm held up. Using the telephone (one hand to hold receiver and another to dial the number Rolling up a towel Unscrewing a jar. Turning the key in lock

RESULTS The results in table 5.4 show that MPT of Wolf-motor Function Scale after 2 weeks of bilateral training program was significantly less. Similarly FAS score improved significantly after a 2 weeks training program.

Table-1 Group Analysis

Each

participants

were

taught

about

individually and Sitting at the chair comfortably in front of the table.

1.

To ask the patient to hold the one cup with The results showed that there was significant difference in the bilateral arm training group, both pre intervention and again after 2 weeks of training.

one hand (non-affected) which was initially filled with water and asked to hold the cup with other hand (affected) and both hands held up the table. Instruct the patient to pour the water first from non-affected hand to affected hand and then affected hand to non-affected. This task was performed for 5 minutes daily in two sessions. 2. To ask the patients to hold the receiver with DISCUSSION The study compared the effects of bilateral upper limb-task training on upper limb motor functions during post stroke rehabilitation. The result of this study showed that there was a significant improvement in functional performance of upper extremity on G.W.M.F.T. and FuglMeyer scale in chronic stroke patients after 2 weeks of bimanual functional practice. The result of the study showed that there was significant difference in bimanual Pre and Post practice group on GWMFT (Pre MPT: p=0.70 &
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one hand (non-affected) and the numbers with another hand (affected) again this task performed alternately hold the receiver with affected hand and dials the numbers with affected hand. 3. Initially fold the towel lengthwise and asked

the patient to roll the towel with both hands up to the towel end. 4. Asked the patients to hold the jar with non-

affected and practiced to open the jar or move the cup of the jar to clockwise and anticlockwise. This

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Post MPT: p=0.75 and Pre FAS: p=0.32 & Post FAS: p=0.312) and Fugl-Meyer score. (Pre: p=0.519 and Post: p=0.43) Participants of bimanual practice group showed a decrease in performance time (p=0.002) and increase on functional ability score (p=0.00) and showed highly significant improvement on motor functional performance of Fugl-Meyer scale (p=0.00).The mean time to perform 15 tasks in GWMFT was (17.13+4.60) which decreased after 2 weeks of bimanual practice training

processing information from the non-paretic limb, while simultaneously attempting to perform new, progressively changing, relatively complex precise motor goals with both arms may have provided a dual-task challenge greater than in other studies. The effectiveness of bilateral movement training in promoting stroke recovery is also likely to depend on the extent of damage sustained to direct corticospinal pathways58. While bilateral movements may also help recruit secondary motor areas in both hemispheres, recovery promoted by these areas will be less than that obtained through direct corticospinal projections
58, 59

(15.80+5.53) and the functional ability score (1.75+0.46) improved after training

. This can be

(2.05+0.57).The result showed that 2 weeks of bimanual training improved motor functional performance on Fugl-Meyer scale (42.87+5.25). The result showed that 2 weeks of bimanual training improves motor functional performance on Fugl-Meyer scale (44.53+6.20). The result of the study suggested that, training involving the practice of actions bilaterally and simultaneously is effective in promoting recovery of upper limb motor function in chronic stroke patients. Of particular importance was significant increase in participants of the bilateral training group in functional ability of the upper limb, demonstrating a generalization from the training of a specific movement to general upper limb function. Individuals receiving bilateral training showed improvements in the time to complete the graded wolf motor function test (GWMFT) movement with the impaired limb . In the study, participants were trained in complex multi joint functionally relevant tasks, whereas other bilateral training studies have involved
35, 15

explained by the changes in the functional ability of impaired limb as evidenced by GWMFT scores and in motor performance by Fugl-Meyer score in the patient group used in the study. Recent research has shown that lesion location greatly influences the pattern of motor cortex excitability observed 60. Intervention timing may have influenced outcomes. The study showed significant effects of bilateral training in chronic stroke participants, whereas some studies showed no effects of bilateral training in patients with acute stroke
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Stroke appears to alter normal transcallosal inhibition resulting in increased intact hemisphere excitability during hemiparetic arm movement that may be inhibitory in nature, thus suppressing output from the damaged hemisphere
23

Depending on the lesion site and size, these over activation appear transient, and more normal contralateral activation pattern resume over time
49

. Identical motor commands generated in each during bilateral movement may

hemisphere

protocols
36

using

simple
48

repetitive or auditory and

modulate transcallosal inhibition, balancing stroke related interhemspheric over activity and

movements with electric stimulation cueing . Furthermore

visualizing

facilitating output from the damage hemisphere as

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well as from normally inhibited ipsilateral pathway of the undamaged hemisphere to augment movement of the paretic arm 50. there is a strong neurophysiological evidence to suggest that when the impaired and non impaired arms are moved symmetrically, crossed facilitatory drive from the intact hemisphere will be produced increase excitability in homologous motor pathways in the impaired limb
50, 51

bimanually.Initially, just after stroke, bimanual movement enhanced activation in the primary motor cortex M1 of the affected hemisphere did not differ between unimanual paretic hand and bimanual movement 14. The frequency and duration of the program may not have been optimal. One may ask whether 20 25-minutes sessions devoted to the bimanual task are sufficient to trigger brain reorganization and to observe a change. This scheduled was based on practical reason and although it is similar to that used in previous study 34, 61, The study does not suggest the training characteristics, such as the nature of the tasks and strength of inter limb coupling required for effects , may influenced outcomes: therefore future work should examined the optimal timing, dose and training tasks that might optimize the already known facilitatory effects of interlimb coupling. CONCLUSION This study suggest that 2 sessions of 25 minutes a day of bilateral training of functionally related tasks is effective for upper limb functional recovery in chronic stroke patients, regardless of the initial severity of the impairment. Furthermore, for recovery of functional motor performance, bilateral training appears beneficial. Several other studies have found benefits of bimanual training: therefore, this approach can be accepted as an upper limb intervention in stroke on the basis of finding this study. The study does not suggest the training characteristics, such as the nature of the tasks and strength of inter limb coupling required for effects, may influenced outcomes: therefore future work should examine the optimal timing, dose and training tasks that might optimize the already known facilitatory effects of interlimb coupling.
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Additionally, cortical damage from stroke produces hyperexcitability of the contralesional M1

52

leading to abnormally high levels of

transcollasal inhibition (TCI) on the legend hemisphere, thereby further impairing motor performance of the paretic hand 53. There is recent evidence of improved affected hand performance in chronic stroke patients from reducing the abnormal inhibitory drive to the ipsilesional hemisphere
54, 55

Further
56

more,

balanced

interhemspheric interactions appear necessary for normal voluntary movements of the normal
57

and the restitution the two

balance

between

hemispheres has been linked to better recovery following stroke . It has been hypothesized that

practicing by lateral symmetrical movements may facilitate motor output from the ipsilesional hemisphere by normalizing (TCI) influences. Interestingly, in the subset of patients assessed with wolf motor function test and Fugl-Meyer scale in the study the bilateral trained patients exhibiting the largest increase in functional ability. In addition, bilateral training may promote increased involvement of pathways not

investigated in the present study such as spared corticopropriospinal pathways 50. The chronic nature of stroke might have allowed the plastic nature of brain to adjust to the various levels of tasks to be performed

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Thus, null-hypothesis proved.

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CORRESPONDING AUTHOR: *PhD Research Scholar, Singhania University **Consultant Orthopaedics, Kapoor Medical Center

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