a)
b)
c) / BRIEF RESUME OF THE STUDY
Introduction:-
Stroke is defined as a clinical syndrome characterized by rapidly developing clinical symptoms and or signs of focal and at times global (applied to patient in deep coma and those with subarachnoid haemmohrage) loss of cerebral function with symptoms lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin (HATANO 1976)1 World Health Organization.
According to World Health Organization 15 million people suffer from stroke worldwide each year2 The causative factors being thrombolic, Embolic and Hemorrhagic stroke. The stroke classified on specific vascular territory where the arteries of the brain are involved
1.Anterior cerebral artery syndrome
2.Posterior cerebral artery syndrome
3.Middle cerebral artery syndrome
4. Vertebrobasilar artery syndrome. MCA is the most common site of occlusion in stroke. Upper limb involvement is more seen in MCA than in ACA3
The acute phase lastsupto 6 months of stroke. There is flaccidity of upper and lower limb muscles opposite the side of affection, tone is reduced and the reflexes are absent. Neurological deficits following stroke in acute phase is motor co-ordination, hemianopia, visual perceptual deficits, aphasia, dysarthia, sensory deficits, cognitive deficits (memory), depression, bladder control and dysphagia3
In acute stroke the upper limb pattern of long term return of motor function is usually more proximal, with distal functioning in the fingers being the last to return. Stroke patients who regained full recovery of motor function in the upper extremity exhibited the onset of this return of the function within the first two weeks of the onset of the stroke and always within the first month. Most subjects achieved full active movement within the first month and all of them recovered function by the third month. A recent studyreported that statistically significant improvement in arm function is seen only in the first 3 months following the onset of stroke4.
In the Chronic phase flaccidity is replaced by the development of spasticity, hyper reflexia and mass patterns of movement termed as Obligatory synergies. The Obligatory synergy patterns following stroke are Flexion Synergy patterns and Extension Synergy patterns.Hyper reflexia, spasticity and mass movement patterns hinder the subject’s activities of daily living.3 To reduce the complication in chronic stroke; physiotherapy should be started early in acute stroke.5
Rehabilitation strategies in acute stroke are, Positioning given for modulation of muscle tone, preventing damage to affected limbs, supporting and stabilizing body segments.6 Quick icingmay stimulate activity in the muscles when applied before an active movement is attempted.In Tapping,the therapist sweep firmly and briskly over the muscle group, given to increase the tone and the muscle activity.Weight bearing activitiesgiven to activate the muscles which stabilizes the joint and activity is stimulated reflexely through compression of the joints.7 Passive movement improve joint integrity and flexibility.3Passive movement is given for maintenance of full pain-free range of movement without traumatizing the joint and the structures which surround it.7
Neuro Muscular Electrical stimulation – NMES also helps to regain motor control and tone in the acute phase of stroke. According to a study done on 46 subjects where symmetric biphasic pulses with the pulse width of 300microsecond and frequency of 25 to 50 Hz, was given to extensor digitorum communis and extensor carpi radialis for 1 hour a day for 15 sessions. The study concluded that NMES enhances upper limb motor recovery in acute stroke survivors.8
According to a study done on 60 hemiplegic stroke patients who received standard treatment with electrical stimulation versus standard treatment alone concluded electrical stimulation of wrist extensors enhances recovery of isometric wrist extensors strength.9
Fugl-Meyer assessment of physical performance (FMA) is an impairment based test with items organized by sequential recovery stages. Specific descriptions for performance accompanyindividual test items. Subtests exist for Upper Extremity function, Lower Extremity function, Balance, Sensation, Range Of Motion and Pain. The Upper Extremity maximum score is 66. FMA has a good construct validity and high reliability (r = 0.99)for determining motor function and balance.3
Motor function was assessed with the upper extremity motor sub score of the fugl-Meyer Motor Assessment. The items in the motor subsections were derived from Brunnstrom’s stages of post stroke motor recovery.8
NEED FOR THE STUDY
Although previous studies have stated the benefits ofNeuro facilitatory techniques in acute rehabilitation of upper extremity function in stroke patients. And many studies have been done on combination of neuro facilitatory technique with neuro muscular electrical stimulation. Thus need for the study arises where the comparison has to be done between neuro facilitatory techniques alone compared with neuro facilitatory techniques with neuro muscular electrical stimulation on the function of upper extremity in acute stroke.
OBJECTIVES OF THE STUDY
To Compare effectiveness of neuro muscular electrical stimulation with Neuro facilitatory techniques versus Neuro facilitatory technique alone on the upper extremity function in acute stroke subject.
HYPOTHESIS
H0: There will be no significant improvement in the upper extremityoutcome measures inneuro facilitatory techniques with neuro muscular electrical stimulation group compared to neuro facilitatory technique group alone in acute stroke subjects.
H1: There will be significant improvement in the upper etremity outcome measures inNeuro facilitatory techniques with neuro muscular electrical stimulation group compared toneuro facilitatory technique group alone in acute stroke subjects.
REVIEW OF LITERATURE
In acute phase,Hemiplegic patients are at high risk for development of contractures. The development of spasticity contributes to development of contractures through sustained posturing of the limbs in certain position. The harmful effects of immobility can be ameliorated by regular passive stretching and moving the joints through the full range of motion preferably twice daily. There is strong belief that early mobilization is beneficial for the patient outcome by reducing the risk of, contracture formation, skin breakdown & orthostatic intolerance. Mobilization involves a set of physical activities that may be started passively but that quickly progress to active participation by the patient in the activity specific tasks includes from turning from side to side in the bed and changing position. If the patient condition is stable, however, mobilization should begin as soon as possible within 24hrs of admission.10
In a study "Early and Repetitive Stimulation can Substantially Improve the Long-Term Outcome After Stroke. A 5-Year Follow-up of a Randomized Trial,100 consecutive stroke patients were randomly allocated. Adding a specific intervention for the arm during the acute phase after a stroke resulted in a clinically meaningful and long-lasting effect on motor function. The effect can be attributed to early, repetitive, and targeted stimulation5
The Neurofacilitatory technique given in the acute stroke are in the form of positioning, given to minimize the effect of unwanted tonic reflex activity ,a brief application of cold stimuli to appropriate dermatomes to have a stimulating effect on corresponding moyotomes.( It is applied to the skin in 3 quick wipes), relaxed passive movements, compression through the joints, preferably via weight bearing areas of the skin to have the effect of encouraging extension or co-contraction.11
The Stroke Association’s therapy research unit conducted a survey to identify current physiotherapy practice for positioning patients in first week following stroke. Specific positions were recommendedduring the first week following stroke by 98% of the respondents. Positioning is still an important part of physiotherapy practice and therefore requires evaluation. The positions used and the aims of positioning identified by clinicians accord with those in the literature.6
A study was conducted to assess the efficacy of neuromuscular stimulation in enhancing the upper extremity motor and functional recovery of acute stroke survivors. 46 subjects were admitted and 28 subjects completed the study. NMES was given for all the subjects 1hour per day for 15 sessions. Outcome was measured on Fugl-Meyer Motor Assessment and the self-care component of the functional independence measure at pre treatment, after treatment and at 4 and 12 weeks after treatment. The data suggested that neuromuscular stimulation enhances the upper extremity motor recovery of acute stroke survivors. However, the sample size in this study was too small to detect any significant effect of neuromuscular stimulation on self-care function.8
6 randomized control trial study was conducted which aimed at improving impairments of the upper extremity in stroke. To identify the effect of Therapeutic electrical stimulation on the motor control and the functional abilities. The methodological quality of the studies was assessed systematically by two raters. The scores ranged from 7 to 16 (maximum 19). The present review suggests apositive effect of electrical stimulation on motor control. No conclusions could be drawn with regard to the effect on functional abilities.12
A study was conductedon Fugl-Meyer Assessment of Physical performance (FMA). This instrument has a good construct validity and high reliability for determining motor function and balance. A quantifiable outcome data allow this instrument to be accurately used for the research purposes ( a gold standard) and document over a time.3
A comparative study was done to assess the relative responsiveness of 2 commonly used upper extremity motor scales, The Action Reach Arm Test (ARAT) and the Fugl-Meyer-Assessment (FMA),in evaluating recovery of upper extremity function after an acute stroke in patients undergoing inpatient rehabilitation. Both the FMA motor score and the ARAT were equally sensitive to change during inpatient acute rehabilitation and could be routinely used to measure recovery of upper-extremity motor function.13
PROCEDURE, MATERIALS AND METHOD
SOURCE OF DATA COLLECTION :
In and out patients, Department of Physiotherapy.
S.D.M.College of Medical Sciences and Hospital, Dharwad.
METHOD OF COLLECTION OF DATA:
MATERIAL :
Assessment sheet.
Upper extremity component of Fugl-Meyer Assessment of Physical performance scale.
Equipment- Phy Action, Uniply, Guidance E Machine. Hintek electronics with accessories.
Croytherapy Unit.
Equipments used for acute rehabilitation of stroke.
Inclusion criteria:
  1. Subjects Diagnosed with stroke.
  2. Subjects within 4 weeks after stroke.
  3. Either gender.
  4. Stroke occurring in subjects between 18- 65 years.
Exclusion criteria:
  1. Subjects with medical co-morbidity.
  2. Un co-operative subjects.
  3. Subjects who are contraindicated to electrical stimulation.
  4. Subjects with previous history of stroke
  5. Subjects with fixed deformities in wrist and hand on affected side.
Study design:An experimental design
Study duration: 1 year
Sample: Sample size was calculated by14

2Sp2 [Z1-α/2+Z1-β]
µd2
48 subjects which are referred for physiotherapy diagnosed as stroke by Medical practioner will be divided into 2 groups of 24 each.Random allocation will be done by using lottery method.
PROCEDURE
After obtaining the ethical clearance,all the subjects with acute stroke(Inpatient and Outpatient) referred to physiotherapy at S. D. M. College of Medical Sciences and Hospital, Dharwad will be taken for the study. After finding their suitability as per inclusion criteria they will be requested to participate in study.
Subjects willing to participate in study will be explained about the study and intervention. After explaining, a writtenconsent will be taken. The participants will be assigned into 2 groups A and B. Upper extremity domain of Fugl-Meyer-Assessment of Physical Performance.
Group A – 24 Subjects in this group will receive Tailor madeFacilitatory technique in the form of Quick icing, tapping, weight bearing activities etc.
Strokes oficing will be given on the dorsum of the forearm in upward direction with ice cubes.8 Quick icing is given in the form of a quick wipe with an ice cube, this has excitatory effect which is immediate and most effective when applied to the skin overlying the extensors of the limbs. It is applied to the skin in 3 quick wipes.
Tapping will be given to provoke muscle and tendon reflexes and to stimulate muscle. Tapping will be given to the dorsum of the fore arm by the therapist. The therapist supports the subjects arm with one hand and with the other hand a firm and brisk tapping will be given over the extensor group of muscles of fore arm from its origin above the elbow to the finger tips. The Tapping movement is performed with the therapist fingers in extension.
Weight bearing activities given to promote development of tone in the muscles. Weight bearing activities is given to the patient in high sitting, patient is made to bear weight on the affected arm with elbow and wrist into extension, the therapist sits on the affected side and brings the subjects weight over the affected upper limb towards the therapist. The therapist hand in the axilla facilitates this lengthening; other hand of the therapist is over the side flexors on the opposite side to facilitate their shortening when the therapist draws the subject towards her. Bridging activity will be given to weight bear on affected lower limb.
Group B – 24 subjects in this group will receivethe Facilitatory techniqueas group A with a symmetric Biphasic wave to the upper extremity. The subjects will receive electrical stimulation of 15 sessions of 1 hour. Wrist and finger extensors (extensor carpi radialis longus and brevis, extensor carpi ulnaris and extensor digitorum communis) will be stimulated with a pair of carbon electrodes. One carbon electrode will be placed proximally over the fore arm on the common extensor origin and the other will be placed distally on the fore arm (positioned for optimally balanced joint movement). Electrical stimulation with a pulse width of 300microsecond and frequency of 50 Hz with the amplitude set at a minimum level required to produce full joint extension. With a rest period of 10 seconds and a ramp up and ramp down of 2 seconds each will be given.
Apart from the neuromuscular facilitatory technique passive movement, positioning, bridging, lower extremity weight bearing were given for both the groups. Treatment will be given for 5 days a week for 4week in the facilitatory group where as in stimulation group 5 days a week for 3 weeksin the next week for 5 days only facilitatory techniques will be continued.
Outcome measure: Will be taken on 0 day and end of 4th weekon upper extremity component of Fugl-Meyer-Assessment of physical Performance.
Statistical Test Used: The data will be analyzed by using,
  1. Unpaired t-test or Mann-Whitney U-test will be used to assess the comparison of to independent groups.
  2. Paired t-test or Wilcoxon matched pairs test by ranks will be performed to see the effect of particular therapy between interventions.
DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS?
IF SO DESCRIBE BRIEFLY – YES
HAS ETHICAL CLEARANCE BEEN OBTAINED BY YOU –YES
LIST OF REFERENCES
  1. Available from: URL: rehab unit.ie/en. Text, 12599
  2. World Health Report-2007, from the World health Organization; international cardiovascular disease statics (2007 update), a publication from the American Heart Association.
  3. O’Sullivan SB, Schmitz TJ. Physical Rehabilitation. 5thEd. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd. 2007.
  4. Kottke FJ, Lehmann JF. Krusen’s Hand Book of Physical Medicine and Rehabilitation. 4th ed. Philadelphia(USA): W. B. Saunder Company.1985.
  5. Feys H, Weerdt WD, Verbeke G, Steck GC, Capiau C, Kickens C et al. Early and repetitive stimulation of the arm can substantially improve the long term Outcome after stroke; A5-Year Follow up Study of a Randomized Trial. The Stroke Journal of the American Heart Association. 2004; 35; 924-929.
  6. Chatterton HJ, Pomeroy VM, Gratton J. Positioning for stroke patients: a survey of physiotherapist’s aims and practices. The Stroke Association’s Therapy Research Unit, The University of Manchester, HopeHospital, Salford, U.K.
  7. Davis PM. Steps to follow, A Guide to the treatment of Adult Hemiplegia. 1sted. New York, Tokyo. Springer-VerlagBerlinHeidelberg. 1985.
  8. Chae J, Bethoux F, Bohinc T, Dobos L,Davis T and Friedl A. Neuromuscular Stimulation for Upper Extremity motor and Functional Recovery in Acute Hemiplegia. Stroke Journal of the American Heart Association 1998; 29; 975-979
  9. Powell J, Pandyan AD, Granat M, Cameron M and Stott DJ. Electrical stimulation of wrist extensors in Post stroke Hemiplegia. The Stroke Journal of American Heart Association 1999; 30; 1384-1389
  10. Delisa JA, Gans BM, Walsh NE, Bocknek WL, Fronteva WR Geiringer SR. Physical Medicine and Rehabilitation Principles and Practice. 4thed.Piladelphia (USA). Lippincot Williams and Wilkins.2005; vol. 2.
  11. Downie PA. Cash Textbook of Neurology for Physiotherapist. 4thed. New Delhi (INDIA) Jaypee Brothers Medical Publishers (P) Ltd.
  12. JR de Kroon, JH van der Lee, MJ IJerman, GJ Lankhorst. Therapeutic electrical stimulation to improve motor control and functional abilities of the upper extremity after stroke: a systemic review. Clinical Rehabilitation 2002; 16; 350-360
  13. Rabadi M H, Rabadi F M. Comparison of the Action research Arm Test and the Fugl-Meyer assessment as Measures of Upper Extremity Motor Weakness after Stroke. Arch Phys Med Rehabil 2006; 16; 962-966
  14. Skim J, Dailey R J. Biostatistics for oral health care. 1st Ed. New Delhi: Blackwell Munksgaard; 2008. p.85-90

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