Effectiveness of Supervised Graded Repetitive Arm Supplementary Program On Arm Function in Subjects With Stroke
Effectiveness of Supervised Graded Repetitive Arm Supplementary Program On Arm Function in Subjects With Stroke
Effectiveness of Supervised Graded Repetitive Arm Supplementary Program On Arm Function in Subjects With Stroke
Dr.Harsha Tummala, MPT (Neurology)*, Dr.V.Srikumari, MPT (Neuro), PhD.**, Dr. K.Madhavi,
MPT (CT), PhD., ***
ABSTRACT
PURPOSE: The aim of the present study is to evaluate the effect of supervised GRASP protocol in improving
arm function in subjects with stroke. DESIGN: A RCT, Prospective-exp-design with pre test-post-test design.
SETTING: College of physiotherapy OPD, General ward of Sri Venkateswara Institute of Medical Sciences
(SVIMS), Tirupati. SUBJECTS: 30 subjects divided into 2 groups, control group (n=15) & experimental
group (n= 15). INTERVENTION: For experimental group: Conventional physiotherapy with Supervised
GRASP protocol for upper limb (In the presence of therapist or caregiver). For control group:Conventional
physiotherapy with home program exercises with printed GRASP material. DURATION: 6 weeks, 5days in a
week. OUTCOME MEASURES: (1) The Chedoke Arm and Hand Activity Inventory-9 (CAHAI) was used to
evaluate the performance of the paretic upper limb in the completion of activities of daily living (ADL). (2)
The Box and Block test (B&BT) to measure upper limb functional performance of basic manual dexterity. (3)
Isometric grip strength of the paretic hand was tested using a jammer hand grip dynamometer. RESULTS:
According to the obtained values, the pre and post test values of CAHAI-9, B&BT and grip strength had an
extremely significant effect with p value < 0.0001 in both control and experimental group. On comparing the
results between the groups: The experimental group CAHAI-9, (p-value is 0.0001) and B&BT (p-value is
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0.0020) is considered very significant comparing to control group. The grip strength (p-value is 0.0005) is
considered extremely significant than the control group. CONCLUSION: After 6 weeks of intervention
program, both the supervised and unsupervised groups had a greater improvement in arm function with
GRASP protocol; but, supervised group had a better improvement in ADL performance, manual dexterity and
grip strength when compared to unsupervised group. Hence this study recommends the supervised GRASP
protocol for improving arm functions in subjects with stroke.
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Scientific Research Journal of India ● Volume: 2, Issue: 4, Year: 2013
practical, inexpensive and well-received by glasses(2), hand towel, tooth paste and tooth
the patients and clinicians are needed to brush, knife, fork, thera putty,
deliver greater amounts of therapy with a
Inclusion criteria: Stroke subjects with 40
focus on improving functional tasks of upper
to70 years of age; both males and females;
extremity. One of such method is Graded
with active scapular elevation (shoulder
Repetitive Arm Supplementary Program
shrug) against the gravity; voluntary control
(GRASP)
grading of 2 and 3 ;MAS score between 1 to
GRASP is mostly used as a home 2 and Fugl-Meyer Upper Limb Motor
based exercise program which serves as a Impairment Scale score between 26 and 45.
complement to the regular physical therapy.
Exclusion criteria: Stroke subjects with
It is a self-directed arm and hand exercise
unstable cardiovascular status; MMSE below
program which is supervised by a therapist,
20; Cognitive deficits; Musculo-skeletal
but done independent by the patient (and
disorders; Receptive aphasia & Non co-
with their family if possible). But the
operative patients.
effectiveness of any home based exercise
regimen is not clearly studied because of the OUTCOME MEASURES: The Chedoke
adherence to the program and patient Arm and Hand Activity Inventory-9
motivation. So, this needs to supervise by the (CAHAI) were used to evaluate the
therapist or a caregiver. The need of this performance of the paretic upper limb in the
study is to find out the importance of completion of activities of daily living
therapist supervision in implementing (ADL).
GRASP program to stroke subjects.
1. The Box and Block test to measure
Material and methodology: Subjects were upper limb functional performance of
recruited from the college of Physiotherapy basic manual dexterity.
OPD & General ward of Sri Venkateswara 2. Isometric grip strength of the paretic
Institute of Medical Sciences (SVIMS), hand was tested using a hand grip
Tirupati, India. dynamometer.
Materials: Hand gripper, ball, light rubber All the subjects were selected on the
weight (half kg), clothe pegs, Lego-pieces, basis of inclusion criteria; were divided into
paper clips &target board, Jammer hand grip 2 groups; Control group & experimental
dynamometer & Box and block test kit. group with 15 subjects in each group. The
CAHAI materials : plastic jar & lid, subjects participated in this study voluntarily
telephone, scale(30 cms), pencil, water after signing the consent form. The
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Fugl-meyer arm 34.6 35.2 (6.2) Statistical analysis was done using
score, max=66 (4.6) ‘Graph pad instant 3’ version software. For
(mean ± SD) this purpose the data was entered into
Microsoft Excel spread sheet, tabulated and
CAHAI-9, 25.8(8.5) 23.4(6.9)
subjected to statistical analysis.
max=63,(mean±SD
) To compare the pre and post
B&BT, (mean±SD) 10.2(5.0) 10.6(4.8) treatment effect within the group paired
sample t test was used, and to compare the
Grip strength, 3.2(1.1) 3.5(0.88) pre and post test treatment effect between the
(mean±SD), kg groups unpaired t-test was used.
RESULTS:
Results of control group: (Refer table: 2)
CAHAI-9 result: The p-value is < 0.0001
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Scientific Research Journal of India ● Volume: 2, Issue: 4, Year: 2013
which shows there is a extremely significant intervention had shown significant impact on
difference. The t-test value is 21.767 with 14 the subjects.
degrees of freedom. It is observed that the post
Grip strength result: The p-value is < 0.0001
intervention had shown significant impact on
which shows there is a extremely significant
the subjects.
difference. The t-test value is 9.727 with 14
B&BT result: The p-value is < 0.0001 which
degrees of freedom. It is observed that the post
shows there is a extremely significant
intervention had shown significant impact on
difference. The t-test value is 9.057 with 14
the subjects.
degrees of freedom. It is observed that the post
value
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Table 3: Analysis of Experimental group with pre and post intervention
14 <0.0001
14 <0.0001
14 <0.0001
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Scientific Research Journal of India ● Volume: 2, Issue: 4, Year: 2013
Mean S.D df
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verbal guidance and rewards to help the practiced the grip strength exercises such as
patient to learn the task or to complete the Grip power, finger power, the twist and finger
GRASP protocol. strength in the GRASP Protocol with the help
of thera putty. During these thera putty
Physical guidance are also used by the
exercises, the subjects are complained about
therapist throughout the whole protocol/task to
the fatigueness and pain in the hands in both
demonstrate what is to be done and how to do
groups
the task and it is given during the beginning,
middle and in finishing the task. All these But in supervised group, proper resting
above factors help the supervised group to time and changing of exercises are advised.
improve the CAHAI. But Modification of exercises are also done by
the therapist when the patient is not able to
In the supervised group, the therapist
perform the protocol and during these putty
used the extrinsic feedback. The extrinsic
exercises.
feedback is provided to the subjects with
knowledge of result (KR) and knowledge of In unsupervised group, due to pain
performance (KP) by the therapist’s verbal and fatigue, subjects less used these theraputty
and tactile cuing during intervention exercises compared to other exercises. Due to
poor adherence, (participating in less than half
For example, to improve manual
required time), there is no therapist or family
dexterity, the therapist used extrinsic
member to explore the reasons behind the
feedback. Here, the goal is to pickup small
problems and lack of solutions for the
blocks from the peg board. KR is given in the
problems.
form of amount of time needed to complete
the task (whole peg board). KP is given The result of GRASP is better with the
regarding information about the movement involvement of therapist of caregiver or who
patterns in the shoulder, elbow, wrist and can assist with the exercises like track the
finger during grasping a block and during amount of exercise, motivation to the patient,
releasing a block. So, with the help of helping counting the repetitions; assist with
extrinsic feedback (KR and KP), the the positioning equipment like the target board
supervised group had a statistically greater etc.
improvement in manual dexterity of hand with
Researchers noted that the motor
box and block test (B&BT).
cortex (M1) changes occurred (motor
When compared to the unsupervised learning) when (a) New or novel task were
grip strength, the supervised grip strength is used, (b) when movements were practiced
extremely significant because, the subjects together, (c) when movements were frequently
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Scientific Research Journal of India ● Volume: 2, Issue: 4, Year: 2013
repeated and (d) when movements were biomechanical basis, and practicing on real
important to the individual [15]. Our life activities. It is established well that real
intervention program (GRASP protocol), life practice are more beneficial for motor
meets the above same criteria which play a relearning. The present study aimed to assess
important role in motor learning. The whether there is any significant difference in
supervised group, play a major role in motor the effectiveness of GRASP protocol between
learning and neural plasticity. supervised and non supervised program in arm
function. On the above discussed & tabulated
Hence, the use of verbal and tactile
data and results after 6 weeks of intervention
cues, proper sensory input, verbal guidance,
program, it is concluded that both the
motivation, rewards and with proper feedback
supervised and unsupervised GRASP
by the therapist helps in process of motor
protocols shown greater improvement in arm
learning. Hence, this motor learning enhances
function. Further, supervised Grasp protocol
the neural plasticity of the brain.
helps in better improvement in ADL
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CORRESPONDING AUTHOR:
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