A Study to Compare The Effects of Unilateral Arm Training Versus Bilateral Arm Training in Post-Stroke Patients with Motor Impairment of Hand

Background of The Study: Motor function deficits are life changing and devastating consequences of stroke9. It affects the patient’s mobility, daily life activities, participation in society. The most common manifestation of upper extremity motor impairment includes muscle weakness, changes in the tone and impaired motor control. Both unilateral and bilateral arm training found to be an effective strategy for the recovery of upper limb motor function after stroke. Aim of The Study: The aim of the study is to compare the effects of unilateral arm training versus bilateral arm training in post-stroke patients with motor impairment of hand. Objective Of The Study: Ø To assess the effects of unilateral arm training in post-stroke patients with motor impairment of hand. Ø To assess the effects of bilateral arm training in post-stroke patients with motor impairment of hand. Ø To compare the effects of unilateral arm training versus bilateral arm training in poststroke patients with motor impairment of hand. Method: 30 post stroke patients were recruited for the study based on the inclusion criteria and were divided into group A and group B consisting of 15 subjects each. Group A were treated with unilateral arm training and Group-B were treated with bilateral arm training. Pretest and posttest scores assessment was done. Result: It showed significant improvement in functional ability of the upper limb as measured by ARAT and CAHAI-13. The p value of both the group is <0.05. This study showed that Group-B subjects who were treated with Bilateral arm training proved to be more effective than Group-A who were treated with unilateral arm training in post stroke patients with motor impairment of hand. Conclusion: This study showed that bilateral arm training is more effective than unilateral arm training in improving the overall motor function of hand in post stroke individuals. Key WordS: Post-stroke, unilateral, bilateral arm training, chedoke arm and hand activity inventory. Introduction Stroke represents a clinical syndrome rather than a specific disease. Stroke is a common, serious, and Corresponding Author: Manjula S, MPT, ASST PROF, School of Physiotherapy, VISTAS, Thalambur, Tamil Nadu600130, India. disabling global health-care problem, and rehabilitation is a major part of patient Care.1The World Health Organization (WHO) defined stroke as “rapidly developed clinical signs of focal (or global) disturbances of cerebral function, lasting, more than 24 hours or leading to death, with no apparent cause other than of a vascular origin2. About 1.2% of deaths in India are due to stroke, the incidence is 105 per 1 lakh population in 64 Indian Journal of Physiotherapy and Occupational Therapy. October-December 2020, Vol. 14, No. 4 urban community and 262 per lakh in rural community3. Stroke is the leading cause for long-term disability4. Approximately, 20% of stroke are due to cerebral haemorrhage. The remaining 80% are due to ischemic stroke which is sub divided into: large artery disease, cardio-embolism and small vessel diseases. Common problems after stroke are impaired motor functions including balance, trunk control and gait disturbances.6 In stroke patients, it is known that the initiation of the trunk muscles is delayed, because the muscles involved in reach arm are activated earlier than the trunk muscles.5 Impaired trunk balance and increased risk of falling toward the paretic side is found to be significantly correlated with locomotor function, functional abilities and length of stay inpatient rehabilitation facilities.7 Unilateral arm training is a common rehabilitative strategy used in patients with stroke which includes repetitive task-related training, which is focused on rehabilitating the affected arm. Bilateral arm training has shown efficacy, not only with stroke survivors with mild impairments, but also for individuals with moderate and severe motor impairments8. Bilateral arm training incorporates task oriented motor relearning strategies including intense practice, intrinsic feedback, bimanual coordination and goal-focused movements that improve upper extremity function15. A basic assumption of bilateral arm training is that the symmetrical bilateral movements activate similar neural networks in both hemispheres when homologous muscles are simultaneously activated11, which been established in stroke that even if one limb is activated with moderate force, it can produce motor overflow to the other limb such as both arms are engaged in the same or opposite muscle contractions, although at different levels of force 12,13.. Both unilateral arm training and bilateral though representing conceptually contracting approaches, serves an ultimate goal and is found to be and effective strategies for the recovery of upper limb motor function after stroke10. These arm training exercises were performed on trunk and specifically aimed at improving trunk performance and balance.14 Aim of The Study The aim of the study is to compare the effects of unilateral arm training versus bilateral arm training in post-stroke patients with motor impairment of hand. Objective of the Study The objectives of the study are as follows: Ø To assess the effects of unilateral arm training in post-stroke patients with motor impairment of hand. Ø To assess the effects of bilateral arm training in post-stroke patients with motor impairment of hand. Ø To compare the effects of unilateral arm training versus bilateral arm training in poststroke patients with motor impairment of hand. Research Design and Methodology: An experimental study design was conducted with 30 patients who fulfilled the inclusion criteria. The samples were divided into group A and Group B consisting of 15 samples each. Inclusion Criteria: Ø Hemi-paretic patients with 40-70 years of age Ø Stroke at least six months to three years prior Ø No significant range of motion limitations in hemi-paretic upper limb Ø Mini-mental status examination score >24 Ø Voluntary movement control to perform the task Exclusion Criteria: Ø Perceptual disorders Ø Recurrent stroke Ø Symptomatic cardiac failure Ø Patients who are not able to follow the commands Outcome Measures: CHEDOKE ARM AND HAND ACTIVITY INVENTORY (CAHAI-13)7 The CAHAI-13 is a performance test using 13 functional items which evaluates the functional ability of the paretic arm and hand to perform tasks Indian Journal of Physiotherapy and Occupational Therapy, October-December 2020, Vol. 14, No. 4 65 ACTION REACH ARM TEST7 The action research arm test is a 19 item measure divided into four sub-types (grasp, grip, pinch, gross arm movement). This test is used to assess the upper limb functioning using observational method. Procedure: In this experimental study, 30 post stroke patients who have met the inclusion criteria were selected for this study, and were grouped into two groups: Group-A and Group-B, consisting of 15 subjects each. Group-A patients were treated with unilateral arm training which includes six task-specific activities performed with the affected arm. Each activity was repeated for 30 times, progression is done once in two weeks as 30 repetitions in the first two weeks with 2 sets, 45 repetitions in the next two weeks with 3 sets, 2-5 minutes of rest time was provided between each task. Group-B patients were treated with Bilateral arm training which includes six task-specific activities which were performed with both the hands simultaneously. Each activity is repeated for 30 times, progression is done once in two weeks as 30 repetitions in the first two week, 45 repetitions in the next two weeks with 3 sets. 2-5 minutes of rest time was provided between each task. Duration of the treatment is 4 weeks. Pre and post-test assessment was done by means of CAHAI-13 and ARAT. Intervention: 1.UNILATERAL ARM TRAINING: Ø Wiping the table Ø Reaching and placing objects Ø Moving an object from table to shelf with affected arm Ø Elbow extension during horizontal reach Ø Grasp an empty glass, take it to mouth and return to starting position Ø Cup stacking 2.BILATERAL ARM TRAINING: Ø Wiping the table with both hands Ø Reaching and placing objects with both hands Ø Moving an object from table to shelf with both arms Ø Bilateral Elbow extension during horizontal reach Ø Grasp an empty glass, take it to mouth and return to starting position with both hands Ø Cup stacking with both hands DATA ANALYSIS: The collected pre and post test data were analysed. For the descriptive statistics, the mean and standard deviation were calculated. The results were tabulated. • Intra Group Analysis – Paired Samples t-test • Inter Group Analysis – Independent Samples t-test Intra-Group Analysis Treatment A Null Hypothesis, H0: μd = 0, Alternate Hypothesis, H1: μd > 0, (μd = mean difference between Pre and Posttest scores) Level of significance, α = 0.05, Test to be applied: Paired Sample t-test Testing the effect of Treatment A in increasing CAHAI Score H0: There is no significant effect of Treatment A in increasing CAHAI score H1: There is significant effect of Treatment A in 66 Indian Journal of Physiotherapy and Occupational Therapy. October-December 2020, Vol. 14, No. 4 increasing CAHAI score The above hypothesis is tested by the use of Paired t-test: Output of Paired t-test: TABLE :1 OUTPUT OF PAIRED T-TEST – GROUP-A(CAHAI) t-Test: Paired Two Sample for Means Pre Post