Comparison between Effectiveness of Hand Arm Bimanual Intensive Training and Repetitive Facilitation Exercises on Upper Limb Functions In Post Stroke Hemiparetic Patients

Background and Objective: According to world Health Organization (WHO) stroke is defined as “rapidly developing clinical sign of focal (or global) disturbance of cerebral function lasting more than 24 hours or leading to death, with no apparent cause other than vascular origin. Focal neurological deficits must persists for at least 24 hours, motor deficits are characterized by paralysis (hemiplegia) or weakness (hemiparesis), typically on the side of the body opposite site of lesion. Materials and Methods: The study was performed among 30 patients of both genders, aged 45-60 years. Subjects were selected on the basis of inclusion criteria and randomly divided into two groups by convenience sampling and allocating alternate patient group A and group B, 15 in each group. Group A was treated with Repetitive Facilitation Exercises (RFE), Group B was treated with Hand Arm Bimanual Intensive Training (HABIT). Baseline assessments were taken using WMFT and FMA and data was analyzed. Results: The groups showed significant differences in WMFT and FMA variables. But on comparing the mean of both the groups: there was no significant difference between both the groups. Conclusion: This study concluded that RFE and HABIT both are effective in treatment of patients with hemiparesis.


INTRODUCTION
According to world Health Organization (WHO) stroke is defined as "rapidly developing clinical sign of focal (or global) disturbance of cerebral function lasting more than 24 hours or leading to death, with no apparent cause other than vascular origin. 1 Focal neurological deficits must persists for at least 24 hours, motor deficits are characterized by paralysis (hemiplegia) or weakness (hemiparesis), typically on the side of the body opposite site of lesion. Strokes can be classified into two major categories: ischemic or hemorrhagic. 2 Stroke is the most common cause of disability of survivors, an estimated one third will be functionally dependent after one year experiencing with difficulty of activities of daily living, ambulation and speech, with 30% to 66% of individuals lose functional ability in more affected arm and hand. 3 Functional recovery of the paretic upper extremity post stroke continue to be the one of the greatest challenges faced by the rehabilitation professionals, although most of the patients gain walking ability but fail to gain functional use of their arms and hands. 4 Upper extremity rehabilitation protocol for stroke hemiparesis have traditionally primary on the paretic

Methodology
The study design was quasi experimental and comparative in nature. 30 hemiparetic subjects aged between 45-60 years were included on the basis of inclusion criteria: Sub acute stroke patients (30 days -6 months), both male and female subjects, patients with hemorrhagic and ischemic stroke, patients having minimum 10 degree wrist extension and finger extension actively for habit group, patients with mini mental state examination score of 24 or more, patients demonstrate independent full range of motor of upper limb passively, patient is able to maintain sitting balance. Patients were excluded from the study on the basis of exclusion criteria: visual-perceptual problems, participating in any experimental study which include upper limb treatment, communication barrier, patients with behavioural disturbances and psychologically non cooperative, shoulder pain insensitive to standard therapy, hand swelling sufficient to prevent fist formation, painful arthritis of the shoulder or wrist and finger joint, excessive spasticity, defined as having a score of 3 on the Modified Ashworth Spasticity Scale, participating in any experimental rehabilitation or drug studies, severe Subjects received the treatment for 5 session/week for consecutive 2 weeks (total 10 sessions). Post reading was taken at 2 weeks (after 10 sessions).

Group A:
The RFE session consisted of stretch reflex by rapid passive stretching of the muscles and the skin-muscle reflex which is induced by tapping or rubbing on the muscles in a specific posture that maintained the tension in the targeted muscles. Each repetitive exercise was given for 100 repetitions per session for 2 weeks.

Group B:
The activities were divided into five movement categories that focus on the distal extremity. Total time for each set of movements was 10 minutes and rest for 2 minutes. The total treatment time was 1hours.

Statistical Analysis
Unpaired t-test was used to compare the scores of baseline assessments between the two groups to find out whether the two groups were comparable or not.         Table 1 showed that there was no significant difference in the age group. So, the groups were comparable. Table 2 showed that there were significant changes of WMFT variable within the group A. Table 3 showed that there were significant changes of WMFT variable within the group B. Table  4 showed that there were significant changes of FMA variable within the group A. Table 5 showed that there were significant changes of FMA variable within the group B. Table 6 showed that there were not significant changes of WMFT variable between the groups. Table 7 showed that there were not significant changes of FMA variable between the groups.

DISCUSSION
The study was done to evaluate the effect of repetitive facilitation exercises and hand arm bimanual intensive training on wolf motor function test and fugl-meyer for upper extremity in post stroke hemiparetic patients. The hypothesis was that the significant change in the effectiveness between Repetitive facilitation exercises (RFEs) and Hand arm bimanual intensive training (HABIT) on upper limb functions in post stroke hemiparetic patients.
It is necessary to know that the functional recovery of the paretic Upper extremity continues to be the one of greatest challenge. Patient with history of stroke can gain walking ability but fail to use of their upper extremity function . 11 The massed practice design used to improve the function of individual with hemiparesis by constraining the less affected arm .12 The effects of the RFEs used in the novel facilitation technique that was developed on the isolation from synergy and the manipulation of objects of the hemiplegic upper limb. The novel facilitation methods used in previous studies were designed to give focused sufficient physical stimulation to realize the patient's intended movements. These physical stimulation were the stretch reflex, skin-muscle reflex, and alpha and gamma linkage, which were induced by tapping or rubbing the muscles, rapid passive stretching of the muscle or slight resistance against the intended movements. In the present study we were followed the same repetitive facilitation exercises regimen with 5 movements rather than 8 movements .13 In  Regarding the activities in bimanual training, Larisa R. Hoffman et al(2007) gave bimanual training to cervical spinal cord injury patient who had complete motor spinal cord injury at the level of C6 .The training include five activities -Grasp, Grasp with rotation, finger isolation, pinch and pinch with rotation. There is significant improvement seen in both the upper limbs in the present study, same activities were taken to see the improvement in hand function. 15 One of the previous study on hand arm bimanual intensive training was conducted by Jeanne Charles, Andrew M Gordon et al(2006) 16 found that it is becoming increasingly clear that the key to eliciting improvement in function is to provide sufficient practice. However, rather than just focusing on repetition, the practice must be structured, based on how the central nervous system responds during learning; i.e. optimal responses with increasing movement complexity and provision of motivation and reward. 17 Thus, appropriate intensity must be provided with these guidelines in mind. There is rapid development of ipsilateral and contralateral corticospinal projections from the undamaged hemispheres . The corticospinal system underlying skilled manipulative control is capable of reorganization after damage, probably underlying recovery of function. 18 Ipsilateral pathways have been shown to be implicated in the recovery of function after stroke. Thus, tasks recruiting the ipsilateral pathways such as symmetrical bilateral movements may be beneficial. 19

Wolf motor Function Test (WMFT)
There were significant changes in the effectiveness of different treatments given by repetitive facilitation exercises and hand arm bimanual training on wolf motor function test (WFMT) on post stroke hemiparetic patients. All subjects treated with 60 minutes RFE showed decreased WMFT score (140.9 + 5.26) after 2 weeks, which were statistically significant from baseline. On the other hand, all subjects who received 60 minutes hand arm bimanual intensive training (HABIT) protocol also showed decreased WMFT score (137.8 + 8.08) after 2 weeks treatment, which were statistically significant from baseline. When compared both the groups, both the treatments were equally effective in context of wolf motor function test (WMFT  20 who demonstrated significant improvement in WMFT within the group comparison. The study found that when one limb must move further or aimed towards a smaller target compared to the other, the behaviour of one hand is affected by the task requirement of contralateral hand. This is known as assimilation effect. Assimilation effect are usually asymmetric in nature such that the limb performing more difficult task impacts the limb performing a easier task to a greater extent than the converse. ➢ This study can also be done on younger age group. ➢ Gender specific study can also be done. ➢ This study can be done in different phases of stroke (Acute and chronic)

Ethical clearance
No ethical clearance required.

Source of funding
No funding was required to carry out this work.