DIFFERENTIATED MANUAL TREATMENT OF THE HAND AND THE FOREARM IN THE EARLY REHABILITATON OF STROKE PATIENTS.
A CONTROLED STUDY.
E. Mikulecká 1, L. Petrušková 1, M. Mayer 1, 2, I. Vlachová 3
1 Department of Physiotherapy, Faculty of Physical Culture, Palacký University, Olomouc
2 Department of Rehabilitation, Faculty Hospital, Medical Faculty, Palacký University, Olomouc 3 Department of Neurology, Faculty Hospital, Medical Faculty, Palacký University, Olomouc
SUMMARY
1) Background
Dysfunction of the paretic hand after the stroke is an important factor limiting the functional outcome and the quality of life of the patient. Contemporary neurophysiology and neuroimaging on the one hand and clinical experience on the other hand point to the extreme importance of the intensive and early stimulation and training of the hand after stroke.
2) Methods
40 stroke patients with hemiparesis were divided to the treated and the control groups. In the treated group, a differentiated manual treatment and sensory stimulation of the hand and of the forearm was performed as add-on therapy. The treatment was performed in proximodistal direction and consisted of tactile stimulatin of the skin (rubbing), the release of soft tissues, mobilization of the joints of the wrist, metacarpals and fingers and of digital pressure of selected points. At the beginning and in the end of the investigation period, functional assessment of the hand was done (Jebsen-Taylor test, and the new test developed by authors - Visual assessment of the functional task of the hand -VAFTH). In the end, a functional assessment of the shoulder was performed using Visual analogue scale for pain assessment, Apprehension test according Hoppenfeld, Roockwood test for anterior instability, Jerk test according Magee. The Kruskal-Wallis test for the nonparametric data, the Friedman test for the parametric data and the Spearman correlation were used for the statistic evaluation of the results of the study.
3) Main results
In the treated group, improvement of the hand function in the most of items of the tests used was significantly greater compared to the control group. Interestingly, better outcome for the pain symptomatology and function of the affected shoulder was proved in the treated group compared to the control group. In some cases, substantial reduction of the neglect was observed during the treatment.
4) Conclusions
In summary, the differentiated manual treatment and sensory stimulation of the hand and forearm significantly contribute to the functional outcome of the hand and shoulder in the stroke patients. This treatment can be recommended as add-on therapy in the early stages of the stroke rehabilitation.
Key words: stroke – rehabilitation – hand
VISUAL ASSESSMENT OF THE FUNCTIONAL TASK OF THE HAND (VAFTH)
A) Reaching (function of the upper limb as a whole)
0- no performance
1- foreshadow, indication of intention without effective movement
2- partialy aimed movement without contact with the target
3- contact with the target, ineffective, tremor, incoordination, rough ataxia, no grasp
4- contact with the target, grasp, not effective
5- Nearly normal, normal performance
B) Preparation to a grasp, grasping aperture, grasp (function of the hand)
0- no performance
1- foreshadow, indication of opening of the hand
2- opening of the hand with minimal opposition of the thumb
3- as in previous grade, partial wrist dorsiflection
4- wrist dorsiflection, opening of the hand, opposition of the thumb, pathology still eveident
5- nearly normal, normal performance
C) Manipulation (transferring an empty grasped can to a distance of 30 cm on the table, function of the upper limb as a whole)
0- no performance
1- trying to perform without substantial trajectory
2- partially, effective transfer still absent
3- task performed incorrectly, great incoordination, great compensatory mechanisms and substitutions especially of the trunk
4- whole task performed , still incoordination, compensatory mechanisms still present
5- nearly normal, normal performance
D) Release of the grasp (function of the hand)
0- no performance
1- foreshadow, indication
2- not effective attempt
3- partial release of the grasp, insufficient, great synergies, incoordination
4- full release, synergies and incoordination still present
5- nearly normal, normal performance
Total score = A+B+C+D
The performance of the task can be evaluated directly or recorded as a videofile, coded and evaluated by a blinded assessor .
The reliability, validity and further properties of the scale are described in the work of Petrušková et. al (master thesis, paper in preparation).
The scale is designed for the evaluation of the hand function in the patient in early stages after the stroke. For other purposes, the scale can be modified, especially the grade 5 can be further divided to:
5 - nearly normal performance
6 - normal fully effective and physiological performance
MAIN RESULTS IN GRAPHS AND IN A TABLE
Graf 1: Differences of Jebsen –Taylor test values (before and after the treatment period) in the treated and control groups
W - wrinting
TOC - turning over cards
PSO - picking up small subjects
SE - simulated eating
SC - stacking checkers
LC - light cans
HC - heavy cans
TS - total score
Graph. 2: Differences of the values of the new test developed by authors - Visual assessment of the functional task of the hand –VAFTH (see above)
Table 1. Visual analog scale (VAS) values and total score of functional shoulder tests
T / CM / SD / M / SD / F / p
VAS / 1,15 / 2,52 / 3,3 / 3,47 / 4,78 / 0,03*
Tests / 1 / 2,36 / 2,8 / 2,4 / 8,6 / 0,003* *
T - treated group
C - control group
M - mean values
SD - standard deviation
F - criterium of statiscal significance
p - level of statistical significance of the difference between the groups
Škála v češtině – Scale in the Czech language
Skóre vizuálního hodnocení funkčního úkolu ruky (SVH)
A) dosahování – reaching (funkce horní kočetiny)
0 – žádný výkon
1 – náznak intence bez pohybu
2 – částečný pohyb bez dostižení cíle
3 – dostižení cíle, ale neefektivní třes, inkoordinace, ataxie, žádný úchop
4 – dostižení, úchop, ale nekvalitní
5 - kvalitní výkon
B) Příprava úchopu a úchop (funkce ruky)
0 – žádný výkon
1 – náznak otevření ruky
2 – otevření ruky plus náznak opozice palce
3 – výkon jako v bodě 2 plus dorzální flexe zápěstí před úchopem (částečně)
4 – dorzální flexe zápěstí, otevření dlaně, opozice palce, ale ne kvalitní
5 – kvalitní, téměř fyziologický, fyziologický výkon
C) Manipulace (funkce horní končetiny)
0 – žádný výkon
1 – naznačený pokus
2 – částečně, bez užitečného výkonu
3 – celý úkon proveden, značně nekvalitně, velké chyby, velké synergie
4 – cely úkon proveden, vykonání žádaného úkonu, zřetelná nejistota, inkoordinace apod.
5 - kvalitní, téměř fyziologický, fyziologický výkon
D) Uvolnění úchopu (funkce ruky)
0 – žádný výkon
1 – náznak
2 – nefunkční pokus o uvolnění
3 – částečné uvolnění úchopu, ale málo funkční, velké synergie, inkoordinace
4 – plné uvolnění, funkčně dostatečné, i když patrné synergie, inkoordinace
5 – kvalitní, téměř fyziologický, fyziologický výkon