Int J Physiother.

Vol 1(4), 227-232, October (2014) ISSN: 2348 - 8336

1
Jibi Paul

ABSTRACT
Background: Stroke is one of the most common neurological diseases that lead to disability in elderly
population. Functional impairment of upper limb affects performance of activities in daily life. The
primary objective of this study was to investigate and compare the effect of motor relearning program
and thermal effect to improve upper limb motor function among stroke subjects.
Methods: Random sampling method was used to select subjects with right middle cerebral artery stroke.
Twenty subjects were included and randomly divided into three groups by using lottery method, ten in
each group A and B. Group A trained with MRP and group B with thermal stimulation. The outcomes
were measured by the MMAS, and STREAM scale.
Result: Analysis of variance (ANOVA) used to find the significance of study parameters between the
groups. Dependent t test was used to find the significance of study parameters between pre and post
assessment within the group. According to the result Group A shows better improvement than group
B, It shows that upper limb motor function improved significantly higher in Group A (P<0.001) when
compared to Group B in MMAS and STREAM scale evaluation.
Conclusion: The present study concluded that physiotherapy treatment by the use of motor relearning
program and thermal stimulation are effective technique in improvement of upper limb motor function
among Stroke subjects. It has also proved that motor relearning program was more effective on
improvement of motor functions in upper limb among MCA Stroke subjects.
Keywords: Stroke, Motor relearning program, Thermal stimulation, Modified motor assessment scale,
Stroke Rehabilitation Assessment of Movements.

Received 12th September 2014, revised 22nd September 2014, accepted 01st October 2014

DOI: 10.15621/ijphy/2014/v1i4/54565

www.ijphy.org

CORRESPONDING AUTHOR

1
Jibi Paul, MPT, (PhD)
Lecturer Physiotherapy Program,
School of Health Sciences,
KPJ Healthcare University College,
Kota Seriemas, Nilai, Malaysia
e-Mail: [email protected]

Int J Physiother 2014; 1(4) Page | 227

INTRODUCTION for this study. 20 subjects were participated in this
study after selection criteria.
Stroke is an acute onset of neurological dysfunction
due to an abnormality in cerebral vascular Simple random sampling was selected so that each
circulation with resulting signs and symptoms that and every unit in the population had an equal
corresponds to focal areas of brain. The most probability of being selected in the sample. Lottery
common characteristics of MCA stroke are contra method was used to randomly divide the selected
lateral spastic hemi paresis, motor and sensory 20 subjects into two groups with 10 subjects in each
disturbance of face, motor weakness of upper group namely A and B. Group A was comprised of
extremity and lower extremity with upper limb is 5 male and 5 female subjects with age group
more affected than lower limb. between 55 and 65years. The subjects in group A
were given MRP treatment. Group B was
Spasticity usually develops slowly with anti gravity
comprised of 6 male and 4 female with minimum
muscles of the upper extremity and usually affects
age 55years and maximum age 66 years. These
the depressors of the shoulder girdle and arm; the
subjects were given treatment with thermal
fixators and retractors of the scapula, the side
stimulation.
flexors of the trunk, the adductors and internal
rotators of the arm, the flexors and pronators of the Inclusion Criteria
elbow and wrist, the flexors and adductors of the Subjects in this study were with age group between
fingers. 50 to 70 years of both genders, right MCA infract,
Physiotherapy interventions for stroke subjects are duration of the stroke between 6weeks to 6months
represented by various approaches, for example and having 20 or more than 20 score in Stroke
proprioceptive neuromuscular facilitation, Rehabilitation Assessment of Movement
Brunnstrom, Bobath and motor relearning (STREAM).
program. There is a general opinion that Exclusion Criteria
physiotherapy improves the function of the stroke
subjects. But the benefit seems to be statistically Subjects excluded from this study were patients
small and limited. In few controlled studies on with disorientation, hemorrhagic stroke, Stroke
these subjects there was no proper documentation due to progressive lesion like tumors, stroke due to
showing the effect of above mentioned trauma, significant musculo tendinous or bony
physiotherapy approaches gives better result than restrictions of the affected upper limb and with
the other approaches. 1, 2, 3 unsound mind.
Motor relearning program (MRP) was developed by Tools used for this study
Carr and Shepherd for stroke that incorporates 1. Modified motor assessment scale (MMAS): This
many aspects of motor learning theory and tool was selected for evaluate the changes in
provides practical guidelines for retraining motor function following intervention in two
functional skills. The learning of task is best to groups. In this study items assessed were
stimulate the brain to adopt and reorganize upper-arm function, hand movements and
generalizations and transfer training from the advanced hand activities. All items are assessed
rehabilitation setting into everyday life. 4, 5 using a 7-point scale from 0 - 6. A score of 6
Primary objective of the study was to compare the indicates optimal motor behavior 6.
effect of MRP and thermal stimulation on its 2. Stroke Rehabilitation Assessment of
individual effect to improve upper limb motor Movements (STREAM) Scale: The reliability of
function following stroke. Secondary objectives of the STREAM scores was demonstrated by
this study were to investigate the individual effect generalizability coefficients of 0.99 for total
of motor relearning program and thermal scores and of 0.96 to 0 .99 for subscale scores.
stimulation to improve upper limb motor function The internal consistency of the STREAM score
following stroke. was greater than 0.98 on the subscales and
overall. 7, 8
METHODOLOGY
Materials Used
The subjects of this study were diagnosed stroke
patients due to middle cerebral artery occlusion. Thermal stimulation provided with cold and hot
The study was conducted in the Physiotherapy packs, other materials used were stopwatch,
department of Florence Rehabilitation Centre, jellybeans, polystyrene cup, rubber ball, wooden
Bangalore, India. Samples screened as right MCA stool, comb, spoon, pen, teacups, table, couch,
stroke with upper limb motor function impairment prepared sheets for drawing lines, and cylindrical
and satisfied the selection criteria were included objects like a jar.
Int J Physiother 2014; 1(4) Page | 228
Method of collection of data Above table 1 show the gender ratio and mean age
group of stroke patients in group A and Group B
Data collected before and after the intervention
program. These subjects were given motor Figure 1: Age distribution of the subjects studied
relearning program in task oriented manner and
66
thermal stimulation for upper limb as treatment.
The intervention was applied for a period of 64
6weeks continuously, comprising total of 30

Age in years
62
sessions. Each week had 5 sessions of intervention
and each session was given for 30 minutes for both 60

groups. 58

Statistical analysis 56

Analysis of variance (ANOVA) has used to find the 54

significant effect of study parameters between the
groups. Dependant t test was used to find the 52
Group A Group B
significance of effect between pre and post
assessment within the group. Above figure 1 show the mean age group of stroke
patients in group A and Group B
RESULT
Figure 2: Sex distribution of the groups studied
Comparative study on effect of MRP and thermal
stimulation found that MRP is more effective on Male Female
improving upper limb motor function among 70
65
stroke subjects between the groups (Inter group 60
analysis by ANAOVA). The individual effect of 55
Percentages

50
MRP and thermal stimulation found that both 45
interventions have effect on improving upper limb 40
35
motor function of stroke subjects within the group 30
25
(Intra group analysis dependent t test). 20
15
Table 1: Basic characteristics of the subjects studied 10
5
Basic 0
Group A Group B Group A Group B
characteristics
Age in years; Above figure 2 shows the sex distribution of stroke
60.60  4.14 60.00  3.71
Mean  SD patients in group A and Group B
Sex; Male:
5:5 6:4
Female

Table 2: Pre-Post analysis of Modified Motor Assessment Scale in group A and B

Modified-Motor Pre-Assessment Post Assessment

T -Value P-value
Assessment Scale (Mean  SD) (Mean  SD)
t=17.678
Group A 1.10  0.74 6.50  0.97 P<0.001**
df =9
t=9.858
Group B 1.00  0.67 4.10  0.88 P<0.001**
df =9
The above table 2 show, the analysis of pre and post following intervention with significant value of
assessment data of MMAS score for Group A and P<0.001**.
Group B .Computed data analysis showed that
MMAS score improved significantly in both groups

Figure 3: Pre-Post analysis of MMAS in group A and B

Int J Physiother 2014; 1(4) Page | 229
 8
Pre-assessment

Modified Motor Assessment

7
Post-assessment
6
5
4
3
2
1
0
Group A Group B
Above figure3 shows the significance in pre-post
test analysis for motor assessment scale of group A
and group B
Table 3: Pre-Post analysis of Stream scale in group A and B
Post
Stream scale Pre-assessment T -Value P-value
assessment
t=24.41
Group A 28.005.87 65.50  3.69 P<0.001**
df =9
t=18.98
Group B 27.506.35 58.50  4.12 P<0.001**
df =9
The above table 3 shows the analysis of pre and following intervention in group A and group B with
post assessment data of stream scale for Group A significant value of P<0.001**.
and Group B. Computed data analysis showed that
stream score improved significantly in both groups
Figure 4: Pre-Post analysis of Stream scale in group A and B
80 Pre-assessment Post-assessment

70
60
50
Stream scale

40
30
20
10
0
Group A Group B
Above figure 4 shows the significance in pre-post
test analysis for STREAM scale of group A and
group B.
Table 4: Comparison of Modified Motor Assessment scale and Stream scale between group A and Group B
Group A Group B
Outcome P-value
(Mean  SD) ( Mean  SD)
Modified Motor F=103.4
6.500.97 4.10 0.88
Assessment scale P< 0.0001****
F=151.7
Stream scale 65.50 3.69 58.50 4.12
P< 0.0001****

Above table 4 shows the significant difference in mean value with 6.500.97 and 65.50 3.69
effect between the groups. Group A has higher respectively for Modified Motor Assessment scale
Int J Physiother 2014; 1(4) Page | 230
and Stream scale when compared with mean value Stimulation was found to be significant in
of 4.10 0.88 and 58.50 4.12 of Group B .The study improving motor function of upper limb in right
found significant difference in outcome between MCA stroke subjects. The same view was proved
the groups A and B, with F=103.4, P< 0.0001 and earlier by, jia- ching chen et al. In this study he
F=151.7, P< 0.0001 respectively for MMAS and proved that the performance of Brunnstrom stage,
STREAM evaluation. wrist extension and sensation were improved
significantly after thermal stimulation in stroke
Figure 5: Comparison of Outcome –Modified
subjects 9, 10, 11, 12.
Motor Assessment scale
Comparative effect of this study has proved that
7
Group A with motor relearning program is more
6 effective over Group B with thermal stimulation for
improvement of upper limb motor function among
Outcome-MMS

4
stroke subjects. Individual effect of motor
relearning program and thermal stimulation found
3
effective on improvement of upper limb motor
2 function among MCA stroke subjects. The ‘p’ value
1 for the post test of both groups A and B for MMAS
0
and STREAM was P<0.0001, it shows that there
Group A Group B was significant difference in improvement of
Above figure 5 shows the significance difference in motor function after the intervention in upper limb
effect on Modified Motor Assessment scale among stroke subjects.
between group A and group B. LIMITATIONS OF THE STUDY
Figure 6: Comparison of Outcome –Stream scale In this study the sample size was relatively small.
45 Larger sample size will help to randomize the
40 result. This study was done for six weeks and
Outcome-Stream scale

35 measured upper limb motor functions by MMAS

30
and STREAM but no long term follow up was done.
25
The lack of follow up has drawback that it could not
20
reveal the improvement and further change in
15
motor function of upper limb among stroke
10
subjects.
5 CONCLUSION
0 This study concluded that use of motor relearning
Group A Group B
program technique is more effective to improve
Above figure: 6 shows the significance difference the upper limb motor function with mild to
in effect on Stream scale between group A and moderate impairment in right MCA stroke
group B subjects. Both motor relearning program and
DISCUSSION thermal stimulation techniques have shown
According to the assessment with MMAS and significant changes in functional recovery of the
STREAM group A shows that subjects got upper limb of right MCA stroke patients.
significant (P<0.001) improvement in motor RECOMMENDATION
function following MRP sessions. So statically, it
was proved that the individual effect of Motor The study can be replicated with a larger sample
Relearning Programme was found to be significant size. Follow –up and long term effects of motor
in improving motor function of upper limb in right function and functional recovery, upper extremity
MCA stroke subjects. This view was well supported performance and changes in these parameters
by the recent research study conducted by following withdrawal from the training program
Ceravolo MG, Provinciali.L He has proved that can be done. Longer duration can be chosen for the
Motor Relearning Programme improved motor intervention in future research for better
functions of stroke subjects. understanding of the effectiveness.

Group B showed that subjects got improvement in

motor function on MMAS, and STREAM following REFERENCE
thermal Stimulation with P<0.001. So statically, it
has proved that the individual effect of thermal

Int J Physiother 2014; 1(4) Page | 231

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Citation
Jibi Paul. (2014). COMPARATIVE STUDY ON THE EFFECT OF TASK ORIENTED MOTOR
RELEARNING PROGRAM AND THERMAL STIMULATION OVER UPPER LIMB MOTOR FUNCTION
AMONG STROKE SUBJECTS. International Journal of Physiotherapy, 1(4), 227-232.

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