Preeti Gazbare et al IJSRE Volume 05 Issue 05 May 2017 Page 6408 Volume||5||Issue||05||May-2017||Pages-6408-6412||ISSN(e):2321-7545 Website: http://ijsae.in Index Copernicus Value- 56.65 DOI: http://dx.doi.org/10.18535/ijsre/v5i05.06
Comparison of Motor Relearning Programme With Proprioceptive Neuromuscular
Facilitation on Upper Limb Function In Stroke Patients
Authors
Preeti Gazbare1, Tanuja Mahajan2, Tushar Palekar3, Manisha Rathi4, Shilpa Khandare5
1,2,3,4,5
Dr. D.Y.Patil College of Physiotherapy, Dr. D.Y. Patil Vidyapeeth Pune, India Email- [email protected], [email protected]
Corresponding Author Tanuja Mahajan
Email- [email protected] ABSTRACT
Introduction-Stroke is an acute, neurological event that is caused by an alteration in blood flow to the brain leading to loss of upper limb function contributing to functional disability, affecting quality of life and independence in ‘basic’ and ‘instrumental’ activities. Motor Relearning Programme (MRP) is a task-oriented approach to improving motor control, focusing on the relearning of activities and PNF approach is a neuro-motor development training to improve motor function and facilitate maximal muscular contraction.
Objective- the study was done to find the effectiveness of Motor Relearning Programme and Proprioceptive Neuromuscular Facilitation in improving upper limb function in stroke patients.
Methods-30 stroke patients with upper extremity tone of less than 2 on Modified Ashworth Scale and Brunnstorm Voluntary Control score of 4 and 5 were selected. They were divided into two groups by simple random sampling: One group received MRP training while other with PNF training along with conventional therapy for 4 times a week for 4 weeks. Pre and post assessment was done by using Fugl Meyer Upper Extremity and Upper Extremity Stream Index. Statistical analysis done by using Wilcoxon Signed Rank Test and Mann Whitney U test.
Results-Significant improvement within the groups seen in Fugl Meyer Upper Extremity and Upper Extremity Stream Index but when compared there was no statistical significance seen in Fugl Meyer(p=0.738) and STREAM(p=0.231).
Conclusion: MRP and PNF training were equally effective in improving upper limb function in stroke patients.
Keywords- Stroke, Fugl Meyer, Stream Index, MRP, PNF
INTRODUCTION
Stroke is an acute, neurological event that is caused by an alteration in blood flow to the brain. The traditional definition of stroke, devised by WHO in the 1970s is a ‘Neurological deficit of cerebrovascular cause that persists beyond 24hrs or is interrupted by death within 24 hours.1 It is a global health problem with an annual incidence of 0.2 to 2.5 per 1000 population. Ischemic and hemorrhagic stroke accounts for about 87% and 13% respectively.2
Preeti Gazbare et al IJSRE Volume 05 Issue 05 May 2017 Page 6409 enormously to functional disability, affecting quality of life and independence in ‘basic’ (washing, grooming, feeding, dressing, etc.) and ‘instrumental’ activities (shopping, home/financial management, etc.) of daily living.4 After an injury, the damaged brain will utilize surviving structures and networks that can generate some form of motor signal to spinal cord motor neurons. There is some experimental evidence that physical therapy techniques are associated with changes in the activity of brain areas and improved transmission in the corticospinal pathways. Motor training results in performance improvements that are associated with reorganization.5
The Motor Relearning Programme (MRP) is a task-oriented approach to improving motor control, focusing on the relearning of daily activities. There are four steps in motor relearning programme: Analysis of the task, Practice of missing component, Practice of task, Transference oftraining.6 The PNF is motor learning approach used to improve motor function and facilitate maximal muscular contraction. The basic procedures for facilitation are: Resistance, Irradiation, Manual contact, Body position and body mechanics, Verbal commands, Vision, Traction or approximation,Stretch,Timing,Patterns.7 There is paucity of literature for which approach is better over other so this study will provide the efficacy between MRP and PNF to improve upper limb functions in stroke patients.
METHODS
Ethical clearance for the study was obtained. 30 subjects were selected based on inclusion criteria of one-time stroke,MMSE SCORE>23, Brunnstorm stage 4 and 5 for upper limb, tone of 1-2 on Modified Ashworth Scale, duration of stroke between 1-3yrs after occurrence and individuals having any musculoskeletal disorders, neurological disorder other than stroke, visual impairment, non- co-operative patients were excluded. They were divided into two groups of 15 subjects each. Treatment procedure was explained & a written consent was taken. Group-A received MRP in which task related exercises were given as follows: reaching and grasping different objects of different sizes, shape and weights, reaching for objects in different directions using both the hands.6 Group-B received PNF exercises in upper limb pattern that included Rhythmic movement initiation, replication, dynamic reversals, Combination of isotonic contraction according to the particular goal. All exercises would be given.8 Both the groups were given conventional therapy that includes active movements, strengthening to lower limb, trunk stability and balance exercise. Pre and post treatment assessment was done by using Upper extremity component of STREAM and Fugl-Meyer scale. Treatment will be given for 30 min, 4 days per week for 4 weeks.
DATA ANALYSIS AND INTERPRETATION-
Statistical analysis was done using Wilcoxons Signed Test for Pre and Post test within the group & Mann Whitney Test for comparing between groups. Data analyzed by using Epi Info 7 and Primer for statistics. Table 1- Comparison of Pre and Post FMA-UE Score and Stream Score of MRP Group
Table 2- Comparison of Pre and Post FMA-UE Score and STREAM Score of PNF Group
MEAN- PRE MEAN-POST P value
FUGL MEYER 35.5±5.4 44.4±5.8 p= <0.001
STREAM 10.2±1.89 13.8±2.07
MEAN- PRE MEAN-POST P value
FUGL MEYER 33.4±6.05 44.4±4.03 p= <0.001
Preeti Gazbare et al IJSRE Volume 05 Issue 05 May 2017 Page 6410 Graph 3- Comparison of Mean Difference of FMA-UE of MRP and PNF Group
Graph 4 - Comparison Of Mean Difference of UE STREAM Index of MRP And PNF Group
RESULTS
Data of 30 stroke patients were collected and statistical analysis was done using Primer software and Epi-info 7 for normality distribution. Normality tests were applied to the data i.eShapro-Wilk test. Data was found to be not normally distributed. Hence, non-parametric tests of Wilcoxon Signed Rank testand Mann-Whitney U test were applied.
Tests of Normality
Kolmogorov-Smirnova Shapiro-Wilk
Statistic df Sig. Statistic Df Sig.
PRE1f .166 15 .200* .903 15 .108
POST1f .236 15 .024 .880 15 .048
PRE1s .179 15 .200* .923 15 .212
POST1s .159 15 .200* .969 15 .841
PRE2f .128 15 .200* .959 15 .677
POST2f .134 15 .200* .969 15 .850
PRE2s .136 15 .200* .938 15 .361
POST2s .128 15 .200* .925 15 .229
To compare the pre values of Fuglmeyer assessment and Upper Extremity Stream Index between the groups Mann-Whitney U test was used whose p value was >0.05 which is not statistically significant which means that both the groups are comparable.
11
8.9
0 2 4 6 8 10 12
MRP PNF
MEAN DIFF
4.8
3.6
0 1 2 3 4 5 6
MRP PNF
Preeti Gazbare et al IJSRE Volume 05 Issue 05 May 2017 Page 6411 Table 1 and 2 shows statistical significance in FMA-UE and STREAM score within MRP and PNF group with p value <0. 001thus suggesting MRP and PNF training individually are effective in improving upper limb function in Stroke patients.
Graph 3 and 4 shows comparison between MRP and PNF group which has no statistical significance in FMA-UE and STREAM score in MRP (p=0.73) and PNF (0.231) group. This suggest MRP and PNF training was equally effective in improving upper limb function in Stroke patients.
DISCUSSION AND CONCLUSION
The present study compared the effect of Motor Relearning Programme and Proprioceptive Neuromuscular Facilitation on upper limb function in stroke patients. The Group A was given MRP treatment along with conventional therapy, while the Group B was treated with PNF with conventional therapy, for 4 times/week for 4 weeks. The upper limb function was assessed before and after 4 weeks of treatment with Fugl-Meyer Assessment Scale-Upper Extremity (FMA-UE) and Upper Extremity Stream Index. Result was that MRP and PNF both were equally effective in improving upper limb function in stroke patients.
Gražina Krutulytė, et al in 2002 studied the effect of Bobath approach with Motor Relearning Programme in improving activities of daily living. They examined 240 patients and divided them to two groups. One group received Bobath while the other was given MRP. The mobility of patients was evaluated according to European Federation for Research in Rehabilitation (EFRR) scale. Activities of daily living were evaluated by Barthel index. In Bobath method the aim of it was to improve quality of the affected body side’s movements in order to keep both sides working as harmoniously as possible. Physical therapist guided patient’s body on key–points, stimulating normal postural reactions, and training normal movement pattern. MRP method was based on movement science, biomechanics and training of functional movement. Program is based on idea that movement pattern shouldn’t be trained; it must be relearned. Hence it concluded that physiotherapy with task-oriented strategies represented by MRP, is preferable than Bobath programme, in the rehabilitation of stroke patients (p< 0.05).9
Sana Batool et al in 2015compared the effectiveness of constraint induced movement therapy versus motor relearning programme to improve motor function of hemiplegic upper extremity after stroke. 42 patients were screened and were divided into 2 groups group. Experimental group was treated with CIMT while control group with MRP. Pre and post treatment measurements were determined by upper arm section of Motor Assessment Scale (MAS) and Self Care item of Functional Independence Measure (FIM) Scale. CIMT group showed more significant improvement in motor function and self-care performance of hemiplegic upper extremity as compared to MRP group in patients with sub-acute stroke assessed by the MAS and FIM scales. Thus CIMT is proved to be more statistically significant and clinically effective intervention in comparison to motor relearning programme among the patients aged between 35-60 years. Hence, results found in the above studies support this study proving that MRP is an effective treatment in improving upper limb function in stroke patients.10
Franco et al. indicate that the technique to gain muscular strength, muscular endurance and range of motion as well as obtaining relaxation of the antagonist pattern are contributing factors to the functionality.11 Dean et al. reports the use of the technique in the presence of spasticity, which generates changes in morphological, physiological and biomechanical characteristics of the muscle, promoting pain relief and increased range of motion.12
Preeti Gazbare et al IJSRE Volume 05 Issue 05 May 2017 Page 6412 using 'Repty' Functional Index scale. The result of this study showed that PNF-based rehabilitation exercise of late post-stroke patients significantly improved in their ADL functional performance and in locomotion when compared to the control group treated with conventional therapy.13
Thus, in the present study, MRP and PNF were statistically effective treatments for improving the upper limb function in stroke patients Clinically MRP group showed more improvement than the PNF group in improving the FMA-UE and Upper Extremity Stream Index score, post treatment.
CONCLUSION-
Thus the study concludes that both MRP and PNF are equally effective in the treatment of upper limb function in stroke patients.
Conflict Of Interest
There was no conflict of interest found in this study.
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