The Indian Journal of Occupational Therapy : Vol. XLI : No. 2 (May 2009 - August 2009) EFFECT OF OCCUPATIONAL THERAPY TASK ORIENTED APPROACH ON RECOVERY OF UPPER-EXTREMITY MOTOR FUNCTION AND ACTIVITIES OF DAILY LIVING IN STROKE PATIENTS * Amit Kumar Mandal, M. O.T., Co-Author : **Sunil P. Mokashi, M.O.T. Abstract : The loss of upper extremity motor control due to stroke not only affects the upper extremity function but also its use in daily occupation. The purpose was to study the effect of Occupational Therapy task oriented approach in rehabilitation of chronic stroke patients and to determine the relationship between recovered upper extremity motor function and functional status achieved at post intervention. A different subject, prospective, experimental design was used. 26 subjects were equally divided into two groups.11 subjects of each group completed the study duration. Control group received conventional Occupational Therapy and experimental group received additional protocol based on Occupational Therapy task oriented approach. Upper extremity motor function was measured by Fugl-Meyer scale and functional status was measured by Functional Independence Measure. The result of study revealed that experimental group improved better than the control group. There was positive correlation between upper extremity motor function and functional status achieved at post intervention. Keywords: Motor control, Functional status, Task oriented, Occupation INTRODUCTION I want to use my arm again - a goal that occupational therapist hears from stroke survivors during almost every evaluation. Like Gillen 1, occupational therapists today also continue to face similar question from stroke patients. Stroke can cause disruption of motor and sensory pathways and their integration, leading to disorder of muscle tone, posture and the selective control of movement. The variety and severity of the symptoms are dependent on the site and extent of the cerebrovascular accident. The loss of upper extremity control is common after stroke, with 88% of the survivors having some level of upper extremity dysfunction 1. * Occupational Therapist ** Asstt. Prof. & H.O.D. Place of Study : Deptt. of Occupational Therapy, SVNIRTAR, Cuttak. Period of Study : October 2006 - March 2007 Correspondence : Dr. Amit Kumar Mandal Deptt. of Occupational Therapy Swami Vivekanand National Institure for Rehabilitation Training & Research, Olatpur, Bairoi, Cuttak-754010 Tel. : 09437191126 E-mail : Paper was presented in 46th Annual National Conference of AIOTA : EMCON'09 in Jan. 2009 at Jaipur. Basic ADL skills are compromised during acute stroke, with 67% to 88% of patients demonstrating partial or complete dependence. Independence in ADL improves with time with only 24% to 53% of survivors requiring partial or total assistance 6 months to 1 year later. 2 In conventional practice in stroke rehabilitation for upper extremity function different Neurophysiological approaches such as Rood s (1954), sensory motor approach, Knott and Voss (1968) PNF, Brunnstrom s (1970) movement therapy, Bobath s (1978, 1990), Neurodevelopmental treatment are mostly used. 3 Mathioewtz and Haugen proposed OT Task-oriented approach in 1994 based on systemic model of motor control, motor development and motor learning theories. 4 In stroke rehabilitation use of different Neurophysiological and task related training are well established with their limits. Task is a sequence of activities that share a purpose and goal. 5 The OT task oriented - approach, in which real object is used in probable natural environment may give a new idea about motor behavior problem in stroke rehabilitation. Nancy Flinn in a single case report emphasized OT task oriented approach to the rehabilitation in stroke patient. She used OT task oriented approach to improve sensory motor system of the patient. The results had shown significant improvement in sensory motor area along with occupational 31
performance. 6 Hence, the purpose is to study the effect of occupational therapy task oriented approach in rehabilitation of stroke patients. AIMS AND OBJECTIVES: 1. To find out effect of occupational therapy task oriented approach on recovery of upper extremity motor function and activities of daily living in stroke patients. 2. To determine the relationship between recovered upper extremity motor function and functional status achieved in activities of daily living. LITERATURE REVIEW: Large numbers of studies suggest that task training can improve motor function and functional status in stroke patients. Literature search reveals that a single case report by Nancy Flinn used occupational therapy task oriented approach for the case study. 6 Shepherd and colleagues conducted a study on task oriented training to improve performance of seated reaching tasks after stroke. The study included 20 people with stroke resulting in hemiplegia of more than one year duration. It was found that task related training improved performance of seated reaching tasks after stroke. 7 Malouin and others gave a case report on use of an intensive task oriented gait training program of 10 acute stroke patients, 60 to 75 years of age with middle cerebral artery infarction. Subjects who received task oriented gait training (treadmill) in 2 nd week had shown better improvement in mobility. 8 Dean with associates conducted a study to know the effect of task related circuit training in chronic stroke stage. Strengthening and functional activities were given for experimental group. Only functional activities were given for control group. Experimental group performed better on walking speed and endurance and on force production. 9 In a study by Richard and colleagues found that task specific treatment in stroke patients was important during early intervention. 10 Nancy Flinn described a case study of a 34 years old woman with left sided hemiplegia. The treatment program focused on participating in graded functional task that systematically increased the motor demands on the more affected upper extremity. After 6 months of task oriented occupational therapy (33 sessions), the patient had substantially improved level of occupational performance and was able to return to work few months after discharge. 6 Most of the previous studies were based on Carr and Shepherd s approach which uses a frame work for assessing and improving four categories of motor performances: standing up and sitting down, walking, reaching, and manipulation. STUDY DESIGN METHODOLOGY A different subject, prospective, experimental design was used. SUBJECTS A. A total number of 26 adult stroke patients were selected from Department of Occupational Therapy, SVNIRTAR, Cuttack over a period of 6 months (October 06 to march 07). INCLUSION CRITERIA Subjects were diagnosed as stroke patient by physician Adult stroke patient of both sexes First stroke resulting in Hemiplegia at least 3 months ago and maximum up to 2 years duration Brunnstrom s stage 3 and above MMSE score 21 and above Able to maintain standing position for 5 minutes without manual assistance EXCLUSION CRITERIA Unstable medical condition like severe hypertension, convulsion Shoulder dislocation Fixed deformity of hand Visually impaired Shoulder hand syndrome Aphasia Behavior problems Complete sensory loss of upper limb INDEPENDENT VARIABLES Weight bearing activities Task training DEPENDENT VARIABLES Upper extremity motor functions Functional status 32
INSTRUMENTATIONS Fugl - Meyer assessment of physical performances Functional Independence Measure (FIM) Mini Mental State Examination (MMSE) PROCEDURE Selected 26 subjects were divided into two groups. A. Control group ( 13 subjects) B. Experimental group (13 subjects ) Among the selected 26 subjects, 2 subjects from each group voluntarily dropped out after few days of therapy. Therefore, 11 subjects of each group continued therapy. Evaluation format was used to record data on the 1 st day before the therapy. Mini Mental State Examination was administered to quantify cognitive performance. Fugl-Meyer Assessment of Physical Performance (upper extremity) was used to assess the upper extremity motor function. Each subject item was tested three times after giving the instructions. The score of maximum performance was recorded. Functional Independence Measure was administered to measure functional score of Activities of Daily Living. 11 A 10 minutes test interval was allowed between each test to avoid effects of fatigue. INTERVENTION STRATEGIES: All the subjects went through the therapeutic intervention aimed to improve upper extremity motor function and activities of daily living status. Control group (Group A) received 60 minutes conventional therapy, consecutive 25 sitting protocol based on Bobath s neurodevelopment approach. 12 Experimental group (group B) received conventional therapy for 30 minutes based on neurodevelopment treatment and task training based on occupational therapy task oriented approach for 30 minutes in each session. Therapy was continued consecutive 25 sitting within 5 to 6 weeks. Protocol based on occupational therapy task oriented approach: Performance area Name of the task Time duration Activities of daily living 1. Drinking 2. Eating 3. Brushing teeth 4. Dressing upper garment(men) 30 minutes Work and productive 5. Type writing 6. Pot making Play\leisure 7. Playing carom board games 8. Playing cards Four tasks were selected for each subject in experimental group according to need and interest of the subject. Two tasks were selected from performance area ADL, one from work and productive area and one from play and leisure area according to above table. Pre test 1 st day morning before start of therapy DATA COLLECTION Consecutive 25 sitting of therapy Post test Next day after 25 sitting of therapy at morning DATA ANALYSIS The SPSS version 10.0 was used for data analysis. An alpha level of p< 0.05 was fixed for significance. Mann Whitney U test was used to measure the change of score from pre test to post test for upper extremity motor function and activities of daily living between the groups. Wilcoxon sign rank test was used to measure the change of upper extremity motor function and activities of daily living score within the group. To find out the correlation between upper extremity motor function and activities of daily living the Spearman test was used. 33
RESULTS Table 1 Mean and standard deviation Pre Fugl-Meyer Post Fugl-Meyer Pre FIM Post FIM Control group Mean 25.636 SD 8.11 SE 2.45 Mean 35.364 SD 8.88 SE 2.68 Mean 80.273 SD 15.98 SE 4.82 Mean 89.364 SD 14.88 SE 4.49 Experimental Group Mean 28.909 SD 9.47 SE 2.86 Mean 52.727 SD 6.74 SE 2.03 Mean 78.545 SD 13.84 SE 4.17 Mean 104.09 SD12.93 SE 3.9 Mean and standard deviation in Table1 shows that Experimental group had shown better improvement at post therapy both Fugl Meyer and FIM score. Table 2 Comparison of difference in pre and post test score between Groups Fugl- Meyer FIM (UE motor function) (ADL) Z - 3.986-3.982 P 0.00* 0.00* *Significance at p< 0.05 Table 2 shows the comparison between the groups in improvement of upper extremity motor function (Fugl Mayer) and functional status (FIM) score. P value is 0.00, which is less than acceptable significance of 0.05. Table 3 Comparison between pre and post treatment score in Experimental group Fugl- Meyer FIM (UE motor function) (ADL) Z - 2.938-2.936 P 0.003* 0.003* *Significance at p< 0.05 Table 3 shows that the comparison between upper extremity motor function and function status score in experimental group (within the group). P value is 0.003, which is less than acceptable level of significance of 0.05. Table 4 Comparison between pre and post treatment score in Control group Fugl Meyer FIM Z -2.947-2.944 P 0.003* 0.003* *Significance at p< 0.05 Willcoxon signed rank test shows the significant difference within the control group in Fugl- Meyer and FIM score (Table 4). The correlation is determined with Spearman rank order correlation with γ (Rho) value is 0.835 and at 0.00 level of significant. Graph - 1 Comparison between pre and post treatment scores of both Groups on Fugl-Meyer (FM) The Graph-1 shows that there is significant difference between experimental and control group at Pre and Post therapy in Fugal Meyer Score. Graph 2 Comparison between pre and post treatment scores of Control & Experimental group on FIM 34
The Graph-2 shows the significant difference between experimental and control group at Pre and Post therapy FIM Score. DISCUSSION The result of this study showed that experimental group (Group B) improved better than the control group (Group A). Both, experimental and control group had shown significant improvement in post therapy assessment (Table 1, Graph1& 2). The over all result shows that therapy received by Experimental group (Group B) was better than therapy received by control group (Group A). Carr and Shepherd advocated that task oriented practice improved functional performance of daily activities, such as walking and reaching to grasp objects in stroke patient. 7 Kwakkel and Wagenaar, Richard and colleagues had shown task related practice improved walking ability in post acute stroke patient and use of the arm in chronic stroke patient. 13, 10 A randomized control trial study of Jannette and colleagues had shown additional task related practice improved mobility and upper limb function early after stroke. 14 The results of task training of above studies are in accordance with present study. But, in this study task training was given according to OT task oriented approach. The result of this study is in accordance with the study of Nancy Flinn. 6 She used occupational based functional task to rehabilitate a 34 years old woman with left sided hemiplegia. She was able to rehabilitate the patient successfully, which is the main aim of OT task oriented approach. Statistical analysis had shown strong positive correlation in upper extremity motor function and activities of daily living status (γ= 0.835, p = 0.00). This result is in accordance with study of Nakayama and colleagues. 15 They studied with 115 stroke patients to know the relation between motor recovery and upper extremity functional status. Another study of Nilsson and colleagues had shown that Fugl- Meyer score correlated to activities of daily living (ADL) score (r = 0.64) of 109 subjects measured within 2 weeks of stroke. The result of above study is in accordance with correlation in ADL and Fugl- Meyer of the present study. 16 LIMITATIONS The study had small number of sample size. It was difficult to simulate natural environment within our clinical setting. There was no untreated control group to rule out spontaneous recovery. The numbers of tasks were limited. The long term sustainability of therapy might need further evaluation, which was not done. CONCLUSION From this study it can be concluded that: The experimental group who received task training based on occupational therapy task oriented approach showed better improvement as compared to control group. There is positive co-relation between recovery of upper extremity motor function and activities of daily living status of stroke patients. The occupational therapy task oriented approach may provide better idea about the remediation of motor behavior problems. ACKNOWLEDGEMENT We would like to convey our sincere thanks to Dr. B.M. Pradhan, Director, SVNIRTAR, for allowing us to conduct this study in the Institute. We also express our sincere gratitude to Mr. Ram Kumar Sahu, Mr. Lakshman and all staff of department of OT, SVNIRTAR. Finally, we express our sincere gratitude to all patients and their relatives, for their participation, interest and patience during the study. REFRENCES 1. Gillen G., Burkhardt A. Stroke Rehabilitation: A Functional Based Approach. 2 nd Ed. St. Louis : Mosby, 2004. pp. 59-69, 173-208. 2. O Sullivan SB, Schmitz TJ. Physical Rehabilitation Assessment and Treatment. 4 th Ed. New Delhi: Jaypee Brothers, 2001. pp. 521-539. 3. Harrison MA. Physiotherapy in stroke management. 1 st Ed. London: Churchill Living stone, 1995. pp. 3-22. 4. Bass Haugen J, Mathiowetz V and Flinn N. Optimizing Motor Behaviour using the occupational therapy task oriented approach. In: Trombly CA, Rodomski MV, Editor. Occupational Therapy for Physical Dysfunction, 5 th Ed. William and Wilkins. 2002. pp. 481-499. 5. Watson DE, Wilson SA. Task Analysis: An Individual and Population Approach. 2 nd Ed. Bethesda: AIOTA press, 2003. pp. 182-195. 6. Flinn N. A task-oriented approach to the treatment of a client with hemiplegia: The American Journal of Occupational Therapy. 1995; 49(6): 560-569. 7. Car JH, Shepherd RB. Investigation of a new motor assessment scale for stroke patient. J. Phys. Ther. (Am).1985; 65(2): 175-185. 8. Malouin F, Potvin M, Prevost J, Richards CL. Use of an Intensive Task Oriented Gait Training Programme in a series of patient with acute cerebrovascular accident. J. Phys. Ther. (Am). 1992; 72(11): 781-789. 35
9. Dean CM, Richards CL, Malouin F. Task related circuit training improves performance of locomotor tasks in chronic stroke. Arch. Phys. Med. Rehab. 2000; (81)4: 409-417. 10. Richards CL, Malouin F, Wood-Dauphine S. Task-Specific Physical therapy for optimization of gait recovery is acute stroke patients. Arch. Phys. Med. Rehab. 1993; 74(6): 612-620. 11. The UK FIM + FAM (Functional assessment measure). Developed by the UK FIM+FAM users group. Version 1.1, modified 12.3.99. Harrow, Midsex, UK. 12. Bobath B. Adult Hemiplegia : Evaluation and Treatment. 3 rd Ed. London: Butterworth Heinemann, 1990. pp. 101-138. 13. Kwakkel G, Kollen BJ, Wagenaar RC, Twisk JZ. Intensive leg and arm training after stroke. Journal of Neurosurgery Psychiatry. 2002; 72(4): 473-479. 14. Jannette B, Dite W. Additional task related practice improves mobility and upper limb function early after Stroke: A randomized controlled trail. Aus. J. of Physiotherapy. 2004; 50 : 219-224. 15. Nakyama H, Jorgensen HS, Raasschou HO, Olsen TS. Compensation in recovery of upper extremity function after stroke. The Copenhagen stroke study. Arch. Phys. Med. Rahab. 1994; 75(8): 582-857. 16. Nilsson L, Carlsson JY, Grimby G, Nordholm LA. Assessment of Walking, balance and sensorimotor performance of hemiplegic patients in the acute stage after stroke. Physiotherapy Pract. 1998; 14: 149 57. N O T I C E As per the decision by the Executive Committee of All India Occupational Therapists Association this is to notify to all recognized Occupational Therapy Education Programs that, henceforth undergraduate students of occupational therapy will be allowed to attend and participate in the annual national conference of occupational therapy only if they are student members. This will be in effect from EMCON'2010 at Ahmedabad in January 2010. Dr. Shovan Saha Hon. Secretary, AIOTA E-mail : shovansaha@yahoo.com 36