Project Title
Neuralplasticity-based Sensory-Rehabilitation Protocol in Post- Stroke Hemiparesis (ICMR funded Project: 2019 -2022)
Introduction
In addition to the motor paresis, sensory impairments impacting the recovery are also common after stroke; however usually not focused.
Objective
The objective of the study was to determine the effectiveness of a novel sensory rehabilitation protocol on motor and sensory recoveries, and disability status of the post-stroke hemiparetic subjects.
Methodology
Design: Randomized controlled, assessor blinded trial
Setting: Rehabilitation Institute
Inclusion Criteria: Age: 20 to 80 years, Hemiparesis (right or left), Ischemic or hemorrhagic stroke, 1 to 12 months after the stroke onset, Impaired sensations.
Exclusion criteria: Receptive communication, Contractures of hand, Complex regional pain syndrome, Severe cognitive deficit, Diabetic or other neuropathy
Sample size: 122 (61 subjects in each arm)
Intervention: Experimental: NEuroplasticity-Principles-based SEnsory-Rehabilitation (NEPSER) protocol comprising active, repetitive, and meaningful training utilizing visuo-perceptual, cognitive, motor, and functional tasks; 40 sessions, each of 2 h. Control: standard rehabilitation.
Outcome Measure: Fugl-Meyer Assessment – Upper arm (FMA-UA), Nottingham Sensory Assessment (Erasmus modification) (Em-NSA), NSA-Stereognosis, and Modified Rankin scale (mRS).
Results
Post intervention, the FMA-UA, Em-NSA, and NSA-Stereognosis, favorably changed to 24.64±6.94, 36.75±3.33, and 16.30±4.89, respectively in the experimental group while the same progressed to 21.18±8.90, 21.64±11.36, and 9.93±7.97, respectively among control group participants; the changes were found to be significantly different (95% CI 0.092 – 6.14, 7.84 – 14.40, and 1.89 – 6.89; p= 0.044, < 0.001, 0.001, respectively) between the groups at the follow-up. There were 34 (55.7%) and 40(65.6%) subjects (pre-intervention) and 45 (73.8%) and 46(75.4%) subjects (pre-intervention) were at < mRS-3 stage in the experimental and control groups, respectively (p = 0.878).
Conclusion
This study led to the development of a novel rehabilitation protocol for the management of sensory-motor deficits in stroke. The protocol not only enhanced the sensory recovery but also the motor recovery that may the impact of stroke disability.
2019-20
Projects Completed
- Dr Meenakshi Batra as principal investigator for the project titled “Identifying and modulating establishment of laterality in children with developmental disabilities”.
Completed Research Project (2016-17)
| 1. Synergy based motor therapy program for Stroke patients (July 2015 to September 2016). 2. Principal Investigator – Ms. Shanta Pandian, Lecturer OT Funded by Department of Health Research, Ministry of Health & Family Welfare, Govt. of India |
Synergy, working together of muscles in a coordinated fashion, is a normal neurophysiological mechanism. Abnormal stereotyped motor behaviour appears in post stroke hemiparesis patients. Facilitation of normal synergy and dissociation of abnormal synergy may influence motor recovery. The application of synergy concept in stroke rehabilitation is sparse. Setting: Rehabilitation Institute Participants: 50 (29 males, 40 to 60 years, 28 ischemic) chronic poststroke hemiparetic subjects Design: Pre test post test single group, Phase I trial Interventions: Considering the relation between normal and abnormal synergies, a motor therapy protocol using various tasks / activities was developed. Synergistic movements were selected on the basis of quality, quantity and association of the available movements. For example, shoulder external rotation with elbow extension was utilized to dissociate strong elbow flexion. Outcome measures: Fugl-Meyer Assessment (Upper Extremity)(FMA-UE) – to assess the voluntary motor control, mRS scale and Barthel Index to measure functional use of the upper limb. Results: The motor rehabilitation protocol using synergy concept was feasible among all the participants and across all the stages of motor recovery. Post-intervention subjects exhibited significant (p=0.02) change on FMA-UE (37.75+ 16.93 to 42.5+19.37). Conclusion: Synergy based motor rehabilitation is beneficial in improving motor and functional recovery in stroke patients. The utilization of synergistic linkage should be explored in stroke rehabilitation. Publication / presentation
|
| 4. Interlimb coupling in post-stroke rehabilitation (December 2015 to November 2016). 5. Principal Investigator – Dr. Kamal Narayan Arya, Lecturer (OT) Funded by Indian Council of Medical Research, New Delhi |
In India, stroke incidence has been registering an upward trend in the last few decades. Disability due to motor impairment of the limbs is the most common and challenging manifestation of stroke. Interlimb coordination, a relative timing of events between the four limbs during functional performance gets hampered after stroke. In spite of motor recovery, the post stroke hemiparetic subjects are not able to use their limbs in daily tasks efficiently; thus, increasing their disability level. There is a neural cross talk between 2 brain hemispheres modulates task-specific actions, leading to a complex intra- & interlimb joint interaction. The concept can be explored and utilized in stroke rehabilitation. The intervention based on the principles of interlimb coordination and coupling found to be feasible for stroke subjects. The regime comprises movements of either upper limbs or lower limbs or all 4 limbs using various therapeutic devices. The movements may be provide in various combination of the upper and lower limbs such as bilateral, ipsilateral, contralateral, symmetrical, and asymmetrical. In a randomized controlled trail on 50 subjects, the interlimb coupling program exhibited significant improvement of motor recovery of the upper and lower limbs as measured by Fugl-Meyer assessment [p< 0.001; 95% CI mean of difference = 8.83 (7.60 – 10.06)]. The gait deviation on Rivermead Visual gait assessment reduces significantly [p< 0.001; 95% CI of mean difference = 6.32 (7.51 – 5.13)]. 50% of the experimental subject could reach to the highest level of functional ambulation. 15% experimental-participants demonstrated considerable change of disability level (Modified ranking scale 2 from stage 3 or 4) in comparison to the controls. In summary, the interlimb coupling based stroke rehabilitation may enhance motor recovery and functional ambulation while reducing gait deviation and level of disability. The concept may be incorporated in post stroke management. Publications / Presentations:
|
Completed Research Project (2015-16)
Effect of Activity-Based Mirror Therapy on Lower Limb Motor Recovery in Stroke (Nov. 2014 to March 2016), Principal Investigator – Dr. Kamal Narayan Arya, Lecturer (OT), Funded by – Pt. Deendayal Institute for the Physically handicapped, New Delhi.
The objective of the study was to develop an activity-based mirror therapy program for post-stroke hemiparetic patients. Further, to determine the effectiveness of the program on motor recovery of the paretic lower limb, gait, balance, function & disability. The present study led to development of an economical and evidence based technique for stroke rehabilitation. The method was superior in enhancing the lower limb recovery and walking in the patients.
Association of Anthropometric characteristic to foot type and static postural balance strategy in young adults. Principal Investigator – Mrs. Manju Vats, Lecturer (PT). Funded by – Pt. Deendayal Institute for the Physically handicapped, New Delhi.
- limits of postural stability are set by mechanical factors that include both individual and environmental characteristics. Altogether, the differences in body characteristics and dimensions have been assumed to influence the boundaries of individual postural stability as well as the foot posture in response to compensatory movement strategies. On the other hand the variability of individual characteristics and foot posture may also affect the selection of motor strategies that people use to maintain standing balance control.
Type of the study: cross- sectional observational study
- Total 239 healthy under graduate collegiate students of PDUIPH were randomly screened for anthropometric characteristics, lateral postural analysis and normalized navicular height truncated. The anthropometric measurements were taken in accordance with ISAK standards. The Indices of BMI (Kg/m2), upper body height to lower body height ratio (UBH: LBH); waist to hip circumference ratio (WC: HC); bi-acromial to bi-iliocristal width ratio (BA: BI) were calculated. Static postural Balance strategy (Anterior; neutral; posterior) was analyzed using lateral postural analysis whereas Navicular height to truncated foot length ratio was taken to classify foot type (neutral or pronated types)
- Posterior balance was associated with females only whereas neutral and anterior balance strategy was distributed equally in both male and female subjects. The significant difference in the mean values of certain anthropometric characteristics like WT; BMI; WC; HC; BI; WC: HC and BA: BI were observed for the female population presenting with posterior balance strategy in comparison to females of other two types of balance strategies. It’s also revealed that there is no association between the adopted static postural balance strategy and type of foot. Gender specific analysis revealed that The female subjects of pronated foot group were having significant differences of HT; LBH; BA and UBH: LBH ratio than the females of neutral foot group whereas the male subjects of pronated foot group were found to have significantly difference of WC and WC: HC than the males of neutral foot group.
- there is no association between the adopted balance strategy and type of foot. Though, the significant differences of certain individual anthropometric characteristics are associated with the adopted static balance strategy and type of the foot.
Clinical implication: musculoskeletal impairments and pain of soft tissues and joints have been correlated with the abnormal static balance strategy and foot postures as these can be detrimental to the human musculoskeletal structures by altering the alignment and imposed stresses to various tissues. The results of this study may improve the insight of physiotherapists tor considering the influence of anthropometric characteristics on standing balance strategy and foot posture for assessment and as well as in designing the therapeutic strategies which could be beneficial by directing the approach towards the modifiable body characteristics.
Previously Completed Research Project
Title
Principal Investigator
| Role of less affected upper extremity in post stroke rehabilitation |
Ms. Shanta Pandian, Lecturer OT |
| Effectiveness of Mirror Therapy on motor recovery of upper extremity in chronic stroke patients |
Dr. Kamal Naryan Arya, Lecturer OT |
The standing committee of PDUIPH in its 100th meeting held on 4th July 2012 approved the following studies to be undertaken as project for 6 months each. The same were further approved for 2 months extension in 105th meeting:
- Effectiveness of Mirror Therapy on motor recovery of upper extremity in chronic stroke patients- Principal Investigator: Dr. Kamal Narayan Arya, Lecturer OT.
- Role of less affected upper extremity in post stroke rehabilitation – Principal Investigator: Smt. Shanta Pandian, Suptd. Lecturer OT.
Both the projects have been successfully completed. The brief outcome is summarized below –
Project a: Mirror therapy (MT) is a relatively new therapeutic intervention that uses the concept of visual illusion to enhance movement capability of the impaired limb. The study was randomized controlled trial of forty post-stroke hemiparetic subjects in the occupational therapy department. The experimental group underwent structured conventional therapy and mirror therapy. The 6-week experimental protocol led to 30% improvement in the upper limb motor recovery on Fugl-meyer assessment scale and Brunnstorm stages of motor recovery as compared to only 5% among the control group. The present study led to development of a novel and economical rehabilitation protocol which enhanced motor recovery of the upper extremity in chronic stroke patients.
Publications:
- Inadvertent Recovery in Communication Deficits Following the Upper limb Mirror Therapy in Stroke: A Case Report. Kamal Narayan Arya & Shanta Pandian. Accepted for publication in Journal of Body work & Movement therapy (Elsevier): February 2014.
- Effect of task-based mirror therapy on upper extremity motor recovery in chronic stroke patients; A pilot study. Kamal Narayan Arya & Shanta Pandian. Topics in stroke rehabilitation (Thomas land): May-June 2013
- Task-Based Mirror Therapy (TBMT) augments the Recovery of Wrist and Hand in Poststroke Hemiparesis: A Pilot Randomized Controlled Trial. Kamal Narayan Arya, Shanta Pandian & Dharmendra Kumar. Accepted for Publication in Journal of Stroke & Cerebrovascular Disease
- Mirror Therapy Also Augments The Motor Function Of The Less-Affected Side In Stroke. Kamal Narayan Arya, Shanta Pandian & Dharmendra Kumar. Under review in Archives of Physical Medicine & Rehabilitation.
Project b: Poststroke, less-severe motor impairment occurs on the ipsilesional side of body. The objective of the present study was to evaluate the effectiveness of the motor training involving the less-affected side (MTLA) in stroke. It was a randomized, controlled, double-blinded pilot study carried out in the Occupational therapy department. The MTLA produced statistically significant and clinically relevant improvements on the affected and the less-affected sides of the patients who had a stroke. The present study explored the management of unnoticed impairment in stroke patients.
Publications:
- Effect of motor training involving the less-affected side (MTLA) in poststroke subjects: A Pilot Randomized Controlled Trial. Shanta Pandian, Kamal Narayan Arya & Dharmendra Kumar. Accepted for publication in Topics in stroke rehabilitation (Thomas land): September 2014
- Does Motor Training of the Non-paretic side influences balance and function in chronic stroke? A pilot RCT. Shanta Pandian, Kamal Narayan Arya & Dharmendra Kumar. Accepted for publication in The Scientific World Journal: September 2014
- Atypical Motor Behavior in a Poststroke Subject with Agenesis of the Corpus Callosum: A Case Report. Shanta Pandian & Kamal Narayan Arya. Annals of Physical & Rehabilitation Medicine (Elsevier): April 2014 (57) 200-209.
- Does the Motor Level of the Paretic Extremities Affect Balance In Poststroke Subjects? Kamal Narayan Arya, Shanta Pandian, C.R. Abhilasha & Ashutosh Verma. Rehabilitation Research and Practice Volume 2014, Article ID 767859
Completed Project 2017
Role of long term task-based mirror therapy in inducing motor recovery in post stroke hemiparesis. (December 2015 – November 2017). PI: Dr. Kamal N. Arya, Lecturer OT
The upper limb rehabilitation is a challenging issue in stroke. The objective of the investigation was to establish the effect of the task-based mirror therapy (TBMT) on the upper limb recovery in stroke. A pilot, randomized controlled, assessor-blinded trial was conducted in a Rehabilitation institute. A convenience sample of 33 poststroke (mean duration, 12.5 months) hemiparetic subjects was randomized into 2 groups (experimental, 17; control, 16). The subjects were allocated to receive either TBMT or standard motor rehabilitation, 40 sessions (5/week) for a period of 8 weeks. The TBMT group received movements using various goal-directed tasks and a mirror box. The movements were performed by the less-affected side superimposed on the affected side. The main outcome measures were Brunnstrom recovery stage (BRS) and Fugl-Meyer assessment: upper extremity (FMA-UE) including upper arm (FMA-UA) and wrist-hand (FMA-WH). TBMT group exhibited highly significant improvement on mean scores of FMA-WH (p < 0.001) as well as FMA-UE (p < 0.001) at post assessment in comparison to the control group. Further, there was 12% increase in the number of subjects at BRS stage 5 (out of synergy movement) in the experimental group as compared to 0% rise at the same stage in the control group. This pilot trial confirmed the role of TBMT in improving the wrist-hand motor recovery in poststroke hemiparesis. MT using tasks may be utilized as an adjunct in stroke rehabilitation.