Effect of motor training involving the less-affected side (MTLA) in post-stroke subjects: a pilot randomized controlled trial Shanta Pandian, Kamal Narayan Arya, Dharmendra Kumar Pandit Deendayal Upadhayaya Institute for the Physically Handicapped, New Delhi, India. Introduction: 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. Methods: This was a randomized, controlled, double-blinded pilot study conducted in the occupational therapy unit of a rehabilitation Institute. A convenience sample of 35 stroke subjects (mean poststroke duration, 28.76 weeks) was randomized into two groups (the experimental group: 17 and control group: 18). Thirty-two participants completed the entire study protocol. The experimental group and control group were provided MTLA and neurophysiological-based conventional therapy respectively. Both the groups received 24 treatment sessions (60 minutes each) over the period of two months. The Affected side was assessed using Brunnstrom recovery stage (BRS) and Fugl-Meyer assessment (FMA) whereas the less-affected side was evaluated by Minnesota manual dexterity test (MMDT), Purdue peg board test (PPBT) and Manual Muscle Testing (MMT). Results: Postintervention, the less-affected side of experimental group demonstrated significant improvement for MMDT (P = 0.003), PPBT (P = 0.01) and MMT (Pv 0.001 to 0.043) in comparison to the control group. Further, as compared to the control group, the experimental group exhibited positive significant change for the measure of affected side [BRS (P v 0.001) and FMA (P v 0.001 to 0.03)] at post assessment. Conclusion: MTLA enhanced the muscle strength, dexterity and coordination of the less-affected side as well as the motor recovery of the affected side in poststroke hemiparetic subjects. Keywords: Bimanual training, Hemiparesis, Ipsilesional side, Less-affected side, Motor training, PRE, Stroke rehabilitation

Introduction Unilateral stroke primarily produces substantial motor deficits on the contralesional side. However, the ipsilesional side also exhibits certain motor deficits. The deficits are not as severe as on the contralesional side and usually get unnoticed.1–3 Conventionally, the ipsilesional side has been considered as the sound or unaffected side. However, the motor deficits such as decrease in muscle strength may occur bilaterally.4 The motor deficits were recorded in terms of coordination, dexterity, in-hand manipulation, and muscle strength of the ipsilesional upper extremity. In addition to the obvious clinical impairment, the kinematic analysis may discern certain deficits.2,5–7 The level of ipsilesional impairments depends on the extent of subcortical white and gray matter

Correspondence to: K. N. Arya, Pandit Deendayal Upadhayaya Institute for the Physically Handicapped, 4 VD Marg, New Delhi 110002, India. Email: [email protected] ß W. S. Maney & Son Ltd 2015

DOI 10.1179/1074935714Z.0000000022

involvement.8 The ipsilesional impairments may lead to additional functional limitations in stroke subjects. The understanding of such deficits would also explore the role of ipsilateral hemisphere in controlling movement and the lateralization of specific motor control mechanisms.9,10 Each cerebral hemisphere is specialized for specific motor control. For instance, the dominant hemisphere is responsible for anticipating and planning the purposeful movements while the non-dominant hemisphere is decisive for synchronization of proprioceptive mechanism.11,12 As a result the unilateral brain damage exhibits impairment of hemispherespecific specialized movement on both the sides.11,13 The dominant hemisphere has role in the motor control and joint postures of bilateral upper limbs and in carrying out complex tasks, while the non-dominant hemisphere is responsible for visuospatial accuracy.13,14 As a result, the left brain (dominant) damage leads to impairment in multijoint coordination, whereas the Topics in Stroke Rehabilitation

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right brain (non-dominant) damage creates difficulty in achieving accuracy of final position.9 A cerebral hemisphere functions through motor tracts and is primarily responsible for the contralateral movements; however, some of the tracts have role in the ipsilateral motor function.15 Post-stroke, considerable changes have been observed in both the lesioned and non-lesioned corticospinal systems.16 Abnormal change in motor unit firing has been observed on the less-affected side.17 The ipsilesional side may not be considered as a reference for the motor recovery of contralesional side.3 The impairment of affected limb is influenced by the less-affected side. The linkage between the affected and less-affected sides strongly influences the functional performances.18 Additionally, the ipsilesional motor cortex was found to be active during movement of the less-affected upper limb.19 However, most of the motor therapies are focused on the contralateral side to induce neural reorganization of the damaged hemisphere in post-stroke subjects.20 Brain area which could be harnessed by movement of the ipsilateral side has never been explored. The motor intervention involving the ipsilateral side also may enhance interhemispheric communication and additionally augment the motor recovery of contralateral side.21 Considering the magnitude of paresis, the contalateral arm may be the main focus for intervention, but the ipsilesional side should also be addressed to achieve maximum possible motor and functional skills. However, the motor impairment on the ipsilesional side has never been exclusively treated. This focuses the need of the present study. The objective of the present study was to determine the effect of motor training also involving the less-affected side (MTLA) in post-stroke hemiparetic subjects. MTLA was a rehabilitation protocol for both the less-affected and affected upper and lower limbs in stroke subjects. The program utilized progressive resistive exercises (PRE; for the lessaffected side) and bimanual-task training (BT; for both the sides). PRE is an evident muscle strengthening protocol based on repetition of contraction against the specific resistance.22–24 BT utilizes the symmetrical and assymetricalmovements of bilateral upper or lower extremities to enhance the skilled motor function.25,26

handicapped were recruited for the study. The subjects were briefed about the study before they signed the informed consent. Stroke was diagnosed by a neurologist on the basis of computed tomography or magnetic resonance imaging.27 The inclusion criteria were: (1) 50–70 years of age; (2) ischemic or hemorrhagic stroke; (3) post-stroke duration 24 weeks and above; (4) either right or left sided hemiparesis; and (5) functional ambulation classification28 level 2 and above. The subjects were excluded if they exhibited the following: (1) acute medical illness; (2) other neuromusculoskeletal complication on the less affected side; (3) cardiovascular instability: resting systolic blood pressure w200 mmHg and resting diastolic blood pressure w100 mmHg; (4) serious cardiac conditions (active angina, serious cardiac arrhythmias, hypertrophic cardiomyopathy, severe aortic stenosis); and (5) severe cognitive and perceptual deficits interfered with ability to follow commands.

Methods Participants

Interventions

Post-stroke hemiparetic subjects attending the department of occupational therapy, Pandit Deendayal Upadhaya Institute for the physically 358

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Design The present study was a double blinded controlled clinical trial. The subjects were blinded for the treatment of interest. Thirty-five post-stoke subjects were recruited using the convenient sampling method. Being the pilot study, sample size calculation was not performed. After the baseline assessments, the subjects were randomly assigned either the experimental group (n517) or the control group (n518), using computer-generated random numbers. The blocks were numbered and a random-number generator program was used to select the number. The established sequence of the blocks was allocated to either one or the other group (allocation ratio 1:1). The intervention assignments were enclosed in sealed, opaque and sequentially numbered envelopes. A research assistant at the study site (not the part of study) conducted the random-number program and concealed the allocation till the final enrollment of participants. The experimental and control interventions were given by the two independent therapists. The subjects were blinded for the intervention of interest. Pre- and post assessments, using the outcome measures were carried out by one of the investigators was not involved in the interventions and had no awareness of which intervention the subjects received.

MTLA is a motor therapy program for the less-affected upper limb and lower limb of poststroke subjects. The program utilized PRE for muscle strengthening and BT to enhance skilled interlimb movements. PRE is a

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safe efficacious intervention for any type of muscle force deficits. In the present study, load-resistance exercise principle described by de Lorme was used. The exercise principle is the most commonly preferred and evident protocol for muscle strengthening.23,24 The protocol comprised three sets of exercise. In the first set, 10 movement repetitions against the load equal to the half of 10 repetitions-maximum (10 RM) weight were performed. 10 RM was calculated by assessing the ability of a specific muscle-group to perform 10 movements comfortably against a definite weight. Similarly, in second and third set three-fourth and full 10 RM was considered as the resistance.22 The strengthening method has been used for the stroke subjects; however, for the affected side only.31 The weakness on less-affected side is evident but effect of strengthening has never been explored. In the present study, the protocol was applied primarily for all the major muscle groups of the less-affected side: shoulder (flexors, extensors, abductors, adductors, external and internal rotators), elbow (flexors and extensors), forearm (pronators and supinators), wrist (dorsiflexors and palmarflexors), hip (flexors, extensors, abductors, adductors, external and internal rotators), knee (flexors and extensors), and ankle (dorsiflexors and plantarflexors). If any of the muscle group exhibited strength below normal, the strengthening procedure was performed. BT uses the bilateral active participation of either upper limbs or lower limbs. The training, either in synchrony or in alternation, may enhance recovery of the paretic limb with the help of the less-affected limb. The upper limbs are strongly linked as a coordinated unit to the brain during the simultaneous movement.25 Similarly, both the lower limbs are also linked during the locomotion.32 Additionally, the upper and lower limbs get coupled during gait in form of arm-swing.33 BT was provided as various goal-oriented activities. The activities are listed in Table 1. The repetition of activities ranged from 10 to 15 each. The total intervention duration for the experimental group was 60 minutes (PRE and BT: 30 minutes each). Twentyfour treatment sessions were carried out over a period of 2 months for both the groups. The control group subjects were provided dose-matched (in terms of number and duration of sessions) conventional program based on neurophysiological approach.34 The Brunnstrom movement therapy is one of the neurophysiological techniques, and comprises reflexive movement and synergistic muscle linkage to achieve voluntary control of the limbs. The method encompasses intervention for the affected side exclusively.

Effect of MTLA in post-stroke subjects

Table 1 Goal-oriented activities Activities Bilateral inclined sanding (without cord attachment of the two sanders); increasing the complexity of inclination Horizontal sanding with hands, bilaterally; shoulder horizontal abduction and adduction, elbow flexion–extension, wrist radial–ulnar deviation and flexion–extension Rectangular wooden blocks (table and wall mounted) Pronator–supinator board (two sets for bilateral movement) Hand exerciser (two sets for bilateral movement) Tennis ball (two same size for bilateral squeezing and releasing) Multipurpose wheel Plasticine (bilateral squeezing, releasing, kneading, breaking, tip prehension, pressing, making impression with knuckles of all four fingers) Pegs similar size; lifting by both hands doing same movements Functional activities, for example, combing and setting hairs, water bottle, and glass (lifting, carrying, filling, pouring, drinking holding bottle on another hand. Arm cycling (wall mounted arm-bicycle) Bilateral push up against wall Pouring water from jug to cup/glass Folding a towel Roll a rolling pin back and forth Scooping coins off table top into other hand Pour water from one cup to another Typing keyboard Remove small objects from both the pocket, simultaneously Newspaper: holding turning and folding Bilateral reaching up to cupboards for box Bilateral reaching to pick up and place large objects of different shapes and weights Throwing and catching ball of different sizes, shapes and weights Bilateral ankle exerciser Bike riding/Pedo-cycling Foot roller Rocker board Walking carrying objects in both hands Standing up and sitting down holding loaded tray by both hands Rowing machine Alternate ball kicking; sitting and standing position

The experimental group participants were advised to report any uneasiness experienced during PRE. The vital signs of all the participants were observed pre- and post-intervention sessions.

Outcome measures Two types of outcome measures were used in the present study; first type for the affected side and second type for the less-affected side of the study participants. Measures for the affected side: Brunnstrom Recovery Stage (BRS):34 Brunnstrom recovery stages categorize the motor impairment of arm, hand and lower extremity (BRS-A, BRS-H, and BRS-L, respectively) into six stages (0, no voluntary movement to 6, near to normal movement). Topics in Stroke Rehabilitation

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The stage progresses with increased muscle tone to severe spasticity and reflexive to synergistic movement. Finally, the both the tone and voluntary movement appears near to normal. It is one of the oldest methods to assess and broadly classify the sequential recovery of post-stroke hemiparetic subjects. BRS was found to be a valid and responsive tool to assess the recovery.35,36 It showed a strong correlation with spasticity (r50.81, Pv0.0001) and neurophysiological measures.36 BRS demonstrated acceptable predictive validity (75.6%) when compared to Barthel Index.37 Fugl-Meyer Assessment: Fugl–Meyer Assessment (FMA), a motor assessment tool, assesses sensorimotor recovery of the upper and lower limb in postsstroke hemiparesis.38,39 However, FMA provides an objective and comprehensive evaluation of movement components. The maximum score for two motor sections (upper extremity: FMA-UE, 66 and lower extremity: FMA-LE, 34) of FMA is 100. FMA-UE further comprises subsections for upper arm (FMA-UA) and wrist-hand (FMA-WH). The items of the sections are arranged hierarchically as per the recovery stages and assessed on three-point ordinal scale from 0 (item cannot be performed) to two (items can be fully performed). FMA exhibited excellent reliability (r50.98–0.99) and acceptable validity (r50.61–0.94).40–42 FMA-UE and FMA-LE demonstrated good sensitivity (r50.77–0.87 Pv0.001).43,44 Measure for the less-affected side: Minnesota Manual Dexterity Test: The Minnesota manual dexterity test (MMDT) assesses gross armhand dexterity and eye-hand coordination. It measures the speed and accuracy of repetitive, picking up, placing, and turning ability. The test comprises two test batteries; placing and turning. The placing test of 60 disks which evaluates unilateral upper limb performance was used in the present study. The mean time (in seconds) for four trials of placing all the 60 disks is calculated.45 MMDT exhibited good test-retest reliability (r50.87–0.95).46 Purdue Peg Board Test: The Purdue peg board test (PPBT) estimates gross coordination of the arm, hand and fingers. It examines dexterity of the fingers as well as fine coordination. In the present study, one hand prehension subtest which measures the unilateral coordination was used. The subtest requires placing pins by one hand in the allocated holes of the board. The total number of pins inserted within 30 seconds is the maximum score. PPBT showed excellent test–retest reliability (r50.9–0.96).47,48 Manual Muscle Testing: The subjects were examined by the blind assessor experienced in using 360

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manual muscle testing (MMT). The scoring was recorded using 0 (no muscle contraction) to 5 (contraction against maximum resistance) point grading system. All the standardized guidelines of the tests including order of testing, instructions, and scoring was followed. MMT showed acceptable inter-rater reliability (r50.71–0.96) and intra-rater reliability (0.72–0.93).46 The testing method also demonstrated good validity with hand-held dynamometer (r50.59–0.94).45,49 In the present study, group muscle strength testing was done for all the muscle groups of less-affected upper and lower limbs.

Data analysis Data analysis was done by using IBM SPSS, version 21.0. An intention-to-treat analysis was used with the last observation carried forward for the missing data. The Mann–Whitney U (U), independent t (t), Fisher exact (f), and Chi-square tests were used to compare the demographic and baseline characteristics of the two groups. U test was also use to compare the difference between the groups for BRS and MMT. Parametrically, a repeated-measures twoway ANOVA (continuous data; within factor, time; between factor, group) was performed for other variables. The significance level was set at Pv0.05.

Results There were 82 subjects screened for eligibility; 27 subjects did not meet the inclusion criteria, 8 refused to participate further, and 12 had different reasons to be excluded from the study (Fig. 1). All the subjects in the experimental (n517; 9 males, 8 females; mean+ SD age, 45.53+ 11.74) and control (n518; 10 males, 8 females; mean+ SD age, 40.72+ 11.88 years) groups completed the treatment protocol of 2 months. The groups did not significantly differ in any of the demographic and baseline clinical characteristics (Table 2). The intervention sessions were conducted as outpatient program in occupational therapy unit. One subject in the experimental group and two subjects in the control group were lost for the post-assessment. In comparison to the control, the experimental group showed a favorable improvement on motor recovery measures of the affected side at postassessment. Postintervention, the experimental group demonstrated significant improvement than the control group on FMA-UE (F55.174, P50.03), FMA-UA (F56.442, P50.016), and FMA-LE (F520.88, Pv0.001) (Table 3 and Fig. 2). Similarly, the BRS-A, BRS-H, and BRS-L significantly changed (pv0.001) from pre-test to post-test. However, FMA-WH did not change significantly across the assessments. Measures

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Enrolment

Assessed for eligibility (n=82)

Excluded (n=47) Did not meet inclusion criteria (n=27) Refuse to participate (n=08) Other reasons (n=12)

Analysis

Follow-up

Allocation: Care providers

Allocation: Patients

Randomization (n=35)

Allocated to experimental intervention (n=17) Received allocated intervention (n=17) Did not receive allocated intervention (n = 0)

Centers (n = 1) performing the intervention Care provider (n=1)

Loss to follow-up (n=1) Discontinued intervention (n=0)

Analyzed (n=17; Last observation carried forward 01) Excluded from analysis (n=0)

Allocated to control intervention (n=18) Received allocated intervention (n=18) Did not receive allocated intervention (n = 0)

Centers (n = 1) performing the intervention Care provider (n=1)

Loss to follow-up (n=2) Discontinued intervention (n=0)

Analyzed (n=18; Last observation carried forward 02) Excluded from analysis (n=0)

Figure 1 CONSORT (Consolidated Standards of Reporting Trials)29,30 diagram showing the flow of participants through each stage of the study.

for the less-affected side were found to be improved in the experimental group as compared with the control. MMDT (F - 10.63, P -0.003) exhibited significant favorable decline, while PPBT (F - 7.56, P - 0.01) showed positive rise in the experimental group over the testing periods in comparison to the control group (Table 3 and Fig. 3). The experimental group also demonstrated positive improvement on MMT grades of 12/26 muscle-groups (Pj 0.001–0.043) (Table 3).

The subjects experienced no serious unpleasant events during the study. Two subjects of the experimental group experienced mild exertion during initial two to three sessions. Some of the subjects, especially females, felt post-exercise muscle soreness, which was tolerable and subsided gradually within one or two days.

Discussion In stroke, most of the motor therapies emphasize the contralesional side. However, there exists a variety of Topics in Stroke Rehabilitation

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Table 2 Demographic characteristics of the control and experimental groups Characteristic

Experimental group (n517)

Control group (n518)

45.53+ 11.74 27.60+ 10.26

40.72+ 11.88 29.92+ 11.43

9/8 (53%/47%) 3 (18%)/ 1 (6%)/ 4 (23.5%)/ 0 (0%)/ 1 (6%)/ 6 (35%)/ 2 (12%) 14 (82%)/ 2 (12%)/ 1 (6%) 0 (0%)/ 5 (29%)/ 11 (65%)/ 1 (6%) 6 (35%)/11 (65%) 4 (23.5%)/ 1 (6%)/ 3 (18%)/ 9 (53%) 17 (100%) 3 (18%) 7 (41%) 2 (12%) 6 (35%) 5 (29%)/12(71%) 16 (94%)/1 (6%)

10/8 (56%/44%) 2 (11%)/ 4 (22%)/ 1 (6%)/ 0 (0%)/ 5 (28%)/ 5 (28%)/ 1 (6%) 15 (83%)/ 2 (11%)/ 1 (6%) 2 (11%)/ 6 (33%)/ 9 (50%)/ 1 (6%) 10 (56%)/8 (44%) 6 (33%) 3 (17%) 2 (11%) 7 (39%) 16 (89%) 3 (17%) 3 (17%) 3 (17%) 5 (22%) 9 (50%)/9 (50%) 18 (100%)/0 (0%)

Age (years), mean+ SD Time since stroke (weeks), mean+ SD Male/female (%) Educational qualification (illiterate/5th/8th/10th/12th standard/ undergraduate/above) (%)

Marital status Married/unmarried/widowed/ or divorced Socioeconomic status (below poverty line/ lower/middle/higher) (%) Ischemic/hemorrhagic (%) Area of involvement (frontoparietal/ basal ganglia/thalamus/multiple)

Hypertensive Chronic smokers Alcoholic Diabetes mellitus Obesity Side of involvement (right/left) (%) Dominant side (right/left) (%)

Test statistics t: P50.238 t: P50.221 Chi-square: P50.877

Chi-square: P50.229

f: P50.486 f: P51 Chi-square: P50.109 f: P50.679 f: P50.632 Chi-square: P50.214

Note: SD: standard deviation; t, independent t-test; Chi-square: Chi-square test; f: fisher exact test.

subtle impairments on the ipsilesional side, interfering with the functional performance.3 The deficit are observed in form of reduced dexterity, in-hand manipulation, coordination, and muscle-strength.2 Considering the impairments, MTLA was formulated, specifically for the ipsilesional along with the affected side. The protocol comprised strengthening of the ipsilesional side and BT to possibly reduce the deficits. MTLA would be the first motor-therapy focusing on the less-affected side exclusively. The present pilot study demonstrated that MTLA was more beneficial in improving the less-affected side as well as the affected side when compared with the conventional rehabilitation program. The improvement was observed in motor recovery of the affected upper extremity, and muscle strength, hand-dexterity and coordination of the less-affected extremity. MTLA protocol allowed the stroke subjects to use the affected side and less-affected side simultaneously or together during the bimanual activities. The bimanual tasks may be responsible for the motor recovery on the affected side, and dexterity and coordination on the less-affected side.50–52 Additionally, the strengthening of the less-affected 362

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side may cause facilitation of bimanual performance. Further, the ipsilateral motor inputs may induce activation of bilateral primary motor cortex. There occurs an important communication between the corticospinal system from both the hemispheres.15,53 This could also be the explanation for adequate recovery on the affected side in MTLA group. PRE led to the improvement of muscle strength as evident in the other muscle weakness disorders. Further, it is also recognized that carry-over effect of PRE influences functional performance.31 FMA-WH showed no significant difference between the intervention groups. None of the muscle-group of elbow, forearm, and knee improved significantly in response to MTLA. In accordance with the previous study, ankle plantar flexors (median grade 3) were found to be weakest of all the muscle groups among all the participants.2 The plantar flexors reached to median grade 4 in response to MTLA. Further, five (29%) MTLA subjects reached to independent ambulation from dependent or supervised ambulation in comparison to one (6%) control subject achieving similar change in ambulation. The change could be explained on the basis of improved loading on the less-affected lower limb.54

AffectedSide BRS-A(median) BRS-H(median) BRS-L(median) FMA-UE Mean+ SD Maximumscore—66 FMA-UA Mean+ SD Maximumscore—36 FMA-WH Mean+ SD Maximumscore—30 FMA-LE Mean+ SD Maximumscore—34 Less-affectedside MMDT(seconds) PPBT MMTmedian Shoulder Flexors Extensors Abductors Adductors Externalrotators Internalrotators Elbow Flexors Extensors Forearm Pronators Supinators Wrist Flexors Extensors Ulnardeviators Radialdeviators Hip

Outcomemeasure

4 4 4 4 4 4

4 4

3z 4 4 4

90.35+ 13.06 9.82+ 1.84

4 4

98.94+ 14.17 9.50+ 1.46

21.53+ 3.085

4 4

19.61+ 3.63

10.06+ 9.33

3z 3{ 3z 4 3z 4{

9.72+ 8.98

22.94+ 7.36

3z 3 3z 4 3z 3z

20.50+ 7.55

33.00+ 16.45

Controlgroup (n518)

4 2–3 3–4 30.22+ 15.97

4 3 4

Experimentalgroup (n517)

Pre

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U:P50.423 U:P50.065 U:P50.101 U:P50.455

U:P50.894 U:P50.117

U:P50.397 U:P50.455

U:P50.525 U:P50.423 U:P50.764 U:P50.499 U:P50.659 U:P50.251

t:P50.072 t:P50.568

t:P50.103

t:P50.914

t:P50.340

U:P50.100 U:P50.154 U:P50.081 t:P50.616

Test statistics

Table 3 PreandPostoutcomemeasuresoftheexperimentalandcontrolgroups

4 4 4 4z

4 4

4 4

4 4{ 4z 4 4 4

76.67+ 9.79 12.53+ 1.90

29.24+ 2.70

23.24+ 4.52

32.24+ 3.649

6 5 5–6 55.47+ 7.82

Experimentalgroup (n517)

4 4 4 4

4 4

4 4

3z 3{ 3z 4 3{ 4{

96.33+ 15.47 10.06+ 1.21

21.33+ 3.67

12.67+ 10.129

23.33+ 8.06

36.00+ 17.73

4 3 4

Controlgroup (n518)

... ... ... ...

... ...

... ... ... ... ... ... ... ... ...

22.94–5.31 0.36–2.43

2.72–7.09

{0.03–11.11

1.12–10.21

... ... ... 1.17–21.07

95%CI(differencebetweenthegroups post-intervention)

Post

... ... ... ...

... ...

... ... ... ... ... ... ... ... ...

10.63 7.56

20.88

3.840

6.442

... ... ... 5.174

F

U:P50.928 U:P50.985 U:P50.481 U:P50.004*

U:P50.125 U:P50.964

U:P50.787 U:P50.980

U:Pv0.001* U:P50.043* U:P50.001* U:P50.249 U:P50.037* U:P50.001*

0.003* 0.010*

v0.001*

0.059

0.016*

U:Pv0.001* U:Pv0.001* U:Pv0.001* 0.030*

Pvalue

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3z 3z 3z 3z 3z 3z 4 4 3 4 4 4

4 4 3 4 4 4

Controlgroup (n518)

3z 3z 3 3z 3z 3z

Experimentalgroup (n517)

Pre

U:P50.827 U:P50.721 U:P50.462 U:P50.440

U:P50.972 U:P50.486

U:P50.442 U:P50.512 U:P50.129 U:P50.853 U:P51.000 U:P50.853

Test statistics

4 4 4 4

4 4

4 4{ 4z 4{ 4{ 4{

Experimentalgroup (n517)

3 4 4 4

4 4

3z 3z 3z 3z 3z 3z

Controlgroup (n518)

... ... ... ...

... ...

... ... ... ... ... ...

95%CI(differencebetweenthegroups post-intervention)

Post

... ... ... ...

... ...

... ... ... ... ... ...

F

U:P50.016* U:P50.057 U:P50.829 U:P50.205

U:P50.387 U:P50.636

U:Pv0.001* U:Pv0.001* U:Pv0.001* U:P50.055 U:Pv0.001* U:Pv0.001*

Pvalue

Note:n:number;SD:standarddeviation;CI:confidenceinterval;t,independentttest;F:testvalueforrepeated-measurestwo-wayANOVA.*Statisticallysignificant,BRS-A:Brunnstromrecoverystagesofarm;BRS-H:Brunnstromrecoverystagesofhand;BRS-L:Brunnstromrecoverystagesoflowerextremity;FMA-UE:Fugl–Meyerassessment(upperextremity);FMA-UA:Fugl–Meyerassessment(upperarm);FMA-WH:Fugl-Meyerassessment(wristandhand);MMDT:MinnesotaManualDexterityTest;PPBT:PurduePegBoardTest;MMT:ManualMuscleTesting.

Flexors Extensors Abductors Adductors Externalrotators Internalrotators Knee Flexors Extensors Ankle Plantarflexors Dorsiflexors Evertors Invertors

Outcomemeasure

Table 3 Continued

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Effect of MTLA in post-stroke subjects

Figure 2 Changes in the FMA-UE and FMA-LE scores, respectively (mean and confidence interval) between the groups at pre- and post-assessment; continuous line (experimental group), doted line (control group). Significant improvements were noted for both the measures at post-intervention.

Figure 3 Changes in the MMDT and PPBT scores, respectively (mean and confidence interval) between the groups at preand post-assessment; continuous line (experimental group), doted line (control group). Significant improvements (decline in MMDT and rise in PPBT) were noted for both the measures at post-intervention.

The interhemispheric communication restrains and adjusts the goal-directed bilateral and unilateral movements. Such communication also leads to interlimb joint interaction during a task performance.55–57 Hence, there exists a strong association between the affected and less-affected sides leading to bimanual motor impairments in form of asymmetry and reduced coordination.33,58 The impairment influences

functional performances of both upper limbs and lower limbs. Stroke rehabilitation has usually been focused on the affected (contralateral) side. The rehabilitation should consider both the bodyside to facilitate neural interaction between the hemispheres augmenting motor and functional recovery. Unequal number of right and left hemiparetic subjects in experimental group was one of the limitations Topics in Stroke Rehabilitation

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of this study. The range of post-stroke duration was varied. The sample size was small to deduce the additional findings. Further studies are needed to refine the MTLA protocol as well as to longitudinally observe its effect on a large sample. It is also recommended to investigate the MTLA on the homogenous (types of stroke, side of paresis, level of recovery, and chronicity) groups of post-stroke subjects.

Conclusion In post-stroke subject, the MTLA augmented the motor recovery of the affected side as well as the muscle strength, hand-dexterity, and coordination of the lessaffected side. The improvement was superior to that achieved by the conventional rehabilitation.

Disclaimer Statements Contributors S.P.: conceiving and designing the study, obtaining funding and ethics approval, collecting and interpreting the data, writing and revising the article. K.N.A.: conceiving and designing the study, collecting, analyzing and interpreting the data, writing and revising the article. D.K.: designing the study, interpreting the data, writing and revising the article. Funding The present study was funded by Pt. Deendayal Upadhyaya Institute for the Physically Handicapped, New Delhi, India. Conflicts of interest The authors have no conflict of interest related to this article. Ethics approval The study was approved by the ethics committee of Pandit Deendayal Upadhyaya Institute for the physically handicapped.

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