INTRODUCTION

A stroke, also known as a cerebrovascular accident (CVA), is the rapid

loss of brain function due to disturbance in the blood supply to the brain. This can
be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial
embolism), or a hemorrhage (leakage of blood). As a result, the affected area of
the brain cannot function, which might result in an inability to move one or more
limbs on one side of the body, inability to understand or formulate speech, or an
inability to see one side of the visual field.
A

stroke

is

a medical

emergency and

can

cause

permanent neurological damage, complications, and death. Risk factors for stroke
include old

age, hypertension,

transient

ischemic

attack,

diabetes, high

cholesterol, cigarette smoking and atrial fibrillation.

One direct consequence of stroke is the loss of upper limb function.
Approximately 70-80% of people post-stroke experience impairments in their
upper limb, that reduce upper limb function and impact on a persons ability to
perform activities of daily living. Upper limb rehabilitation is thus important.
Functional return of the upper limb is best enhanced by intensive task specific
practice of functional activities; however, practice should be supervised to enhance
learning of new motor skills. We considered the possibility that upper limb circuit
training groups may potentially be a practical solution to provide intensive task

specific practice in a supervised environment. The evidence in support of circuit

training for the upper limb is limited. Dean et al stated that circuit training has the
potential to provide intensive task specific therapy for the upper limb in stroke.
Cryo means cold or freezing and cryotherapy refers to the practice of using
cold to achieve therapeutic goals. Cooling agents such as cold packs, cold
whirlpool and ice massage are commonly used in the management of pain,
edema and are also effective in decreasing muscle spasm.

STATEMENT OF THE STUDY

Effectiveness of cryotherapy along with upper limb circuit training to
improve upper limb function in stroke patients.

REVIEW OF LITERATURE
Dean et al., 1975
Stated that circuit training has the potential to provide intensive task
specific therapy for the upper limb in stroke.
Lincolone et al., 1995
Found that cryotherapy significantly reduces the shoulder pain and
improving hand function on patients with stroke.
Roberta de oliveiral 1999
Concluded that upper limb circuit training was significantly reduced
shoulder pain and significantly improved hand function in patients with
stroke.
Walsh.K 2000
Stated that upper limb circuit training significantly improving hand function
in patients with stroke.
B Kollen et al., 2002
Suggested that patients maintained their functional gains for up to 1 year
after stroke after receiving a 20 week upper or lower limb function training
programme. However, a significant number of patients with incomplete

recovery showed improvements or deterioration in dexterity, walking ability,

and ADL beyond the error threshold.
Carolynm patten et al.,2004
Concluded that persons with poststroke weakness can improve strength
through resistance exercise in the absence of negative side effects, including
exacerbation of hypertonia. Moreover, these improvements in strength
appear to transfer to functional improvements.
Marijke rensink et al.2008
Found that by actively using task-oriented training in the daily nursing care
of stroke survivors, functional outcomes and overall health-related quality of
life will be improved for these people.
Jocelyn E.harris et al.,2009
Concluded that there is evidence that strength training can improve upperlimb strength and function without increasing tone or pain in individuals
with stroke.
Susan L Hillier et al.,2009
Circuit class therapy is safe and effective in improving mobility for people
after moderate stroke and may reduce inpatient length of stay

further

research is required, investigating quality of life, participation and cost-

benefits, that compares circuit class therapy to standard care and that also
investigates the differential effects of stroke severity, latency and age.
Beverley French et al.,2010
Concluded that repetitive task training resulted in modest improvement
across a range of upper limb outcome measures.
Dorian rose et al.,2010
Concluded that circuit-training model resulted in greater gains in upper limb
function over the course of inpatient rehabilitation compared to the standard
model of care.
Kelly Robinson., 2011
Found that positive effect on upper limb performance for these patients
with chronic stroke at completion of the eight week upper limb circuit
group.

DESIGN AND METHODOLOGY

RESEARCH DESIGN
The study is quasi experimental in nature.
1 st day

8 th week

cryotherapy with Circuit training

Pre - test

post test

Twenty samples were taken for this study. All subjects underwent Pretest
measurements for upper limb function with motor assessment scale (MAS). After
the pre test, the subjects received cryotherapy along with upper limb circuit
training for eight weeks once in a week. Post test measurements were taken on the
8th week in a similar fashion as that of pre test measurements.
CRITERIA FOR SELECTION
INCLUSION CRITERIA
Subjects age group 50 - 65 years
Both sex were included
Subjects those cognitive competency to give informed consent,

 post stroke duration 3months to one year

EXCLUSION CRITERIA
subjects those inability to give informed consent
subjects those unable to follow verbal and written instructions
transient ischemic attack in last three weeks was excluded
chedoke McMasters Stroke Assessment (CMSA) lower than 4
any other neurological or vestibular disorder,
any other comorbid conditions that would make participation in exercise
unsafe.

POPULATION
All the patients who fulfilled the selection criteria were taken as the
Population of the study.
SAMPLE SIZE AND METHOD OF SELECTION
Twenty samples were selected from the population using simple Random
sampling method.
VARIABLES
Independent variable
cryotherapy

 circuit training

Dependent Variable
upper limb function

VALIDITY AND RELIABILITY OF THE TOOL USED

The Motor Assessment Scale (MAS) was used to assess activity based
problems. The Motor assessment scale has three upper limb focused subsections;
upper arm, arm and hand, and has proven validity and reliability (Carr et al 1985).
SETTING
This

study

was

conducted

in

the

out

patient

department

of

physiotherapy,Vinayaka Missions Medical College Hospital. Salem.

METHODOLOGY
Cryotherapy
Ice cube was taken in a turkey towel exposing one surface and stroked over
the shoulder joint, maintaining a continuous and direct contact for 10 minutes.
Circuit training
All participants attended the upper limb circuit training group for one hour
once a week, for eight weeks. Each session commenced with the participants
stretching their muscles in their affected upper limb that had increased muscle

tone, for example the wrist flexors and biceps. Participants then rotated between
six stations, spending six minutes at each station. Six forms of therapy were
included and consisted of; 1) reach and grasp activities, 2) fine motor skill
activities, 3) strength training, 4) sensory retraining, 5)virtual reality activities, and
6) cardiovascular training (table 1). A variety of options were available at each
station to suit the individuals capabilities

Table 1: Overview of the different workstations, ranging in difficulties, for the

upper limb circuit group
NO
1

Work station
Reach and
Grasp
+/- FES
+/- Slings

Exercise
1

Exercise
2

Slide
pillow case
on table:
- back and
forward
-round in
circles

Reach for
objects
in one box
and
move them
into
another box
(change
height if
appropriate)
Play
solitaire on
a
large board

Exercise
3

Exercise
4

Move a
stack of
cones from
left
hand side
of the
table to the
right,
one at a
time
Fine
Motor Writing
Move items Take pegs
Skills
in and
on and
out of a
off a pole
box with
tweezers
Strength
Play with Lift heavy
Resist
putty
objects
movements
out of a box using
Theraband
Sensory
Weight
Retrieve all
bearing
items
on affected from within
hand
a tub

Exercise
5

Turn over
pack of
cards, one
card at
the time

Nintendo Wii

Fitness

whilst
reaching
with the
other
hand to
stack
cones
Bowling
game
Arm bike
Low
resistance

of rice

Baseball
game
Arm bike
Medium
resistance

Tennis
game
Arm bike
High
resistance

In the first week the examiner assessed the participants capabilities and
assigned the appropriate exercises to be carried out at each of the six stations. The
examiner used clinical experience to guide progression of the exercises at each
station over the eight weeks. Participants received copies of the exercise
programmes to continue practicing at home after discharge. Family members and
carers were educated on facilitating the correct exercise techniques.

OBSERVATION AND ANALYSIS

The collected data were analyzed using paired t test.
Table 1.1
Circuit training
Variables

t cal value

t table value

Upper limb function

9.46

2.093

t calculated value > t table value

Significant at 5% level.

RESULTS AND DISCUSSIONS

RESULTS
The data was subjected to statistical analysis and the following results were
obtained
There is a statistically significant improvement in the upper limb function
for the patients who underwent cryotherapy along with circuit training.

DISCUSSION
The results of this study indicate that 8 weeks of cryotherapy along with
circuit training exercise significantly improve upper limb function in patients with
stroke.
The application of cryotherapy leads to reduced velocity of nerve conduction
and depressed sensitivity of receptors such as muscle spindle. The stimulus
produced by cold also has an inhibitory effect on the alpha motor pool which
ultimately reducing the pain.
Our data show a significant improvement in upper limb function in patients
with stroke after a relatively brief 8 weeks of cryotherapy along with circuit

training, which indicates that circuit training has a beneficial effect on upper limb
function in stroke patients.
It is our belief the results raise two issues of interest with regard to improved
understanding of upper limb management following a stroke event. Firstly, the
persons recovering from stroke the eight week upper limb circuit group appeared
to have a positive effect on aspects of their upper limb performance. This is in
concordance with previous reports that upper limb function improves with
additional task related practice (Blennerhasset and Dite 2004).
Secondly, in terms of pain the upper limb circuit training did not have a
negative effect on self reported pain. This supports the findings of English et al
(2008). In fact, at three months follow up, reported a reduction in pain which
coincided with an improvement in participation.
At an individual level, there was an overall positive effect following the eight week
intervention in performance of the upper limb circuit group. These improvements
were more specific to advanced hand activity scores and may be associated with
two factors. Firstly, for these patients the time since stroke was relatively short.
Secondly, both scored highly at baseline for arm and hand measures and may,
therefore, have been more likely to achieve a higher upper limb function
(Nakayama et al 1994).

RECOMMENDATIONS
The limited number of participants included in this study varied widely in:
days post stroke, types of right sided infarct and severity of symptoms which may
have lead to difficulties in identifying firm trends regarding the effectiveness of the
group. Further research would need a larger more homogeneous sample size to
establish a relationship between the upper limb circuit group and upper limb
performance.

CONCLUSIONS
The results of this study make us to conclude that cryotherapy along with
upper limb circuit training is effective to improve upper limb function on patients
with stroke. These findings indicate that regular cryotherapy along with circuit
training could be a part of inpatient and outpatient stroke rehabilitation programs.

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APPENDIX