Scientific Research Journal of India ● Volume: 2, Issue: 4, Year: 2013

EFFECTIVENESS OF SUPERVISED GRADED REPETITIVE ARM

SUPPLEMENTARY PROGRAM ON ARM FUNCTION IN SUBJECTS WITH
STROKE

Dr.Harsha Tummala, MPT (Neurology)*, Dr.V.Srikumari, MPT (Neuro), PhD.**, Dr. K.Madhavi,
MPT (CT), PhD., ***

ABSTRACT
PURPOSE: The aim of the present study is to evaluate the effect of supervised GRASP protocol in improving
arm function in subjects with stroke. DESIGN: A RCT, Prospective-exp-design with pre test-post-test design.
SETTING: College of physiotherapy OPD, General ward of Sri Venkateswara Institute of Medical Sciences
(SVIMS), Tirupati. SUBJECTS: 30 subjects divided into 2 groups, control group (n=15) & experimental
group (n= 15). INTERVENTION: For experimental group: Conventional physiotherapy with Supervised
GRASP protocol for upper limb (In the presence of therapist or caregiver). For control group:Conventional
physiotherapy with home program exercises with printed GRASP material. DURATION: 6 weeks, 5days in a
week. OUTCOME MEASURES: (1) The Chedoke Arm and Hand Activity Inventory-9 (CAHAI) was used to
evaluate the performance of the paretic upper limb in the completion of activities of daily living (ADL). (2)
The Box and Block test (B&BT) to measure upper limb functional performance of basic manual dexterity. (3)
Isometric grip strength of the paretic hand was tested using a jammer hand grip dynamometer. RESULTS:
According to the obtained values, the pre and post test values of CAHAI-9, B&BT and grip strength had an
extremely significant effect with p value < 0.0001 in both control and experimental group. On comparing the
results between the groups: The experimental group CAHAI-9, (p-value is 0.0001) and B&BT (p-value is

31
 ISSN: 2277-1700 ● Website: http://srji.drkrishna.co.in ● URL Forwarded to: http://sites.google.com/site/scientificrji

0.0020) is considered very significant comparing to control group. The grip strength (p-value is 0.0005) is
considered extremely significant than the control group. CONCLUSION: After 6 weeks of intervention
program, both the supervised and unsupervised groups had a greater improvement in arm function with
GRASP protocol; but, supervised group had a better improvement in ADL performance, manual dexterity and
grip strength when compared to unsupervised group. Hence this study recommends the supervised GRASP
protocol for improving arm functions in subjects with stroke.

KEY WORDS: Stroke, Upper limb, GRASP, CAHAI, ADL

INTRODUCTION limb is vital to the completion of many

Among all the neurological diseases
of adult life, stroke or cerebrovascular
accident (CVA) clearly ranks
frequency and importance. It is a leading
cause of disability among adults in developed
countries and it may persist for lifelong and
limits independence and quality of life
Approximately 20 million people each year
will suffer from stroke and of these 5 million
[2].
will not survive The incidence of stroke
in developing countries will
approximately 30% between 2000 and 2025.
In 2005 it accounts for 5.7million deaths
worldwide and it is estimated that this
number will climb to 6.3 million in 2015 and
7.8 million in 2030.
Although most of the stroke survivors regain
independent ambulation, many
difficulty in performing activities of daily
living (ADL) especially their self care and
[3].
house hold duties More than 70% of
individuals experience upper-limb paresis
[4].
after stroke The functional limitation in
upper extremity is one of the most common
disabling deficits after stroke. Use of upper
activities of daily living (ADL), as well as to
socialization and health-related quality of life
[5, 6].
first in
According to the theory learned non-use
repeated disappointments in attempts to use
[1]. the affected arm in acute phase can lead to
negative reinforcement of using the affected
arm. The individual learns not to use the
affected extremity[7, 8]. This compensation has
been show to hinder recovery of function in
grow
the upper limb and suppression of movement.
The restraint and training techniques
appeared to be effective because they
successfully overcame the learned non-use [9].
Greater amounts of upper extremity
therapy during rehabilitation can improve the
ability to use one’s arms and hands In the
have
rehabilitation treatment for the paretic upper
limb, it is apparent that increased treatment
intensity using repetitive task oriented
methods improves motor and functional
recovery compared to facilitative approaches
[10].
Thus, a novel method which is

32
 Scientific Research Journal of India ● Volume: 2, Issue: 4, Year: 2013

practical, inexpensive and well-received by glasses(2), hand towel, tooth paste and tooth
the patients and clinicians are needed to brush, knife, fork, thera putty,
deliver greater amounts of therapy with a
Inclusion criteria: Stroke subjects with 40
focus on improving functional tasks of upper
to70 years of age; both males and females;
extremity. One of such method is Graded
with active scapular elevation (shoulder
Repetitive Arm Supplementary Program
shrug) against the gravity; voluntary control
(GRASP)
grading of 2 and 3 ;MAS score between 1 to
GRASP is mostly used as a home 2 and Fugl-Meyer Upper Limb Motor
based exercise program which serves as a Impairment Scale score between 26 and 45.
complement to the regular physical therapy.
Exclusion criteria: Stroke subjects with
It is a self-directed arm and hand exercise
unstable cardiovascular status; MMSE below
program which is supervised by a therapist,
20; Cognitive deficits; Musculo-skeletal
but done independent by the patient (and
disorders; Receptive aphasia & Non co-
with their family if possible). But the
operative patients.
effectiveness of any home based exercise
regimen is not clearly studied because of the OUTCOME MEASURES: The Chedoke
adherence to the program and patient Arm and Hand Activity Inventory-9
motivation. So, this needs to supervise by the (CAHAI) were used to evaluate the
therapist or a caregiver. The need of this performance of the paretic upper limb in the
study is to find out the importance of completion of activities of daily living
therapist supervision in implementing (ADL).
GRASP program to stroke subjects.
1. The Box and Block test to measure
Material and methodology: Subjects were upper limb functional performance of
recruited from the college of Physiotherapy basic manual dexterity.
OPD & General ward of Sri Venkateswara 2. Isometric grip strength of the paretic
Institute of Medical Sciences (SVIMS), hand was tested using a hand grip
Tirupati, India. dynamometer.

Materials: Hand gripper, ball, light rubber All the subjects were selected on the
weight (half kg), clothe pegs, Lego-pieces, basis of inclusion criteria; were divided into
paper clips &target board, Jammer hand grip 2 groups; Control group & experimental
dynamometer & Box and block test kit. group with 15 subjects in each group. The
CAHAI materials : plastic jar & lid, subjects participated in this study voluntarily
telephone, scale(30 cms), pencil, water after signing the consent form. The
33
 ISSN: 2277-1700 ● Website: http://srji.drkrishna.co.in ● URL Forwarded to: http://sites.google.com/site/scientificrji

demographic data, baseline measurements

were collected from both the groups and the
INTERVENTION
purpose of the study was explained to all the
subjects. All the three outcome Experimental Group: Conventional
measurements are measured initially before physiotherapy + Supervised GRASP protocol
the intervention and after 6weeks of for upper extremity. (In the presence of
intervention in both the groups. therapist or caregiver.)

Control Group: Conventional physiotherapy

+ Home program exercises with printed
Table 1: Demographic & Clinical
GRASP material (Telugu and English
characteristics of sample at baseline.
versions)
Control Experi-
Conventional physiotherapy: Stretching’s
group mental
Variable’s to spastic group of muscles of upper
group
(n=15) limb;Electrical stimulation to weaker group
(n=15) of muscles of upper limb;Strengthening
exercises to arm and hand;Free exercises and
Sex, n 9M / 6F 8M /7F
active movements to upper limbs &Weight
Age (mean), yrs 56.5 54.2 bearing exercises to upper limb.

Side of paresis, n 8R/7L 10R/5L STATISTICAL ANALYSIS:

Fugl-meyer arm 34.6 35.2 (6.2) Statistical analysis was done using
score, max=66 (4.6) ‘Graph pad instant 3’ version software. For
(mean ± SD) this purpose the data was entered into
Microsoft Excel spread sheet, tabulated and
CAHAI-9, 25.8(8.5) 23.4(6.9)
subjected to statistical analysis.
max=63,(mean±SD
) To compare the pre and post

B&BT, (mean±SD) 10.2(5.0) 10.6(4.8) treatment effect within the group paired
sample t test was used, and to compare the
Grip strength, 3.2(1.1) 3.5(0.88) pre and post test treatment effect between the
(mean±SD), kg groups unpaired t-test was used.

RESULTS:
Results of control group: (Refer table: 2)
CAHAI-9 result: The p-value is < 0.0001
34
 Scientific Research Journal of India ● Volume: 2, Issue: 4, Year: 2013

which shows there is a extremely significant intervention had shown significant impact on
difference. The t-test value is 21.767 with 14 the subjects.
degrees of freedom. It is observed that the post
Grip strength result: The p-value is < 0.0001
intervention had shown significant impact on
which shows there is a extremely significant
the subjects.
difference. The t-test value is 9.727 with 14
B&BT result: The p-value is < 0.0001 which
degrees of freedom. It is observed that the post
shows there is a extremely significant
intervention had shown significant impact on
difference. The t-test value is 9.057 with 14
the subjects.
degrees of freedom. It is observed that the post

Table 2: Analysis of control group with pre and post intervention:

Parameter Mean SD t-value DF P-

value

Pre 25.866 8.676 21.767 14 <0.0001

CAHAI-9 Post 29.666 9.005

Pre 10.866 3.523 9.057 14 <0.0001

B&BT Post 12.933 3.674

Pre 2.967 1.274 9.727 14 <0.0001

Grip strength Post 3.9 1.339

Results of experimental group :( Refer table: 3)

CAHAI-9 result: The p-value is < 0.0001
which shows there is a extremely significant
difference. The t-test value is 13.266 with 14
degrees of freedom. It is observed that the post
intervention had shown significant impact on
the subjects.
B&BT result: The p-value is < 0.0001 which
shows there is a extremely significant
difference. The t-test value is 18.806 with 14
degrees of freedom. It is observed that the post
intervention had shown significant impact on
the subjects.
Grip strength result: The p-value is < 0.0001
which shows there is a extremely significant
difference. The t-test value is 12.426 with 14
degrees of freedom. It is observed that the post
intervention had shown significant impact on
the subjects.

35
Table 3: Analysis of Experimental group with pre and post intervention

Parameter mean SD t-value DF p- value

Pre 23.466 6.906 13.266

CAHAI-9 Post 37.93 3.955

14 <0.0001

Pre 10.666 4.865 18.806

B&BT Post 18.666 5.394

14 <0.0001

Pre 3.4 1.256 12.426

Grip strength Post 5.9 1.429

14 <0.0001

COMPARISON BETWEEN THE GROUPS:

CAHAI Results: To compare the results of
between the group of control & experimental
groups, the unpaired t-test was selected. The
p-value is 0.0030, the difference is considered
very significant. The values of CAHAI are
improved in control group as well as
experimental group, but the improvement is
more is experimental group.
B&BT Results: The p-value is 0.0020, the
difference is considered very significant. The
values of B&BT are improved in control
group as well as experimental group, but the
improvement is more is experimental group.
Grip strength results: The p-value is 0.0005,
the difference is considered extremely
significant. The values of B&BT are improved
in control group as well as experimental
group, but the improvement is more is
experimental group.

Table 4: Comparison of between the groups of control and experimental group

36
 Scientific Research Journal of India ● Volume: 2, Issue: 4, Year: 2013

Para-meter t-value p-value

Mean S.D df

CAHAI-9 Experimental 37.93 3.955 28 0.0030

Control 29.666 9.005 3.255

B&BT Experimental 18.666 5.394 28 0.0020

Control 12.933 3.674 3.402

Grip Experimental 5.9 1.429 28 0.0005

strength
Control 3.9 1.339 3.955

DISCUSSION: involving meaningful interaction with an

The results of the present study
revealed that there is a significant difference in
both control and experimental group which
indicates that GRASP protocol is effective in
improving arm function in stroke subjects.
Our intervention techniques (GRASP)
are based on the repetitive task oriented
practice which contains 3 designed principles;
such as, skill acquisition of functional tasks,
active participation training and individualized
adaptive training. All these 3 principles are
helped in improving arm function with
GRASP protocol. The task oriented training is
emerging as the dominant and most effective
approach to motor rehabilitation of upper
extremity function after stroke[11].
And these task oriented exercises are
based on the concrete task rather than abstract
task. Subjects showed a superior motor
performance when performing a concrete task
object compared to an abstract task with no
object involved [12]. The movement was
faster in the concrete task than in the abstract
task [13]. Repetitive exercise may be as
critical to motor learning and it may drive
brain reorganization by what appears to be as
process of motor learning [14]. Time spent
completing the GRASP protocol was a
significant predictor of improvement in both
variables (CAHAI and B&BT) in both the
groups.
But, the supervised exercises is very
significant than unsupervised with CAHAI
and B&BT, and it is extremely significant in
grip strength. In the supervised group, during
intervention with the subjects, therapist used
the verbal cues and tactile cues to the subject
to complete the task in a proper way & in a
correct manner to avoid wrong synergy
pattern. And, therapists used sensory input,

37
 ISSN: 2277-1700 ● Website: http://srji.drkrishna.co.in ● URL Forwarded to: http://sites.google.com/site/scientificrji
verbal guidance and rewards to help the
patient to learn the task or to complete the
GRASP protocol.
Physical guidance are also used by the
therapist throughout the whole protocol/task to
demonstrate what is to be done and how to do
the task and it is given during the beginning,
middle and in finishing the task. All these
above factors help the supervised group to
improve the CAHAI.
In the supervised group, the therapist
used the extrinsic feedback. The extrinsic
feedback is provided to the subjects with
knowledge of result (KR) and knowledge of
performance (KP) by the therapist’s verbal
and tactile cuing during intervention
For example, to improve manual
dexterity, the therapist used
feedback. Here, the goal is to pickup small
blocks from the peg board. KR is given in the
form of amount of time needed to complete
the task (whole peg board). KP is given
regarding information about the movement
patterns in the shoulder, elbow, wrist and
finger during grasping a block and during
releasing a block. So, with the help of
extrinsic feedback (KR and
supervised group had a statistically greater
improvement in manual dexterity of hand with
box and block test (B&BT).
When compared to the unsupervised
grip strength, the supervised grip strength is
extremely significant because, the subjects
practiced the grip strength exercises such as
Grip power, finger power, the twist and finger
strength in the GRASP Protocol with the help
of thera putty. During these thera putty
exercises, the subjects are complained about
the fatigueness and pain in the hands in both
groups
But in supervised group, proper resting
time and changing of exercises are advised.
But Modification of exercises are also done by
the therapist when the patient is not able to
perform the protocol and during these putty
exercises.
In unsupervised group, due to pain
and fatigue, subjects less used these theraputty
exercises compared to other exercises. Due to
poor adherence, (participating in less than half
required time), there is no therapist or family
extrinsic
member to explore the reasons behind the
problems and lack of solutions for the
problems.
The result of GRASP is better with the
involvement of therapist of caregiver or who
can assist with the exercises like track the
amount of exercise, motivation to the patient,
helping counting the repetitions; assist with
KP), the the positioning equipment like the target board
etc.
Researchers noted that the motor
cortex (M1) changes occurred (motor
learning) when (a) New or novel task were
used, (b) when movements were practiced
together, (c) when movements were frequently
38
 Scientific Research Journal of India ● Volume: 2, Issue: 4, Year: 2013

repeated and (d) when movements were biomechanical basis, and practicing on real
important to the individual [15]. Our life activities. It is established well that real
intervention program (GRASP protocol), life practice are more beneficial for motor
meets the above same criteria which play a relearning. The present study aimed to assess
important role in motor learning. The whether there is any significant difference in
supervised group, play a major role in motor the effectiveness of GRASP protocol between
learning and neural plasticity. supervised and non supervised program in arm
function. On the above discussed & tabulated
Hence, the use of verbal and tactile
data and results after 6 weeks of intervention
cues, proper sensory input, verbal guidance,
program, it is concluded that both the
motivation, rewards and with proper feedback
supervised and unsupervised GRASP
by the therapist helps in process of motor
protocols shown greater improvement in arm
learning. Hence, this motor learning enhances
function. Further, supervised Grasp protocol
the neural plasticity of the brain.
helps in better improvement in ADL

CONCLUSION: performance, manual dexterity and in grip

strength when compared to unsupervised
Task oriented program has been GRASP. Hence this study recommends that
proven one of effective methods of supervised GRASP protocol for improving
management for stroke related disabilities. arm functions in stroke subjects.
The GRASP program is based on the concepts
of task oriented program which aims to treat DEDICATION: To our beloved

the motor problems on the neuro ‘Physiotherapy’ profession &God Almighty.

REFERENCES

[1]. Duncan PW, Samsa GP, Weinberger M, Goldstein L, Bonito A, Witter D,Enarson C, Matchar D. Health status of
individuals with mild strokes. Stroke. 1997; 28:740–745.
[2]. Dalal P, Bhattacharjee M, and Vairale J, Bhat P. UN millennium development goals: can we halt the stroke
epidemic in India? Ann Indian Acad Neurol 2007; 10: 130-6.

39
 ISSN: 2277-1700 ● Website: http://srji.drkrishna.co.in ● URL Forwarded to: http://sites.google.com/site/scientificrji

[3]. S Sunder, Text book of rehabilitation. 2nd edition, New Delhi, Jaypee publication, 2002, page 351.
[4]. Nakayama H, Jorgensen HS, Raaschou HO, Olson TS. Recovery of upper limb function in stroke patients: the
Copenhagen stroke study. Arch Phys Med Rehabil. 1994;75:394–398.
[5]. Dromerick AW, Lang CE, Birkenmeier R, Hahn MG, Sahrmann SA, Edwards DR. Relationship between upper-limb
functional limitations and self-reported disability 3 months after stroke. J Rehabil Res Develop.2006; 43:401–408.
[6]. Nichols-Larsen DS, Clark PC, Zeringue A, Greenspan A, Blanton S. Factors influencing stroke survivors’ quality of
life during subacute recovery. Stroke. 2005;36:1480–1484.
[7]. Taub E, Berman A. Movement and learning in the absence of sensory feedback. In: Freedman S, ed. The
neuropsychology of spatialy oriented behavior. Homewood: Dorsey Press; 1968, p. 173–192.
[8]. Taub E, Miller NE, Novack TA, Cook EW, 3rd, Fleming WC,Nepomuceno CS, et al. Technique to improve chronic
motor deficit after stroke. Arch Phys Med Rehabil 1993; 74: 347–354.
[9]. Jean-Marie Andre, Jean-Pierre Didier, and Jean Paysant. FUNCTIONAL MOTOR AMNESIA” IN STROKE (1904)
AND “LEARNED NON-USE PHENOMENON” (1966); J Rehabil Med 2004; 36: 138–140.

[10]. Barreca S,Wolf sl, Fasoli S,Bohannon R. Treatment interventions for the paretic upper limb of stroke survivors: A
critical review. Neurorehabil Neural Repair.2003Dec;17(4):220-6.
[11]. Schweighofer N, Choi Y,Winstein c. Task-oriented rehabilitation robotics. Am J Phys Med Rehbil. 2012 Nov;91(11
suppl 3):s270-9.
[12]. Vander weel,FR,et al (1991). Effect of task on movement control in cerebral plasy: Implications for assessment and
therapy. Dev Med child Neurol,33,419-426.
[13]. Van vliet p, Kerwin DG, Sheridan M et al.(1995). The influence of goals on the kinemetics of reaching following
stroke. Neurol Rep,19,11-16.
[14]. A sanuma H, Kellera(1991) Neuronal mechanisms of motor learning in mammals. Neuro report,2,217-224.

[15]. Byl N : The neural consequences of repetition, Neural Rep 24:60-70,2000.

CORRESPONDING AUTHOR:

*MPT (Neurology), MIAP, College of physiotherapy, SVIMS, Tirupati, India. Email

:tummalaharsha@gmail.com

** MPT (Neuro), Ph.D., Assistant professor, college of physiotherapy, SVIMS, Tirupati.

*** MPT (CT), Ph.D., Professor, principal, college of physiotherapy, SVIMS.

40