effect of the bobath concept on upper limb and hand

EFFECT OF THE BOBATH CONCEPT ON UPPER LIMB

AND HAND FUNCTION IN STROKE INDIVIDUALS

WITH MODERATE TO SEVERE ARM DEFICIT

BY

MISS THANCHANOK PUMPRASART

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF

THE REQUIREMENTS FOR THE DEGREE OF MASTER OF

SCIENCE (PHYSICAL THERAPY)

FACULTY OF ALLIED HEALTH SCIENCES

THAMMASAT UNIVERSITY

ACADEMIC YEAR 2017

COPYRIGHT OF THAMMASAT UNIVERSITY

Ref. code: 25605812030533ARL

Thesis Title EFFECT OF THE BOBATH

CONCEPT ON UPPER LIMB AND

HAND FUNCTION IN STROKE

INDIVIDUALS WITH MODERATE

TO SEVERE ARM DEFICIT

Author Miss Thanchanok Pumprasart

Degree Master of Science

Major Field/Faculty/University Physical Therapy

Faculty of Allied Health Sciences

Thammasat University

Thesis Advisor

Thesis Co-Advisor

Academic Year

Asst. Prof. Noppol Pramodhyakul,

Ph.D, PT.

Pagamas Piriyaprasarth, Ph.D, PT.

2017

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ABSTRACT

Background/Aims:

Many chronic stroke individuals still have neurological deficits with

impairments and activity limitations. Most are unable to use their affected upper limb.

The therapy based on the Bobath concept could improve upper limb and hand function

in chronic stroke, yet its effect has not been clearly demonstrated in patients with

different degrees of deficit severity. Therefore, the aim of this study was to compare

the effectiveness of the Bobath therapy program on upper limb and hand function,

muscle tone, and sensation in chronic stroke with moderate to severe arm deficits.

Methods:

The current study was the quasi-experimental study. The intervention program

consisted of the preparation phase 15 minutes (passive stretching and muscle

mobilization), movement facilitation (shoulder flexion, scapular protraction, elbow

extension, wrist extension, finger extension and opposition), and task specific training

with and without objects (target location, reaching, and skilled grasp). The treatment

frequency was 3 days/ week for 6 weeks. In each session, participants practiced 20

repetitions per set, 3 sets per task. The Wolf Motor Function Test was used to evaluate

upper limb function. The Fugl-Meyer Assessment of upper extremity (FMA-UE), the

Modified Ashworth Scale (MAS), and the Revised Nottingham Sensory Assessment

(RNSA) was used to evaluate impairments.

Results:

The participants were chronic stroke individuals in community with moderate

arm deficits (n=13) and severe arm deficits (n=13). Almost all items of the WMFT

(functional ability scale and movement time) and the FMA-UE demonstrated

statistically significant improvements (p < 0.05) between pre and post interventions.

The MAS of shoulder adductors, wrist flexors, and finger flexors demonstrated

statistically significantly decrease post the intervention (p < 0.05). For sensory

assessment, only stereognosis demonstrated statistically significantly difference post

intervention

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Conclusions:

The findings supported the use of the Bobath therapy program in 6 weeks for

enhancing upper limb and hand function as well as impairment minimization in chronic

stroke with moderate to severe arm deficits. Further investigation on the retention effect

such as at 3, 6 months, and one year post intervention is warrant.

Keyword Bobath therapy, chronic stroke, upper limb and hand function, arm deficits

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ACKNOWLEDGEMENTS

I would like to express my sincere gratitude to my advisor Asst. Prof. Noppol

Pramodhyakul and Pagamas Piriyaprasarth for their excellent academic support, good

advice and continuous supervision during entire process of dissertation.

I would like to thank all participants of this study. The thesis could not have

been completed without their participation. I am extremely thankful to the research

assistants for their great effort and valuable time. I am grateful to village health

volunteers and all authority who participated in Khlongluang municipality, Thaklong

municipality and Rangsit city municipality for contacting participants.

I would like to thank Thammasat University for research fund. It would not be

possible for me without their support. Finally, I would like to thank my family and my

friends for their assistance.

Miss Thanchanok Pumprasart

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TABLE OF CONTENTS

Page

ABSTRACT (1)

ACKNOWLEDGEMENTS (3)

LIST OF FIGURES (9)

LIST OF TABLES (10)

CHAPTER 1 INTRODUCTION 1

1.1 Background and rationale 1

1.2 Research question 3

1.3 Objective 3

1.4 Research hypothesis 3

1.5 The variables used in the study 5

1.6 Potential benefits of the study 5

CHAPTER 2 LITERATURE REVIEW 6

2.1 Stroke 6

2.1.1 Definition 6

2.1.2 Incidence of stroke 6

2.1.3 Impairments post stroke 7

2.1.4 Problems of arm deficits post stroke 7

2.1.5 Recovery after a stroke 8

2.1.6 Factors affecting recovery of stroke 9

2.1.7 The prognosis of arm recovery post stroke 9

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2.2 Interventions for improving upper limb

and hand function in patients with stroke 10

2.3 Bobath therapy 12

2.3.1 Bobath concept 12

2.3.2 Theoretical underpinning the Bobath concept 13

2.3.3 Bobath approach for upper limb

and hand function improvement 14

2.3.4 Clinical applications of Bobath therapy 14

2.4. Measurements of impairments and function of upper limb and hand 15

CHAPTER 3 MATERIAL AND METHOD

3.1 Intra- and Inter-rater reliability test of the Wolf Motor Function Test and

Fugl-Meyer assessment of the upper extremity 18

3.1.1 Participants (Patients with stroke) 19

3.1.1.1 Sample size 19

3.1.1.2 Inclusion criteria 21

3.1.1.3 Exclusion criteria 21

3.1.2 Assessors 22

3.1.3 Assessment tools and equipment 22

3.1.4 Method 23

3.2 Effect of the Bobath therapy on upper limb and hand function in stroke

individuals with moderate to severe arm deficit 23

3.2.1 Participants (patients with stroke) 23

3.2.1.1 Sample size 23

3.2.1.2 Sampling 25

3.2.1.3 Discontinuous criteria 25

3.2.2 Trainer 25

3.2.3 Assessors 25

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3.2.4 Assessment tools and equipment 25

3.2.5 Research design and setting 27

3.2.6 Method 27

3.2.7 Assessment 27

3.2.8 Variables 27

3.2.9 Interventions 28

3.2.9.1 Intervention Program 29

3.2.9.2 Bobath therapy 31

3.3 Data Analysis 41

CHAPTER 4 RESULTS

4.1 Intra- and inter-rater reliability test of the Wolf Motor Function

Test and the Fugl-Meyer Assessment of the upper extremity 42

4.1.1 Intra- and inter-rater reliability test of

the Wolf Motor Function Test 42

4.1.2 Intra- and inter-rater reliability test of

the Fugl-Meyer assessment of the upper extremity 47

4.2 Effect of the Bobath therapy on upper limb and hand function in

stroke individuals with moderate to severe arm deficits 48

4.2.1 Characteristics of the participants in the reliability study 49

4.2.2 Wolf Motor Function Test (movement time) of the affected side 51

4.2.3 Wolf Motor Function Test (functional ability scale)

of the affected side 52

4.2.4 Fugl-Meyer assessment of the upper extremity 53

4.2.5 Modified Ashworth Scale 57

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4.2.6 Revised Nottingham Sensory assessment 58

CHAPTER 5 DISCUSSION

5.1 Intra- and inter-rater reliability test of the Wolf Motor Function Test

and the Fugl-Meyer assessment of the upper extremity 59

5.2 Effect of the Bobath therapy on upper limb and hand function

in stroke individuals with moderate to severe arm deficits 59

5.2.1 The characteristics of participants 61

5.2.2 The effect of the Bobath therapy on upper limb

and hand function 61

5.2.3 The effect of the Bobath therapy on upper limb

and hand impairments 65

5.2.3.1 Muscle tone 66

5.2.3.2 Sensation 69

CHAPTER 6 CONCLUSION 73

REFERENCES 74

APPENDICES

APPENDIX A Ethical approval 91

APPENDIX B Information sheet 94

APPENDIX C Informed consent form 110

APPENDIX D General data form 116

APPENDIX E Thai version - The Mini–Mental State Examination 117

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APPENDIX F Visual Analog Scale 121

APPENDIX G Wolf Motor Function test 122

APPENDIX H Fugl - Meyer Assessment (upper extremity) 124

APPENDIX I Modified Ashworth Scale 128

APPENDIX J Revised Nottingham Sensory Assessment 129

APPENDIX K Raw data

Intra- rater and inter-rater reliability test of the Wolf Motor Function

Test and the Fugl-Meyer assessment of the upper extremity 134

APPENDIX L Raw data

Effect of the Bobath therapy on upper limb and hand function in

stroke individuals with moderate to severe arm deficits 145

APPENDIX M Result

Comparison between moderate and severe level of severity 174

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LIST OF FIGURES

Page

Figure 1.1 Conceptual framework 4

Figure 2.1 Recovery after a stroke 8

Figure 3.1 Experimental flowchart 40

Figure 4.1 Participant flowchart 48

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LIST OF TABLES

Tables Page

Table 3.1 Assessment (pre-intervention) 28

Table 3.2 Detail of intervention 29

Table 3.3 Preparation for treatment 30

Table 3.4 Bobath therapy 31

Table 4.1.1 Characteristics of the participants 43

Table 4.1.2 Intra and inter-rater reliability of the

Wolf Motor Function Test (movement time) of the affected side 44

Table 4.1.3 Intra- and inter-rater reliability of the Wolf Motor Function Test

(movement time) of the less-affected side 45

Table 4.1.4 Intra- and inter-rater reliability of the

Wolf Motor Function Test (functional ability scale)

of the affected side 45


Wolf Motor Function Test (FAS) of the less-affected side 46



Table 4.2.1 Characteristics of the participants 50

Table 4.2.2 Pre- and post-assessment of the Wolf Motor Function Test

(movement time) of the affected side 51

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Table 4.2.3 Pre- and post-assessment of the Wolf Motor Function Test

(functional ability scale) of the affected side 52

Table 4.2.4 Pre-assessment and post-assessment of the


Table 4.2.5 Pre-assessment and post-assessment of the

Modified Ashworth Scale 57

Table 4.2.6 Pre-assessment and Post-assessment of the

Revised Nottingham Sensory assessment 58

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Chapter 1

Introduction

1.1 Background and rationale

Stroke or cerebrovascular accident is a global public health problem. The incidence

of stroke is almost 17 million each year worldwide (1) . In Thailand, the incidence of

stroke is estimated to be more than 250,000 new stroke cases each year (2). The situation

worldwide and in Thailand demonstrated that stroke is the common non-communicable

disease of the global population.

Stroke could lead to disabilities. Chronic stroke individuals could still have

neurological deficits with impairments and activity limitations. Most patients with

stroke are unable to use their affected upper limb. Only fourteen percent of stroke

survivors with severe arm deficits have full recovery of upper limb and hand function

(3). Problems of those with moderate to severe arm deficits are reach and grasp

incoordination, delay in time to maximal grip aperture (TMA), prolong movement time

(reach to grasp), and lack of accuracy (4, 5). Physical therapy is essential for the stroke

individuals with moderate to severe motor deficits to improve their functional ability

(3).

Interventions for improving upper limb and hand function are various. Bobath

therapy, task- specific training (6), sensorimotor training (7), mental practice (8), orthosis

(9), constraint- induced movement therapy (10), EMG/ Biofeedback (11), functional

electrical stimulation ( FES) (12), mirror therapy (13), robot- assisted therapy (14), virtual

reality (15) are the examples of interventions for improving upper limb and hand function

post stroke. Nevertheless, handling technique is applicable for stroke survivors in

community given no specific tools are required. The rehabilitation at patient’ s home

could also reduce cost and benefit for patients (16). Most interventions of upper

extremity have been reported for improving function in the stroke patients with mild to

moderate arm paresis. Interventions for improving severe arm deficits are less available

and details were unclear. The patients with mild paresis have ability to do activity of

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daily living more than those with other levels of deficits. They may increase in their

upper limb and hand function as a result of activities performing in daily life. In

addition, the evidence of therapy based on the Bobath concept in chronic stroke very

few. All in all, interventions for improving upper limb and hand function in stroke

patients with moderate and severe paresis should be further investigated.

The Bobath concept is one of the first neurological physical therapy approaches

used in the management of patients following neurological deficits. The Bobath concept

is one of most commonly uses for rehabilitation in patients with central nervous system

disorders (17). The Bobath therapy focuses on postural control, selective movement,

and sensorimotor integration (18). Studies have been shown that when a person started

moving their upper extremities, postural tone has been adapted earlier ( anticipatory

postural adjustment ( APA) ) (19). In a previous study, therapy based on the Bobath

concept showed improvement of upper limb and hand function in chronic stroke (20).

However, the implementation of the Bobath concept on upper limb and hand function

in stroke individuals are limited due to the lack of specific details of treatment as well

as flaws in research methodology. The details of the Bobath intervention programs were

unclear regarding therapeutic doses in previous studies (21, 22). The arguments and

summary that the Bobath therapy is not better than other approaches are bias- hidden.

For example, having non-equivalent doses of treatments was aiming to verify the

effectiveness of another treatment as compared to the Bobath therapy (22, 23). In addition,

there was no study regarding chronic stroke with different degrees of deficit severity in

terms of community based rehabilitation. Together with few effective interventions to

improve upper limb and hand function in those with severe deficits, the aim of this

study was to investigate the effect of the Bobath therapy for improving upper limb and

hand function in chronic stroke with moderate to severe arm deficits.

As the presented in figure 1.1, the conceptual framework consisted of the activity

limitation, problem in moderate and severe arm deficits impairments, the Bobath

therapy and the recovery.

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1.2 Research question

Could the Bobath therapy improve arm and hand functions in chronic stroke with

moderate to severe arm deficits?

1.3 Objectives

Primary objectives

1.3.1 To compare pre- post intervention effectiveness of the Bobath

therapy on upper limb and hand functions in chronic stroke with

moderate to severe arm deficits.

Secondary objectives

1.3.2 To compare pre- post intervention effectiveness of the Bobath

therapy on motor impairments, muscle tone, and sensation of upper

limb and hand in chronic stroke with moderate to severe arm

deficits.

1.4 Research hypotheses

1.4.1 There will be a difference of upper limb and hand functions

between pre- and post-intervention.

1.4.2 There will be differences in motor impairments, muscle tone, and

sensation of upper limb and hand between pre- and post-

intervention.

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Chronic stroke

Problems in moderate and severe arm deficits

Impairment

o Muscle weakness

o Decrease ability to control movement

o Slow movement and less accuracy

o Reach/grasp incoordination

o Minimal grip aperture

o Delay in movement time

Bobath therapy

- Addressed on anticipatory postural adjustment (APA)

- Selective movement for co-ordinated sequences of

movement

- Sensorimotor integration through specific handlings

Recovery

Primary outcome measure

Wolf Motor Function Test

Secondary outcome measures

Fugl Meyer Assessment - UE

Modified Ashworth Scale

Revised Nottingham Sensory Assessment

Figure 1.1 Conceptual framework

Activity limitation

- Reaching

- Grasping

- Holding

- Releasing

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1.5 The variables used in the study

1.5.1 Independent variables: time period: pre and post intervention of the

Bobath therapy for improving upper limb and hand functions.

1.5.2 Dependent variables: upper limb and hand function as assessed by

using the Wolf Motor Function Test, and impairments by using the

Fugl-Meyer assessment of the upper extremity (FMA-UE), the

Modified Ashworth Scale, and the revised Nottingham Sensory

Assessment.

1.6 Potential benefits of the study

1.6.1 To provide the effectiveness of the Bobath therapy on upper limb and

hand functions in chronic stroke individuals with moderate to severe

deficits.

1.6.2 To provide the insights of clinical applications in stroke individuals

with moderate to severe arm and hand functions for physical

therapists.

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Chapter 2

Literature review

This chapter detailed the literature review related to the topic of research

proposal on stroke, Bobath Concept, and interventions for improving upper limb and

hand function post stroke.

2.1 Stroke

2.1.1 Definition

By the definition of WHO, stroke or cerebrovascular accident (CVA) is a

disorder within specific arteries in the brain. The neurological symptoms

persisted at least 24 hours leading to disabilities or could lead to death (1). Causes

of stroke are arterial occlusion, stenosis or hemorrhage (24). Symptoms and

severity of stroke depend on the lesion. Stroke is accounted for a period of time

after having a stroke one month to six months. Finally, chronic stroke is

accounted for a period of time after having a stroke longer than six months (2 5 ,

2 6 ) . Stroke is classified by 2 types according to pathology of stroke which are

ischemic and hemorhagic stroke. Hemorhagic stroke cause from rupture of the

cerebral vessels, due to high blood pressure excessive on arterial walls. Ischemic

strokes or cerebral infarcts (CI) are the result of development of thrombosis,

embolus leading block and affect to deficiency of oxygen pass to brain tissues

(27).

2.1.2 Incidence of stroke

Stroke is one of the most common non-communicable diseases. The

incidence of stroke worldwide has been occures almost 17 millions per year so

the campaign stroke awareness was developed for pleple. The incidence of

stroke is increasing every year in Thailand (2) and evidenced in 2552-2557 BE

(28). More than 250,000 new cases with stroke is estimated each year (2). The

female has been incidence of stroke (1 in 5 people) higher the male (1 in 6

people) was reported from world stroke organization (WSO) (29). Age at onset

of most patients with stroke worldwide is older than 65 years (30). The average

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age is 45 - 64 years (31). Similary in Thailand, patients with stroke are 45 - 64

years and most are older than 65 years (32).

2.1.3 Impairments post stroke

Impairments of stroke are varied across individuals. The impairments

include deficits in motor function, cranial nerve function (speech, swallowing),

muscle weakness, altered reflexes, postural instability, coordination problems

and apraxia. Impairments of the sensory system included loss or impaired

sensation, and perceptual disorders (33). Patients may feel numbness, tingling

and hyper-sensitivity. Moreover, they could have more complex sensory

deficits such as astereognosis, agraphia and loss of double stimultaneous

stimuli. Impairments of the visual system included monocular blindness and

cortical blindness. In addition, some patients may have deficits in cognition and

emotion. They may have problems of memory, attention and mood disorders

such as depression. The important one is motor impairment including deficits

in motor function and functional limitation of the upper limb and hand function

is the major problem of activity daily living in stroke patients (34).

2.1.4 Problems of arm deficits post stroke

Most patients with stroke were unable to use their affected upper limb. It

has been reported that around eighty percent of patients with arm deficits post

stroke had incomplete recovery after six months (35). The severity of arm deficits

ranged from mild to severe. The severity of arm deficits has been defined based

on Fugl-Meyer score as mild > 50/66, moderate 26-50/66, and severe < 26/66

(36). Another criteria that have been used to identify those with mild to moderate

arm deficits is active range of wrist extension of at least twenty degrees and

finger extension ten degree. Previous study showed that most chronic stroke in

community are mild paresis (36 percent), followed by severe (14 percent) and

moderate paresis (10 percent) (37). One study showed that most patients with

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mild arm paresis have full recovery (78 percent) and only few of those with

severe arm paresis have full recovery (18 percent) at 11 weeks post stroke (3).

Problems of those with severe arm deficits are incoordination of arm and

hand during reach to grasp, delay in time to maximal grip aperture (TMA),

minimal grip aperture (aperture scaling during reach to grasp), prolong

movement time in reach to grasp, lack of accuracy, and muscle weakness (4, 5).

2.1.5 Recovery after a stroke

Following a stroke, motor recovery is rapid within 30 days and gradually

continued to 90 days. Recovery reaches the plateau after 90 days to six months

(38).

Figure 2.1 Recovery post stroke in patients with different levels of severity (A)

mild level, (B) moderate level, (C) severe level, and (D) very severe level (38).

In Figure 2.1, neurologic means the neurological examination such as

muscle strength, reflex, sensation, conscious (39) and functional means the

ability to perform function such as ADL (40).

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2.1.6 Factors affecting recovery of stroke

There are several factors affecting effective interventions. First, the patient

with recurrence stroke mostly presented with severe activity limitations than

patients with first stroke, and especially if the recurrence occurred in the other

side of first stroke (41). Second is the severity of weakness (42). Patients with

severe weakness of contralateral arm (active wrist extension less than 20° and

finger extension at less than 10°) have shown slow recovery (10). Third, control

of dominant arm and non-dominant arm movements are different in chronic

stroke patients (43). In addition, cognitive impairments have been shown to have

a negative effect on the patient’s functional independence (44).

2.1.7 The prognosis of arm recovery post stroke

The initial severity of muscle weakness is the major prognosis of arm

recovery post stroke (45). Nevertheless, 14 percent of stroke survivors with

severe arm deficits have full recovery of upper limb and hand function within

11 weeks (3). The recovery does not depend on genders, ages, and types of stroke

(46) but depend on neuroplasticity and physical rehabilitation. Physical

rehabilitation could make permanent change of neural function through motor

learning. In which, neuroplasticity is the process of neuronal changes of neurons

such as connection between neurons. These resulted in the recovery of function

post stroke (47). Ability to move the affected arm within 23 days post stroke

indicated a good prognosis (48) and if arm cannot move and grasp cannot be

made at four weeks post stroke indicated poor prognosis (49).

One study investigated arm function recovery after stroke over a period of

four years. Even after sixteen weeks, improvement still occurred in some stroke

patients. Nevertheless, effective treatments could improve arm functions and

decrease disabilities (50). Physical therapy addressing upper limb and hand

function training is important for improving patient’ s ability to perform daily

living activities independently (51) or with minimal assistance, social

participation, and quality of life (52). In addition, one previous study has shown

that chronic stroke patients with severe arm paresis (FMA-UE score 0-25) had

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some improvements after upper limb training half an hour per day for 30 days

(FMA score increased 0 – 6 points) (37).

In addition, the repetition of training is a current focus as a factor of

recovery. In chronic stroke patients with moderate paresis, the typical number

of home- based functional muscle strengthening repetitions in a single session

was 12 per task in 30 minutes and three sessions per week. This amount of

training resulted in good outcomes for the upper-extremity level of activity (53).

Another observational study reported the average number of 32 repetitions per

session consisting of task- specific, functional upper extremity movements in

upper limb rehabilitation for stroke. The average session duration was 36

minutes (54). It is may be not adequate to recovery neural reorganization

poststroke. In one study, 300 repetitions of various tasks, 60 minutes per day, 4

days per week of high- repetition upper- extremity task- specific training in 19

sessions demonstrated improvement in impairments and activities (55).

2.2 Interventions for improving upper limb and hand function in patients with

stroke

Interventions for improving upper limb and hand function are various (56). Bobath

therapy is one of the pioneer interventions originally addressed on the use of the

affected side. Through the development of intervention and the updated knowledge on

neurosciences, currently the Bobath therapy is focused on anticipatory postural

adjustment (APA), selective movement, and sensorimotor integration (18). Task-specific

training is focused on motor learning and experience influencing neural plasticity (6).

Sensorimotor training used the principle of sensory information to stimulate motor

output (7). Mental practice is the intervention focused on motor imagery and improved

performance ( 8 ) . Orthoses have the purpose to reduce spasticity and pain, prevent

contracture and edema, and assist in the improvement of function ( 9 ) . Constraint-

Induced Movement Therapy (CIMT) is the intervention limiting the movement of the

less-affected side while shaping the movements of the affected side (57). EMG/

Biofeedback is the intervention focused on audio or visual feedback on eliciting

movements (11) and Functional Electrical Stimulation (FES) assisted movement via

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electrical stimulation (12). Mirror therapy is the intervention focused on visual imagery

to convey visual stimuli (1 3 ) . Music Upper Limb Therapy- Integrated (MLT-I) is the

intervention focused on physical, psychological and social domains of rehabilitation

(58). Arm Weight Support training is using the ArmeoSpring for recovery arm and hand

(59).

Some other interventions addressed on minimizing impairments such as strength

training, stretching. Complementary interventions are robotics training (13), bilateral

arm training (60), Virtual Reality training (61), Transcranial magnetic stimulation (TMS)

(6 2 ) and rehabilitation program in community. After discharging from acute hospital,

patients with stroke are either referred back to another hospital or their own homes

depending on their medical conditions and health care needed. In Thailand, most

patients with stroke are discharged to their own homes in community and may are

unable to access health care as needed due to limitation in access or other personal

issues. Without rehabilitation, they may have been left with activity limitation and

disabilities. Rehabilitation at home has many advantages for the patients, especially for

those who have trouble accessing health care sectors (63).

A study on stroke rehabilitation in UK community addressing reach to grasp

training showed that the patients have the improvement of reaching. Training in this

study consisted of active movement of shoulder flexion, with and without gravity effect

and reaching training in various directions. The total treatment time was 14 hours in six

weeks.

One previous study investigated the effectiveness of standardized rehabilitation

program consisting of active exercise, resisted exercise, and ADL training in patients

with stroke in a local hospital setting in Thailand. The results showed that the

rehabilitation program could improve function and quality of life for patients

(64). Physical therapy interventions addressing on improving, endurance, strength

balance, flexibility, strength and upper- limb function has been reported to improve

daily living activities (65). The home- based program has also been reported for its

effectiveness in subacute and chronic stroke in improving recovery and maintaining

their functional ability (66).

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In previous study, the effect of interventions of moderate to severe arm deficits have

similar efficiencies that increasing the performance and the speed of movement. The

most of study have no significant between groups.

2.3 Bobath therapy

2.3.1 Bobath concept

This approach was invented by Berta Bobath, a physiotherapist

and pediatrician Dr. Karel Bobath who believed that appropriate treatment for

patients with paralyzed body parts is to stimulate the movement of those parts

by means of movement facilitation through sensory stimulation (1 7 ) .

Neuroscience knowledge has been applied to explain the efficacy

of therapy based on the Bobath Concept.

The important aim of the therapy followed the Bobath concept is to

improve quality of movement. Quality of movement is the characteristic of

behavior movement which is important for effective neuro - rehabilitation

strategies (17, 67). The Bobath concept focuses on postural control for stabilizing

the trunk while moving limbs, maintain alignment and preparation of a joint

movement. Selective movement is the other main focus of this concept to

control specific movement and limit abnormal movement pattern. Last is the

address on sensorimotor integration to improve effective movement. Sensory

inputs contribute on motor learning and shaping motor output (68). The sensory

information is the essential in the specification and regulation of activation

thresholds of movement (69).

For motor relearning, therapists can use sensory inputs in the form of

tactile information from the hands to shape movement and gradually removing

manual guidance when the capable of self- generated movement has been

achieved. Proper placing of the therapist’s hands is thought to guide a patient to

move their limbs in the target movement. The cutaneous and other sensory

signals can adapt motor output (70).

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Sensory receptors included those in joints (stimulated through

compression and distraction), Golgi tendon organs, cutaneous receptors, muscle

spindles are involved in movement facilitation. Sensory and proprioceptive

information through handling at key points of control are used as feedback and

facilitation strategy (17, 19). Thus, sensory guidance is the principles of movement

production.

2.3.2 Theoretical underpinning the Bobath concept

The Bobath therapy is based on system model of motor control, theory of

plasticity and motor learning. Motor control is the control of movement in the

interaction with various tasks and environment. Within individual person,

movement is contributed by the coordination between perception, cognition and

action. Many systems are involved in the integration and response to the

succession of motor goals (17).

Motor control is the current theoretical underpinning of the Bobath

concept. It was important to have understanding the movement system. The

control of integrated movement to interacting systems cooperative work (71).

The emphasis of the Bobath concept is on motor control based upon a

continuous interaction of individuals. This is based on a nervous system

working with theory of motor control and multilevel processing (19).

The plasticity of nervous structures is the modification or changes from

motor learning and the practice (72, 73). The nervous system and neuromuscular

system can adapt or change the structure based on experiences and effective

functional goals in a variety of environments.

Motor learning refers to permanent change in motor performance (72). The

motor learning requires active participant, practice and meaningful goals. There

are essential for learning (74).

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2.3.3 Bobath approach for upper limb and hand function improvement

The Bobath approach could be applied to any body parts including trunk

and limbs. Approaches for upper limb and hand function have been designed to

tailor individual’ s problems. This included reaching, joint realignment, hand

shaping, and fine movement (18). Treatment addressed selective movement

while concerning postural control through specific handlings. After facilitation

of individual joint movement, functional training is advice for patients to learn

movement in function. Target location and skilled grasp are the example of

training together with movement facilitation.

2.3.4 Clinical applications of the Bobath therapy

Studies on the effectiveness of the Bobath therapy showed improved

upper limb and hand function (22, 23, 75). There were assessed by the Fugl-Meyer

for upper extremity, Wolf Motor Function Test, Action Research Arm Test

(ARA), joint motion/ pain scores, Motor Evaluation Scale, functional ability,

speed of movement, quality of movement, hand functions and ADL in the

affected arm (22, 76).

The Bobath therapy in the literature review of arm activity training has

been performed in various situations such as reaching the object on the floor,

side lateral and various other positions. The physical therapist provided training

for the patients with or without objects. The duration of a treatment session

varied from 30 to 60 minutes, with the most frequent report of 45 minutes. The

frequency of treatment varied from five days or less per weeks and the total

period of treatment varied from two weeks to six months (22, 75).

The Bobath therapy has been compared with CIMT, arm basis training,

and motor relearning program. In which, there were no significant difference

between groups, but significant differences were found pre and post

intervention within each group (22, 75, 77). However, when the Bobath therapy

study was compared with orthopedic approach there was a significant difference

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between groups. That is, the Bobath therapy improved the function of upper

limb and hand post intervention better than the orthopedic approach (20).

2.4. Measurements of function and impairments of upper limb and hand

There are several existing measures for assessing upper limb and hand function in

patients with stroke. For example, Action Research Arm Test (ARAT) has been

designed to assess upper limb and hand dexterity (78), Box and Block Test is used for

assessing performance of gross dexterity (79). The Chedoke - McMaster Stroke

Assessment Scale (CMSA) is used for assessing physical impairment inventory and a

disability inventory (80), Wolf Motor Function Test (WMFT) is designed for assessing

upper extremity motor function (81).

The aim of the Wolf Motor Function Test (WMFT) is to assess upper extremity

motor function for patients with stroke. The WMFT is an assessment tool with high

inter-rater reliability, internal consistency, test-retest reliability, and adequate stability.

Next, Minimal detectable change (MDC) for timed items has been reported of 0.7

seconds and for WMFT functional ability scale is 0.1 points (81, 82).

The widely used version of the WMFT consists of 17 items; 15 function-based

task and two strength-based tasks. Both performance time and functional ability of

upper limb and hand function are assessed. Items 1-6 are timed functional tasks, items

7-14 are measures of strength and the remaining 9 items also analyzing movement

quality. The test focused on the less affected side upper limb. The assessment tool is 6-

point ordinal scale; scale 0 for no attempt and scale 6 for normal performed movement

(scale 6). The equipment used in WMFT consisted of a standardized table (54 inches

long, 30 inches wide, and 29 inches high) and chair, standardized test item template,

height-adjustable bedside table, box (one that does not require patient to flex or abduct

shoulder more than 90 degrees), individual wrist weights, 1-20 pounds, 12-oz beverage

can, unopened, 7 inches pencil with 6 flat sides, 2 inches paper clip, 3 checkers, 3

inches x 5 inches note cards, standardized lock and key board at 45 degree angles,

standardized face towel, standardized basket, dynamometer, talcum powder to reduce

friction as needed, stopwatch, and video camera (optional) (81).

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Impairments of upper limb and hand post stroke could be seen as paresis, impaired

sensation, and abnormal muscle tone. The Stroke Impairment Assessment Set (SIAS)

(83), Chedoke- McMaster Stroke Assessment (84) have been used to assess motor

recovery. Accelerometer assess acceleration of movement (85). Goniometer or

inclinometer have been used to assess the range of motion (86). Virtual Peg Insertion

Test have been used to assess the virtual reality and haptic feedback for sensorimotor

functions assessment (87). The Fugl-Meyer Assessment has long been used for assessing

motor and sensory impairments and joint range of motion is usually assessed by using

goniometry in clinical settings. The Fugl-Meyer Assessment: Upper Extremity (FMA-

UE) is the section of the Fugl- Meyer Assessment and has been used to measure motor

and sensory recovery of the upper limb in patients with stroke. This assessment is the

one of most widely measures for motor impairment with excellent inter-rater and intra-

rater reliability (r = 0.995-0.996) and construct validity (36). The responsiveness of FMA

is proper to detect change for patients after stroke rehabilitation (88). Minimal clinically

important difference of 10 points-change in FMA Upper extremity is comparable to 1.5

changes in the Functional Independence Measure (FIM). The Item are 3 point score

ordinal scale (89).

Voluntary movement assessed by measuring active range of motion has also been

used to indicate the severity of hand movement (90). Range of motion is clinically

measured by using goniometry. One study reported excellent intra- rater reliability of

goniometry (ICC- 3, k = 0.94) and digital inclinometry (ICC- 3, k = 0.95) for measuring

active shoulder flexion, abduction, internal and external rotation mobility measurement.

In addition, the concurrent validity between both measures was good. This study

supported the use goniometry or digital inclinometer for measuring range of motion of

shoulder joint (91).

Muscle spasticity could be assessed by using the Ashworth Scale (92) and

Modified Ashworth Scale. The purpose of the Modified Ashworth Scale is to grade

muscle spasticity in patients with lesions of the central nervous system ( CNS) . The

reliability has been reported of very good (Kappa = 0.84 for inter-rater reliability and

0. 83 for intra- rater reliability) (93). Convergent validity has been demonstrated

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as excellent correlations between the Modified Ashworth Scale and motor performance

tests (94).

Sensory assessment is also necessary for the upper limb and hand function. This

is the indicator the effectiveness of an intervention. The Fugl-Meyer (FM) assessment,

the Nottingham Sensory Assessment, and the Revised Nottingham Sensory Assessment

could be used to assess sensory function post stroke. The Fugl-Meyer (FM) assessment

has been reported of adequate inter- rater reliability for the section of sensory

assessment.

The Revised Nottingham Sensory assessment has been developed from the

Nottingham Sensory Assessment (95) with good to excellent inter- rater reliability has

been reported (96). This is a suitable assessment for the use in patients with stroke (97).

From the literature review, only few studies are available on improving upper

limb and hand function in stroke individuals with moderate to severe arm weakness.

Most studies are conducted in those with ability to move their arms and hands. In

addition, studies in communities did not include those with severe arm weakness. Next

chapter will detail the methodology of the current study.

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Chapter 3

Material and method

In this chapter, inclusion and exclusion criteria, material and method, statistical

analysis were described.

Prior to the main study investigating the effect of the Bobath therapy on upper

limb and hand function, the reliability of the Wolf Motor Function Test and the Fugl-

Meyer assessment of the upper extremity (FMA-UE) was evaluated.

3.1 Intra- and inter-rater reliability test of the Wolf Motor Function Test and

Fugl-Meyer assessment of the upper extremity

Two major outcome measures of the current study were the WMFT and FMA-UE.

The Wolf Motor Function test (WMFT) assessment consisted of 17 items. However,

only 15 items not involving in direct measure of muscle strength were chosen in this

study. Both movement time and functional ability was tested. The functional ability

scale is the 6-point ordinal scale (0-5). Each item has specific detail for scoring the

functional ability.

The Fugl-Meyer assessment of upper extremity (FMA-UE) - motor impairment

consisted of upper extremity, wrist, hand and coordination sections. There are 33 sub

items. Scoring is based on the 3-point ordinal scale (0-2). The maximum score is 66

points.

3.1.1 Participants (Patients with stroke)

3.1.1.1 Sample size

1) Intra-rater reliability of the Wolf Motor Function Test

Sample size in this study was calculated from the data

reported in the study by Morris and colleagues (2012) (81)

investigating hand function using the Wolf Motor Function Test

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(performance time). The sample size determination was

computed using the following formula (98):

N = + 3 when Z = 0.5 × In

N = Sample size

Zα = Z-value for the type І error; One-tailed = 1.645

Zβ = Z-value for the type ІІ error; Zβ = Z0.8 = 0.84

Z = 2.526

r = Correlation coefficient (0.92)

α = 0.05

Power = 0.8

Sample size = 4

2) Inter-rater reliability of the Wolf Motor Function Test


reported in the study by Morris and colleagues (2012) ( 8 1 )

investigating hand function using the Wolf Motor Function Test

(performance time). The sample size determination was

computed using the following formula (98):

N = + 3 when Z = 0.5 × In

N = Sample size

Zα = Z-value for the type І error; One-tailed = 1.645



Z = 2.526

α = 0.05

Power = 0.8

Sample size = 4

Zα + Zβ

Z

2

1 - r

1 + r

Z 1 - r

Zα + Zβ

1 + r 2

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3) Intra-rater reliability of the Fugl- Meyer assessment of

the upper extremity


reported in the study by Sullivan and colleagues (2011) (89) using

the Fugl-Meyer assessment of the upper extremity (FMA-UE) .

The sample size determination was computed using the

following formula (98):

N = + 3 when Z = 0.5 × In

N = Sample size Zα = Z-value for the type І error; One-tailed = 1.645



Z = 2.526

α = 0.05

Power = 0.8

Sample size = 4

4) Intra-rater reliability of the Fugl- Meyer assessment of

the upper extremity


reported in the study by Sullivan and colleagues (2011) (89) using

the Fugl-Meyer assessment of the upper extremity (FMA-UE) .

The sample size determination was computed using the

following formula (98):

N = + 3 when Z = 0.5 × In

N = Sample size Zα = Z-value for the type І error; One-tailed = 1.645



Z = 2.526

α = 0.05

Power = 0.8

Sample size = 4

1 + r Z 1 - r

Zα + Zβ

Z 1 - r

Zα + Zβ

1 + r

2

2

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3.1.1.2 Inclusion criteria

1) Having first stroke confirmed by medical diagnosis

2) Chronic stroke (onset more than six months) caused by

ischemic and hemorrhagic

3) Age 45 years or older

4) Fugl-Meyer Assessment of the Upper Extremity: motor

Assessment scores for moderate level (26-50/66) to

severe level (< 26/66)

5) Live in community

6) Thai nationality

7) Able to sit independently for at least 30 minutes

8) Able to understand and follow one-step command

9) Stable medical condition

3.1.1.3 Exclusion criteria

1) Having other neurological conditions apart from stroke

2) Having musculoskeletal pain affecting reaching

3) Severe shoulder pain

(visual analog scale = 75 – 100 mm) (99)

4) Limited passive range of motion of shoulder flexion less

than 90 degree

5) Modified Ashworth Scale (grade) more than 2

6) Cognitive impairment considered by using the Thai

Mini Mental State Examination based on educational

criteria (score for people education less than primary

school ≥ 14, primary school ≥ 17, and higher than

primary school ≥ 22)

7) Having unilateral neglect

8) Participated in other interventions

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3.1.2 Assessors

Assessors were two physiotherapists with clinical experience in stroke

rehabilitation and have been trained to assess upper limb and hand function

using the Wolf Motor Function Test, and the Fugl-Meyer Assessment of the

upper extremity.

3.1.3 Assessment tools and equipment

3.1.3.1 Thai-MMSE

3.1.3.2 Fugl-Meyer Assessment of the upper extremity

1) Tennis ball

2) Small can

3) Pencil

4) Paper

5) Hammer jerk

3.1.3.3 Wolf Motor Function test

1) Box

2) Sand bag

3) 12-oz beverage can, unopened

4) 7ʺ pencil with 6 flat side

5) 2ʺ paper clip

6) 3ʺ checkers

7) Three 3ʺ x 5ʺ note cards

8) Standardized lock and key board at 45 degree angle

9) Standardized face towel

10) Standardized basket

11) Stopwatch

3.1.3.4 Modified Ashworth scale (MAS)

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3.1.4 Method

Firstly, the researcher recorded the WMFT and FMA-UE assessments

of healthy volunteers using the video for training the assessors. Then, the

researcher appointed assessors for training the assessments by using the

video recording. During the training session, the researcher explained

scoring system and demonstrated the assessments to assessors. The

researcher recorded the WMFT and FMA-UE assessments of another four

volunteers with stroke using the video. After that, the researcher appointed

assessors for watching and rating the video recording of four patients with

stroke (each file was displayed no more than twice). Assessors assessed the

WMFT (movement time) assessment by using a stopwatch and rated the

WMFT (FA) and FMA by ordinal scoring. Re-assessment via the video

recording was taken again seven days later. The researcher calculated data

by using the SPSS program, Version 22. Finally, the researcher evaluated

reliability of the assessments using the criteria of acceptable reliability (ICC

greater than 0.8). If the reliability was less than acceptance, the reliability

protocol was repeated.


individuals with moderate to severe arm deficits

3.2.1 Participants (patients with stroke)

3.2.1.1 Sample size

Sample size in this study was calculated from the data reported in

the study by Huseyinsinoglu and colleagues (2012) (22) investigating

hand function using the Wolf Motor Function Test (performance time)

after the Bobath therapy in patients with stroke. The sample size

determination was computed using the following formula (98):

n =

2 (Zα + Zβ) 2 𝜎2

∆2

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n = sample size

∆ = mean difference

= mean (pre-intervention) – mean (post-intervention)

Mean group pre-intervention = 31.5

Mean group post-intervention = 20.5

∆ = 31.5 - 20.5 = 11

𝜎 = 18

Effect size = 0.513

α = 0.05

Power = 0.7

Zα

Zβ = Z-value for the type II error;

Zβ = Z0.3 = 0.524

n =

n = 2 (1.645 + 0.524)2 182

n = 25.19

Sample size = 25

With the additional number of 20% drop out, the number of participants in this

study were 30 cases.

= Z-value for the type I error;

One–tailed = 1.645

2 (Zα + Zβ) 2 𝜎2

∆2

112

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3.2.1.2 Sampling

Purposive sampling or judgement sampling was used to sampling

participants. The researcher recruited participants with stroke in Pathum

Thani, Thailand using the following criteria.

3.2.1.3 Discontinuous criteria

1) Having other health conditions requiring hospitalization

2) No longer required to participate in this study

3.2.2 Trainer

A physiotherapist with clinical experience in stroke rehabilitation who has

been trained with the Bobath therapy for at least 30 hours.

3.2.3 Assessors

Assessors were two physiotherapists who have clinical experience in

stroke rehabilitation and have been trained to assess upper limb and hand

function using the Wolf Motor Function Test, the Fugl- Meyer Assessment of

the upper Extremity, Modified Ashworth Scale ( MAS) and the revised

Nottingham Sensory Assessment. Each assessor was assigned by the researcher

with the same assessor did the baseline assessment and post intervention

assessment for the same participant.

Intra-rater and inter-rater reliability were tested before starting baseline

assessment as described in section 3.1.

3.2.4 Assessment tools and equipment

3.2.4.1 Thai-MMSE

3.2.4.2 Fugl-Meyer Assessment of the upper extremity

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1) Tennis ball

2) Small can

3) Pencil

4) Paper

5) Hammer jerk

3.2.4.3 Wolf Motor Function test

1) Box

2) Sand bag

3) 12-oz beverage can, unopened

4) 7ʺ pencil with 6 flat side

5) 2ʺ paper clip

6) 3ʺ checkers

7) Three 3ʺ x 5ʺ note card

8) Standardized lock and key board at 45 degree angle

9) Standardized face towel

10) Standardized basket

11) Stopwatch

3.2.4.4 Modified Ashworth scale (MAS)

3.2.4.5 Goniometer for assessing AROM

3.2.4.6 Revised Nottingham Sensory Assessment

1) 10 Coin

2) 2 Coin

3) 50 Coin

4) Brio

5) Pencil

6) Comb

7) Scissors

8) Sponge

9) Flannel

10) Cup

11) Glass

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3.2.5 Research design and setting

Quasi-experimental study was implemented in this study. This study

investigated effect of the Bobath therapy on upper limb and hand functions in

chronic stroke with severe arm deficits. The settings were communities in

Pathum Thani, Thailand.

3.2.6 Method

All stroke participants were voluntarily provided a written consent prior

to their participation in this study. General characteristics were obtained using

the interview on age, sex, stroke onset, affected side, dominant arm, and highest

education. Screening tests were performed in the sitting position to identify

eligible participants using the criteria of the Fugl- Meyer Assessment of upper

extremity scores less than 50 (moderate level: 26- 50/66 and severe level:

<26/66) (Figure 3.1 Experimental flowchart).

3.2.7 Assessment

Impairments and functions of upper limb and hand were assessed using

following tools:

3.4.1.1 Fugl-Meyer Assessment of upper extremity (motor function)

3.4.1.2 Wolf Motor Function Test (performance and movement time)

3.4.1.3 Modified Ashworth Scale

3.4.1.4 The Revised Nottingham Sensory Assessment (body part;

shoulder, elbow, wrist and hand).

3.2.8 Variables

3.4.2.1 Independent variables: intervention (the Bobath therapy)

3.4.2.2 Dependent variables: Wolf Motor Function Test, Fugl- Meyer

assessment of the upper extremity, Modified Ashworth Scale,

and the Revised Nottingham Sensory Assessment.

3.2.9 Interventions

The intervention program has been designed based on individual’s

ability as assessed by using the Wolf motor function test (Table 3.1).

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Table 3.1 Intervention program details based on pre-intervention Wolf motor

function test

Upper limb function

limitation

Hand function limitation Upper limb and hand

function limitation

Assessed by WMFT

Item 1-8

Scapula, shoulder

and elbow

movement

(movement facilitation or

active assisted training)

Upper limb

function training

(reaching)

Assessed by WMFT

Item 12, 13, 15

Wrist and hand

movement

(movement

facilitation or

active assisted

training)

Hand function

training (grasping)

Assessed by WMFT

Item 9, 10, 11, 16, 17

Scapula, shoulder

and elbow

movement

(movement facilitation or

active assisted training)

Upper limb and

hand function

training

(reaching, grasping)

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3.2.9.1 Intervention Program

All participants received same training preparation consisting of

muscle stretching. The repetitions of movement training in the actual

training session in the program depended on the ability of individual

participants and noted by the physical therapy. Shapes of the object used

in training and re-assessments were similar, for example, a glass and a

can.

The overall details of therapy in the Bobath group are outlined

in Table 3.2 and through details of treatment preparation are illustrated

in Table 3.3.

Table 3.2 Details of interventions used in this study Bobath therapy

Preparation phase 15 minutes

(passive stretching and muscle mobilization)

Muscle mobilization: scapular, shoulder, elbow, wrist, and finger muscles

Treatment:

Frequency: three days/ week for six weeks

During each session, participants practiced 20 repetitions per set, 3 sets of each task. Rest

time 1-2 minutes as needed between sets.

Movement facilitation;

shoulder flexion, scapular protraction, elbow extension, wrist extension, and finger

extension.

Functional training with and without object

(target location, reaching, skilled grasp)

If participants could do movement independently, the trainer withdrew the

facilitation for improving of movement.

If participants could perform selective movement of upper limb and hand without

facilitation, the trainer stopped the practice of selective movement.

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Table 3.3 preparation for treatment

Treatment Details

Stretching/ muscle mobilization

Starting position

Stretching

- Shoulder internal

rotator, elbow

flexors, forearm

pronator, wrist

flexors, hand

flexors.

- Hold 15-30 sec,

2-4 repetitions.

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3.2.9.2 Bobath therapy

Therapy based on the Bobath concept was implemented in

accordance with impairments and limitation of upper limb and hand

functions of individual participants. The trainer withdrew the facilitation

as movement improved.

The trainer observed and corrected the posture and body

alignment of individual participants before and during practice. The

trainer evaluated participant’s ability and made the decision to change

the training program next practice. The details are as follows (Table 3.4):

Facilitation of shoulder, elbow, wrist and finger movements

Upper limb and hand function training

If the participants presented with sensory impairments, they

were also received the sensory facilitation.

Table 3.4 Bobath therapy intervention

Treatment Details

Scapular protraction

Starting position

Lateral view

Starting position; sitting position

- One hand placed on the

lateral side of thenar

muscles.

- Another hand placed under

inferior angle of scapular.

- Facilitation of scapular

protraction through full

range of motion.

- Relaxation to the starting

position.

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Treatment Details

Posterior view

Lateral view

Posterior view

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Treatment Details

Elbow extension

Starting position

starting position; sitting position

- One hand placed on thenar

muscles on the lateral surface.

- Another hand placed on

triceps brachii tendon.

- Facilitation of elbow

extension through full range

of movement.


position.

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Treatment Details

Wrist extension

Pattern I

Starting position


Sitting position

- Hand and wrist joint rest on the

table.

- Compression toward wrist

joint and facilitation through

full range of wrist extension.


position.

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Treatment Details

Pattern II

Starting position

If the participant presented with

severe spasticity of muscle or

severe tightness of muscle, the

trainer would use pattern II for

treatment.


- Hand and wrist joint rest on the

table.

- Compression toward wrist

joint and facilitation through

full range of wrist extension.


position.

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Treatment Details

Finger opposition

Thumb to little finger

Starting position

Starting position; Sitting position

- Placed the affected forearm

and hand in supination on the

table.

- Compression on

metacarpophalangeal joint and

facilitation through full range

of finger opposition.


position.

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Treatment Details

Thumb to index finger

Starting position


- The hand rest on the table

in the supination position.

- Compression on


facilitation through full range

of finger opposition.


position.

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Treatment Details

Supination with object

Starting position


- Forearm rest on the table

(mid position).

- Compression through the wrist

to the elbow joint.

- Facilitation of forearm

supination.


position.

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Treatment Details

Grasping an object/Releasing an object

Starting position


- Assisted grasping.

- Compression on


facilitation full range of

grasping.

- Distraction of

metacarpophalangeal joint to

full range of releasing.


position.

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\ฃฃ

Screening for eligibility

Inclusion criteria

1) First stroke confirmed by medical diagnosis

2) Chronic stroke (stroke onset more than six months)

3) Age 45 years or older

4) Fugl-Meyer Assessment of the Upper Extremity

: Motor assessment scores for moderate level

(26-50/66) to severe level (<26/66)

5) Thai nationality

6) Live in community

7) Able to sit independently for at least 30 minutes

8) Able to understand and follow one-step command

9) Stable medical condition

Exclusion criteria

1. Having other neurological conditions apart from stroke

2. Having musculoskeletal pain affecting reaching

3. Severe shoulder pain (visual analog scale = 75 – 100 mm) 4. Limited passive range of motion of shoulder flexion less than 90 degree

5. Modified Ashworth Scale (grade) more than 2

6. Cognitive impairment

7. Having unilateral neglect

8. Participated in other interventions

Baseline assessment

- Wolf Motor Function Test

- Fugl-Meyer Assessment of the upper extremity

- Muscle tone (Modified Ashworth Scale)

- The Revised Nottingham Sensory Assessment

- Treatment preparation; 15 minutes

- Movement facilitation; shoulder flexion, protraction,

elbow extension, wrist extension, finger extension

Functional training with and without object

(Target location, reaching and skilled grasp)

Three days/ week for six weeks

6 week Post assessment as same as at baseline

Figure 3.1 Experimental flowchart

30 patients

Purposive sampling

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3.3 Data Analysis

Descriptive statistics was used to analyze baseline characteristic data. Intra-Class

Correlation (ICC) (3,1) was used to determine intra- rater reliability and ICC (2,1) was

used to determine inter-rater reliability of the Wolf Motor Function Test and Fugl-

Meyer assessment of the upper extremity.

Data distribution was analyzed using skewness and the Kolmogorov- Smirnov test

(K- S test). Descriptive statistics was used to analyze baseline characteristic data.

Wilcoxon Signed rank test was used to compare non- normal distributed data and

ordinal data. In this study, the significant level was set at 0. 05. SPSS Version 22 was

used to analyze all data.

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Chapter 4

Results

4.1 Intra- and Inter-rater reliability test of the Wolf Motor Function Test and


The characteristic of four patients with stroke patients were those with moderate

upper limb and hand deficits (n = 2) and severe deficit (n = 2). The average age was

62.25 ± 11.76 years (Table 4.1.1).

4.1.1 Intra- and Inter-rater reliability test of the Wolf Motor Function Test

Intra and inter-rater reliability of the Wolf Motor Function Test

(movement time) of the affected side are presented in Table 4.1.2. Intra-rater

reliability ranged from 0.829 to 1.00 for assessor ‘1’ and 0.946 to 1.00 for

assessor ‘2’, respectively. Furthermore, inter-rater reliability of the Wolf Motor

Function Test (movement time) of the affected side ranged from 0.883 to 1.00.

Intra and inter-rater reliability of the Wolf Motor Function Test

(movement time) of the less-affected side are presented in Table 4.1.3. Intra-

rater reliability ranged from 0.806 to 1.00 for assessor ‘1’ and 0.836 to 1.00 for

assessor ‘2’, respectively. Furthermore, inter-rater reliability of Wolf Motor

Function Test (movement time) of less-affected side ranged from 0.875 to 1.00.

Intra- and inter-rater reliability of the Wolf Motor Function Test (FAS) of

the affected side are presented in Table 4.4. Intra-rater reliability ranged from

0.923 to 1.00 for assessor ‘1’ and 0.941 to 1.00 for assessor ‘2’, respectively.

Furthermore, inter-rater reliability of the Wolf Motor Function Test (FAS) of

the affected side ranged from 0.818 to 1.00.

Intra- and inter-rater reliability of the Wolf Motor Function Test (FAS) of

the less-affected side are presented in Table 4.5. Intra- and inter-rater reliability

of the Wolf Motor Function Test (FAS) of the less-affected side were all 1.00.

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Table 4.1.1 Characteristics of the participants in the reliability study

Characteristics Participants (n= 4)

Sex

- Female (n (%))

- Male (n (%))

1 (25%)

3 (75%)

Age (years) (Mean ± SD) 62.25 ± 11.76

Onset of stroke (months) 42.00 ± 52.00

Upper limb and hand deficits

- Moderate level (n (%))

- Severe level (n (%))

2 (50%)

2 (50%)

Affected side

- Left side (n (%))

- Right side (n (%))

2 (50%)

2 (50%)

Dominant-hand

- Left side (n (%))


-

4 (100%)

Education

- Primary School (n (%))

- Secondary School (n (%))

- Bachelor Degree (n (%))

-

2 (50%)

2 (50%)

Mini – Mental State Examination:

Thai version 2002

(scores)

(Mean ± SD)

29 ± 2.00

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Table 4.1.2 Intra and inter-rater reliability of the Wolf Motor Function Test

(movement time) of the affected side

Item

ICC

Intra-rater reliability Inter-rater

reliability

Assessor ‘1’ Assessor ‘2’

1 Forearm to table 0.963 0.948 0.947

2 Forearm to box 0.926 0.946 0.941

3 Extend elbow (side) 0.912 0.953 1.000

4 Extend elbow (weight) 0.829 0.946 0.883

5 Hand to table 0.902 0.995 0.953

6 Hand to box 1.000 1.000 1.000

8 Reach and retrieve 1.000 1.000 1.000

9 Lift can 1.000 1.000 1.000

10 Lift pencil 1.000 1.000 1.000

11 Lift paper clip 1.000 1.000 1.000

12 Stack checkers 1.000 1.000 1.000

13 Flip card 1.000 1.000 1.000

15 Turn key in lock 1.000 1.000 1.000

16 Fold towel 1.000 1.000 1.000

17 Lift basket 1.000 1.000 1.000

Average time 1.000 1.000 1.000

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(movement time) of the less-affected side

Item

ICC


reliability Assessor ‘1’ Assessor ‘2’

1 Forearm to table 0.890 0.970 0.925

2 Forearm to box 0.823 0.838 0.890



5 Hand to table 0.968 0.978 0.875

6 Hand to box 0.900 0.878 0.879


9 Lift can 0.958 0.990 0.961

10 Lift pencil 0.856 0.996 0.957

11 Lift paper clip 0.806 0.997 0.911

12 Stack checkers 0.836 0.959 0.931

13 Flip card 0.957 0.998 0.931

15 Turn key in lock 0.975 0.977 0.960

16 Fold towel 0.964 0.959 0.892

17 Lift basket 0.993 0.994 0.989

Average time 0.979 0.981 0.972


(FAS) of the affected side

Item

ICC


reliability Assessor ‘1’ Assessor ‘2’

1 Forearm to table 1.000 1.000 0.895

2 Forearm to box 0.930 1.000 0.879



5 Hand to table 1.000 1.000 0.818

6 Hand to box 0.958 0.941 0.920


9 Lift can 1.000 1.000 1.000

10 Lift pencil 0.923 1.000 0.952

11 Lift paper clip 0.923 1.000 0.952

12 Stack checkers 0.923 1.000 0.952

13 Flip card 1.000 1.000 1.000

15 Turn key in lock 1.000 1.000 1.000

16 Fold towel 1.000 1.000 1.000

17 Lift basket 1.000 1.000 1.000

Total 0.984 0.999 0.978

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(FAS) of the less-affected side

Item

ICC

Intra-rater reliability

Inter-rater reliability


1 Forearm to table 1.000 1.000 1.000

2 Forearm to box 1.000 1.000 1.000



5 Hand to table 1.000 1.000 1.000

6 Hand to box 1.000 1.000 1.000


9 Lift can 1.000 1.000 1.000

10 Lift pencil 1.000 1.000 1.000

11 Lift paper clip 1.000 1.000 1.000

12 Stack checkers 1.000 1.000 1.000

13 Flip card 1.000 1.000 1.000

15 Turn key in lock 1.000 1.000 1.000

16 Fold towel 1.000 1.000 1.000

17 Lift basket 1.000 1.000 1.000

Total 1.000 1.000 1.000

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4.1.2 Intra- and inter-rater reliability test of the Fugl-Meyer assessment of

the upper extremity

Intra- and inter- rater reliability of the Fugl- Meyer assessment of the upper

extremity of the affected side are presented in Table 4.6. Intra- rater reliability ranged

from 0.800 to 1.000 for assessor ‘1’ and 0.836 to 1.00 for assessor ‘2’ , respectively.

Furthermore, inter-rater reliability of the Fugl-Meyer assessment of the upper extremity

of the affected side ranged from 0.805 to 1.000.

Table 4.1.6 Intra- and inter-rater reliability of the Fugl-Meyer assessment

of the upper extremity

Item

ICC

Intra-rater reliability Inter-rater reliability


A1 1.000 1.000 1.000

A2 0.888 0.874 0.805

A3 1.000 1.000 1.000

A4 0.936 0.941 0.862

A5 1.000 1.000 1.000

B 0.800 1.000 0.939

C 0.872 0.836 0.858

D 0.835 0.945 0.862

Total 0.980 0.969 0.910

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Screening test

(n = 46)

Excluded (n=20)

- Mild level of upper limb

and hand function

- (n = 9)

- Severe level of spasticity

(n = 7)

- Cognitive impairment

(n = 2)

- Recurrent stroke (n = 2)

Included

(n = 26)

Pre-assessment

Bobath therapy

3 days/week

6 weeks

(n = 26)

Post-assessment

Figure 4.1 Participant flowchart

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This study included only 26 participants because the sample size calculation of

the study was 25 and there was no drop out in this study. Forty-six patients with stroke

were screened and only 26 patients met the inclusion criteria. However, the calculation

of power of the test from the data of 26 participants demonstrated 80 percent. This

power of test showed that amount of sample size was sufficient for detecting the

changes between pre- and post- assessment.

4.2.1 Characteristics of the participants

Participants in this study (n = 26) were chronic stroke with moderate level

( n = 13) and severe level ( n = 13) of upper limb and hand deficits. The

characteristics are shown in Table 4.7. The average age of the participants was

59. 69 ± 8. 69 years. The average score of the FMA-UE was 24. 77 ± 11. 39.

Moreover, the onset of stroke was 69.65 ± 65.13 months.

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Table 4.2.1 Characteristics of the participants

a assessed by using the Fugl-Meyer assessment of the upper extremity

Characteristics Participants (n=26)

Moderate levela

(n=13)

Severe levela

(n=13)

Total

(n=26)

Sex

- Female (n (%))

- Male (n (%))

3 (23.08)

10 (76.92)

5 (38.46)

8 (61.54)

10

16

Age (years) 61.23 ± 10.64 58.15 ± 6.24 59.69 ± 8.69

Onset of stroke (months) 67.77 ± 69.11 71.54 ± 63.67 69.65 ± 65.13

Affected side

- Left side (n (%))


5 (38.46%)

8 (61.54%)

5 (38.46%)

8 (61.54%)

10 (38.46%)

16 (61.54%)

Dominant-hand

- Left side (n (%))


0 (0%)

13 (100%)

1 (7.69%)

12 (92.31%)

1 (3.85%)

25 (96.15%)

Education

- Primary (n (%))

- Secondary (n (%))

- Bachelor (n (%))

7 (53.85%)

5 (38.46%)

1 (7.69%)

5(38.46%)

7(53.85%)

1 (7.69%)

12 (46.15%)

12 (46.15%)

2 (7.69%)

Mini – Mental State

Examination: Thai

version 2002 (scores)

(mean ± SD)

23.69 ± 4.73

24.23 ± 3.37

23.96 ± 4.03

Fugl-Meyer assessment

of the upper extremity

(scores) (mean ± SD)

34.46 ± 6.78

15.08 ± 4.57

24.77 ± 11.39

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4.2.2 Wolf Motor Function Test (movement time) of the affected side

Time used in forearm to box, extend elbow ( weight) , hand to box, reach

and retrieve, lift can, lift pencil, lift paper clip, flip card, turn key in lock, fold

towel, lift basket and total movement time demonstrated statistically significant

difference (p < 0.05) between pre and post assessment of movement time of the

Wolf Motor Function Test (movement time) of the affected side. However, time

spent in stack checkers did not show a significant difference (Table 4.2.2).

Table 4.2.2 Pre- and post-assessment of the Wolf Motor Function Test (movement

time) of the affected side

Item Pre – assessment

(n=26)

(seconds)

(mean ± SD)

Post – assessment

(n=26)

(seconds)

(mean ± SD)

P-value

1 Forearm to table 7.26 ± 23.04 2.73 ± 5.11 ≤ 0.001*

2 Forearm to box 13.17 ± 31.76 11.23 ± 32.05 0.007*

3 Extend elbow (side) 66.36 ± 59.10 48.79 ± 57.57 0.031*

4 Extend elbow (weight) 63.41 ± 57.85 44.99 ± 55.89 0.001*

5 Hand to table 8.12 ± 23.29 2.82 ± 5.24 0.005*

6 Hand to box 30.00 ± 50.33 10.87 ± 32.14 0.001*

8 Reach and retrieve 30.34 ± 50.21 2.85 ± 2.11 0.006*

9 Lift can 98.93 ± 44.18 76.99 ± 55.63 0.009*

10 Lift pencil 80.38 ± 55.56 56.87 ± 56.04 0.011*

11 Lift paper clip 100.05 ± 42.28 71.93 ± 57.27 0.006*

12 Stack checkers 101.91 ± 38.78 93.56 ± 44.99 0.176

13 Flip card 101.66 ± 38.75 83.91 ± 44.63 0.019*

15 Turn key in lock 96.63 ± 44.03 79.25 ± 48.63 0.015*

16 Fold towel 96.03 ± 44.66 58.00 ± 46.12 ≤ 0.001*

17 Lift basket 74.30 ± 56.41 43.64 ± 49.66 0.005*

Average time 64.51 ± 28.10 45.98 ± 30.50 0.000*

*P-value < 0.05

Calculated by the Wilcoxon signed rank in SPSS program

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4.2.3 Wolf Motor Function Test (Functional Ability Scale) of the affected

side

All items of the Wolf Motor Function Test (FAS) of the affected side

demonstrated statistically significant difference (p < 0.05) between pre-

assessment and post-assessment, except for lift can and stack checker (Table

4.2.3).

Table 4.2.3 Pre- and post-assessment of the Wolf Motor Function Test (FAS) of

the affected side

Item Pre – assessment

(n=26)

(score)

(mean ± SD)

Post – assessment

(n=26)

(score)

(mean ± SD)

P-value

1 Forearm to table 3.23 ± 0.95 4.23 ± 0.99 ≤ 0.001*

2 Forearm to box 3.04 ± 1.08 4.08 ± 1.20 0.001*

3 Extend elbow (side) 1.69 ± 1.23 2.88 ± 1.73 ≤ 0.001*

4 Extend elbow (weight) 1.88 ± 1.31 2.77 ± 1.58 ≤ 0.001*

5 Hand to table 3.19 ± 0.80 4.04 ± 0.92 ≤ 0.001*

6 Hand to box 2.58 ± 1.14 4.00 ± 1.13 ≤ 0.001*

8 Reach and retrieve 2.81 ± 1.44 4.08 ± 0.94 ≤ 0.001*

9 Lift can 1.38 ± 0.85 1.77 ± 1.28 0.056

10 Lift pencil 1.73 ± 1.12 2.42 ± 1.47 0.003*

11 Lift paper clip 1.46 ± 0.99 2.15 ± 1.43 0.007*

12 Stack checkers 1.38 ± 0.85 1.69 ± 1.26 0.084

13 Flip card 1.35 ± 0.80 1.77 ± 0.95 0.005*

15 Turn key in lock 1.50 ± 1.07 1.96 ± 1.43 0.038*

16 Fold towel 1.50 ± 1.14 2.23 ± 1.11 0.001*

17 Lift basket 1.60 ± 0.10 2.89 ± 1.53 0.003*

Total 29.65 ± 10.70 42.08 ± 14.64 ≤ 0.001*

*P-value < 0.05


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4.2.4 Fugl-Meyer assessment of the upper extremity

All items of the Fugl- Meyer assessment of the upper extremity

demonstrated statistically significant difference between pre- and post-

assessment (p < 0.05), except for reflex activity and normal reflex activity

(Table 4.2.4).

Table 4.2.4 Pre-assessment and post-assessment of the Fugl-Meyer assessment of

the upper extremity

Item

Pre –

assessment

(n=26)

(score)

(mean ± SD)

Post –

assessment

(n=26)

(score)

(mean ± SD)

P-value

Upper extremity

- Reflex activity

Flexors: Biceps and finger flexors

Extensors: triceps

2.00 ± 0.00

1.92 ± 0.39

2.00 ± 0.00

1.92 ± 0.39

1.000

1.000

- Volitional movement within

synergies

Shoulder retraction

elevation

abduction (90°)

external rotation

Elbow flexion

Forearm supination

Shoulder adduction/internal

rotation

Elbow extension

Forearm pronation

0.88 ± 0.65

1.08 ± 0.56

1.04 ± 0.59

0.81 ± 0.69

1.23 ± 0.58

0.23 ± 0.43

1.08 ± 0.79

0.92 ± 0.68

0.31 ± 0.47

1.42 ± 0.57

1.50 ± 0.58

1.35 ± 0.74

1.15 ± 0.78

1.58 ± 0.70

0.88 ± 0.76

1.46 ± 0.58

1.23 ± 0.65

0.81 ± 0.74

0.003*

0.002*

0.059

0.039*

0.007*

0.001*

0.032*

0.033*

0.002*

Subtotal II (max 18) 7.38 ± 3.68 11.38 ± 4.67 ≤ 0.001*

*P-value < 0.05


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the upper extremity (continued)

*P-value < 0.05


Item

Pre –

assessment

(n=26)

(score)

(mean ± SD)

Post –

assessment

(n=26)

(score)

(mean ± SD)

P-value

- Volitional movement

mixing synergies

Hand to lumbar spine

Shoulder flexion 0°-90°

Elbow at 0°

Pronation-supination 0°

Pronation-supination

Elbow at 90°

Shoulder at 0°

0.85 ± 0.73

0.54 ± 0.70

0.65 ± 0.62

1.27 ± 0.72

1.04 ± 0.91

1.12 ± 0.65

0.002*

0.005*

0.007*

Subtotal III (max 6) 1.96 ± 1.66 3.46 ± 1.75 ≤ 0.001*

- Volition movement with

little or no synergy

Shoulder abduction 0 - 90°

Elbow at 0°

Forearm pronated

Shoulder flexion 90 - 180°

Elbow at 0°


Pronation/supination

Elbow at 0°

Shoulder at 30° - 90° flexion

0.54 ± 0.58

0.35 ± 0.65

0.46 ± 0.58

0.85 ± 0.88

0.69 ± 0.78

0.96 ± 0.77

0.033*

0.058

0.002*

Subtotal IV (max 6) 1.35 ± 1.26 2.65 ± 1.83 ≤ 0.001*

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Item

Pre – assessment

(n=26)

(score)

(mean ± SD)

Post – assessment

(n=26)

(score)

(mean ± SD)

P-value

- Normal reflex activity

Biceps, triceps, finger

flexors

1.31 ± 0.78

1.54 ± 0.64

0.177

- Wrist

Stability at 15° dorsiflexion

Elbow at 90°, forearm

pronated

Shoulder at 0

Repeated dorsiflexion /

volar flexion


pronated

Shoulder at 0°, slight finger

flexion



pronated

Slight shoulder

flexion/abduction

Repeated dorsiflexion /

volar flexion


pronated

Slight shoulder

flexion/abduction

Circumduction

0.46 ± 0.64

0.46 ± 0.70

0.35 ± 0.56

0.38 ± 0.57

0.35 ± 0.62

1.00 ± 0.84

0.96 ± 0.82

0.85 ± 0.78

0.96 ± 0.77

0.77 ± 0.71

0.003*

0.003*

0.002*

0.001*

0.002*

Total B (max 10) 1.85 ± 2.54 4.54 ± 3.58 ≤ 0.001*

*P-value < 0.05


Ref. code: 25605812030533ARL

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Item

Pre – assessment

(n=26)

(score)

(mean ± SD)

Post – assessment

(n=26)

(score)

(mean ± SD)

P-value

- Hand

Mass flexion

Mass extension

- Grasp

A- flexion in PIP and DIP

(digit II-V) extension in

MCP II-V

B- thumb adduction

1-st CMC, MCP, IP at 0,

scrap of paper between

thumb and 2-nd MCP joint

C – opposition pulpa of the

thumb against the pulpa of

2-nd finger, pencil, tug

upward

D - cylinder grip

Cylinder shaped object

(small can) tug upward,

opposition in digits I and II

E – spherical grip

Fingers in

abduction/flexion, thumb

opposed, tennis ball

1.12 ± 0.81

0.54 ± 0.76

1.31 ± 0.83

0.65 ± 0.89

0.73 ± 0.87

0.88 ± 0.86

0.77 ± 0.81

1.58 ± 0.57

0.88 ± 0.86

1.50 ± 0.64

1.27 ± 0.77

1.19 ± 0.89

1.58 ± 0.70

1.35 ± 0.74

0.012*

0.073

0.293

0.001*

0.015*

0.001*

0.001*

Total C (max 14) 6.00 ± 4.49 9.12 ± 4.41 ≤ 0.001*

*P-value < 0.05


Ref. code: 25605812030533ARL

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Item

Pre – assessment

(n=26)

(score)

(mean ± SD)

Post – assessment

(n=26)

(score)

(mean ± SD)

P-value

- Coordinate/Speed

Tremor

Dysmetria

Time

0.67 ± 0.65

0.52 ± 0.60

0.49 ± 0.40

0.76 ± 0.62

0.90 ± 0.62

0.38 ± 0.49

0.782

0.020*

0.083

Total D (max 6) 1.47 ± 1.39 2.16 ± 1.39 0.042*

Total 24.77 ± 11.39 38.23 ± 15.41 ≤ 0.001*

*P-value < 0.05


4.2.5 Modified Ashworth Scale

As presented in Table 4.2.5, the Modified Ashworth scale of shoulder

adductors, wrist flexors and finger flexors of demonstrated statistically

significant difference between pre- and post- assessment (p < 0.05).

Table 4.2.5 Pre-assessment and post-assessment of Modified Ashworth Scale

Muscle Pre – assessment

(n=26)

(score)

(mean ± SD)

Post – assessment

(n=26)

(score)

(mean ± SD)

P-value

Shoulder internal rotators 0.17 ± 0.42 0.14 ± 0.39 0.317

Shoulder adductors 0.71 ± 0.71 0.56 ± 0.65 0.039*

Elbow flexors 0.85 ± 0.66 0.67 ± 0.68 0.086

Elbow extensors 0.46 ± 0.68 0.44 ± 0.65 0.317

Pronators 0.19 ± 0.47 0.15 ± 0.44 0.785

Wrist flexors 1.06 ± 0.62 0.87 ± 0.62 0.026*

Finger flexors 0.92 ± 0.74 0.77 ± 0.67 0.046*

MAS Grade 0 = 0, Grade 1 = 1, Grade 1+ = 1.5, Grade 2 = 2

*P-value < 0.05


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4.2.6 Revised Nottingham Sensation assessment

As presented in Table 4.2.6, only stereognosis demonstrated statistically

significant difference (p = 0.028) between pre- and post-assessment of the

revised Nottingham Sensory assessment.

Table 4.2.6 Pre-assessment and Post-assessment of the Revised Nottingham

Sensory assessment

Item

Pre – assessment

(n=26)

(score)

(mean ± SD)

Post – assessment

(n=26)

(score)

(mean ± SD)

P-value

Tactile sensation

Light touch

15.50 ± 3.40

15.42 ± 1.33

0.343

Temperature 13.92 ± 3.20 14.46 ± 3.04 0.059

Pinprick 14.77 ± 2.32 15.27 ± 1.76 0.109

Tactile

localization

15.00 ± 1.69 15.26 ± 1.3 0.059

Bilateral

Simultaneous

touch

7.15 ± 1.80 7.19 ± 1.98 0.783

All 103.08 ± 16.57 104.08 ± 14.83 0.645

Proprioception 8.50 ± 3.52 9.92 ± 8.21 0.067

Stereognosis 9.80 ± 2.65 12.31 ± 8.85 0.028*

*P-value < 0.05


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Chapter 5

Discussion

This chapter explained the significant results of this study based on current

principles and comparison with previous studies.

5.1 Intra- and inter-rater reliability test of the Wolf Motor Function Test and the


The purpose was to evaluate the intra-rater and inter-rater reliability of the Wolf

Motor Function Test (movement time and functional ability scale and the Fugl-Meyer

assessment of the upper extremity of two assessors. The participants with stroke in this

study were four patients with moderate (n=2) to severe deficits (n=2) of upper limb and

hand. All of them were chronic stroke.

5.1.1 Reliability of the Wolf Motor Function Test

The intra-rater and inter- rater reliability of the Wolf Motor Function Test

(movement time and functional ability scale) was excellent. This is in line with

previous studies regarding high intra-rater and inter-rater reliability of the Wolf

Motor Function Test in chronic stroke (ICC ranged from 0.88-0.97) (81, 100). The

Wolf Motor Function Test has standardized particularity which is the important

reason for good psychometric properties (81). Moreover, brief training for two

assessors in the current study enhanced acceptable reliability. Excellent

reliability of the WMFT ensured the rating consistency of the raters and

demonstrated actual changes from the intervention used in the current study.

5.1.2 Reliability of the Fugl-Meyer Assessment of the upper extremity

The intra-rater and inter-rater reliability of individual items and total score

of the Fugl-Meyer assessment of the upper extremity was good to excellent (ICC

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˃ 0.8). Brief training of the test for new assessors could enhance the reliability

of assessment (101). In addition, rating the assessment via video recording (102) or

via direct observation (101, 103) did not affect the reliability of the Fugl-Meyer

Assessment. In previous studies, intra-rater and inter-rater reliability ranged

from 0.95-0.99 (ICC) (101-103). High intra-rater and inter-rater reliability ensured

the consistency of re-assessments by the same rater and across raters.



The effectiveness of the Bobath therapy on upper limb and hand function was

shown in Study 2. Motor impairments, muscle tone and sensation of upper limb and

hand were also assessed in chronic stroke individuals with moderate to severe arm

deficits.

The Bobath therapy implemented problem solving approach for assessment and

treatment (104). The details of the Bobath therapy program in this study featured the

preparation of muscle length, selective movement training, and functional training.

Therefore, the Bobath therapy could improve the function and minimize impairments

of the upper limb and hand in stroke individuals.

This concept is based on motor control and motor learning theory. Active

participation of individual participants is the main ingredient of motor control in the

intervention program (18). Sufficient repetitions of practiced movements also

contributed to motor learning (105). According to the neuronal plasticity, the neuronal

structures and function changed and modified as motor learning occurred (106, 107).

Repeated movements using movement facilitation enhanced sensory stimulation to the

sensorimotor cortex through the stimulation of exteroceptors and proprioreceptors (108).

These sensory inputs are then enhanced the activation of motor cortex as well as motor

pathway, resulting in better control of movement (109).

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5.2.1 The characteristics of participants

All participants in this study were included according to the inclusion

criteria. They were chronic stroke without cognitive deficits. The proportion of

those with moderate deficits and those with severe deficits of upper limb and

hand functions as assessed by using the Fugl-Meyer Assessment of the upper

extremity was equivalent. As demonstrated in several studies, patients with mild

to moderate deficits could achieve completely recovery more than patients with

severe deficits (110, 111). The current study emphasized the therapy to improve

upper limb and hand function in those with severe deficits as well as those with

moderate deficits.

Chronicity also has strong impact on recovery post stroke. The progress

of recovery in chronic stroke are slower than subacute and acute stroke (112, 113)

The valid prognostication of upper extremity (UE) functions recovery was

difficult over 11 weeks post stroke for those with severe deficits (114). However,

the study by Broeks and colleagues (1999) showed that some subacute stroke

individuals still improved in their upper limb and hand functions after four

months post stroke (50). For chronic stroke, improvement in their movements has

been evidenced regardless the onset of stroke (115).

In the current study, all participants were not involved in any

rehabilitation programs. The results in this study were mainly from the effect of

training using the Bobath therapy.

5.2.2 The effect of the Bobath therapy on upper limb and hand functions

The Bobath therapy was effective in improving upper limb and hand

functions as presented in the results. Improvement of upper limb and hand

functions in stroke with moderate to severe deficits in the current study could

be explained by task specific training. The practice of specific repetitive tasks

would result in motor learning and improvement in upper limb and hand

functions (116, 117). The features of the Bobath therapy program used in the

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current study were facilitation technique of hand orientation movement

(CHOR) and hand function. CHOR is the basic movement of various hand

functions such as grasping, picking up an object, and release the object from the

hand (18).

Another explanation is sufficient number of movement repetitions for

motor learning. The patients with stroke whom received the sufficient number

of movement repetitions could improve their upper limb and hand functions

(118). In the current study, almost all items of the WMFT demonstrated

significant improvement after the interventions compared to the baseline.

Various items in the WMFT were similar to tasks practices in the intervention.

Therefore, the functional training with and without objects and movement

facilitation training in the Bobath program could improve functions of upper

limb and hand. The Bobath therapy used in the current study consisted of

selective movement training of individual upper limb joints, for example,

shoulder flexion and wrist flexion. Once the participants had better control of

movement, facilitation was decreased and functional training with and without

objects were administered. As the facilitation decreased, the participants had to

gain more control in executing movements. This self-control promoted motor

learning (119).

The postural control in the Bobath therapy program is also related to upper

limb and hand movements (120). In the previous study, the external trunk support

improved upper limb and hand function as assessed by using the Wolf Motor

Function test in chronic stroke patients. The appropriate degrees of freedom in

trunk (upper and lower part) had positive effect on the reorganization of motor

system and coordination of reaching task. The trunk stabilization supported the

movement of proximal and distal segment in chronic stroke (121). Moreover, the

trunk stability was a base of torque generation for upper limb movement (122).

The Bobath concept emphasized on the posture and movement through the

alignment of body (19). During practice, correct trunk posture was in concern.

Postural control is essential in improving upper limb and hand function (123).

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The address of postural control before and during practice in the Bobath

therapy program in the current study enhanced body orientation and

stabilization. The trainer gave feedback on postural control for individual

patients. In addition, proximal and central and key point of control have a

dynamic interrelationship for motor control (68). Appropriate postural tone and

postural control are related to functional movement (19).

Moreover, selective movement improved joint movements control and

normal patterns of movement through specialized handling. These handling

techniques also improved sensorimotor integration (18). In the Bobath therapy

program used in the current study, the therapist assisted in correcting

movement and joint orientation during movement facilitation. Sensory

information (joint position sense, light touch, joint compression and

distraction) and optimal joint alignment from the handling technique could

also promote the reorganization of the central nervous system (CNS) through

sensorimotor integration and resulting in motor output (124, 125).

Total number of movements used in the current study was 60 repetitions

per task and 300 – 600 repetitions per session. This is considered a sufficient

dose to improve the control of upper limb and hand movement. From the

literature review, optimal training program was indicated by total treatment

time. For example, the modified CIMT program effectively improved upper

limb and hand functions used three hours for a training session and altogether

10 sessions (22). This dose is comparable to the amount of practice used in the

current study. Nevertheless, the participants in the current study were patients

with chronic stroke who no longer received rehabilitation program prior to their

participation in this study. Improvements gained were therefore mainly the

effect from the intervention program.

All in all, the Bobath therapy could improve function, minimize

impairments of the upper limb and hand in chronic stroke. Minimization of

impairments will be discussed in the following section. Although the training

frequency per week for individual participants was not equal. Some participants

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were ill and had medical appointments during the intervention schedule.

However, total times of interventions delivered for participants were equivalent.

Stack checker (item 12) and can lifting (item 9) did not show significant

improvements post interventions as compared to baseline in the current study.

This could be due to the tasks are the most difficult items and complex (126, 127).

For the stack checker, there was no change of both the movement time and

functional ability scale. This task is a complex activity and involving multiple

joints during movement (127). Coordination and holding ability are essential for

task achievement (128). For the participants in the current study, their

coordination as assessed by using the FMA-UE showed moderate deficits at

baseline. However, there was a significant improvement in dysmetria.

Therefore, the finding of no significant improvement in the complex task may

mainly cause by insufficient ability to control movement rather than

incoordination. Movement components of stack checker are shoulder flexion,

scapular protraction, elbow extension, wrist extension, finger extension,

opposition of thumb and index finger. For the can lifting, there was a change in

movement time but not in the functional ability scale of the WMFT. Movement

components in the training program such as wrist extension and hand opening

were similar to the movement components in can lifting. In addition, this task

is required muscle strength in order to lift an unopened can. The practice in this

study might be not enough for improving muscle strength for manipulating an

object with weight. However, changing in functional ability scale required

specific amount of training (129). Movement repetitions used in previous studies

are similar to the current study, but different in participants’ characteristics (6,

118, 130). In the current study, participants were chronic stroke with moderate to

severe deficits of upper limb and hand while the participants in other three

previous studies were acute to subacute stroke. This could imply that sufficient

number of movement repetitions in practice is also efficient in chronic stroke

with severe deficits.

In the current study, the functional ability scale of other items changed

1-2 scale. However, movement change was not yet comparable to the normal

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movement. The practice components of the Bobath therapy used in the current

study were related to upper limb and hand function such as reaching, grasping,

hand opening, and fine movements. These movement components are involved

in various activities (131, 132). The recovery of upper limb and hand functions are

essential for the quality of life of stroke individuals (18, 67, 133). The current study

had various tasks of the training, for example, hand function training with and

without objects. The participants received the appropriately functional training

for improving upper limb and hand performance. Therefore, they had

improvement in the functional ability scale and movement time in the WMFT.

Additional comparison between moderate and severe deficits has been made

and the findings showed more improvement of the complex task ability in stroke

with moderate deficits than those with severe deficits. The progression of

recovery and performance of task in stroke individuals with moderate deficits

was better than those with severe deficits.

5.2.3 The Effect of the Bobath therapy on upper limb and hand

impairments

The Bobath therapy was effective in minimizing impairments of the upper

limb and hand in individuals with chronic stroke. As presented in the results,

almost all items of the Fugl- Meyer assessment of the upper extremity

demonstrated statistically significant improvement post interventions. As thumb

adduction, spherical grip, cylinder grip and opposition showed good

improvement, these were in accordance with the improvement of hand function.

In addition, the Bobath program consisted of the facilitation of selective upper

limb and hand movement. This was effective in improving the impairments in

terms of the control of individual joint movements. The selective movement and

task specific training promoted neuroplasticity (synapse changing, synaptic

transmission), muscular plasticity (fiber length, sarcomeres numbers), and

cortical plasticity (motor and sensory cortical area activation) (134, 135). One

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previous study showed that the task specific training program could improve

the cortical area activation (primary motor, sensorimotor cortex, primary

sensory and premotor cortex) in patients with stroke (136).

Handling scapula in the program used in the current study enhanced

upper limb and hand movement. Handling proximal key point at scapular

provided stability, alignment and movement guidance for normal movement

pattern (19). It has been shown that appropriate scapular position increased the

activation of the muscles surrounding the shoulder joint and improved the

function of the upper extremity (137). This is in accordance with another previous

study that the scapular stabilization program could improve upper limb and

hand function in the patients with chronic stroke (138).

Huseyinsinoglu and colleagues (2012) studied the effectiveness of the

Bobath therapy compared with the constraint-induced movement therapy. Their

results showed improvements in impairments between pre and post intervention

in subacute and chronic stroke participants with high level function of arm

(active wrist extension more than twenty degrees and active extension of the

metacarpophalangeal joints and interphalangeal joint of all digits more than ten

degrees). In their study, the intervention program based on the Bobath concept

consisted of muscle tone normalization, postural stability, and upper limb and

hand activities during unilateral or bilateral tasks. The treatment time was one

hour per session, last for 10 weeks (22). Although participants in the current study

were chronic stoke individuals with moderate to severe impairments,

improvements in impairments were demonstrated.

5.2.3.1 Muscle tone

Hypertone was manifested in almost all of the stroke participants

in the current study at baseline. Based on the Bobath concept, hypertone

occurred from the loss of inhibitory control (18). Spasticity limited joint

range of motion and induced the deviation of normal functional pattern

of upper limb and hand (139, 140). From the findings, the MAS of shoulder

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adductors, wrist flexors and finger flexors decreased significantly post-

interventions as compared to pre-interventions. In the current study, the

patients showed improvement in motor impairment and involuntary

movement. The results were in accordance with one previous study

demonstrated the relation of spasticity with motor units and involuntary

control of spastic muscles activation (141). As a result, as motor control

improve, spasticity reduced.

Passive stretching implemented during the preparation phase

results in muscle tone normalization in the current study. In addition,

movement facilitation addressed elbow extension in reaching, and wrist

extension in hand opening and grasping. The selective movement of

wrist and hand movement helped the relaxation of the wrist and hand

flexor muscles. In addition, the number of hand manipulation in

practices was greater than the number of movement repetitions for

reaching. As a result, muscle tone decreased in only wrist and finger

flexors. In addition, shoulder abduction was the movement component

in several tasks being practiced in the current study. This could explain

the finding that muscle tone of shoulder adductor muscles decreased.

A number of studies supported the effect of a combination of

electrical stimulation on the dorsiflexor muscles and inhibitory Bobath

techniques Bobath therapy on the decrease of hypertone. For example,

the study by Bakhtiary and colleagues (2008) demonstrated that the

intervention could decrease the spasticity of plantarflexor muscle as

assessed by MAS in patients with stroke (142). The intervention program

consisted of the Bobath inhibitory techniques for fifteen minutes,

passive movement of hip abduction, hip external rotation, knee

extension, ankle dorsiflexion (inhibitory movement pattern) and nine

minutes electrical stimulation. Furthermore, the Bobath therapy

program of guide line by the physical therapy 10 sessions demonstrated

decreased spasticity of elbow flexors muscle or elbow extensors muscle

in subacute and chronic stroke patients (21). Different muscles being

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decreased in muscle tone across studies may be due to the difference in

movements being practiced and the characteristics of participants. The

participants in previous studies were subacute and chronic stroke and

the movement being practiced focused recovery the muscle tone.

While there were significant changes in shoulder adductors,

wrist and finger flexors, there was no significant changes in shoulder

flexors, elbow extensors, elbow flexors and pronators post-interventions

as compared to pre-interventions. The participants had spasticity in these

muscle groups as well as moderate to severe deficits of upper limb and

hand at baseline. Minimal changes in the score of MAS in severe

spasticity muscles has been reported (85, 143). In current study, only some

participants had the spasticity of shoulder internal rotator. For elbow

flexor muscles and elbow extensor muscles, there was no change in

MAS as the spasticity of these muscles was in greater degree than other

muscles.

Sustained stretching from 1 to 2 minutes, 12 times per session 4

times a week, 8 weeks decreased spasticity of upper limb muscle (144).

Stretching and muscle mobilization in preparation phase are 15 minutes.

Stretching in the preparation phase in the current study addressed elbow

flexor, wrist and finger flexor. Although no significant improvement,

elbow flexor muscles and elbow extensor muscles showed a trend to

improve in muscle tone.

The characteristics of training in the current study, for example,

hand function training and reaching might also affect muscle tone of

forearm pronator muscles. Most of task practices were in the position

of forearm pronation. Therefore, there were less occasions that forearm

pronator was stretched. Nevertheless, muscle contraction and relaxation

is one possible mechanism to normalize muscle tone. As agonist muscle

is contracting, the antagonist muscles are being lengthened (145). For

example, lower limb pattern practice with the rhythmic initiation of a

repeated stretch and a combination of isotonic technique in

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Proprioceptive Neuromuscular Facilitation (PNF) treatment led to tone

normalization of lower extremity muscles (146). For the PNF

intervention, they applied a lower extremity hip extension-abduction-

internal rotation with knee extension pattern, together with the rhythmic

initiation of a repeated stretch and a combination of isotonic techniques.

Among the many important muscles used in walking and balancing, this

pattern simultaneously stimulates the semitendinosus, the lateral

gastrocnemius, the medial gastrocnemius, the rectus femoris, and the

biceps femoris semitendinosus. The PNF decrease abnormally increased

muscle tone. The intervention increased the muscle activity of lower

extremities muscles.

Overall, muscle tone of the upper limb and hand in chronic

stroke improved post the specified Bobath program. These is in

accordance to the previous study that muscle tone impairment and

functions are associated (147). The improvement of spasticity may change

the task being performed of stroke individuals (148). The baseline

impairment was the important predictor of the neuroplastic changing in

response to treatment program (149).

5.2.3.2 Sensation

In the current study, only stereognosis was found to be different

post intervention comparing to the baseline. Movement facilitation

technique based on the Bobath concept provided sensory input such as

proprioception and tactile for the patients (18). This technique helped

enhancing positive changes to the sensory system (150). The sensorimotor

integration induced the cortical reorganization (151, 152). The cortical area

could be modified through cortical reorganization by sensory input,

experience and learning (18, 153). The stereognosis is cortical sensation

(154). Therefore, changes in stereognosis post the Bobath therapy

program in the current study could be explained by the improvement of

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somatosensory integration. In the current study, many patients with

stereognosis improvement were intact in other sensations. Activation of

cortex area (primary sensory area) might affect object recognition.

One role of the somatosensory association cortex is sensory information

integration from the primary somatosensory cortex to recognition (155).

Task oriented arm practice has been demonstrated to improve the

cortical area (primary sensory area (S1) activation in patients with stroke

(156). In accordance to the study by Rich and colleagues (2017), changing

in stereognosis was demonstrated post CIMT (task specific training) in

chronic stroke with hemiparesis (157). As the components of the Bobath

therapy used in the current study was task specific training. This could

enhance stereognosis.

Moreover, learning and memory is the essential factor for

emphasizing stereognosis (158). In the current study, intervention

program showed improvement in motor learning as demonstrated by

improved upper limb and hand function. As motor control improved,

patients could explore environments themselves and these also had

positive effect on the stereognosis. The ability of hand, for example,

grasping, releasing and finger movement could influence sensory input

via the hand. In the current study, the decrease in muscle tone, and the

increase of hand ability (the result of hand impairments and function

improvement) may also improve hand sensation through the touching

area in the palm. The association of stereognosis and hand ability has

been demonstrated in children with hemiparetic CP ( 1 5 6 ) . Hand

manipulation improved recognition of the objects such as surface and

shape of the object. Stereognosis improvement has been shown to be

related with improvement in motor deficits (159).

Meyer and colleagues (2016) demonstrated a moderate

relationship between somatosensory (stereognosis) and motor deficits

(r = 0.51-0.60) in patients with subacute stroke (159). Likewise, in the

current study, both motor deficits and stereognosis showed

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improvement. A review summarized that treatments minimizing

impairments could enhance the recovery of function post stroke (160).

All other sensory modalities did not show a statistically

significant difference between pre and post assessment. At baseline,

many participants had no deficits in sensation. Therefore, intervention

may not further improve sensory for these participants. This result was

supported by the study by Platz and colleagues (2005) that arm sensation

such as the light touch and joint position sense of arm were not affected

by the Bobath therapy in subacute stroke with severe arm paresis (161).

The practices in their study consisted of muscle tone normalization,

upper limb and hand activities in various positions with and without the

objects, both unilateral and bilateral task in four weeks. Their Bobath

therapy program also considered perception, balance, and movement.

These components of practice are similar to the current study but

practice period and the characteristics of patients are different. The

characteristics of participants were chronic stroke with moderate to

severe deficits in the current study while the participants in their study

were subacute stroke with severe arm paresis.

Limitations of the study

1. Improvement in participation level and quality of life as a result of improvement

in impairments and activities was not explored in the current study.

2. The trainer in the Bobath therapy program must have skill professional or

receive training from an expert.

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Clinical implications

1. In this study, the frequency of the Bobath intervention program for improving

upper limb and hand function was three times per week and continued for six

weeks.

2. The Bobath therapy is one appropriate intervention for stroke individuals with

moderate to severe level of deficits. In clinical practice, the Bobath therapy is

applicable in the conjunction with the other appropriate interventions in chronic

stroke with moderate to severe level of deficits.

3. The Bobath intervention program is one appropriate approach to be used for

stroke individuals in communities.

Further study

1. Further exploration shall also address the assessment of the quality of life as

well as the participation restriction of individuals with stroke as a result of

improvement of impairments and activities of upper limb and hand.

2. Further investigation on the retention effect 3, 6 months and one year post

intervention is warrant. If the retention effect is demonstrated, it will be the

indicator for sufficient practice. If there is no retention effect, it will be the

indicator for additional training required.

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Chapter 6

Conclusion

6.1 Intra- and inter-rater reliability test of the Wolf Motor Function Test and


Overall items of WMFT and FMA presented acceptable to excellent reliability

(ICC ˃ 0.8) for both intra-rater and inter-rater reliability. This ensured that the finding

in this study could demonstrate true effect of the intervention program and not from the

measurement error.



The findings demonstrated the benefit of the Bobath intervention program in

chronic stroke individuals with moderate to severe deficits. Task specific training with

repetitions, together with specific handling and preparation phase used in the program

improved selective movement and sensorimotor integration which resulted in the

improvement of upper limb and hand functions. All components in the program

promoted wrist and finger extension essential for grasping as well as reaching.

After the intervention, muscle tone of involved muscles in the training program

became more normalized. These are wrist and finger flexors. Among sensory

modalities, only stereognosis showed improvement after the Bobath intervention.

In summary, the findings supported the use of the Bobath therapy within 6 weeks

for enhancing upper limb and hand function as well as impairment minimization in

chronic stroke with moderate to severe arm deficits.

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APPENDICES

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APPENDIX A

Ethical approval

APPENDIX A

Ethical approval

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APPENDIX B

Participant Information Sheet

ขอมลส ำหรบอำสำสมครวจย (Participant Information Sheet)

โครงกำรวจย ชอเรอง (ไทย) : ผลของการรกษาดวยแนวคดของโบบาธตอการท างานของแขนและมอ ในผปวยโรคหลอดเลอดสมองทมปญหาการท างานของรยางคสวนบนระดบปานกลางถงรนแรง ชอเรอง (ภำษำองกฤษ) : The effect of Bobath therapy on upper limb and hand function in stroke individuals with moderate to severe arm deficit

ชอผวจย นางสาวธนยชนก พมประสาท ต าแหนง นกศกษาปรญญาโท สถานทตดตอผวจย

(สถานศกษา) ภาควชากายภาพบ าบด คณะสหเวชศาสตร มหาวทยาลยธรรมศาสตร โทรศพท (สถานศกษา)02-986-9213-9 โทรศพทมอถอ 082-3243681 E-mail [email protected]

อำจำรยทปรกษำวจยหลก อ.ดร. ผกามาศ พรยะประสาธน สถานทตดตอ

ภาควชากายภาพบ าบด คณะสหเวชศาสตร มหาวทยาลยธรรมศาสตร โทรศพท (ทท างาน) 02-926-9213-9 ตอ 7256 โทรศพทมอถอ 081-6152622

E-mail [email protected]

อำจำรยทปรกษำวจยรอง ผชวยศาสตราจารย ดร.นพพล ประโมทยกล

ภาควชากายภาพบ าบด คณะสหเวชศาสตร มหาวทยาลยธรรมศาสตร

โทรศพท (ทท างาน) 02-986-9213-9 ตอ 7237 โทรศพทมอถอ 086-6448738


AF 04_07

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กอนททานจะตดสนใจเขารวมการวจย ทานควรท าความเขาใจถงเหตผล และทราบวางานวจยนเกยวของกบอะไร กรณาใชเวลาในการอานขอมลตอไปนอยางละเอยดรอบคอบ และสอบถามขอมลเพมเตมหรอขอมลทไมชดเจนไดตลอดเวลา

1. เหตผลและควำมจ ำเปนทตองท ำกำรวจย โรคหลอดเลอดสมองน าไปสความพการ ผปวยโรคหลอดเลอดสมองระยะเรอรง (นานกวา 6

เดอน) ยงพบความผดปกตและบกพรองและจ ากดการท ากจกรรมตางๆ และผปวยโรคหลอดเลอด

สมองจ านวนมากทมปญหาการใชงานแขนและมอขางทออนแรง

โดยหลกการของการรกษาดวยแนวคดของโบบาธคอ เทคนคการใชมอของนกกายภาพบ าบด

ในการฝกเพอกระตนการท างานของกลามเนอโดย เนนการทรงตว การเคลอนไหวทเปนปกต และ

กระบวนการกระตนระบบประสาทสมผส โดยผานการใหแรงกดและดงผานขอตอตางๆของรยางค

สวนบนและมอ ซงมความเหมาะสมทสามารถน าไปใชในการฝกผปวยในชมชน ดวยเทคนคการรกษา

และการน าไปใชกบผปวยไดงาย ในการศกษากอนหนาทมการรกษาดวยแนวคดของโบบาธ แสดงให

เหนวามการเพมขนของการท างานของแขนและมอในผปวยโรคหลอดเลอดสมองระยะเรอรง แตยง

ขาดรายละเอยดทมความเฉพาะเจาะจงของการรกษา

2.วตถประสงคของกำรวจย

กำรศกษำควำมนำเชอถอของกำรประเมนหลกทใชในงำนวจย

1. เพอหาคาความนาเชอถอในการวดซ าของแบบประเมน Wolf Motor Function Test และ Fugl-Meyer assessment of the upper extremity โดยผวด (assessor) แตละคน

2. เพอหาคาความนาเชอถอระหวางผวดทงสองคน (assessors) ของแบบประเมน Wolf Motor Function Test และ Fugl-Meyer assessment of the upper extremity

3. รำยละเอยดของอำสำสมคร ผปวยโรคหลอดเลอดสมองในจงหวดปทมธาน

เกณฑกำรคดเขำ

1) เปนโรคหลอดเลอดครงแรก

2) มอายตงแต 45 ปขนไป

Ref. code: 25605812030533ARL

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3) มความบกพรองการท างานของรยางคสวนบนและมอระดบปานกลางถงรนแรง ประเมนดวย

แบบประเมนความบกพรองในการเคลอนไหวรยางคสวนบน(Fugl-Meyer Upper

Extremity Motor Assessment

4) มสญญาณชพคงท ไดแก อตราการเตนของหวใจ อตราการหายใจ และความดนโลหต

5) สามารถนงไดอยางนอย 30 นาท 6) สามารถเขาใจและปฏบตตามค าสงทละขนตอนได

เกณฑกำรคดออก

1) เปนโรคทางระบบประสาทอนๆรวมดวย 2) มอาการปวดจากโรคทางกระดกและกลามเนอทสงผลกระทบตอการฝกรยางคสวนบนและ

มอ 3) มอาการปวดไหลระดบรนแรง 4) เคลอนไหวในทาทางการงอขอไหล ไดนอยกวา 90 องศา 5) มการเกรงตวของกลามเนอแขนและมอระดบรนแรง 6) มปญหาดานการเขาใจและการรบร 7) มอาการเพกเฉยและละเลยตอรางกายดานตรงขาม 8) อยในระหวางการฟนฟหรอการรกษาทเกยวของกบการเคลอนไหวของรยางคสวนบนและมอ

4. กระบวนกำรวจย และกำรใหขอมลแกอำสำสมคร

ขนตอนด ำเนนกำรวจย (Experimental protocol)

กำรศกษำควำมนำเชอถอของกำรประเมนหลกทใชในงำนวจย

การศกษาขนตอนน ท าการเกบขอมลโดยผวจยจะท าการเกบขอมลโดยใชกลองวดโอถายภาพ

เคลอนไหวของการประเมนอาสาสมครทเขารวมในขนตอนการศกษานจ านวน ทงหมด 4 คน ซงม

คณสมบตตามเกณฑการคดเลอก จะไดรบการประเมนโดยแบบประเมน Wolf Motor Function

Test และแบบประเมน Fugl-Meyer assessment of the upper extremity

Ref. code: 25605812030533ARL

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1. ผวจยอธบายวตถประสงค ขนตอนการวจย และประโยชนของการวจยครงนแก อาสาสมคร และขอความยนยอมจากอาสาสมครเปนลายลกษณอกษร

2. ผวจยแนะน าวธการประเมนแกอาสาสมคร

3. ประเมนกอนการคดเขา (screening test)

- ประเมนการรบรดวยแบบประเมน Mini Mental State Examination (MMSE)

- ประเมนการปวดขอไหลดวย Visual Analogue Scale (VAS) ถาผปวยมอาการปวดไหล

คดเลอกอาสาสมครตามทเกณฑทระบไวในเกณฑการคดเขาและคดออก

4. ประเมนความสามารถในการใชมอและแขนในการใชงานดวยประเมนแบบประเมน Wolf Motor Function Test 5. ประเมนความบกพรองในการเคลอนไหวรยางคสวนบนดวยแบบประเมน Fugl-Meyer assessment of the upper extremity (FMA-UE) หวขอ motor function

6. บนทกวดโอขณะท าการประเมน

7. วเคราะหผลและสรปผลคาความนาเชอถอในการวดซ าของผประเมนแตละคนและคาความนาเชอถอระหวางผประเมน

5. ในกำรคดกรองอำสำสมครวจย หำกพบวำผนนไมอยในเกณฑคดเขำ และอยในสภาวะท

สมควรไดรบความชวยเหลอ/แนะน า ผวจยจะใหความชวยเหลอและค าแนะน าตามทสามารถท าไดใน

สวนของงานกายภาพบ าบด

6.ควำมเสยงหรออนตรำยทจะเกดขน และ/หรอควำมไมสะดวกสบำยของอำสำสมครท

อำจไดรบ และมำตรกำรทผวจยเตรยมไวปองกน

อาสาสมครอาจมความเสยงตอการเกดอาการเกรงของกลามเนอและเกดความเหนอยลา ระหวางการทดสอบ ผวจยจะอธบายวธการทดสอบและการฝกเพอลดความเสยงหรออนตรายทอาจเกดขน ซงกอน ระหวาง และหลง การทดสอบแตละกจกรรมทานสามารถพกไดตามตองการ โดยผวจยจะมการประเมนอตราการเตนของหวใจและคาความเหนอย และมระยะเวลาพกใหแกอาสาสมคร หากอาสาสมครรสกวาการทดสอบและการฝกไมปลอดภยหรอยากเกนไปจนอาจเสยงตอการเกดอนตรายตอตวอาสาสมครสามารถหยดการทดสอบไดตลอดเวลา ผวจยจะอยกบอาสาสมครตลอดเวลาระหวางการทดสอบและการฝก

Ref. code: 25605812030533ARL

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กำรดแลรกษำและแกปญหำอนกรณเกดผลแทรกซอนแกอำสำสมคร การทดสอบจะหยดทนทเมออาสาสมครประสงคจะหยดหรอไมสามารถท าตอได หากเกดผล

ขางเคยงทไมพงประสงคจากการวจยครงน เชน หากอาสาสมครมอาการลา จะไดรบระยะเวลาพก

เพมขนเทาทตองการ ถามอาการหนามด จะไดรบการปฐมพยาบาลเบองตน และหากเกดผลขางเคยง

อนๆ ทไมสามารถปฐมพยาบาลเบองตนได จะไดรบการน าตวสงสถานพยาบาลทใกลเคยงทสด โดย

คณะผวจยจะเปนผรบผดชอบคาใชจายในการรกษาอาการแทรกซอนทเปนผลจากการวจย

โดยจะมการระมดระวงถงความปลอดภยและรายงานอาการไมพงประสงค ผวจยจะท าการ

สงเกต อาการผดปกตตางๆ ทเกดขนระหวางใหการประเมนกบอาสาสมคร เชน อาการเหนอย โดยใชการสอบถามและแบบประเมนความเหนอย

7. ประโยชนในกำรเขำรวมวจย ประโยชนทคาดวาจะเกดขนจากการท าวจย

1.) เพอทราบความนาเชอถอในการวดซ าของผประเมนแตละคนและคาความนาเชอถอระหวางผประเมน

2.) เพอใหการประเมนกอนและหลงการรกษาในงานวจยหลกมความนาเชอถอ

8. การเขารวมในการวจยของอาสาสมครเปนโดยสมครใจ และสามารถปฏเสธทจะเขารวมหรอถอนตวจากการวจยไดทกขณะ โดยไมตองใหเหตผลใหทราบลวงหนา และการไมเขารวมการวจยหรอถอนตวออกจากโครงการวจยนจะไมมผลกระทบตอการบรการและการรกษาทสมควรจะไดรบแตประการใด 9. การศกษานไมมคาตอบแทนในการเขารวม โดยอาสาสมครจะไดรบคาเดนทาง เปนเงนจ านวน 500 บาท

10. “หากอาสาสมครไม ได รบการปฏบตตามขอมลด งกล าวสามารถรองเรยน ไดท :

คณะอนกรรมการจรยธรรมการวจยในคน มหาวทยาลยธรรมศาสตร ชดท 3 อาคารราชสดา ชน 1

ภายในศนยสงเสรมสขภาพ คณะพยาบาลศาสตร มหาวทยาลยธรรมศาสตร ศนยรงสต โทรศพท 02-

986-9213 ตอ 7373 โทรสาร 02-5165381

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11. ขอมลทเกยวของกบทานจะเกบเปนควำมลบ หากมการเสนอผลการวจยจะเสนอเปน

ภาพรวม ขอมลใดทสามารถระบถงตวทานไดจะไมปรากฏในรายงาน ขอมลสวนตวของทานจะถกเกบ

รกษาไว ไมเปดเผยตอสาธารณะเปนรายบคคล แตจะรายงานผลการวจยเปนขอมลสวนรวม ขอมล

ของผเขารวมเปนรายบคคลอาจมคณะบคคลบางกลมเขามาตรวจสอบได เชน ผใหทนวจย สถาบน

หรอองคกรของรฐทมหนาทตรวจสอบ คณะกรรมการจรยธรรมฯ เปนตน

Ref. code: 25605812030533ARL

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ขอมลส ำหรบผประเมน

(Assessor Information Sheet)

โครงการวจย ชอเรอง (ไทย) : ผลของการรกษาดวยแนวคดของโบบาธตอการทางานของแขนและมอ ในผปวยโรคหลอดเลอดสมองทมปญหาการท างานของรยางคสวนบนระดบปานกลางถงรนแรง ชอเรอง (ภาษาองกฤษ) : The effect of Bobath therapy on upper limb and hand function in stroke individuals with moderate to severe arm deficit


(สถานศกษา) ภาควชากายภาพบ าบด คณะสหเวชศาสตร มหาวทยาลยธรรมศาสตร โทรศพท (สถานศกษา) 02-986-9213-9 โทรศพทมอถอ 082-3243681 E-mail [email protected]








AF 04_07

Ref. code: 25605812030533ARL

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กระบวนการกระตนระบบประสาทสมผส โดยผานการใหแรงกดและดงผานขอตอตางๆ ของรยางค





การศกษาครงนเปนสวนหนงของงานวจยหลกทจะท าการศกษาผลของการรกษาทาง

กายภาพบ าบดทจ าเพาะเพอการฟนฟการใชงานแขนและมอขางทออนแรงของผปวยโรคหลอดเลอด

สมองระยะเรอรง

2.วตถประสงคของกำรวจย

1) เพอหาคาความนาเชอถอในการวดซ าของแบบประเมน Wolf Motor Function Test และ Fugl-Meyer assessment of the upper extremity โดยผประเมนแตละคน

2) เพอหาคาความนาเชอถอระหวางผประเมน ของแบบประเมน Wolf Motor Function Test และ Fugl-Meyer assessment of the upper extremity

Ref. code: 25605812030533ARL

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3.รำยละเอยดของผประเมน 1) เปนนกกายภาพบ าบดทมประสบการณการรกษาผปวยโรคหลอดเลอดสมอง

2) ไดรบการฝกการประเมนดวยแบบประเมนทใชในงานวจย ไดแก แบบประเมน Wolf Motor

Function Test และแบบประเมน Fugl-Meyer Assessment of upper extremity (FMA-

UE)

4. กระบวนกำรวจย และกำรใหขอมลแกอำสำสมคร

ขนตอนด ำเนนกำรวจย (Experimental protocol)

การศกษาขนตอนน ท าการเกบขอมลโดยมผประเมนจ านวน 2 คน ประเมนความสามารถใน

การเคลอนไหว และการท างานของรยางคสวนบนและมอของผปวยโรคหลอดเลอดสมองจากวดโอ

ถายภาพเคลอนไหวของการประเมน อาสาสมครทเขารวมในขนตอนการศกษานจ านวน ทงหมด 4

คน ซงมคณสมบตตามเกณฑการคดเลอก ไดแกการประเมนดวยแบบประเมน Wolf Motor

Function Test และแบบประเมน Fugl-Meyer assessment of the upper extremity ดงน

1) ผวจยอธบายวตถประสงค ขนตอนการวจย และประโยชนของการวจยครงนแก ผประเมน และขอความยนยอมจากอาสาสมครเปนลายลกษณอกษร

2) ผวจยแนะน าวธการประเมนทใชในงานวจยแกผประเมน ผประเมนจะไดรบการฝกการป ร ะ เ ม น แบบ ปร ะ เ ม น Wolf Motor Function Test แ ล ะประ เ ม น Fugl-Meyer assessment of the upper extremity (FMA-UE) หวขอ motor function

3) ผประเมนท าการประเมนความสามารถในการใชมอและแขนในการใช งานของผปวยโรคหอลดเลอดสมอง 4 ราย ดวยประเมนแบบประเมน Wolf Motor Function Test ซงการศกษานจะประเมนความสามารถการท างานของแขนและมอ 15 หวขอ

4) ผประเมนท าการประเมนความบกพรองในการเคลอนไหวรยางคสวนบนของผปวยโรคหลอดเลอดสมอง 4 ราย ดวยแบบประเมน Fugl-Meyer assessment of the upper extremity (FMA-UE) หวขอ motor function

5) ผวจยท าการวเคราะหผลและสรปผลคาความนาเชอถอในการวดซ าของผประเมนแตละคนและคาความนาเชอถอระหวางผประเมน

Ref. code: 25605812030533ARL

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6.ควำมเสยงหรออนตรำยทจะเกดขนและ/หรอควำมไมสะดวกสบำยของผประเมนทอำจ

ไดรบ และมำตรกำรทผวจยเตรยมไวปองกน

งานวจยนมความเสยงนอย แตอยางไรกตาม การจดจอกบการประเมนเปนระยะเวลาตดตอกน อาจะท าใหผประเมนเกดความเหนอยลา ดงนน ระหวางการทดสอบ การทดสอบแตละกจกรรม อาสาสมครสามารถพกไดตามตองการ

กำรดแลรกษำและแกปญหำอนกรณเกดผลแทรกซอนแกผประเมน การทดสอบจะหยดทนทเมออาสาสมครประสงคจะหยดหรอไมสามารถท าตอได หากเกดผล

ขางเคยงทไมพงประสงคจากการวจยครงน เชน หากอาสาสมครมอาการลา สามารถพกเพมขนเทาท

ตองการ


1.) ไดทราบความนาเชอถอในการวดซ าของผประเมนแตละคนและคาความนาเชอถอระหวางผประเมน

2.) เพอใหการประเมนกอนและหลงการรกษาในงานวจยหลกมความนาเชอถอ

8. การเขารวมในการวจยของผประเมนเปนโดยสมครใจ และสามารถปฏเสธทจะเขารวมหรอถอนตวจากการวจยไดทกขณะ โดยตองใหเหตผลใหทราบลวงหนา 9. มคาตอบแทน ใหแกผประเมน รายละ 500 บาทในการเขารวมการศกษาครงน

10. “หากผ ประเมน ไม ได ร บการปฏบ ต ตามขอมลด งกล าวสามารถรอ ง เร ยน ไดท :



986-9213 ตอ 7373 โทรสาร 02-5165381






Ref. code: 25605812030533ARL

104

ขอมลส ำหรบอำสำสมครวจย (Participant Information Sheet)

โครงการวจย ชอเรอง (ไทย) : ผลของการรกษาดวยแนวคดของโบบาธตอการทางานของแขนและมอ ในผปวยโรคหลอดเลอดสมองทมปญหาการท างานของรยางคสวนบนระดบปานกลางถงรนแรง ชอเรอง (ภาษาองกฤษ) : The effect of Bobath therapy on upper limb and hand function in stroke individuals with moderate to severe arm deficit


(สถานศกษา) ภาควชากายภาพบ าบด คณะสหเวชศาสตร มหาวทยาลยธรรมศาสตร โทรศพท (สถานศกษา) 02-986-9213 โทรศพทมอถอ 082-3243681 E-mail [email protected]









AF 04_07

Ref. code: 25605812030533ARL

105






กระบวนการกระตนระบบประสาทสมผส โดยผานการใหแรงกดและดงผานขอตอตางๆ ของรยางค





2. วตถประสงคของกำรวจย

วตถประสงค เพอเปรยบเทยบประสทธผลการรกษาดวยแนวคดของโบบาธตอการท างาน

ความบกพรองของแขนและมอ ความเกรงตวของกลามเนอ และการรบรความรสกในผปวย

โรคหลอดเลอดสมองระยะเรอรงทมปญหาการท างานของรยางคสวนบนและมอระดบปาน

กลางถงรนแรงกอนและหลงการรกษา

3. รำยละเอยดของอำสำสมคร ผปวยโรคหลอดเลอดสมองไทย ระยะเรอรงในจงหวดปทมธาน

เกณฑกำรคดเขำ

1) เปนโรคหลอดเลอดสมองครงแรก และมระยะเวลาทเปนโรคหลอดเลอดสมองตงแต 6

เดอน

2) มอายตงแต 45 ปขนไป

3) มความบกพรองการท างานของรยางคสวนบนและมอระดบปานกลางถงรนแรง โดยการ

ประเมนดวยแบบประเมนความบกพรองในการเคลอนไหวรยางคสวนบน (Fugl-Meyer

Upper Extremity Motor Assessment)

4) มสญญาณชพคงท (ไดแก อตราการเตนของหวใจ อตราการหายใจ และความดนโลหต)

5) สามารถนงไดอยางนอย 30 นาท

Ref. code: 25605812030533ARL

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6) สามารถเขาใจและปฏบตตามค าสงทละขนตอนได

เกณฑกำรคดออก

1) เปนโรคทางระบบประสาทอนๆ รวมดวย 2) มอาการปวดจากโรคทางกระดกและกลามเนอทสงผลกระทบตอการฝกรยางคสวนบนและ

มอ 3) มอาการปวดไหลระดบรนแรง 4) เคลอนไหวในทาทางการงอขอไหล ไดนอยกวา 90 องศา 5) มการเกรงตวของกลามเนอแขนและมอระดบรนแรง 6) มปญหาดานการเขาใจและการรบร 7) มอาการเพกเฉยและละเลยตอรางกายดานตรงขาม 8) อยในระหวางการฟนฟหรอการรกษาทเกยวของกบการเคลอนไหวของรยางคสวนบนและมอ

4. กระบวนการวจย และการใหขอมลแกอาสาสมคร

ขนตอนการเตรยมการ; ผวจยจะอธบายวตถประสงค ขนตอนการวจย และประโยชนของการวจยครงนแกอาสาสมคร และขอความยนยอมจากอาสาสมครเปนลายลกษณอกษร โดยจะมผเขารวมเปนอาสาสมครทงหมด 30 คน

Ref. code: 25605812030533ARL

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ขนตอนกำรเกบขอมล

พจารณาเลอกผเขารวมวจยตามเกณฑทก าหนด

อาสาสมครทจะเขารวมลงนามแสดงความยนยอมในการเขารวม

การวจย

ผวจยอธบายถงวตถประสงค ขนตอนการวจย และประโยชนของการวจยแก

อาสาสมคร

การประเมนความสามารถการเคลอนไหวของแขนและมอ โดยใชการตรวจการเคลอนไหว และประเมนความตงตวของกลามเนอ ประกอบดวย

- Wolf Motor Function Test

- Fugl Meyer Assessment - UE

- Modified Ashworth Scale

- Revised Nottingham Sensory Assessment

การรกษาดวยแนวคดของโบบาธ 3 วน / สปดาห ทงหมด 6 สปดาห

ประเมนหลงการรกษาในวนถดไปหลงจาก ใหการรกษาครงสดทาย

วนถดมา 1 วน

วนถดมา 1 วน

Ref. code: 25605812030533ARL

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5. ในกำรคดกรองอำสำสมครวจย หำกพบวำผนนไมอยในเกณฑคดเขำ และอยในสภาวะ

ทสมควรไดรบความชวยเหลอ/แนะน า ผวจยจะใหความชวยเหลอและค าแนะน าตามทสามารถท าได

ในสวนของงานกายภาพบ าบด

6.ควำมเสยงหรออนตรำยทจะเกดขน และ/หรอควำมไมสะดวกสบำยของอำสำสมครท

อำจไดรบ และมำตรกำรทผวจยเตรยมไวปองกน

อาสาสมครอาจมความเสยงตอการเกดอาการเกรงของกลามเนอและเกดความเหนอยลา ระหวางการทดสอบหรอการฝก ผวจยจะอธบายวธการทดสอบและการฝกเพอลดความเสยงหรออนตรายทอาจเกดขน ซงกอน ระหวาง และหลง การทดสอบหรอการฝกแตละกจกรรมทานสามารถพกไดตามตองการ โดยผวจยจะมการประเมนอตราการเตนของหวใจและคาความเหนอย และมระยะเวลาพกใหแกอาสาสมคร หากอาสาสมครรสกวาการทดสอบและการฝกไมปลอดภยหรอยากเกนไปจนอาจเสยงตอการเกดอนตรายตอตวอาสาสมครสามารถหยดการทดสอบและการฝกไดตลอดเวลา ผวจยจะท าการสงเกต อาการผดปกตตางๆ ทเกดขนระหวางใหการประเมนหรอรกษากบอาสาสมคร เชน อาการเหนอย โดยใชการสอบถามและแบบประเมนความเหนอย

กำรดแลรกษำและแกปญหำอนกรณเกดผลแทรกซอนแกอำสำสมคร การทดสอบจะหยดทนทเมออาสาสมครประสงคจะหยดหรอไมสามารถท าตอได หากเกดผล

ขางเคยงทไมพงประสงคจากการวจยครงน เชน หากอาสาสมครมอาการลา จะไดรบระยะเวลาพก

เพมขนเทาทตองการ ถามอาการหนามด จะไดรบการปฐมพยาบาลเบองตน และหากเกดผลขางเคยง

อนๆ ทไมสามารถปฐมพยาบาลเบองตนได จะไดรบการน าตวสงสถานพยาบาลทใกลเคยงทสด โดย

คณะผวจยจะเปนผรบผดชอบคาใชจายในการรกษาอาการแทรกซอนทเปนผลจากการวจย


1.) เพอทราบประสทธผลของการรกษาดวยแนวคดของโบบาธในผปวยทมปญหาการท างานของแขนและมอในผปวยโรคหลอดเลอดสมองระดบปานกลางถงรนแรง

2.) เพอเปนแนวทางในการประยกตใชการรกษาทางกายภาพบ าบดในผปวยทมปญหาการท างานของแขนและมอในผปวยโรคหลอดเลอดสมองระดบปานกลางถงรนแรง ซงจะเปนประโยชนในการใหการวางแผนรกษาผปวยโรคหลอดเลอดสมองในชมชน

Ref. code: 25605812030533ARL

109

นอกจากนอาสาสมครจะไดรบความร ขอแนะน าทางกายภาพบ าบดในการฝกการเคลอนไหว เขาใจในอาการและความบกพรองตางๆ มากขน ส าหรบน าไปปรบใชในการด าเนนชวตประจ าวน เพอสงเสรมการเคลอนไหวทดขน

8. การเขารวมในการวจยของอาสาสมครเปนโดยสมครใจ และสามารถปฏเสธทจะเขารวมหรอถอนตวจากการวจยไดทกขณะ โดยไมตองใหเหตผลใหทราบลวงหนา และการไมเขารวมการวจยหรอถอนตวออกจากโครงการวจยนจะไมมผลกระทบตอการบรการและการรกษาทสมควรจะไดรบแตประการใด 9. คาตอบแทน “การศกษานไมมคาตอบแทนในการเขารวม”

10. “หากอาสาสมคร ไม ได ร บการปฏบต ตามขอมลด งกล าวสามารถรอง เร ยนไดท :



986-9213 ตอ 7373 โทรสาร 02-5165381






Ref. code: 25605812030533ARL

110

APPENDIX C

Informed Consent Form

หนงสอแสดงควำมยนยอมเขำรวมกำรวจยของอำสำสมครวจย (Informed Consent Form)

ตอนท 1

ท าท..................................................................... วนท.............เดอน.......................พ.ศ. ..............

เลขท อาสาสมครวจย…...................……

ขาพเจา ซงไดลงนามทายหนงสอน ขอแสดงความยนยอมเขารวมโครงการวจย ชอโครงการวจย ผลของการรกษาดวยแนวคดของโบบาธ ตอการท างานของแขนและมอ ในผปวยโรคหลอดเลอดสมองทมปญหาการท างานของรยางคสวนบนระดบปานกลางถงรนแรง (The effect of Bobath therapy on upper limb and hand function in stroke individuals with moderate to severe arm deficit)

ตอนท 1 การทดสอบความนาเชอถอของผประเมนในการใชแบบประเมน Wolf Motor

Function Test และ Fugl-Meyer assessment of the upper extremity

ชอผวจย นางสาวธนยชนก พมประสาท ทอยทตดตอ ภาควชากายภาพบ าบด คณะสหเวชศาสตร มหาวทยาลยธรรมศาสตร โทรศพท (ทท างาน) 02-986-9213 โทรศพทมอถอ 082-324-3681 อำจำรยทปรกษำ อำจำรยทปรกษำวจยหลก อ.ดร. ผกามาศ พรยะประสาธน ทอยทตดตอ ภาควชากายภาพบ าบด คณะสหเวชศาสตร มหาวทยาลยธรรมศาสตร โทรศพท (ทท างาน) 02-926-9213-9 ตอ 7256 โทรศพทมอถอ 081-6152622 อำจำรยทปรกษำวจยรอง ผชวยศาสตราจารย ดร.นพพล ประโมทยกล ทอยทตดตอ (ทท างาน) ภาควชากายภาพบ าบด คณะสหเวชศาสตร มหาวทยาลยธรรมศาสตร โทรศพท (ทท างาน) 02-986-9213-9 ตอ 7237 โทรศพทมอถอ 086-6448738

AF 05_07

Ref. code: 25605812030533ARL

111

ขาพเจาไดรบทรำบรายละเอยดเกยวกบทมาและวตถประสงคในการท าวจย รายละเอยดขนตอนตางๆ ทจะตองปฏบตหรอไดรบการปฏบต ความเสยง/อนตราย และประโยชนซงจะเกดขนจากการวจยเรองน โดยไดอานรายละเอยดในเอกสารชแจงอาสาสมครวจยโดยตลอด และไดรบค ำอธบำยจากผวจยจนเขำใจเปนอยำงดแลว

ขาพเจาจงสมครใจเขารวมในโครงการวจยน ตามทระบไวในเอกสารชแจงอาสาสมครวจยโดยขาพเจายนยอมสละเวลาตอบแบบสอบถามขอมลทวไป รบการประเมนการท างานและกจกรรมตางๆดวยแบบประเมน Wolf Motor Function Test และรบการประเมนความบกพรองในการเคลอนไหวโดยแบบประเมน Fugl-Meyer assessment of the upper extremity (FMA-UE) เมอเสรจสนการวจยแลว ขอมลทเกยวของกบอาสาสมครวจยจะถกท าลาย

ขาพเจามสทธถอนตวออกจากการวจยเมอใดกไดตามความประสงค โดยไมตองแจงเหตผล ซงการถอนตวออกจากการวจยนน จะไมมผลกระทบตอการบรการและการรกษาทสมควรจะไดรบแตประการใด

ขาพเจาไดรบค ารบรองวา ผวจยจะปฏบตตอขาพเจาตามขอมลทระบไวในเอกสารชแจงอาสาสมครวจยและขอมลใดๆ ทเกยวของกบขาพเจา ผวจยจะเกบรกษำเปนควำมลบ โดยจะน าเสนอขอมลการวจยเปนภาพรวมเทานน ไมมขอมลใดในการรายงานทจะน าไปสการระบตวขาพเจา

หำกขำพเจำไมไดรบกำรปฏบตตรงตำมทไดระบไวในเอกสำรชแจงอำสำสมครวจย ขาพเจาสามารถรองเรยนไดท: คณะอนกรรมการจรยธรรมการวจยในคน มหาวทยาลยธรรมศาสตร ชดท 3 อาคารราชสดา ชน 1 ศนยสงเสรมสขภาพ คณะพยาบาลศาสตร มหาวทยาลยธรรมศาสตร ศนยรงสต โทรศพท 02-986-9213 ตอ 7373 โทรสาร 02-5165381

ขาพเจาไดลงลายมอชอไวเปนส าคญตอหนาพยาน ทงนขาพเจาไดรบส าเนาเอกสารขอมลส าหรบ อาสาสมครวจย และส าเนาหนงสอแสดงความยนยอมเขารวมการวจยของอาสาสมครวจยไวแลว

ลงชอ............................................................... (..................................................................)

ผวจยหลก วนท……..…/……….……./…………

ลงชอ................................................................ (.......................................................................)

อาสาสมครวจย วนท……..…/……….……./…………

ลงชอ................................................................ (.................................................................... ...)

พยาน วนท……..…/……….……./…………

ลงชอ....................................................... ......... (.......................................................................)

พยาน วนท……..…/……….……./…………

Ref. code: 25605812030533ARL

112

หนงสอแสดงควำมยนยอมเขำรวมกำรวจยของผประเมน (Informed Consent Form)

ท าท..................................................................... วนท.............เดอน.......................พ.ศ. ..............


ขาพเจา ซงไดลงนามทายหนงสอน ขอแสดงความยนยอมเขารวมโครงการวจย ชอโครงการวจย ผลของการรกษาดวยแนวคดของโบบาธ ตอการท างานของแขนและมอ ในผปวยโรคหลอดเลอดสมองทมปญหาการท างานของรยางคสวนบนระดบปานกลางถงรนแรง (The effect of Bobath therapy on upper limb and hand function in stroke individuals with moderate to severe arm deficit)

ตอนท 1 การทดสอบความนาเชอถอของผประเมนในการใชแบบประเมน Wolf Motor

Function Test และ Fugl-Meyer assessment of the upper extremity

ชอผวจย นางสาวธนยชนก พมประสาท ทอยทตดตอ ภาควชากายภาพบ าบด คณะสหเวชศาสตร มหาวทยาลยธรรมศาสตร โทรศพท (ทท างาน) 02-986-9213 โทรศพทมอถอ 082-324-3681 อำจำรยทปรกษำ อำจำรยทปรกษำวจยหลก อ.ดร. ผกามาศ พรยะประสาธน ทอยทตดตอ ภาควชากายภาพบ าบด คณะสหเวชศาสตร มหาวทยาลยธรรมศาสตร โทรศพท (ทท างาน) 02-986-9213-9 ตอ 7256 โทรศพทมอถอ 081-6152622 อำจำรยทปรกษำวจยรอง ผชวยศาสตราจารย ดร.นพพล ประโมทยกล ทอยทตดตอ (ทท างาน) ภาควชากายภาพบ าบด คณะสหเวชศาสตร มหาวทยาลยธรรมศาสตร โทรศพท (ทท างาน) 02-986-9213-9 ตอ 7237 โทรศพทมอถอ 086-6448738

AF 05_07

Ref. code: 25605812030533ARL

113

ขาพเจาไดรบทรำบรายละเอยดเกยวกบทมาและวตถประสงคในการท าวจย รายละเอยดขนตอนตางๆ ทจะตองปฏบตหรอไดรบการปฏบต ความเสยง/อนตราย และประโยชนซงจะเกดขนจากการวจยเรองน โดยไดอานรายละเอยดในเอกสารชแจงอาสาสมครวจยโดยตลอด และ ไดรบค ำอธบำยจากผวจยจนเขำใจเปนอยำงดแลว

ขาพเจาจงสมครใจเขารวมในโครงการวจยน ตามทระบไวในเอกสารชแจงผประเมนโดยขาพเจายนยอมสละเวลาเกบขอมลอาสาสมครผปวยโรคหลอดเลอดสมอง โดย ประเมนการท างานและกจกรรมตางๆดวยแบบประเมน Wolf Motor Function Test และประเมนความบกพรองในการเคลอนไหวโดยแบบประเมน Fugl-Meyer assessment of the upper extremity (FMA-UE) เมอเสรจสนการวจยแลว ขอมลทเกยวของกบผประเมนจะถกท าลาย

ขาพเจามสทธถอนตวออกจากการวจยเมอใดกไดตามความประสงค โดยตองแจงเหตผลใหทรำบลวงหนำ

ขาพเจาไดรบค ารบรองวา ผวจยจะปฏบตตอขาพเจาตามขอมลทระบไวในเอกสารชแจงผประเมนและขอมลใดๆ ทเกยวของกบขาพเจา ผวจยจะเกบรกษำเปนควำมลบ โดยจะน าเสนอขอมลการวจยเปนภาพรวมเทานน ไมมขอมลใดในการรายงานทจะน าไปสการระบตวขาพเจา

หำกขำพเจำไมไดรบกำรปฏบตตรงตำมทไดระบไวในเอกสำรชแจงผประเมน ขาพเจาสามารถรองเรยนไดท: คณะอนกรรมการจรยธรรมการวจยในคน มหาวทยาลยธรรมศาสตร ชดท 3 อาคารราชสดา ชน 1 ศนยสงเสรมสขภาพ คณะพยาบาลศาสตร มหาวทยาลยธรรมศาสตร ศนยรงสต โทรศพท 02-986-9213 ตอ 7373 โทรสาร 02-5165381


ลงชอ............................................................... (..................................................................)

ผวจยหลก วนท……..…/……….……./…………

ลงชอ................................................................ (.......................................................................)


ลงชอ................................................................ (.......................................................................)

พยาน วนท……..…/……….……./…………

ลงชอ................................................................ (.......................................................................)

พยาน วนท……..…/……….……./…………

Ref. code: 25605812030533ARL

114

หนงสอแสดงควำมยนยอมเขำรวมกำรวจยของอำสำสมครวจย (Informed Consent Form)

ท าท..................................................................... วนท.............เดอน.......................พ.ศ. ..............


ขาพเจา ซงไดลงนามทายหนงสอน ขอแสดงความยนยอมเขารวมโครงการวจย ชอโครงการวจย ผลของการรกษาดวยแนวคดของโบบาธ ตอการท างานของแขนและมอ ในผปวยโรคหลอดเลอดสมองทมปญหาการท างานของรยางคสวนบนระดบปานกลางถงรนแรง (The effect of Bobath therapy on upper limb and hand function in stroke individuals with moderate to severe arm deficit) ชอผวจย นางสาวธนยชนก พมประสาท ทอยทตดตอ ภาควชากายภาพบ าบด คณะสหเวชศาสตร มหาวทยาลยธรรมศาสตร โทรศพท (ทท างาน) 02-986-9213 โทรศพทมอถอ 082-324-3681 อำจำรยทปรกษำ อำจำรยทปรกษำวจยหลก อ.ดร. ผกามาศ พรยะประสาธน ทอยทตดตอ ภาควชากายภาพบ าบด คณะสหเวชศาสตร มหาวทยาลยธรรมศาสตร โทรศพท (ทท างาน) 02-986-9213-9 ตอ 7256 โทรศพทมอถอ 081-6152622 อำจำรยทปรกษำวจยรอง ผชวยศาสตราจารย ดร.นพพล ประโมทยกล ทอยทตดตอ (ทท างาน) ภาควชากายภาพบ าบด คณะสหเวชศาสตร มหาวทยาลยธรรมศาสตร โทรศพท (ทท างาน) 02-986-9213-9 ตอ 7237 โทรศพทมอถอ 086-6448738

ขาพเจาไดรบทรำบรายละเอยดเกยวกบทมาและวตถประสงคในการท าวจย รายละเอยดขนตอนตางๆ ทจะตองปฏบตหรอไดรบการปฏบต ความเสยง/อนตราย และประโยชนซงจะเกดขนจากการวจยเรองน โดยไดอานรายละเอยดในเอกสารชแจงอาสาสมครวจยโดยตลอด และ ไดรบค ำอธบำยจากผวจยจนเขำใจเปนอยำงดแลว

AF 05_07

Ref. code: 25605812030533ARL

115

ขาพเจาจงสมครใจเขารวมในโครงการวจยน ตามทระบไวในเอกสารชแจงอาสาสมครวจยโดยขาพเจายนยอมสละเวลาตอบแบบสอบถามขอมลทวไป ประเมนการท างานและกจกรรมตางๆ ดวยแบบประเมน Wolf Motor Function Test ประเมนสมรรถภาพทางกายและความบกพรองในการเคลอนไหวโดยแบบประเมนFugl-Meyer assessment of the upper extremity (FMA-UE) ประเมนการเกรงตวของกลามเนอ Modified Ashworth Scale และประเมนดานการรบรความรสก Revised Nottingham Sensory Assessment เมอเสรจสนการวจยแลว ขอมลท เกยวของกบอาสาสมครวจยจะถกท าลาย

และไดรบการรกษาตามโปรแกรม ครงละประมาณ 60 นาท 3 วนตอสปดาห เปนระยะเวลา 6 สปดาห

ขาพเจามสทธถอนตวออกจากการวจยเมอใดกไดตามความประสงค โดยไมตองแจงเหตผล ซงการถอนตวออกจากการวจยนน จะไมมผลกระทบตอการบรการและการรกษาทสมควรจะไดรบแตประการใด

ขาพเจาไดรบค ารบรองวา ผวจยจะปฏบตตอขาพเจาตามขอมลทระบไวในเอกสารชแจงอาสาสมครวจยและขอมลใดๆ ทเกยวของกบขาพเจา ผวจยจะ เกบรกษำเปนควำมลบ โดยจะน าเสนอขอมลการวจยเปนภาพรวมเทานน ไมมขอมลใดในการรายงานทจะน าไปสการระบตวขาพเจา

หำกขำพเจำไมไดรบกำรปฏบตตรงตำมทไดระบไวในเอกสำรชแจงอำสำสมครวจย ขาพเจาสามารถรองเรยนไดท: คณะอนกรรมการจรยธรรมการวจยในคน มหาวทยาลยธรรมศาสตร ชดท 3 อาคารราชสดา ชน 1 ศนยสงเสรมสขภาพ คณะพยาบาลศาสตร มหาวทยาลยธรรมศาสตร ศนยรงสต โทรศพท 02-986-9213 ตอ 7373 โทรสาร 02-5165381


ลงชอ............................................................... (..................................................................)

ผวจยหลก วนท……..…/……….……./…………

ลงชอ................................................................ (.......................................................................)


ลงชอ................................................................

(.......................................................................) พยาน

วนท……..…/……….……./…………

ลงชอ................................................................ (.......................................................................)

พยาน วนท……..…/……….……./…………

Ref. code: 25605812030533ARL

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APPENDIX D

General data form

รหสผเขารวมวจย..........................................

1. อาย.......................... ป 2. เพศ ชาย หญง

3. สถานะภาพสมรส

โสด สมรส หมาย/หยา/แยกกนอย

4. ระยะเวลาทเปนโรคหลอดเลอดสมอง .....................ป .....................เดอน

5. ดานทมอาการออนแรง........................... ดานทถนด..............................

6. น าหนก.......................กโลกรม สวนสง.........................เซนตเมตร

7. โรคประจ าตว โรคเบาหวาน โรคความดนโลหตสง

โรคหวใจ

โรคอนๆ (ระบ) ................................................

8. สบบหรและดมสราหรอไม (ถาเคยใหระบความถ) สบบหร ไมสบ เคยสบแตปจจบนไมไดสบแลว ระบความถ............................. ดมสรา ไมดม เคยดมแตปจจบนไมไดดมแลว ระบความถ.............................. 9. ระดบการศกษา ต ากวาหรอเทยบเทามธยมศกษา อนปรญญา ต ากวาประถมศกษา

ปรญญาตรหรอสงกวา ประถมศกษา อนๆ 10. อาชพหรอลกษณะงานทท าอยในปจจบน (ระบลกษณะงาน)............................................. 11. ทานเคยไดรบการรกษาทางกายภาพบ าบดหลงจากการเกดโรคหลอดเลอดสมองหรอไม ไมเคย เคย

ระบการรกษา...................................

v

v

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APPENDIX E

Thai version - The Mini–Mental State Examination

(MMSE-Thai 2002)(162)

Orientation for time (5 คะแนน) คะแนน วนนวนทเทาไร วนนวนอะไร เดอนนเดอนอะไร ปนปอะไร ฤดนฤดอะไร Orientation for place (5 คะแนน) # กรณอยสถานพยาบาล สถานทตรงนเรยกวาอะไร และ.........ชอวาอะไร ขณะนอยชนทเทาไรของของตวอาคาร ทนอยในอ าเภออะไร ทนจงหวดอะไร ทนภาคอะไร Orientation for place (ตอ) # กรณอยทบานของผถกทดสอบ สถานทตรงนเรยกวาอะไร และบานเลขทเทาไร ทนหมบาน หรอละแวก/คม/ยาน/ถนนอะไร ทนอยในอ าเภอ/เขตอะไร ทนจงหวดอะไร ทนภาคอะไร Registration (3 คะแนน) (ตอบถก 1 ค าได 1 คะแนน) บอกชอของ 3 อยางแลวใหผถกทดสอบพดตาม

ดอกไม แมน า รถไฟ ในกรณทท าแบบทดสอบซ าภายใน 2 เดอน ใหใชค าวา

ตนไม ทะเล รถยนต

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Attention/ Calculation (5 คะแนน) (ใหเลอกขอใดขอหนง) คดเลขในใจใหเอา 100 ตง ลบออกทละ 7 ไปเรอยๆ ไดผลลพธเทาไร ……. ……. …….. ……. ……. Attention/ Calculation (ตอ) สะกดค าวามะนาวใหฟง แลวใหผถกทดสอบสะกดถอยหลงจากพยญชนะตวหลงไปตวแรก “มอมา-สระอะ-นอหน-สระอา-วอแหวน” ……. ……. …….. ……. ……. ว า น ะ ม Recall (3คะแนน)” (ตอบถก 1 ค าได 1 คะแนน) เมอสกครทใหจ าของ 3 อยาง จ าไดไหมมอะไรบาง ดอกไม แมน า รถไฟ ในกรณทท าแบบทดสอบซ าภายใน 2 เดอน ใหใชค าวา ตนไม ทะเล รถยนต Naming ( 2 คะแนน) ยนดนสอใหผถกทดสอบดและถามวา “ของสงนเรยกวาอะไร” ชนาฬกาขอมอใหผถกทดสอบดและถามวา “ของสงนเรยกวาอะไร” Repetition (1 คะแนน) พดขอความแลวใหพดตาม โดยบอกเพยงครงเดยว “ใครใครขายไกไข”

Ref. code: 25605812030533ARL

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Verbal command (3คะแนน) # บอกผถกทดสอบวาจะสงกระดาษให แลวใหรบดวยมอขวา พบครงดวยมอ 2 ขาง แลววางไวท....................... (พน, โตะ, เตยง) # สงกระดาษเปลาขนาดประมาณ เอ-4 ไมมรอยพบ ใหผถกทดสอบ �รบดวยมอขวา �พบครง �วางไวท (พน, โตะ, เตยง) Written command (1 คะแนน) # ใหผถกทดสอบอานขอความทก าหนด แลวใหท าตาม จะอานออกเสยงหรออานในใจกได # ผทดสอบแสดงกระดาษทเขยนวา “หลบตา” หลบตาได Writing (1 คะแนน) ใหผถกทดสอบเขยนขอความอะไรกไดทอานแลวรเรอง หรอมความหมายมา 1 ประโยค …………………….……………… ประโยคมความหมาย

Ref. code: 25605812030533ARL

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Vasoconstriction (1 คะแนน) ขอนเปนค าสง “ใหวาดภาพเหมอนภาพตวอยาง”

รวมคะแนน คะแนนเตม 30 จดตดส าหรบคะแนนทสงสยภาวะสมองเสอม ระดบการศกษา จดตด คะแนนเตม # ไมไดเรยนหนงสอ (อานไมออก-เขยนไมได) < 14 23 (ไมตองท าขอ 4, 9, 10) # เรยนระดบประถมศกษา < 17 30 # เรยนระดบสงกวาประถมศกษา < 22 30

Ref. code: 25605812030533ARL

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APPENDIX F

Visual Analog Scale(163)

VAS pain intensity

- No pain (0–4 mm)

- Mild pain (5–44 mm)

- Moderate pain (45–74 mm)

- Severe pain (75– 100 mm)

Ref. code: 25605812030533ARL

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APPENDIX G

Wolf Motor Function test (164)

Participant’s study ID :

Evaluation date :

Evaluator’s initials : …………/…………..

Arm’s test More-affected R/L Less-affected R/L

Task Time Functional ability Time

Comment

1. Forearm to table (side) ……………………… 0 1 2 3 4 5 ………………………

2. Forearm to box (side) ……………………… 0 1 2 3 4 5 ………………………

3. Extend elbow (side) ……………………… 0 1 2 3 4 5 ………………………

4. Extend elbow (weight) ……………………… 0 1 2 3 4 5 ………………………

5. Hand to table (front) ………………………. 0 1 2 3 4 5 ………………………

6. Hand to box (front) ………………………. 0 1 2 3 4 5 ………………………

7. Weight to box ………….……………lbs. ………………………lbs.

8. Reach and retrieve ………………………. 0 1 2 3 4 5 .………………………

9. Lift can ………………………. 0 1 2 3 4 5 ………………………

10. Lift pencil ………………………. 0 1 2 3 4 5 .……………………..

11. Lift paper clip ………………………. 0 1 2 3 4 5 ………………………

12. Stack checkers ………………………. 0 1 2 3 4 5 ..……………………..

13. Flip cards ………………………. 0 1 2 3 4 5 ………………………

14. Grip strength ……………………….kgs. . .……………………kgs.

15. Turn key in lock ………………………. 0 1 2 3 4 5 .……………………..

16. Fold towel ………………………. 0 1 2 3 4 5 ……………………….

17. Lift basket ………………………. 0 1 2 3 4 5 ……………………….

รหสผเขารวมวจย......................................................................

First /Last

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0 - Dose not attempt with upper extremity being tested

1 - UE being tested dose not participate functionally; however, attempt is made to

use the upper limb. In unilateral tasks the upper limb not being tested may be used to

move the upper limb being tested.

2 - Dose, but requires assistance of the UE not being tested for minor

readjustments or change of position, or requires more than two attempts to complete,

or accomplishes very slowly. In bilateral tasks the UE being tested may serve only as a

helper

3 - Dose, but movement is influenced to some degree by synergy or is performed

slowly or with effort.

4 - Dose; movement is close to normal*, but slightly slower; may lack precision,

fine coordination or fluidity

5 - Dose; movement appears to be normal*

(*) For the determination of normal, the less-involved UE can be utilized as an available

index for comparison, with pre-morbid UE dominance taken into consideration.

Ref. code: 25605812030533ARL

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APPENDIX H

Fugl- Meyer Assessment: Upper Extremity (FMA-UE) (165)

A.UPPER EXTREMITY, sitting position

I. Reflex activity none can be elicited

Flexors: Biceps and finger flexors

Extensors: triceps

0 2

0 2

Subtotal I (max 4)

II. Volitional movement within synergies, without gravitational

help

none partial full

Flexor synergy: Hand

from contralateral knee to

ipsilateral ear. From

extensor synergy (shoulder

adduction/ internal

rotation, elbow extension,

forearm pronation) to

flexor synergy (shoulder

abduction/ external

rotation, elbow flexion,

forearm supination). Extensor synergy: Hand

from ipsilateral ear to the

contralateral knee

Shoulder retraction

elevation

abduction (90°)

external rotation

Elbow flexion

Forearm supination

0

0

0

0

0

0

1

1

1

1

1

1

2

2

2

2

2

2

Shoulder adduction/internal rotation

Elbow extension

Forearm pronation

0

0

0

1

1

1

2

2

2

Subtotal II (max 18)

III. Volitional movement mixing synergies, without compensation none partial full

Hand to lumbar spine cannot be performed, hand in front of

SIAS hand behind of SIAS (without

compensation) hand to lumbar spine

(without compensation)

0

1

2

Shoulder flexion 0°-90°

Elbow at 0°


Immediate abduction or elbow flexion

abduction or elbow flexion during

movement complete flexion 90°, maintain

0°in elbow

0

1

2

Pronation-supination

Elbow at 90°

Shoulder at 0°

No pronation/supination, starting position

impossible limited pronation/supination,

maintains position complete

pronation/supination, maintains position

0

1

2

Subtotal III (max 6)

IV. Volitional movement with little or no synergy none partial full

Shoulder abduction 0 - 90°

Elbow at 0°

Forearm pronated

immediate supination or elbow flexion

supination or elbow flexion during

movement

abduction 90°, maintains extension and

pronation

0

1

2

Shoulder flexion 90 - 180°

Elbow at 0°

immediate abduction or elbow flexion 0

1

รหสผเขารวมวจย.............................................................

.........

Ref. code: 25605812030533ARL

125

Pronation-supination 0° abduction or elbow flexion during

movement complete flexion, maintains 0°

in elbow

2

Pronation/supination

Elbow at 0°

Shoulder at 30° - 90°

flexion

No pronation/supination, starting position

impossible Limited pronation/supination,

maintains extension

Full pronation/supination, maintain elbow

extension

0

1

2

Subtotal IV (max 6)

V. Normal reflex activity evaluated only if full score of 6 points achieved on part IV

Biceps, triceps, finger

flexors

0 points on part IV or 2 or 3 reflexes

markedly hyperactive

1 reflex markedly hyperactive or at least 2

reflexes lively

Maximum of 1 reflex lively, none

hyperactive

0

1

2

Subtotal V (max 2)

Total A (max 36)

B. Wrist support may be provided at the elbow to take or hold the

position, no support at wrist, check the passive range of motion prior

testing

none partial Full



pronated

Shoulder at 0

Less than 15° active dorsiflexion

Dorsiflexion 15° , no resistance is

taken

Maintain position against resistance

0

1

2

Repeated dorsiflexion / volar

flexion


pronated

Shoulder at 0°, slight finger

flexion

Cannot perform volitionally

Limited active range of motion

Full active range of motion,

smoothly

0

1

2


Elbow at 0°, forearm pronated

Slight shoulder

flexion/abduction

Less than 15° active dorsiflexion

Dorsiflexion 15° , no resistance is

taken

Maintain position against resistance

0

1

2

Repeated dorsiflexion / volar

flexion

Elbow at 0°, forearm pronated

Slight shoulder

flexion/abduction

Cannot perform volitionally

Limited active range of motion

Full active range of motion,

smoothly

0

1

2

Circumduction Cannot perform volitionally

Jerky movement or incomplete

Complete and smooth

circumduction

0

1

2

Total B (max 10)

C. Hand support may be provided at the elbow to keep 90 flexion, no

support at the wrist, compare with less-affected hand, the objects are

interposed, active grasp

none partial full

Mass flexion

From full active or passive

extension

0 1 2

Mass extension 0 1 2

Ref. code: 25605812030533ARL

126

From full active or passive

flexion

Grasp

A- flexion in PIP and DIP

(digit II-V) extension in MCP

II-V

Cannot be performed

Can hold position but weak

Maintains position against

resistance

0

1

2

B- thumb adduction

1-st CMC, MCP, IP at 0, scrap

of paper between thumb and 2-

nd MCP joint

Cannot be performed

Can hold paper but not against tug

Can hold paper against a tug

0

1

2

C – opposition pulpa of the

thumb against the pulpa of 2-

nd finger, pencil, tug upward

Cannot be performed

Can hold pencil but not against tug

Can hold pencil against a tug

0

1

2

D - cylinder grip

Cylinder shaped object (small

can) tug upward, opposition in

digits I and II

Cannot be performed



0

1

2

E – spherical grip

Fingers in abduction/flexion,

thumb opposed, tennis ball

Cannot be performed



0

1

2

Total C (max 14)

D.Coordination/Speed after one trial with both arms, blind-folded, tip

of the index finger from knee to nose, 5 times as fast as possible

marked slight None

Tremor 0 1 2

Dysmetria Pronounced or unsystematic

Slight and systematic

No dysmetria

0

1

2

˃ 5s 2 – 5s ˂ 1s

Time More than 5 seconds slower than less-affected side

2-5 seconds slower than less-affected side

maximum difference of 1 second between sides

0

1

2

Total D (max 6)

Total A - D (max 66)

A. Upper extremity /36

B. Wrist /10

C. Hand /14

D. Coordination/ Speed / 6

Total A-D (motor function) / 66

Ref. code: 25605812030533ARL

127

Each item is scored with 3 point ordinal scale;

0 = cannot perform

1= perform partially

2= perform fully maximum points

Motor function (Upper extremity maximum score=66)

Ref. code: 25605812030533ARL

128

APPENDIX I

Modified Ashworth Scale(166)

0 = No increase in muscle tone

1 = Slight increase in muscle tone, manifested by a catch and release or by minimal

resistance at the end of the range of motion when the affected part(s) is moved in flexion

or extension

1+ = Slight increase in muscle tone, manifested by a catch, followed by minimal

resistance throughout the reminder (less than half) of the ROM (range of movement)

2 = More marked increase in muscle tone through most of the ROM, but affected part(s) easily move

3 = Considerable increase in muscle tone passive, movement difficult

4 = Affected part(s) rigid in flexion or extension

Ref. code: 25605812030533ARL

129

APPENDIX J

REVISED NOTTINGHAM SENSORY ASSESSMENT(167)

Name………………………………..

Examiner……………………………………

Patient code…………………..….. Side of body affected: Right / Left / Both / Neither

Date of stroke……………………. Date of assessment………………………....

Tactile sensation Regions

of the

body

Light

touch

Temperature Pinprick Tactile

Localisation

Bilateral

Simultaneous

touch

PROPRIOCEPTION

L R L R L R L R

Shoulder

Elbow

Wrist

Hand

Stereognosis

10p Coin Brio Comb Sponge Cup

2p Coin Pencil Scissors Flannel Glass

50p Coin

COMMENTS: e.g. oedoma or bruising present, TEDS,

presence of reflexes

KEY

0 Absent

1 Impaired

2 Normal

9 Unable to test

KEY – Proprioception

0 Absent

1 Appreciation of movement (wrong direction)

2 Direction of movement (˃ 10 degree)

3 Joint Position Sense (< 10 degree)

9 Unable to test

Ref. code: 25605812030533ARL

130

NOTTINGHAM SENSORY ASSESSMENT

Instructions

The patient should be assessed in sitting and in a suitable state of undress

(ideally in shorts & underwear, without TED stockings). It should be ensured the patient

is comfortable and in a quiet area with no distractions. Each test is described and

demonstrated to the patient before he or she is blindfolded. The blindfold is removed

regularly throughout the test to avoid the patient becoming disorientated.

The body area to be tested is as marked on the body chart. Apply the test

sensation to the test area, to the left and right side in a random order. The patient is

asked to indicate, either verbally or by a body movement, whenever he or she feels the

test sensation. Each part of the body is assessed three times for each of the tests. Presence

of a reflex does not count as awareness of sensation, though this should be commented

on in the comment box.

Ref. code: 25605812030533ARL

131

Tactile Sensation

If the patient has problems communicating begin testing light touch, pressure and

pinprick sections.

Scoring criteria

0; Absent Fails to identify the test sensation on three occasions

1; Impaired Identifies the test sensation, but not on all three occasions in each region

of the body or feels duller

2; Normal Correctly identifies the test sensation on all three occasions 9 Unable to test

Light Touch Touch, not brush, the skin lightly with a cotton wool ball.

Pressure Press the skin just enough to deform the skin contour using the index

finger.

Pinprick The skin with a neurotip, maintaining even pressure.

Temperature Touch the skin with the side of one of two test tubes, one filled with

hot water, one filled with cold water (use the sides, not the bases of

the test tubes). Apply hot and cold tubes in random order.

Tactile localisation Only test those areas on which the patient has scored 2 on the

pressure section.

Record all others as 9.

Repeat the pressure test with the index fingertip coated with talcum

powder to mark the spot touched and ask the patient to point to the exact

spot that has been touched. If communication permits, the test may be

combined with the pressure test. 2cm of error are allowed.

Bilateral Simultaneous Touch

Touch corresponding sites on one or both sides of the body using

fingertip and ask the patient to indicate if both or one (and which) have

been touched. Only test those items on which patient has scored 2 on

pressure section. Record all others as 9.

Ref. code: 25605812030533ARL

132

Equipment required: Blindfold, cotton wool ball, Neurotip, two test tubes, hot and

cold water, talcum, powder

Kinaesthetic Sensations

All three aspects of movement are tested: appreciation of movement, its

direction and accurate joint position sense are assessed simultaneously. The limb on the

affected side of the body is supported and moved by the examiner in various directions

but movement is only at one joint at a time. The patient is asked to mirror the change of

movement with the other limb. Three practice movements are allowed before

blindfolding.

The upper limb is tested in sitting

Scoring

0 Absent No appreciation of movement taking place.

1 Appreciation of movement taking place

Patient indicates on each movement that a movement takes place

but the direction is incorrect.

2 Direction of movement sense

Patient is able to appreciate and mirror the direction of the test

movement taking place each time, but is inaccurate in its new

position.

3 Joint Position sense

Accurately mirrors the test movement to within 10°of the new

test position

9 Unable to test

Ref. code: 25605812030533ARL

133

Equipment required: Blindfold.

Stereognosis

The object is placed in the patient's hand for a maximum of 30 seconds.

Identification is by naming, description or by pair-matching with an identical set.

Affected side of the body is tested first. The object may be moved around the affected

hand by the examiner.

Scoring for each object

2 Normal Item is correctly named or matched.

1 Impaired Some features of object identified or attempts at descriptions of

objects.

0 Absent Unable to identify the object in any manner.

9 Unable to test

Equipment required: Blindfold, 2p coin, 10p coin, 50p coin, biro (score 2 if labelled

"pen"), pencil, comb, scissors, sponge, flannel (score 2 if labelled "cloth" or "face cloth"),

cup, glass (score 2 if labelled"beaker

Ref. code: 25605812030533ARL

134

APPENDIX K

Raw data

Intra- rater and inter-rater reliability test of the Wolf Motor Function Test and the Fugl-Meyer assessment of the upper extremity

Table K1 Characteristics of participants

ID Sex Age

(years)

Onset

(months)

Affected

side

Dominant-

hand

Weight

(kilograms)

Height

(centimeters)

Smoke Alcohol Education Underlying MMSE

(score)

Status Severity

level

1 Male 71 17 Rt. Rt. 57 169 S S B DM/HT 30 M Severe

2 Female 65 15 Rt. Rt. 58 160 N N B DLP 30 D Moderate

3 Male 45 16 Lt. Rt. 55 170 N S B DLP 30 S Moderate

4 Male 68 120 Lt. Rt. 82 165 S S S DM/HT/DLP 26 M Severe

(Education: B; Bachelor, S; secondary school) (Status: S; single, D; divorce, M; Married) (Smoke and alcohol: N; never, S; stop) (DLP; Dyslipidemia, HT;

hypertension, DM; diabetes mellitus)

Ref. code: 25605812030533ARL

135

Table K2 Wolf Motor Function Test (movement time)

(Assessor ‘1’) – affected side

Item

ID

1

1st

(seconds)

1

2nd

(seconds)

2

1st

(seconds)

2

2nd

(seconds)

3

1st

(seconds)

3

2nd

(seconds)

4

1st

(seconds)

4

2nd

(seconds)

5

1st

(seconds)

5

2nd

(seconds)

6

1st

(seconds)

6

2nd

(seconds)

8

1st

(seconds)

8

2nd

(seconds)

9

1st

(seconds)

9

2nd

(seconds)

1 3.37 3.41 3.15 3.80 120.00 120.00 120.00 120.00 2.10 1.97 2.84 2.95 3.97 3.91 120.00 120.00

2 1.26 2.57 2.00 2.38 120.00 120.00 120.00 120.00 1.25 1.51 2.08 2.10 3.62 4.56 7.56 7.74

3 1.16 1.27 1.37 1.25 3.19 2.77 2.60 3.02 1.00 0.71 0.69 1.24 1.87 1.20.00 120.00 120.00

4 6.94 6.71 120.00 120.00 120.00 120.00 120.00 120.00 6.08 8.74 120.00 120.00 120.00 120.00 120.00 120.00

(1st; first test, 2nd; second test (one week after the first test))

Table K2 Wolf Motor Function Test (movement time) (continued)


Item

ID

10

1st

(seconds)

10

2nd

(seconds)

11

1st

(seconds)

11

2nd

(seconds)

12

1st

(seconds)

12

2nd

(seconds)

13

1st

(seconds)

13

2nd

(seconds)

15

1st

(seconds)

15

2nd

(seconds)

16

1st

(seconds)

16

2nd

(seconds)

17

1st

(seconds)

17

2nd

(seconds)

1 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00

2 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 17.82 23.23 120.00 120.00

3 4.03 4.41 7.15 6.78 13.93 15.34 120.00 120.00 120.00 120.00 27.59 26.89 120.00 120.00

4 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00


Ref. code: 25605812030533ARL

136

Table K3 Wolf Motor function Test (movement time)


Item

ID

1

1st

(seconds)

1

2nd

(seconds)

2

1st

(seconds)

2

2nd

(seconds)

3

1st

(seconds)

3

2nd

(seconds)

4

1st

(seconds)

4

2nd

(seconds)

5

1st

(seconds)

5

2nd

(seconds)

6

1st

(seconds)

6

2nd

(seconds)

8

1st

(seconds)

8

2nd

(seconds)

9

1st

(seconds)

9

2nd

(seconds)

1 5.06 3.64 3.28 3.23 120.00 120.00 120.00 120.00 2.20 2.09 2.38 2.67 3.95 3.33 120.00 120.00

2 2.62 2.43 2.19 1.69 120.00 120.00 120.00 120.00 1.47 2.04 2.53 2.61 3.63 3.50 7.28 7.63

3 1.25 1.25 1.29 1.40 2.38 2.52 2.60 2.43 1.35 1.15 1.31 1.41 0.97 0.77 120.00 120.00

4 6.18 6.30 120.00 120.00 120.00 120.00 120.00 120.00 9.00 8.87 120.00 120.00 120.00 120.00 120.00 120.00




Item

ID

10

1st

(seconds)

10

2nd

(seconds)

11

1st

(seconds)

11

2nd

(seconds)

12

1st

(seconds)

12

2nd

(seconds)

13

1st

(seconds)

13

2nd

(seconds)

15

1st

(seconds)

15

2nd

(seconds)

16

1st

(seconds)

16

2nd

(seconds)

17

1st

(seconds)

17

2nd

(seconds)

1 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00

2 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 23.31 24.65 120.00 120.00

3 4.19 4.51 5.80 6.75 10.66 13.68 120.00 120.00 120.00 120.00 27.70 23.46 120.00 120.00

4 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00


Ref. code: 25605812030533ARL

137

Table K4 Wolf Motor function Test (movement time)

(Average time) – affected side

Item

ID

Assessor 1

1st

(seconds)

Assessor 2

1st

(seconds)

Assessor 1

2nd

(seconds)

Assessor 2

2nd

(seconds)

1 81.03 81.07 81.12 80.10

2 66.37 66.94 66.87 66.97

3 36.31 38.83 35.96 35.96

4 104.87 105.03 105.01 105.01


Table K5 Wolf Motor Function Test (functional ability scale)


Item

ID

1

1st

(score)

1

2nd

(score)

2

1st

(score)

1

2nd

(score)

3

1st

(score)

3

2nd

(score)

4

1st

(score)

4

2nd

(score)

5

1st

(score)

4

2nd

(score)

6

1st

(score)

6

2nd

(score)

8

1st

(score)

8

2nd

(score)

9

1st

(score)

9

2nd

(score)

1 3 3 1 1 1 1 3 3 3 4 4 3 1 1 1 1

2 4 4 1 1 1 1 3 3 4 4 4 4 3 3 1 1

3 5 4 4 4 4 4 3 3 4 4 5 5 1 1 4 5

4 2 2 1 1 1 1 2 2 2 2 1 1 1 1 1 1


Ref. code: 25605812030533ARL

138

Table K5 Wolf Motor Function Test (functional ability scale) (continued)


Item

ID

10

1st

(score)

10

2nd

(score)

11

1st

(score)

11

2nd

(score)

12

1st

(score)

12

2nd

(score)

13

1st

(score)

13

2nd

(score)

15

1st

(score)

15

2nd

(score)

16

1st

(score)

16

2nd

(score)

17

1st

(score)

17

2nd

(score)

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 1 1 1 1 1 1 1 1 1 1 1 1 1 1

3 4 3 4 3 4 3 1 1 1 1 1 1 1 1

4 1 1 1 1 1 1 1 1 1 1 1 1 1 1




Item

ID

1

1st

(score)

2

2nd

(score)

2

1st

(score)

2

2nd

(score)

3

1st

(score)

3

2nd

(score)

4

1st

(score)

4

2nd

(score)

5

1st

(score)

5

2nd

(score)

6

1st

(score)

6

2nd

(score)

8

1st

(score)

8

2nd

(score)

9

1st

(score)

9

2nd

(score)

1 3 3 1 1 1 1 1 1 3 3 3 3 1 1 1 1

2 3 3 1 1 1 1 1 1 3 3 3 3 3 3 1 1

3 3 4 3 3 3 3 3 3 3 3 5 4 1 1 3 3

4 2 2 1 1 1 1 1 1 2 2 1 1 1 1 1 1


Ref. code: 25605812030533ARL

139



(1st; first test, 2nd; second test (one week after first test))


(total score) – affected side

Item

ID

Assessor 1

1st

(score)

Assessor 2

1st

(score)

Assessor 1

2nd

(score)

Assessor 2

2nd

(score)

1 25 23 28 23

2 29 24 31 26

3 49 38 51 38

4 17 16 18 16

(1st; first test, 2nd; second test (one week after first test))

Item

ID

10

1st

(score)

10

2nd

(score)

11

1st

(score)

11

2nd

(score)

12

1st

(score)

12

2nd

(score)

13

1st

(score)

13

2nd

(score)

15

1st

(score)

15

2nd

(score)

16

1st

(score)

16

2nd

(score)

17

1st

(score)

17

2nd

(score)

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 1 1 1 1 1 1 1 1 1 1 2 2 1 1

3 3 3 3 3 3 3 1 1 1 1 3 3 2 2

4 1 1 1 1 1 1 1 1 1 1 2 2 1 1

Ref. code: 25605812030533ARL

140


(Assessor ‘1’) – less-affected side

Item

ID

1

1st

(seconds)

1

2nd

(seconds)

2

1st

(seconds)

2

2nd

(seconds)

3

1st

(seconds)

3

2nd

(seconds)

4

1st

(seconds)

4

2nd

(seconds)

5

1st

(seconds)

5

2nd

(seconds)

6

1st

(seconds)

6

2nd

(seconds)

8

1st

(seconds)

8

2nd

(seconds)

9

1st

(seconds)

9

2nd

(seconds)

1 0.31 0.30 0.88 0.72 0.62 0.60 0.90 0.99 0.46 0.51 0.25 0.78 1.82 1.75 1.75 1.73

2 0.51 0.50 1.14 1.14 0.34 0.58 1.01 0.75 0.50 0.59 0.72 0.57 2.06 2.37 2.60 2.15

3 0.44 0.38 0.41 0.45 0.56 0.43 0.69 0.81 0.29 0.31 0.34 0.20 0.69 0.83 1.00 0.88

4 0.43 0.47 0.90 0.54 0.72 0.45 1.38 1.37 0.97 0.90 0.4 0.53 1.63 2.10 2.35 3.07




Item

ID

10

1st

(seconds)

10

2nd

(seconds)

11

1st

(seconds)

11

2nd

(seconds)

12

1st

(seconds)

12

2nd

(seconds)

13

1st

(seconds)

13

2nd

(seconds)

15

1st

(seconds)

15

2nd

(seconds)

16

1st

(seconds)

16

2nd

(seconds)

17

1st

(seconds)

17

2nd

(seconds)

1 1.03 1.37 4.59 4.40 3.66 4.36 6.1 7.60 2.69 3.37 17.02 17.58 3.68 4.47

2 1.92 1.82 3.59 3.63 6.32 6.80 11.28 9.88 5.84 5.77 15.97 16.02 8.16 8.16

3 1.03 1.21 3.10 3.51 4.81 3.75 4.56 5.07 3.53 3.50 17.19 17.59 3.63 4.18

4 2.25 1.98 3.50 3.02 6.22 6.25 11.06 12.90 4.97 6.35 19.75 19.68 1.15 1.41


Ref. code: 25605812030533ARL

141






Item

ID

10

1st

(seconds)

10

2nd

(seconds)

11

1st

(seconds)

11

2nd

(seconds)

12

1st

(seconds)

12

2nd

(seconds)

13

1st

(seconds)

13

2nd

(seconds)

15

1st

(seconds)

15

2nd

(seconds)

16

1st

(seconds)

16

2nd

(seconds)

17

1st

(seconds)

17

2nd

(seconds)

1 1.05 1.07 4.75 4.83 3.97 4.07 6.68 6.90 2.56 3.17 15.65 15.48 4.10 3.88

2 1.90 1.89 3.72 3.77 6.28 6.40 11.37 11.12 5.63 5.34 15.59 15.01 8.50 8.13

3 1.02 1.05 3.22 3.29 4.81 4.10 5.09 5.21 3.18 3.00 16.97 17.28 3.50 3.51

4 2.14 2.06 3.00 2.95 6.81 6.61 12.81 13.11 5.25 5.47 19.25 20.00 1.90 2.18


Item

ID

1

1st

(seconds)

1

2nd

(seconds)

2

1st

(seconds)

2

2nd

(seconds)

3

1st

(seconds)

3

2nd

(seconds)

4

1st

(seconds)

4

2nd

(seconds)

5

1st

(seconds)

5

2nd

(seconds)

6

1st

(seconds)

6

2nd

(seconds)

8

1st

(seconds)

8

2nd

(seconds)

9

1st

(seconds)

9

2nd

(seconds)

1 0.20 0.22 0.60 0.58 0.95 0.98 0.94 0.97 0.40 0.33 0.50 0.56 1.46 1.60 1.59 1.65

2 0.50 0.59 1.00 1.11 0.63 0.61 1.06 1.58 0.88 0.77 0.83 1.01 1.75 1.94 2.37 2.42

3 0.56 0.52 0.78 0.68 0.66 0.65 0.50 0.49 0.41 0.45 0.42 0.50 1.02 0.57 1.05 1.02

4 0.86 0.81 0.81 0.97 0.62 0.64 1.32 1.74 1.04 0.97 1.12 0.92 1.71 1.70 2.10 2.28

Ref. code: 25605812030533ARL

142


(Total score) – less-affected side

Item

ID

Assessor 1

1st

(seconds)

Assessor 2

1st

(seconds)

Assessor 1

2nd

(seconds)

Assessor 2

2nd

(seconds)

1 46.04 45.43 46.20 46.27

2 62.34 61.99 58.28 60.94

3 42.63 42.93 40.00 39.12

4 58.10 60.80 57.19 60.97




Item

ID

1

1st

(score)

2

2nd

(score)

2

1st

(score)

2

2nd

(score)

3

1st

(score)

3

2nd

(score)

4

1st

(score)

4

2nd

(score)

5

1st

(score)

5

2nd

(score)

6

1st

(score)

6

2nd

(score)

8

1st

(score)

8

2nd

(score)

9

1st

(score)

9

2nd

(score)

1 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

2 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

3 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5


Ref. code: 25605812030533ARL

143






Item

ID

1

1st

(score)

2

2nd

(score)

2

1st

(score)

2

2nd

(score)

3

1st

(score)

3

2nd

(score)

4

1st

(score)

4

2nd

(score)

5

1st

(score)

5

2nd

(score)

6

1st

(score)

6

2nd

(score)

8

1st

(score)

8

2nd

(score)

9

1st

(score)

9

2nd

(score)

1 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

2 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

3 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5


Item

ID

10

1st

(score)

10

2nd

(score)

11

1st

(score)

11

2nd

(score)

12

1st

(score)

12

2nd

(score)

13

1st

(score)

13

2nd

(score)

15

1st

(score)

15

2nd

(score)

16

1st

(score)

16

2nd

(score)

17

1st

(score)

17

2nd

(score)

1 5 5 5 5 5 5 5 5 5 5 5 5 5 5

2 5 5 5 5 5 5 5 5 5 5 5 5 5 5

3 5 5 5 5 5 5 5 5 5 5 5 5 5 5

4 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Ref. code: 25605812030533ARL

144



Item

ID

10

1st

(score)

10

2nd

(score)

11

1st

(score)

11

2nd

(score)

12

1st

(score)

12

2nd

(score)

13

1st

(score)

13

2nd

(score)

15

1st

(score)

15

2nd

(score)

16

1st

(score)

16

2nd

(score)

17

1st

(score)

17

2nd

(score)

1 1.05 1.07 4.75 4.83 3.97 4.07 6.68 6.90 2.56 3.17 15.65 15.48 4.10 3.88

2 1.90 1.89 3.72 3.77 6.28 6.40 11.37 11.12 5.63 5.34 15.59 15.01 8.50 8.13

3 1.02 1.05 3.22 3.29 4.81 4.10 5.09 5.21 3.18 3.00 16.97 17.28 3.50 3.51

4 2.14 2.06 3.00 2.95 6.81 6.61 12.81 13.11 5.25 5.47 19.25 20.00 1.90 2.18


(total score) – less-affected side

ID Assessor 1

1st

(score)

Assessor 2

1st

(score)

Assessor 1

2nd

(score)

Assessor 2

2nd

(score)

1 75 75 75 75

2 75 75 75 75

3 75 75 75 75

4 75 75 75 75


Ref. code: 25605812030533ARL

145

APPENDIX L

Raw data

Effect of the Bobath therapy on upper limb and hand functions in stroke individuals with moderate to severe arm deficits

Table L1 Characteristics of participants

ID Sex Age

(years)

Onset

(months)

Affected side Dominant-hand Weight

(kilograms)

Height

(centimeters)

Smoker Alcohol

1 male 45 17 Lt. Rt. 79 173 N Y

2 female 57 25 Lt. Rt. Unknown Unknown N N

3 female 55 83 Rt. Lt. 53 155 N N

4 male 57 7 Rt. Rt. 69 171 N S

5 male 63 60 Rt. Lt. 58 160 N S

6 female 56 72 Lt. Rt. 56 165 N N

7 male 45 17 Lt. Rt. 55 170 N S

8 male 59 168 Rt. Rt. 45 145 N N

9 male 64 276 Rt. Rt. 53 160 N N

10 female 47 120 Rt. Rt. 67 160 Y Y

11 male 73 84 Rt. Rt. 54 155 Y S

12 male 60 7 Lt. Rt. 70 166 N Y

13 male 59 33 Rt. Rt. 62 158 N N

14 male 61 84 Lt. Rt. 70 170 N Y

15 male 60 204 Lt. Rt. 67 165 N S

16 female 67 48 Rt. Rt. 52 160 N N

17 female 71 84 Lt. Rt. 62 156 N N

18 male 76 24 Rt. Rt. 73 165 N N

19 male 45 48 Rt. Rt. 80 185 N N

20 male 64 36 Rt. Rt. 66 170 Y Y

21 male 56 60 Lt. Rt. 63 160 N N

22 male 68 120 Rt. Rt. 70 157 S N

Ref. code: 25605812030533ARL

146

23 male 67 24 Rt. Rt. Unknown Unknown S S

24 female 64 20 Rt. Rt. Unknown Unknown N N

25 female 47 6 Rt. Rt. 58 153 N N

26 male 66 84 Lt. Rt. 67 168 S S

(Education: B; Bachelor, S; secondary school) (Status: S; single, D; divorce, M; Married) (Smoke and alcohol: N; never, S; stop, Y; yes)

Ref. code: 25605812030533ARL

147

Table L2 Characteristics of participants

ID Education Underlying

diseases

MMSE

(Score)

VAS

(millimeter)

Status Subluxation

1 P HT 27 - D Y

2 P DM/HT 25 - S Y

3 S DM/HT 29 - M Y

4 B DM/HT 27 shoulder 40 mm M Y

5 P HT / DLP 28 shoulder 15 mm D Y

6 S DM 29 shoulder 10 mm M Y

7 B HT/DLP 30 - S Y

8 P HT 22 - M Y

9 P DLP 28 - M Y

10 S HT 22 - M Y

11 S HT 22 - M Y

12 S HT 30 - M Y

13 P HT 21 - M Y

14 S DLP 28 - M Y

15 S HT 24 - M Y

16 P HT 19 shoulder 40 mm M Y

17 S HT 24 - D Y

18 S HT 24 - M Y

19 P HT 17 - D Y

20 P HT 17 - M Y

21 S HT/DLP 24 - D Y

22 S HT 22 - M Y

23 P HT 17 - M Y

24 P HT 20 - D Y

25 S DLP 22 - M Y

26 P DLP 25

M Y

(Education: B; Bachelor, P; primary school, S; secondary school) (Status: S; single, D; divorce, M; Married)

(DLP; Dyslipidemia, HT; hypertension) (DLP; Dyslipidemia, HT; hypertension, DM; diabetes mellitus) (Y; yes)

Ref. code: 25605812030533ARL

148

Table L3 Wolf Motor Function Test (movement time) at pre-assessment

Item

ID

Item 1 (seconds)

Item 2 (seconds)

Item 3 (seconds)

Item 4 (seconds)

Item 5 (seconds)

Item 6 (seconds)

Item 8 (seconds)

Item 9 (seconds)

Item 10 (seconds)

Item 11 (seconds)

Item 12 (seconds)

Item 13 (seconds)

Item 15 (seconds)

Item 16 (seconds)

Item 17 (seconds)

Average

time (seconds)

1 1.91 1.96 120.00 120.00 2.50 1.54 1.13 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 80.60

2 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 NT 120.00

3 1.35 1.37 120.00 1.35 1.53 4.06 1.19 120.00 9.50 14.13 120.00 13.44 8.88 20.50 16.56 31.78

4 2.06 18.09 120.00 120.00 23.85 120.00 2.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 91.07

5 1.94 1.94 120.00 120.00 1.87 2.35 1.78 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 80.66

6 2.32 2.44 2.00 4.00 2.04 2.16 2.12 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 69.65

7 1.78 2.19 120.00 120.00 2.19 2.98 1.47 120.00 4.16 14.94 14.59 120.00 120.00 13.03 120.00 51.82

8 2.41 1.44 120.00 120.00 2.84 6.72 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 88.89

9 2.82 1.68 120.00 120.00 1.41 1.44 3.41 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 80.71

10 4.28 17.58 5.09 120.00 2.85 1.75 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 NT 79.40

11 2.00 3.31 3.37 3.06 2.59 3.93 2.00 8.44 8.12 120.00 62.87 34.72 17.10 20.50 5.25 19.81

12 3.50 6.21 120.00 120.00 3.31 120.00 2.56 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 89.03

13 4.78 120.00 120.00 120.00 4.18 120.00 1.91 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 96.72

14 0.78 0.91 2.19 2.34 0.94 1.12 0.70 5.79 120.00 120.00 120.00 120.00 36.93 11.09 3.72 36.43

15 4.16 3.65 120.00 120.00 2.22 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 NT 95.00

16 7.21 8.26 120.00 10.66 12.87 12.57 19.19 120.00 120.00 120.00 120.00 120.00 120.00 120.00 NT 73.63

17 2.10 5.52 3.91 18.93 2.28 120.00 1.53 120.00 3.00 120.00 26.75 120.00 120.00 120.00 NT 56.00

18 1.72 1.72 1.22 1.47 2.43 1.81 5.04 120.00 3.31 3.31 13.34 10.47 6.25 15.72 6.06 12.92

19 2.16 3.28 4.72 16.87 2.16 2.56 8.06 120.00 120.00 120.00 120.00 120.00 120.00 120.00 4.06 58.92

20 4.28 1.56 1.10 1.22 1.62 1.34 2.16 120.00 4.57 120.00 120.00 120.00 120.00 120.00 NT 52.70

21 4.00 3.75 120.00 120.00 2.63 0.72 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 NT 86.50

22 3.94 3.22 120.00 120.00 2.31 3.91 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 NT 86.67

23 1.21 1.68 3.85 9.62 1.94 1.96 3.80 25.43 10.62 45.82 120.00 43.13 38.07 120.00 70.86 33.20

24 2.09 2.44 5.20 6.10 2.85 2.97 3.42 10.59 4.47 120.00 120.00 120.00 120.00 120.00 10.70 43.39

25 2.69 7.19 6.34 5.82 4.87 3.07 3.69 120.00 120.00 120.00 120.00 120.00 120.00 120.00 16.78 59.36

26 1.38 1.09 6.37 7.16 0.97 0.94 1.58 1.93 2.13 3.09 12.04 21.28 5.19 15.94 NT 5.79

Ref. code: 25605812030533ARL

149

Table L4 Wolf Motor Function Test (movement time) at post-assessment

Item

ID

Item 1

(seconds)

Item 2

(seconds)

Item 3

(seconds)

Item 4

(seconds)

Item 5

(seconds)

Item 6

(seconds)

Item 8

(seconds)

Item 9

(seconds)

Item 10

(seconds)

Item 11

(seconds)

Item 12

(seconds)

Item 13

(seconds)

Item 15

(seconds)

Item 16

(seconds)

Item 17

(seconds)

Average

time

(seconds)

1 1.12 1.85 24.15 6.06 1.53 1.60 1.72 120.00 120.00 120.00 120.00 109.00 120.00 94.84 36.10 58.53

2 27.47 120.00 120.00 120.00 28.31 120.00 9.93 120.00 120.00 120.00 120.00 120.00 120.00 120.00 NT 98.98

3 0.97 2.00 1.00 1.03 1.75 1.10 0.90 3.84 4.13 5.41 7.07 16.06 8.12 7.71 6.28 4.49

4 2.07 2.00 120.00 120.00 1.47 1.81 2.97 120.00 120.00 120.00 120.00 120.00 120.00 120.00 26.37 74.45

5 1.16 1.06 120.00 27.91 2.88 2.25 2.81 120.00 38.43 120.00 120.00 120.00 120.00 120.00 120.00 69.10

6 1.28 1.28 1.25 0.87 1.44 0.93 1.89 2.06 46.43 120.00 120.00 120.00 15.65 97.18 4.56 35.65

7 1.44 1.41 5.31 5.36 1.65 1.81 1.60 19.53 4.46 4.97 16.25 120.00 55.62 13.25 6.34 17.27

8 1.18 1.56 7.41 4.68 1.50 1.88 1.41 120.00 120.00 120.00 120.00 120.00 70.56 25.40 120.00 55.71

9 1.78 2.56 120.00 120.00 2.88 2.12 1.39 120.00 120.00 120.00 120.00 120.00 91.68 88.84 86.66 74.52

10 4.41 6.78 120.00 120.00 1.72 0.86 4.03 120.00 13.37 120.00 120.00 120.00 120.00 25.77 NT 64.07

11 2.07 2.19 2.82 3.09 2.10 2.10 1.88 5.13 4.05 4.28 13.88 68.75 9.50 17.22 4.82 9.59

12 1.96 1.94 120.00 120.00 2.40 3.37 1.81 120.00 120.00 120.00 120.00 120.00 120.00 120.00 66.93 77.23

13 2.15 120.00 120.00 120.00 2.43 120.00 1.78 120.00 120.00 120.00 120.00 120.00 120.00 120.00 120.00 96.42

14 0.63 1.19 1.46 1.79 1.25 1.59 1.00 5.72 9.25 10.31 47.06 41.25 47.06 10.28 4.53 12.29

15 2.19 1.81 120.00 120.00 1.19 1.31 3.75 120.00 120.00 120.00 120.00 120.00 120.00 120.00 NT 77.88

16 2.28 2.10 3.50 4.25 1.56 2.97 2.32 2.97 2.32 120.00 120.00 46.47 120.00 32.31 NT 33.08

17 2.12 4.53 4.28 4.75 1.56 1.41 2.56 120.00 3.85 4.94 26.18 83.16 25.55 20.34 NT 21.80

18 1.51 3.78 0.72 1.43 2.22 1.66 2.07 14.07 2.78 4.47 8.53 10.97 5.35 8.13 3.22 4.73

19 1.26 1.31 3.08 10.50 1.36 1.49 3.50 120.00 8.07 120.00 120.00 32.04 120.00 17.23 4.68 37.63

20 2.38 1.44 3.50 3.44 1.47 1.09 1.25 120.00 4.81 7.44 120.00 24.47 120.00 19.50 15.03 29.72

21 2.10 2.22 120.00 120.00 2.00 1.84 5.59 120.00 120.00 120.00 120.00 120.00 120.00 72.00 NT 74.70

22 2.94 3.43 120.00 120.00 3.28 3.28 7.78 120.00 120.00 120.00 120.00 120.00 120.00 120.00 NT 78.62

23 1.10 2.00 5.35 6.00 2.25 2.56 3.25 18.88 11.28 12.06 120.00 33.50 27.03 48.93 NT 21.01

24 1.38 1.60 3.01 4.13 1.09 1.49 3.78 6.81 3.76 4.04 120.00 25.53 15.71 22.00 7.06 14.76

25 1.37 1.16 1.13 3.31 1.10 1.37 2.25 120.00 120.00 10.28 120.00 120.00 120.00 33.06 4.25 43.95

26 0.66 0.71 0.69 1.15 0.85 0.62 1.09 2.75 1.72 2.22 33.68 10.56 8.71 13.97 NT 5.67

Ref. code: 25605812030533ARL

150

Table L5 Wolf Motor Function Test (functional ability scale) at pre-assessment

Item

ID

Item 1

(score)

Item 2

(score)

Item 3

(score)

Item 4

(score)

Item 5

(score)

Item 6

(score)

Item 8

(score)

Item 9

(score)

Item 10

(score)

Item 11

(score)

Item 12

(score)

Item 13

(score)

Item 15

(score)

Item 16

(score)

Item 17

(score)

Total

(score)

1 3 3 1 1 3 3 1 1 1 1 1 1 1 1 1 23

2 1 1 0 0 1 1 1 1 1 1 1 1 1 1 NT 14

3 4 4 1 4 4 3 4 1 3 3 1 3 3 4 1 43

4 2 2 0 0 2 1 4 1 1 1 1 1 1 1 1 17

5 4 4 1 1 4 3 4 1 1 1 1 1 1 1 1 29

6 4 4 1 3 4 4 4 1 1 1 1 1 1 1 1 32

7 3 3 1 1 3 3 3 1 4 3 3 1 1 3 1 34

8 3 3 1 1 3 0 0 1 1 1 1 1 1 0 1 18

9 3 3 1 1 3 3 2 1 1 1 1 1 1 1 1 24

10 3 2 2 1 3 3 1 1 1 1 1 1 1 1 NT 22

11 4 4 4 4 4 4 4 3 2 1 2 2 2 4 3 47

12 3 3 0 0 2 1 4 1 1 1 1 1 1 1 1 19

13 3 1 1 1 2 1 4 1 1 1 1 1 1 0 1 20

14 5 5 3 3 4 4 5 3 1 1 1 1 2 3 4 45

15 2 2 1 1 3 1 1 1 1 1 1 1 1 1 NT 19

16 3 2 1 2 3 3 3 1 1 1 1 1 1 1 NT 25

17 2 3 3 3 4 1 5 1 2 1 4 1 1 1 NT 32

18 5 5 4 4 4 3 3 1 4 4 3 4 5 4 2 55

19 4 3 2 2 3 3 2 1 1 1 1 1 1 1 4 30

20 3 3 4 4 3 3 3 1 3 1 1 1 1 1 2 34

21 2 2 1 1 4 4 1 1 1 1 1 1 1 1 NT 23

22 4 4 1 1 4 3 1 1 1 1 1 1 1 1 NT 26

23 4 4 3 3 4 3 4 3 3 3 1 2 3 2 NT 41

24 3 3 2 2 3 3 2 2 3 1 1 1 1 1 2 27

25 3 2 2 2 3 3 3 1 1 1 1 1 1 1 2 27

26 4 4 3 3 3 3 4 4 4 4 3 3 4 2 NT 45

Ref. code: 25605812030533ARL

151

Table L6 Wolf Motor Function Test (functional ability scale) at post-assessment

Item

ID

Item 1

(score)

Item 2

(score)

Item 3

(score)

Item 4

(score)

Item 5

(score)

Item 6

(score)

Item 8

(score)

Item 9

(score)

Item 10

(score)

Item 11

(score)

Item 12

(score)

Item 13

(score)

Item 15

(score)

Item 16

(score)

Item 17

(score)

Total

(score)

1 4 3 2 2 4 4 4 1 1 1 1 2 1 2 2 34

2 2 1 1 1 1 1 2 1 1 1 1 1 1 1 NT 16

3 5 5 5 5 5 5 5 5 5 5 5 4 4 5 5 73

4 3 3 1 1 3 3 3 1 1 1 1 1 1 1 2 26

5 4 5 1 2 4 5 5 1 2 1 1 1 1 1 1 35

6 5 5 5 5 5 5 5 1 2 1 1 1 4 3 5 53

7 5 5 3 3 4 4 5 3 4 4 4 3 2 3 4 56

8 4 3 3 3 3 3 3 1 1 2 1 1 2 3 1 34

9 3 3 1 1 3 3 4 1 1 1 1 1 1 1 2 27

10 5 4 1 1 5 5 5 1 3 1 1 1 1 2 NT 36

11 5 5 5 4 5 5 5 5 5 5 4 3 5 4 5 70

12 5 5 1 1 4 3 5 1 1 1 1 1 1 1 2 33

13 2 1 1 1 3 1 4 1 3 1 1 1 1 1 1 23

14 5 5 4 4 5 5 5 3 3 3 2 2 2 3 4 55

15 3 5 1 1 4 4 3 1 1 1 1 1 1 1 NT 28

16 4 5 5 4 4 4 4 1 1 1 1 2 0 3 NT 39

17 5 4 5 5 5 5 5 1 4 4 3 2 4 3 NT 55

18 5 3 5 5 4 5 5 3 4 4 4 4 4 4 5 64

19 5 5 3 3 4 4 3 1 2 1 1 2 1 2 4 41

20 3 4 4 3 4 4 4 1 4 3 1 2 1 2 2 42

21 5 5 1 1 5 5 5 1 1 1 1 1 1 2 NT 35

22 5 4 1 1 4 4 3 1 1 1 1 1 1 1 NT 29

23 4 4 3 3 4 4 3 3 3 3 1 3 4 2 NT 44

24 4 4 3 3 4 4 3 3 3 2 1 2 2 2 3 43

25 5 5 5 4 4 4 4 1 1 3 1 1 1 2 3 44

26 5 5 5 5 5 5 4 3 5 4 3 2 4 3 NT 58

Ref. code: 25605812030533ARL

152

Table L7 Fugl – Meyer assessment (upper extremity) at pre-assessment

Item

ID

A1

Flexors

(score)

A1

Extensors

(score)

A2

Shoulder

retraction

(score)

A2

Shoulder

elevation

(score)

A2

Shoulder

abduction

(score)

A2

Shoulder

external

(score)

A2

Elbow

flexion

(score)

A2

Forearm

supination

(score)

A2

Shoulder

adduction

(score)

A2

Elbow

Extension

(score)

A2

Forearm

pronation

(score)

1 2 2 2 2 2 2 2 0 2 1 0

2 2 0 0 1 0 0 0 0 0 0 0

3 2 2 2 1 2 1 2 0 2 2 1

4 2 2 0 1 1 0 1 0 0 0 0

5 2 2 0 1 0 0 1 0 0 0 0

6 2 2 0 1 0 0 1 0 0 1 0

7 2 2 1 1 1 1 1 1 1 1 1

8 2 2 1 1 1 1 1 0 1 1 1

9 2 2 1 1 1 1 1 0 2 2 0

10 2 2 2 1 1 1 1 0 2 2 0

11 2 2 1 1 2 1 1 0 1 1 0

12 2 2 1 1 1 1 1 0 1 1 0

13 2 2 1 1 1 0 0 0 1 0 0

14 2 2 2 2 2 2 2 0 2 2 1

15 2 2 1 1 1 0 1 0 1 1 0

16 2 2 0 0 1 0 1 0 0 0 0

17 2 2 0 0 1 0 2 0 0 1 0

18 2 2 1 1 1 2 1 1 2 1 0

19 2 2 1 1 1 1 1 0 1 1 0

20 2 2 1 2 2 2 2 1 2 1 1

21 2 2 1 1 1 1 2 1 0 1 0

22 2 2 1 0 1 1 1 0 1 0 0

23 2 2 1 2 1 1 2 1 2 1 1

24 2 2 1 1 1 1 1 0 1 0 1

25 2 2 0 1 0 0 1 0 2 2 0

26 2 2 1 2 1 1 2 1 1 1 1

Ref. code: 25605812030533ARL

153

Table L8 Fugl – Meyer assessment (upper extremity) at pre-assessment (continued)

Item

ID

A3 - Hand to

lumbar

(score)

A3 – 2

(score)

A3 – 3

(score)

A4 – 1

(score)

A4 – 2

(score)

A4 – 3

(score)

A5

(score)

B1

(score)

B2

(score)

B3

(score)

B4

(score)

B5

(score)

1 1 1 0 1 1 0 0 0 0 0 0 0

2 0 1 0 0 0 0 1 0 0 0 0 0

3 1 0 1 0 0 1 2 1 1 1 1 1

4 1 0 0 1 0 0 1 0 0 0 0 0

5 1 0 0 0 0 0 2 0 0 0 0 0

6 2 0 0 0 0 0 2 1 1 0 0 0

7 1 1 1 1 1 1 0 1 1 1 1 1

8 1 0 0 1 0 0 1 0 0 0 0 0

9 1 1 1 1 1 1 1 0 0 0 0 0

10 0 0 1 0 0 0 2 0 0 0 0 0

11 2 2 2 1 0 1 2 0 0 0 0 0

12 0 0 0 0 0 0 2 0 0 0 0 0

13 1 0 0 1 0 0 0 1 0 0 0 0

14 2 1 1 2 1 1 1 0 0 1 0 1

15 0 0 0 0 0 0 2 0 0 0 0 0

16 0 0 0 0 0 1 2 0 0 0 1 0

17 2 0 1 0 0 1 2 0 0 0 0 0

18 1 0 1 0 2 2 2 2 2 2 2 2

19 0 0 0 0 0 1 2 1 0 1 1 0

20 1 2 1 1 1 0 1 0 2 0 0 0

21 0 0 1 0 0 0 2 0 0 0 0 0

22 0 0 1 0 0 0 2 1 1 0 1 0

23 2 1 2 1 0 0 0 2 2 1 1 2

24 0 1 1 1 1 0 1 1 1 1 1 1

25 1 1 1 1 0 1 1 0 0 0 0 0

26 1 2 1 1 1 1 0 1 0 1 1 1

Ref. code: 25605812030533ARL

154

Table L9 Fugl – Meyer assessment (upper extremity) at pre-assessment (continued)

Item

ID

C - Mass

flexion

(score)

C - Mass

extension

(score)

C – A

(score)

C – B

(score)

C – C

(score)

C - D

(score)

C – E

(score)

D – Tremor

(score)

D – Dysmetria

(score)

D – Time

(score)

1 1 0 2 0 0 1 0 1 1 0

2 1 1 1 0 0 0 0 NT NT NT

3 2 0 0 0 1 1 0 1 1 1

4 1 0 1 0 0 1 1 NT NT NT

5 0 0 2 0 0 0 0 0 0 0

6 0 0 2 0 0 0 0 1 0 0

7 1 1 2 0 2 2 1 2 2 0

8 1 0 0 0 0 1 1 NT NT NT

9 1 0 1 0 1 2 2 0 0 0

10 2 0 1 0 0 0 0 0 0 0

11 1 0 2 2 2 2 2 2 1 1

12 0 2 2 0 0 0 0 NT NT NT

13 0 0 1 0 0 1 0 NT NT NT

14 2 1 2 1 2 2 2 1 1 0

15 0 0 0 0 0 0 0 0 0 0

16 0 0 0 0 0 0 0 0 0 0

17 2 1 2 2 2 0 1 1 1 1

18 2 2 2 2 1 1 1 0 0 0

19 2 0 2 2 2 0 1 0 0 0

20 2 1 2 2 1 2 2 1 1 0

21 0 0 0 0 0 0 0 1 0 0

22 1 1 0 0 0 0 0 1 0 0

23 2 2 2 2 2 2 2 0 1 0

24 1 0 1 1 1 1 1 1 0 0

25 2 0 2 1 0 2 1 0 1 0

26 2 2 2 2 2 2 2 1 1 1

Ref. code: 25605812030533ARL

155

Table L10 Fugl – Meyer assessment (upper extremity) at post -assessment

Item

ID

A1

Flexors

(score)

A1

Extensors

(score)

A2

Shoulder

retraction

(score)

A2

Shoulder

elevation

(score)

A2

Shoulder

abduction

(score)

A2

Shoulder

external

(score)

A2

Elbow

flexion

(score)

A2

Forearm

supination

(score)

A2

Shoulder

adduction

(score)

A2

Elbow

extension

(score)

A2

Forearm

pronation

(score)

1 2 2 2 2 2 2 2 0 2 1 0

2 2 0 0 1 0 0 0 0 0 0 0

3 2 2 2 1 2 1 2 0 2 2 1

4 2 2 0 1 1 0 1 0 0 0 0

5 2 2 0 1 0 0 1 0 0 0 0

6 2 2 0 1 0 0 1 0 0 1 0

7 2 2 1 1 1 1 1 1 1 1 1

8 2 2 1 1 1 1 1 0 1 1 1

9 2 2 1 1 1 1 1 0 2 2 0

10 2 2 2 1 1 1 1 0 2 2 0

11 2 2 1 1 2 1 1 0 1 1 0

12 2 2 1 1 1 1 1 0 1 1 0

13 2 2 1 1 1 0 0 0 1 0 0

14 2 2 2 2 2 2 2 0 2 2 1

15 2 2 1 1 1 0 1 0 1 1 0

16 2 2 0 0 1 0 1 0 0 0 0

17 2 2 0 0 1 0 2 0 0 1 0

18 2 2 1 1 1 2 1 1 2 1 0

19 2 2 1 1 1 1 1 0 1 1 0

20 2 2 1 2 2 2 2 1 2 1 1

21 2 2 1 1 1 1 2 1 0 1 0

22 2 2 1 0 1 1 1 0 1 0 0

23 2 2 1 2 1 1 2 1 2 1 1

24 2 2 1 1 1 1 1 0 1 0 1

25 2 2 0 1 0 0 1 0 2 2 0

26 2 2 1 2 1 1 2 1 1 1 1

Ref. code: 25605812030533ARL

156

Table L11 Fugl – Meyer assessment (upper extremity) at post-assessment (continued)

Item

ID

A3 - Hand to

lumbar

(score)

A3 – 2

(score)

A3 – 3

(score)

A4 – 1

(score)

A4 – 2

(score)

A4 – 3

(score)

A5

(score)

B1

(score)

B2

(score)

B3

(score)

B4

(score)

B5

(score)

1 1 1 0 1 1 0 0 0 0 0 0 0

2 0 1 0 0 0 0 1 0 0 0 0 0

3 1 0 1 0 0 1 2 1 1 1 1 1

4 1 0 0 1 0 0 1 0 0 0 0 0

5 1 0 0 0 0 0 2 0 0 0 0 0

6 2 0 0 0 0 0 2 1 1 0 0 0

7 1 1 1 1 1 1 0 1 1 1 1 1

8 1 0 0 1 0 0 1 0 0 0 0 0

9 1 1 1 1 1 1 1 0 0 0 0 0

10 0 0 1 0 0 0 2 0 0 0 0 0

11 2 2 2 1 0 1 2 0 0 0 0 0

12 0 0 0 0 0 0 2 0 0 0 0 0

13 1 0 0 1 0 0 0 1 0 0 0 0

14 2 1 1 2 1 1 1 0 0 1 0 1

15 0 0 0 0 0 0 2 0 0 0 0 0

16 0 0 0 0 0 1 2 0 0 0 1 0

17 2 0 1 0 0 1 2 0 0 0 0 0

18 1 0 1 0 2 2 2 2 2 2 2 2

19 0 0 0 0 0 1 2 1 0 1 1 0

20 1 2 1 1 1 0 1 0 2 0 0 0

21 0 0 1 0 0 0 2 0 0 0 0 0

22 0 0 1 0 0 0 2 1 1 0 1 0

23 2 1 2 1 0 0 0 2 2 1 1 2

24 0 1 1 1 1 0 1 1 1 1 1 1

25 1 1 1 1 0 1 1 0 0 0 0 0

26 1 2 1 1 1 1 0 1 0 1 1 1

Ref. code: 25605812030533ARL

157

Table L12 Fugl – Meyer assessment (upper extremity) at post-assessment (continued)

Item

ID

C - Mass

flexion

(score)

C - Mass

extension

(score)

C – A

(score)

C – B

(score)

C – C

(score)

C - D

(score)

C – E

(score)

D – Tremor

(score)

D – Dysmetria

(score)

D – Time

(score)

1 1 0 2 0 0 1 0 1 1 0

2 1 1 1 0 0 0 0 NT NT NT

3 2 0 0 0 1 1 0 1 1 1

4 1 0 1 0 0 1 1 NT NT NT

5 0 0 2 0 0 0 0 0 0 0

6 0 0 2 0 0 0 0 1 0 0

7 1 1 2 0 2 2 1 2 2 0

8 1 0 0 0 0 1 1 NT NT NT

9 1 0 1 0 1 2 2 0 0 0

10 2 0 1 0 0 0 0 0 0 0

11 1 0 2 2 2 2 2 2 1 1

12 0 2 2 0 0 0 0 NT NT NT

13 0 0 1 0 0 1 0 NT NT NT

14 2 1 2 1 2 2 2 1 1 0

15 0 0 0 0 0 0 0 0 0 0

16 0 0 0 0 0 0 0 0 0 0

17 2 1 2 2 2 0 1 1 1 1

18 2 2 2 2 1 1 1 0 0 0

19 2 0 2 2 2 0 1 0 0 0

20 2 1 2 2 1 2 2 1 1 0

21 0 0 0 0 0 0 0 1 0 0

22 1 1 0 0 0 0 0 1 0 0

23 2 2 2 2 2 2 2 0 1 0

24 1 0 1 1 1 1 1 1 0 0

25 2 0 2 1 0 2 1 0 1 0

26 2 2 2 2 2 2 2 1 1 1

Ref. code: 25605812030533ARL

158

Table L13 Modified Ashworth Scale at pre-assessment

Item

ID

Shoulder internal rotators

(scale)

Shoulder adductors

(scale)

Elbow flexors

(scale)

Elbow extensors

(scale)

Pronators

(scale)

Wrist flexors

(scale)

Finger flexors

(scale)

1 1.00 0.00 1.00 0.00 1.00 1.00 1.50

2 0.00 1.50 0.00 0.00 0.00 0.00 0.00

3 0.00 1.00 0.00 0.00 0.00 1.00 0.00

4 0.00 0.00 1.00 2.00 0.00 1.00 1.50

5 0.00 1.00 2.00 2.00 0.00 2.00 2.00

6 0.00 0.00 1.00 2.00 0.00 1.50 1.50

7 0.00 0.00 2.00 0.00 0.00 2.00 1.50

8 0.00 0.00 1.00 2.00 0.00 1.50 1.50

9 1.00 2.00 1.00 2.00 1.50 1.50 1.00

10 0.00 1.50 2.00 0.00 1.50 2.00 2.00

11 0.00 1.00 1.00 0.00 0.00 1.00 0.00

12 0.00 1.50 1.50 1.00 0.00 1.00 1.50

13 1.50 0.00 1.00 1.00 0.00 1.50 2.00

14 0.00 0.00 1.00 0.00 0.00 1.00 1.00

15 0.00 1.50 1.00 0.00 0.00 0.00 0.00

16 0.00 1.50 0.00 0.00 0.00 1.50 1.50

17 0.00 1.00 0.00 0.00 0.00 1.00 0.00

18 0.00 0.00 0.00 0.00 0.00 0.00 0.00

19 0.00 1.50 1.00 0.00 0.00 1.00 1.00

20 1.00 0.00 1.00 1.00 1.00 1.00 1.00

21 0.00 1.00 1.50 0.00 0.00 1.50 1.00

22 0.00 1.50 1.00 1.00 0.00 1.50 1.50

23 0.00 0.00 0.00 0.00 0.00 0.00 0.00

24 0.00 1.00 0.00 0.00 0.00 1.00 0.00

25 0.00 0.00 1.00 0.00 0.00 1.00 1.00

26 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Ref. code: 25605812030533ARL

159

Table L14 Modified Ashworth Scale at post-assessment

Item

ID

Shoulder internal rotators

(scale)

Shoulder adductors

(scale)

Elbow flexors

(scale)

Elbow extensors

(scale)

Pronators

(scale)

Wrist flexors

(scale)

Finger flexors

(scale)

1 0.00 0.00 0.00 0.00 1.00 1.00 1.00

2 0.00 1.00 0.00 0.00 0.00 0.00 0.00

3 0.00 1.00 0.00 0.00 0.00 0.00 0.00

4 0.00 0.00 1.50 1.50 0.00 1.50 1.50

5 0.00 1.00 0.00 2.00 0.00 1.50 1.00

6 0.00 0.00 1.00 1.50 0.00 1.50 1.50

7 0.00 0.00 2.00 0.00 0.00 1.50 1.50

8 0.00 0.00 0.00 1.00 1.50 1.00 1.00

9 1.00 2.00 1.50 1.50 1.50 1.50 1.50

10 0.00 1.00 1.50 0.00 0.00 1.00 1.00

11 0.00 1.00 0.00 0.00 0.00 1.00 0.00

12 0.00 1.50 1.50 1.00 0.00 1.00 1.00

13 1.50 0.00 1.00 1.00 0.00 1.50 2.00

14 0.00 0.00 1.00 0.00 0.00 1.00 1.00

15 0.00 1.50 1.00 0.00 0.00 0.00 0.00

16 0.00 1.50 0.00 0.00 0.00 1.50 1.50

17 0.00 0.00 0.00 0.00 0.00 0.00 0.00

18 0.00 0.00 0.00 0.00 0.00 0.00 0.00

19 0.00 0.00 1.00 0.00 0.00 1.00 1.00

20 1.00 0.00 1.00 1.00 0.00 1.00 1.00

21 0.00 1.00 1.50 0.00 0.00 1.50 1.00

22 0.00 1.00 1.00 1.00 0.00 1.50 1.50

23 0.00 0.00 0.00 0.00 0.00 0.00 0.00

24 0.00 1.00 0.00 0.00 0.00 1.00 0.00

25 0.00 0.00 1.00 0.00 0.00 0.00 0.00

26 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Ref. code: 25605812030533ARL

160

Table L15 Revised Nottingham Sensory Assessment at pre-assessment

Item

ID

Light touch

shoulder A

(score)

Light touch

shoulder L

(score)

Light touch

elbow A

(score)

Light touch

elbow L

(score)

Light touch

wrist A

(score)

Light touch

wrist L

(score)

Light touch

hand A

(score)

Light touch

hand L

(score)

Total light

touch

(score)

1 1 2 2 2 0 2 0 2 11

2 2 2 2 2 1 2 1 2 14

3 2 2 2 2 2 2 2 2 16

4 2 2 2 2 2 2 2 2 16

5 1 2 1 2 1 2 1 2 12

6 2 2 2 2 2 2 2 2 16

7 2 2 2 2 2 2 1 2 15

8 2 2 2 2 2 2 2 2 16

9 2 2 2 2 2 2 2 2 16

10 2 2 2 2 2 2 2 2 16

11 2 2 2 2 2 2 2 2 16

12 2 2 2 2 2 2 2 2 16

13 2 2 2 2 2 2 2 2 16

14 2 2 2 2 2 2 2 2 16

15 1 2 1 2 1 2 1 2 12

16 2 2 2 2 2 2 2 2 16

17 2 2 2 2 2 2 2 2 16

18 2 2 2 2 2 2 2 2 16

19 1 2 1 2 1 2 1 2 12

20 2 2 2 2 0 2 0 2 12

21 2 2 2 2 2 2 2 2 16

22 2 2 2 2 2 2 2 2 16

23 2 2 2 2 2 2 2 2 16

24 2 2 2 2 2 2 2 2 16

25 2 2 2 2 1 2 1 2 14

26 2 2 2 2 2 2 2 2 16

A; affected side, L; less affected side

Ref. code: 25605812030533ARL

161

Table L16 Revised Nottingham Sensory Assessment at pre-assessment (continued)

Item

ID

Temperature

shoulder A

(score)

Temperature

shoulder L

(score)

Temperature

elbow A

(score)

Temperature

elbow L

(score)

Temperature

wrist A

(score)

Temperature

wrist L

(score)

Temperature

hand A

(score)

Temperature

hand L

(score)

Total

(score)

1 1 2 1 2 1 2 2 0 11

2 0 1 0 1 0 1 0 1 4

3 2 2 2 2 2 2 2 2 16

4 2 2 2 2 2 2 2 2 16

5 1 2 1 2 1 2 1 2 12

6 1 2 1 2 1 2 0 2 11

7 2 2 2 2 2 2 1 2 15

8 1 2 2 2 2 2 2 2 15

9 2 2 2 2 2 2 2 2 16

10 2 2 2 2 2 2 2 2 16

11 1 2 2 2 2 2 1 2 14

12 1 1 1 1 1 1 1 1 8

13 2 2 2 2 2 2 2 2 16

14 2 2 2 2 2 2 2 2 16

15 1 2 1 2 1 2 1 2 12

16 2 2 2 2 1 2 1 2 14

17 2 2 2 2 2 2 2 2 16

18 2 2 2 2 2 2 2 2 16

19 0 2 0 2 0 2 0 2 8

20 2 2 2 2 2 2 2 2 16

21 2 2 2 2 1 2 1 2 14

22 2 2 2 2 2 2 2 2 16

23 2 2 2 2 2 2 2 2 16

24 2 2 2 2 2 2 2 2 16

25 2 2 2 2 2 2 2 2 16

26 2 2 2 2 2 2 2 2 16


Ref. code: 25605812030533ARL

162


Item

ID

Pinprick

shoulder A

(score)

Pinprick

shoulder L

(score)

Pinprick

elbow A

(score)

Pinprick

elbow L

(score)

Pinprick

wrist A

(score)

Pinprick

wrist L

(score)

Pinprick

hand A

(score)

Pinprick

hand L

(score)

Total

(score)

1 2 2 0 2 0 2 0 2 10

2 1 2 1 2 0 2 0 2 10

3 2 2 2 2 2 2 2 2 16

4 2 2 2 2 2 2 2 2 16

5 2 2 1 2 2 2 2 2 15

6 2 2 2 2 2 2 2 2 16

7 2 2 2 2 2 2 1 2 15

8 2 2 2 2 2 2 2 2 16

9 2 2 2 2 2 2 2 2 16

10 2 2 2 2 2 2 2 2 16

11 2 2 2 2 2 2 2 2 16

12 2 2 2 2 2 2 2 2 16

13 2 2 2 2 2 2 2 2 16

14 2 2 2 2 2 2 2 2 16

15 0 2 0 2 0 2 0 2 8

16 2 2 2 2 2 2 2 2 16

17 2 2 2 2 2 2 2 2 16

18 2 2 2 2 2 2 2 2 16

19 1 2 1 2 1 2 1 2 12

20 2 2 2 2 1 2 1 2 14

21 2 2 2 2 1 1 1 1 12

22 2 2 2 2 2 2 2 2 16

23 2 2 2 2 2 2 2 2 16

24 2 2 2 2 2 2 2 2 16

25 2 2 2 2 2 2 2 2 16

26 2 2 2 2 2 2 2 2 16


Ref. code: 25605812030533ARL

163


Item

ID

Tactile

localisation

shoulder A

(score)

Tactile

localisation

shoulder L

(score)

Tactile

localisation

shoulder A

(score)

Tactile

localisation

elbow L

(score)

Tactile

localisation

wrist A

(score)

Tactile

localisation

wrist L

(score)

Tactile

localisation

hand A

(score)

Tactile

localisation

hand L

(score)

Total

(score)

1 2 2 1 2 1 2 0 2 12

2 1 2 0 2 0 2 0 2 9

3 2 2 2 2 2 2 2 2 16

4 2 2 2 2 2 2 2 2 16

5 2 2 2 2 1 2 1 2 14

6 2 2 2 2 2 2 2 2 16

7 2 2 2 2 2 2 1 2 15

8 2 2 2 2 2 2 2 2 16

9 2 2 2 2 2 2 2 2 16

10 2 2 2 2 2 2 2 2 16

11 2 2 2 2 2 2 2 2 16

12 2 2 2 2 2 2 2 2 16

13 2 2 2 2 2 2 2 2 16

14 2 2 2 2 2 2 2 2 16

15 0 2 0 2 0 2 0 2 8

16 2 2 2 2 2 2 2 2 16

17 2 2 2 2 2 2 2 2 16

18 2 2 2 2 2 2 2 2 16

19 2 2 2 2 2 2 2 2 16

20 0 2 0 2 0 2 0 2 8

21 2 2 2 2 2 2 2 2 16

22 2 2 2 2 2 2 2 2 16

23 2 2 2 2 2 2 2 2 16

24 2 2 2 2 2 2 2 2 16

25 2 2 2 2 2 2 2 2 16

26 2 2 2 2 2 2 2 2 16


Ref. code: 25605812030533ARL

164

Table L19 Revised Nottingham Sensory Assessment at pre-assessment (continued) (score)

ID Bilateral simultaneous touch

shoulder

(score)

Bilateral simultaneous

touch elbow

(score)

Bilateral simultaneous touch

wrist

(score)

Bilateral simultaneous touch

hand

(score)

Total

(score)

Total all

(score)

1 1 1 1 1 4 48

2 1 1 0 0 2 39

3 2 2 2 2 8 72

4 2 2 2 2 8 72

5 2 2 2 2 8 61

6 2 2 2 2 8 67

7 2 2 2 2 8 68

8 2 2 2 2 8 71

9 2 2 2 2 8 72

10 2 2 2 2 8 72

11 2 2 2 2 8 70

12 2 2 2 2 8 64

13 2 2 2 2 8 72

14 2 2 2 2 8 72

15 1 1 1 1 4 44

16 2 2 2 2 8 70

17 2 2 2 2 8 72

18 2 2 2 2 8 72

19 2 2 2 2 8 56

20 2 2 0 0 4 54

21 2 2 2 2 8 66

22 2 2 2 2 8 72

23 1 1 1 1 4 67

24 2 2 2 2 8 72

25 2 2 2 2 8 72

26 2 2 2 2 8 72

Ref. code: 25605812030533ARL

165


Item

ID

Proprioception

shoulder

(score)

Proprioception

elbow

(score)

Proprioception

wrist

(score)

Proprioception

hand

(score)

Total

(score)

1 1 1 0 0 2

2 2 1 1 0 4

3 2 2 2 2 8

4 1 2 2 2 7

5 1 1 0 1 3

6 2 2 2 2 8

7 3 3 3 3 12

8 1 2 2 2 7

9 2 2 1 1 6

10 0 0 0 0 0

11 3 3 3 3 12

12 3 3 3 3 12

13 3 3 3 3 12

14 3 3 3 3 12

15 3 3 2 2 10

16 3 3 3 3 12

17 3 3 3 3 12

18 3 3 3 3 12

19 3 3 2 2 10

20 3 3 3 3 12

21 2 2 3 1 8

22 3 3 3 2 11

23 2 1 1 1 5

24 2 2 2 2 8

25 2 2 2 2 8

26 2 2 2 2 8

Ref. code: 25605812030533ARL

166

Table L21 Revised Nottingham Sensory Assessment at pre-assessment (stereognosis) (continued)

Item

ID

10

Coins

(score)

5

Coins

(score)

1

Coins

(score)

Brio

(score)

Pencil

(score)

Comb

(score)

Scissors

(score)

Sponge

(score)

Flannel

(score)

Cup

(score)

Glass

(score)

Total

(score)

1 0 0 0 0 0 0 0 0 0 0 0 0

2 0 0 0 0 0 0 0 0 0 0 0 0

3 2 2 0 2 2 2 2 2 2 2 2 20

4 2 2 0 0 1 0 0 0 0 1 2 8

5 0 0 0 0 0 0 0 0 0 0 0 0

6 2 2 2 0 2 0 0 0 2 2 2 14

7 0 0 0 2 2 2 0 0 0 0 0 6

8 0 0 0 0 0 0 0 0 2 0 0 2

9 0 0 0 2 2 2 2 2 2 0 0 12

10 2 2 2 2 2 2 2 2 2 2 2 22

11 2 0 0 2 2 2 2 2 2 2 2 18

12 2 2 2 2 2 2 2 2 2 2 2 22

13 0 0 0 0 0 2 2 0 2 2 2 10

14 2 2 0 2 2 2 2 2 2 2 2 20

15 0 0 0 2 2 2 2 2 0 2 2 14

16 0 0 0 0 2 0 2 0 2 2 2 10

17 0 0 0 0 2 0 2 0 2 0 0 6

18 2 2 2 2 2 2 2 2 2 2 2 22

19 0 0 0 2 0 2 0 0 0 0 0 4

20 0 0 0 0 0 0 0 0 0 0 0 0

21 0 0 0 0 0 0 0 0 0 0 0 0

22 0 0 0 0 0 0 0 0 0 0 0 0

23 0 0 0 0 2 0 0 0 0 0 0 2

24 2 0 0 2 2 2 2 0 2 0 0 12

25 2 2 2 0 0 0 0 0 2 2 2 12

26 2 2 2 2 2 2 2 2 2 2 2 22

Ref. code: 25605812030533ARL

167

Table L22 Revised Nottingham Sensory Assessment at post-assessment

Item

ID

Light touch

shoulder A

(score)

Light touch

shoulder L

(score)

Light touch

elbow A

(score)

Light touch

elbow L

(score)

Light touch

wrist A

(score)

Light touch

wrist L

(score)

Light touch

hand A

(score)

Light touch

hand L

(score)

Total light

touch

(score)

1 2 2 2 2 1 1 0 2 12

2 2 2 2 2 1 2 1 2 14

3 2 2 2 2 2 2 2 2 16

4 2 2 2 2 2 2 2 2 16

5 1 2 1 2 1 2 1 2 12

6 2 2 2 2 2 2 2 2 16

7 2 2 2 2 2 2 1 2 15

8 2 2 2 2 2 2 2 2 16

9 2 2 2 2 2 2 2 2 16

10 2 2 2 2 2 2 2 2 16

11 2 2 2 2 2 2 2 2 16

12 2 2 2 2 2 2 2 2 16

13 2 2 2 2 2 2 2 2 16

14 2 2 2 2 2 2 2 2 16

15 2 2 2 2 2 2 2 2 14

16 2 2 2 2 2 2 2 2 16

17 2 2 2 2 2 2 2 2 16

18 2 2 2 2 2 2 2 2 16

19 1 2 1 2 1 2 1 2 12

20 2 2 2 2 2 2 2 2 14

21 2 2 2 2 2 2 2 2 16

22 2 2 2 2 2 2 2 2 16

23 2 2 2 2 2 2 2 2 16

24 2 2 2 2 2 2 2 2 16

25 2 2 2 2 2 2 2 2 16

26 2 2 2 2 2 2 2 2 16


Ref. code: 25605812030533ARL

168

Table L23 Revised Nottingham Sensory Assessment at post-assessment (continued)

Item

ID

Temperature

shoulder A

(score)

Temperature

shoulder L

(score)

Temperature

elbow A

(score)

Temperature

elbow L

(score)

Temperature

wrist A

(score)

Temperature

wrist L

(score)

Temperature

hand A

(score)

Temperature

hand L

(score)

Total

(score)

1 1 2 1 2 1 2 2 0 11

2 0 1 0 1 0 1 0 1 4

3 2 2 2 2 2 2 2 2 16

4 2 2 2 2 2 2 2 2 16

5 1 2 1 2 1 2 1 2 12

6 1 2 1 2 1 2 0 2 11

7 2 2 2 2 2 2 1 2 15

8 1 2 2 2 2 2 2 2 15

9 2 2 2 2 2 2 2 2 16

10 2 2 2 2 2 2 2 2 16

11 2 2 2 2 2 2 2 2 16

12 2 2 2 2 2 2 2 2 16

13 2 2 2 2 2 2 2 2 16

14 2 2 2 2 2 2 2 2 16

15 1 2 1 2 1 2 1 2 12

16 2 2 2 2 2 2 2 2 16

17 2 2 2 2 2 2 2 2 16

18 2 2 2 2 2 2 2 2 16

19 0 2 0 2 0 2 0 2 8

20 2 2 2 2 2 2 2 2 16

21 2 2 2 2 2 2 2 2 16

22 2 2 2 2 2 2 2 2 16

23 2 2 2 2 2 2 2 2 16

24 2 2 2 2 2 2 2 2 16

25 2 2 2 2 2 2 2 2 16

26 2 2 2 2 2 2 2 2 16


Ref. code: 25605812030533ARL

169

Table L24 Revised Nottingham Sensory Assessment at post- assessment (continued)

Item

ID

Pinprick

shoulder A

(score)

Pinprick

shoulder L

(score)

Pinprick

elbow A

(score)

Pinprick

elbow L

(score)

Pinprick

wrist A

(score)

Pinprick

wrist L

(score)

Pinprick

hand A

(score)

Pinprick

hand L

(score)

Total

(score)

1 2 2 0 2 0 2 0 2 10

2 1 2 1 2 0 2 0 2 10

3 2 2 2 2 2 2 2 2 16

4 2 2 2 2 2 2 2 2 16

5 2 2 1 2 2 2 2 2 15

6 2 2 2 2 2 2 2 2 16

7 2 2 2 2 2 2 1 2 15

8 2 2 2 2 2 2 2 2 16

9 2 2 2 2 2 2 2 2 16

10 2 2 2 2 2 2 2 2 16

11 2 2 2 2 2 2 2 2 16

12 2 2 2 2 2 2 2 2 16

13 2 2 2 2 2 2 2 2 16

14 2 2 2 2 2 2 2 2 16

15 1 2 2 2 2 2 2 2 15

16 2 2 2 2 2 2 2 2 16

17 2 2 2 2 2 2 2 2 16

18 2 2 2 2 2 2 2 2 16

19 1 2 1 2 1 2 1 2 12

20 2 2 2 2 2 2 2 2 16

21 2 2 2 2 2 2 2 2 16

22 2 2 2 2 2 2 2 2 16

23 2 2 2 2 2 2 2 2 16

24 2 2 2 2 2 2 2 2 16

25 2 2 2 2 2 2 2 2 16

26 2 2 2 2 2 2 2 2 16


Ref. code: 25605812030533ARL

170


Item

ID

Tactile

localisation

shoulder A

(score)

Tactile

localisation

shoulder L

(score)

Tactile

localisation

shoulder A

(score)

Tactile

localisation

elbow L

(score)

Tactile

localisation

wrist A

(score)

Tactile

localisation

wrist L

(score)

Tactile

localisation

hand A

(score)

Tactile

localisation

hand L

(score)

Total

(score)

1 2 2 1 2 1 2 0 2 12

2 1 2 0 2 0 2 0 2 9

3 2 2 2 2 2 2 2 2 16

4 2 2 2 2 2 2 2 2 16

5 2 2 2 2 1 2 1 2 14

6 2 2 2 2 2 2 2 2 16

7 2 2 2 2 2 2 1 2 15

8 2 2 2 2 2 2 2 2 16

9 2 2 2 2 2 2 2 2 16

10 2 2 2 2 2 2 2 2 16

11 2 2 2 2 2 2 2 2 16

12 2 2 2 2 2 2 2 2 16

13 2 2 2 2 2 2 2 2 16

14 2 2 2 2 2 2 2 2 16

15 2 2 2 2 2 2 2 2 16

16 2 2 2 2 2 2 2 2 16

17 2 2 2 2 2 2 2 2 16

18 2 2 2 2 2 2 2 2 16

19 2 2 2 2 2 2 2 2 16

20 0 2 0 2 0 2 0 2 8

21 2 2 2 2 2 2 2 2 16

22 2 2 2 2 2 2 2 2 16

23 2 2 2 2 2 2 2 2 16

24 2 2 2 2 2 2 2 2 16

25 2 2 2 2 2 2 2 2 16

26 2 2 2 2 2 2 1 2 15


Ref. code: 25605812030533ARL

171


Item

ID


touch – shoulder

(score)


touch – elbow

(score)


touch – wrist

(score)


touch – hand

(score)

Total

(score)

Total all

(score)

1 1 1 1 1 4 49

2 2 1 0 0 3 40

3 2 2 2 2 8 72

4 2 2 2 2 8 72

5 2 2 2 2 8 61

6 2 2 2 2 8 67

7 2 2 2 2 8 68

8 2 2 2 2 8 71

9 2 2 2 2 8 72

10 2 2 2 2 8 72

11 2 2 2 2 8 72

12 2 2 2 2 8 72

13 2 2 2 2 8 72

14 2 2 2 2 8 72

15 2 2 2 2 8 65

16 2 2 2 2 8 72

17 2 2 2 2 8 72

18 2 2 2 2 8 72

19 2 2 2 2 8 56

20 0 0 0 0 0 56

21 2 2 2 2 8 72

22 2 2 2 2 8 72

23 2 1 1 1 5 69

24 2 2 2 2 8 72

25 2 2 2 2 8 72

26 2 2 2 1 7 70

Ref. code: 25605812030533ARL

172


Item

ID

Proprioception

shoulder

(score)

Proprioception

elbow

(score)

Proprioception

wrist

(score)

Proprioception

hand

(score)

Total

(score)

1 2 1 0 0 3

2 2 2 1 0 5

3 3 3 3 3 12

4 2 2 2 2 8

5 3 3 2 1 9

6 3 3 3 3 12

7 2 2 2 2 8

8 1 2 2 2 7

9 2 2 2 1 7

10 3 3 3 3 12

11 2 2 2 2 8

12 3 3 3 3 12

13 3 3 3 3 12

14 3 3 3 3 12

15 3 3 3 3 12

16 3 3 3 3 12

17 3 3 3 3 12

18 3 3 3 3 12

19 3 3 2 2 10

20 2 2 2 2 8

21 3 3 3 3 12

22 3 3 3 3 12

23 2 2 2 2 8

24 2 2 2 2 8

25 3 3 3 3 12

26 3 3 3 3 12

Ref. code: 25605812030533ARL

173

Table L28 Revised Nottingham Sensory Assessment at post- assessment (stereognosis) (continued)

Item

ID

10 Coins

(score)

5 Coins

(score)

1 Coins

(score)

Brio

(score)

Pencil

(score)

Comb

(score)

Scissors

(score)

Sponge

(score)

Flannel

(score)

Cup

(score)

Glass

(score)

Total

(score)

1 0 0 0 0s 0 0 0 0 0 0 0 0

2 0 0 0 0 0 0 0 0 0 0 0 0

3 2 2 2 2 2 2 2 2 2 2 2 22

4 2 2 2 1 1 0 0 0 0 2 2 12

5 0 0 0 0 0 0 0 0 0 0 0 0

6 0 0 0 0 0 0 0 0 0 0 0 0

7 0 0 0 2 2 2 0 0 0 0 0 6

8 0 0 0 0 0 0 0 0 0 0 0 0

9 0 0 0 2 2 2 2 2 2 0 0 12

10 2 2 2 2 2 2 2 2 2 2 2 22

11 2 2 2 2 2 0 2 2 2 2 2 20

12 2 2 2 2 2 2 2 2 2 2 2 22

13 0 0 0 0 2 2 2 0 2 2 2 12

14 2 2 0 2 2 2 2 2 2 2 2 20

15 2 2 2 2 2 2 2 2 2 2 2 22

16 2 2 2 2 2 2 2 2 2 2 2 22

17 2 2 2 2 2 2 2 2 2 2 2 22

18 2 2 2 2 2 2 2 2 2 2 2 22

19 0 0 0 2 0 2 0 0 0 0 0 4

20 0 0 0 0 0 0 2 0 0 0 2 4

21 0 0 0 2 2 2 2 0 2 2 2 14

22 0 0 2 2 2 0 2 0 2 2 2 14

23 0 0 0 0 2 0 0 0 0 0 0 2

24 2 2 0 2 2 2 2 0 2 0 0 14

25 2 2 2 0 0 0 0 0 2 2 2 12

26 2 2 2 2 2 2 2 2 2 2 2 22

Ref. code: 25605812030533ARL

174

APPENDIX M

Results

Comparison between moderate and severe level of severity

Table M1 Comparison of the Wolf Motor Function Test (movement time) of the

affected side between moderate and severe level of severity (pre- and post-

assessment)

*P-value < 0.05

Calculated by the Mann-Whitney U test

Item

Mean ± SD

(seconds)

p-value

Moderate level

(n=13)

Severe level

(n=13)

1 Forearm to table 0.55 ± 0.54 8.51 ± 25.27 0.011*

2 Forearm to box 0.16 ± 1.03 3.72 ± 4.96 0.017*

3 Extend elbow (side) 25.88 ± 48.16 9.24 ± 56.54 0.359

4 Extend elbow (weight) 19.95 ± 42.08 16.88 ± 38.87 0.388

5 Hand to table 0.26 ± 0.77 10.35 ± 25.27 0.017*

6 Hand to box 9.69 ± 32.73 28.56 ± 50.96 0.270

8 Reach and retrieve 0.73 ± 1.57 54.22 ± 58.37 0.045*

9 Lift can 25.80 ± 46.74 18.07 ± 14.11 0.242

10 Lift pencil 17.82 ± 11.54 29.18 ± 46.73 0.729

11 Lift paper clip 47.78 ± 55.08 8.44 ± 30.43 0.009*

12 Stack checkers 16.68 ± 38.32 0.00 ± 0.00 0.221

13 Flip card 29.82 ± 44.04 5.65 ± 20.39 0.125

15 Turn key in lock 22.93 ± 38.94 11.83 ± 30.97 0.199

16 Fold towel 42.65 ± 44.19 33.40 ± 42.22 0.154

17 Lift basket 27.40 ± 42.48 34.23± 47.26 0.846

Total 10.90 ± 3.03 10.93 ± 3.03 0.689

Ref. code: 25605812030533ARL

175

Table M2 Comparison of the Wolf Motor Function Test (functional Ability Scale)

of the affected side between moderate and severe level of stroke (pre- and post-

assessment)

Item

Mean ± SD

(score)

p-value

Moderate level

(n=13) Severe level

(n=13)

1 Forearm to table 0.85 ± 0.89 1.15 ± 0.98 0.245

2 Forearm to box 0.69 ± 0.85 1.46 ± 1.26 0.142

3 Extend elbow (side) 1.23 ± 1.09 1.15 ± 1.63 0.540

4 Extend elbow (weight) 0.85 ± 0.89 0.92 ± 0.86 0.914

5 Hand to table 0.85 ± 0.55 0.85 ± 0.68 0.953

6 Hand to box 1.38 ± 0.96 1.46 ± 0.96 0.677

8 Reach and retrieve 1.00 ± 1.08 1.54 ± 1.45 0.362

9 Lift can 0.77 ± 1.36 0.00 ± 0.00 0.071

10 Lift pencil 0.92 ± 1.03 0.46 ± 0.77 0.216

11 Lift paper clip 1.15 ± 1.34 0.23 ± 0.59 0.034*

12 Stack checkers 0.62 ± 1.26 0.23 ± 0.59 0.071

13 Flip card 0.77 ± 0.72 0.00 ± 0.00 0.002*

15 Turn key in lock 0.69 ± 1.18 0.23 ± 0.92 0.176

16 Fold towel 0.62 ± 0.65 0.85 ± 0.98 0.676

17 Lift basket 1.50 ± 1.43 1.00 ± 1.41 0.443

Total 14.00 ± 8.29 10.77 ± 5.98 0.410

*P-value < 0.05


Ref. code: 25605812030533ARL

176

Table M3 Comparison of the Fugl- Meyer assessment of the upper extremity

between moderate and severe level of stroke (pre- and post-assessment)

Item

Mean ± SD

(score)

p-value

Moderate level

(n=13)

Severe level

(n=13)

Upper extremity

- A1 Reflex activity

0.00 ± 0.00 0.00 ± 0.00 1.000

- A2 Volitional movement

within synergies

4.08 ± 2.81 3.92 ± 4.71 0.757

- A3 Volitional movement

mixing synergies

1.46 ± 1.45 1.54 ± 1.05 0.496

- A4 Volition movement with

little or no synergy

1.69 ± 1.37 0.92 ± 1.15 0.113

- A5 Normal reflex activity 0.54 ± 0.87 0.00 ± 0.70 0.118

- B Wrist

Stability at 15°

dorsiflexion

Repeated

dorsiflexion/ volar

flexion

Circumduction

3.08 ± 2.78 2.15 ± 2.60 0.361

- C Hand

Mass

flexion/extension

Grasp

2.69 ± 2.59 3.54 ± 4.03 0.588

- D Coordinate/Speed 0.67 ± 1.30 0.83 ± 1.47 0.922

Total 14.23 ± 7.80 12.69 ± 11.60 0.650

*P-value < 0.05


Ref. code: 25605812030533ARL

177

Table M4 Comparison of the Modified Ashworth Scale between moderate and

severe level of stroke (pre- and post-assessment)

Muscle

Mean ± SD

(scale)

p-value Moderate

level (n=13)

Severe level

(n=13)

Shoulder internal rotators 0.08 ± 0.28 0.00 ± 0.00 0.317

Shoulder adductors 0.19 ± 0.48 0.12 ± 0.22 0.794

Elbow flexors 0.12 ± 0.42 0.23 ± 0.63 0.693

Elbow extensors 0.04 ± 0.14 0.15 ± 0.32 0.015*

Pronators 0.08 ± 0.28 0.00 ± 0.61 0.611

Wrist flexors 0.19 ± 0.38 0.19 ± 0.43 0.945

Finger flexors 0.00 ± 0.20 0.30 ± 0.43 0.038*

*P-value < 0.05


Ref. code: 25605812030533ARL

178

Table M5 Comparison of the Revised Nottingham Sensory assessment between

moderate and severe level of stroke (pre- and post-assessment)

Item

Mean ± SD

(score)

p-value Moderate

level (n=13)

Severe level

(n=13)

Tactile sensation

Light touch

0.46 ± 1.12

0.46 ± 1.19

0.972

Temperature 0.15 ± 0.55 0.92 ± 0.25 0.270

Pinprick 0.15 ± 0.55 0.85 ± 2.15 0.488

Tactile localization 0.24 ± 0.59 0.30 ± 0.75 0.497

Bilateral Simultaneous

touch

0.00 ± 0.40 0.38 ± 1.12 0.180

All 0.38 ± 1.12 2.92 ± 6.02 0.363

Proprioception 0.08 ± 2.75 2.69 ± 3.42 0.054

Stereognosis 1.85 ± 4.36 4.00 ± 5.88 0.762

*P-value < 0.05


Ref. code: 25605812030533ARL

179

BIOGRAPHY

Name Miss Thanchanok Pumprasart

Date of Birth December 20, 1993

Educational Attainment 2014: Bachelor of Science

(Physical Therapy)

Thammasat University

Ref. code: 25605812030533ARL

effect of the bobath concept on upper limb and hand

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