A case series to review the effectiveness of an upper limb circuit training group on the performance of the upper limb in stroke patients.
Abstract: This case series explores the benefits of an eight week upper limb circuit training group for an outpatient stroke population with regards to three domains of the International Classification Framework (ICF): body structures and function; activity and participation. There were four participants ranging in age from 52 to 63 years old and in duration post-stroke from 82 to 444 days. The participants attended the group once a week. Each one hour session consisted of six exercise stations designed to include evidence based aspects of upper limb physiotherapy, such as, reach and grasp activities and fine motor skill activities. Participants were assessed by a blinded assessor at three time points; prior to the circuit training; on completion of the training and three months after completion. Outcome measures were chosen to allow interpretation across the three domains of the ICF. The results indicate a positive effect on upper limb performance for these patients with chronic stroke at completion of the eight week upper limb circuit group. Pain remained unchanged or reduced over the course of the study. This case series suggests upper limb circuit training groups may be a feasible way of providing effective physiotherapy to people recovering from stroke and worthy of further investigation.

Robinson K, Mahon J, Yeoman L, Janssen J (2011): A case series to review the effectiveness of an upper limb circuit training group on the performance of the upper limb in stroke patients. New Zealand Journal of Physiotherapy 39(2) 69-74.

Key Words: Upper limb, Stroke, Rehabilitation, Physiotherapy, Circuit training
Article Type: Report
Subject: Pain (Care and treatment)
Physical therapy
Therapeutics, Physiological
Circuit training
Stroke patients
Authors: Robinson, Kelly
Mahon, Jo
Yeoman, Leeanne
Janssen, Jessie
Pub Date: 07/01/2011
Publication: Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 New Zealand Society of Physiotherapists ISSN: 0303-7193
Issue: Date: July, 2011 Source Volume: 39 Source Issue: 2
Accession Number: 288537988
Full Text: INTRODUCTION

Twenty-one people each day experience a stroke in New Zealand, making stroke a major cause of adult disability (Stroke Foundation, 2010). The Stroke Foundation (2010) reports that there are currently 45,000 stroke survivors in New Zealand, the majority of who still experience disability and thus are potentially in need of rehabilitation. One dire consequence of stroke is the loss of upper limb function. Approximately 70-80% of people post-stroke experience impairments in their upper limb (Pang et al 2006, Nakayama et al 1994), that reduce upper limb function and impact on a person's ability to perform activities of daily living (Pang et al 2006). Upper limb rehabilitation is thus important.

Functional return of the upper limb is best enhanced by intensive task specific practice of functional activities (Blennerhassett and Dite 2004, van der Lee et al 2001); however, practice should be supervised to enhance learning of new motor skills (Ada et al 1999, English et al 2007). We considered the possibility that upper limb circuit training groups may potentially be a practical solution to provide intensive task specific practice in a supervised environment.

The evidence in support of circuit training for the upper limb is limited. Dean et al (2000) looked at the effects of a lower limb circuit training group compared with a control group which carried out an upper limb circuit training group in a randomised pilot trial. Despite the aim of the trial to look at the effects of a lower limb exercise class, an improvement in the upper limb function in two out of the four patients in the upper limb training group was noted. These authors further suggest group circuit training offers additional benefits in the domain of participation such as, peer support, social interaction, and in the domain of body function and structures such as improved mobility for the lower limb. Pang et al (2006) further supports that a circuit community-based exercise programme could improve upper limb function in people with chronic stroke. Their randomised controlled trial with 63 people with chronic stroke compared two exercise programmes: one for the lower limb and one designed for the upper limb. Overall there was a significant improvement in both groups (p=0.005), with the gains in upper limb function reported to be significantly higher (p=.001) in the upper limb group than the lower limb group. English et al (2007) conducted a non-randomised trial of 68 individuals with stroke comparing the effects of circuit training for the upper and lower limb with individual physiotherapy sessions. These authors concluded that circuit classes with aspects of upper and lower limb training were as effective a mode of delivery of physiotherapy as individual sessions for treatment of the upper limb. Of interest, these same authors reported in a later study (English et al 2008) that no increase in shoulder pain was found in people with stroke participating in an exercise circuit training class.

We concluded from the literature that circuit training has the potential to provide intensive task specific therapy for the upper limb in stroke. Literature suggests such therapy should include strengthening (Ada et al 2006) and task specific training using motor relearning principles or neurodevelopmental techniques (Teasell et al 2010). Therefore the purpose of this case series was to explore the benefits of an eight week upper limb circuit training group following a stroke event for an outpatient group. First, we wanted to interpret any change over time using the International Classification of Function, Disability and Health (ICF) (World Health Organisation 2001). The focus was the domains of body structures and function, activity and participation. Secondly, we were interested in determining whether there were any changes in shoulder pain reported by participants. We hypothesized that after an eight week upper limb circuit training group functional improvements would be reported in the majority of participants without an increase in shoulder pain.

METHODS

Participants

Participants were recruited from patients receiving outpatient physiotherapy through the Brain Injury Rehabilitation Service (BIRS) in New Zealand. Participants were excluded from the study if they were unable to follow verbal, written or "copy me" instructions; had a Transient Ischemic Attack in the last three weeks; or a score lower than four on the Chedoke McMasters Stroke Assessment (CMSA) (Gowland et al 1993) on the arm or hand subsections. The CMSA threshold was chosen to classify participants who had potential for improvement in motor function as defined by Barreca (2001). Barreca (2001) recommended that patients with a poor prognosis of recovery of the upper limb (defined as a CMSA score of less than four) should receive treatment that focuses on minimizing contractures and pain as exercise interventions may not lead to meaningful functional use.

Protocol

The Upper South A Regional Ethics Committee approved the ethics application. Four patients met the inclusion criteria for the study and were contacted. After written consent was gained a blinded assessor undertook all baseline assessments. These were repeated at completion of the eight week circuit training group and at three months follow up.

Intervention

All participants attended the upper limb circuit training group for one hour once a week, for eight weeks. Each session commenced with the participants stretching their muscles in their affected upper limb that had increased muscle tone, for example the wrist flexors and biceps. Participants then rotated between six stations, spending six minutes at each station. Six forms of therapy were included and consisted of; 1) reach and grasp activities, 2) fine motor skill activities, 3) strength training, 4) sensory retraining, 5) virtual reality activities, and 6) cardiovascular training (table 1). A variety of options were available at each station to suit the individual's capabilities.

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

Outcome Measures

Outcome measures were chosen to include measurement of three areas of the ICF (World Health Organisation 2001).

Body structures and function:

Upper limb impairment and shoulder pain were assessed with the CMSA arm, hand and pain subsections. This measure has been proven valid and reliable with reliability coefficients of 0.97 to 0.99 (Gowland et al 1993). Spasticity was measured with the Modified Tardieu Scale (MTS) (Boyd and Graham 1999). The MTS was chosen over the Ashworth scale due to better reported validity when measuring spasticity (Patrick and Ada 2006) and excellent intrarater reliability when used in upper limb assessment of children with cerebral palsy (Gracies et al 2010). The Medical Research Council (MRC) scale was used to measure muscle power of shoulder flexion, extension, abduction, internal and external rotation, elbow flexion and extension, wrist flexion, extension and radial deviation (MRC, 1981). Gregson et al (2000) reported the MRC scale valid and reliable for use in patients with stroke. Range of motion (ROM) and grip strength were assessed with goniometry and dynamometry respectively.

Activity:

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

Participation:

Participation was measured with the Stroke--Adapted Sickness Impact Profile-30 (SA-SIP30) (Schepers et al 2006, Van Straten et al 1997). Van De Port et al (2004) reported the SA-SIP30 to be a valid and responsive stroke specific scale to determine health related functional status.

Data Analysis

All data from the outcome measures for each participant are presented. Due to the small number of participants in this study statistical significance of change over time was not determined. Clinical significance measured with the minimally clinically important difference (MCID) has not been established for any of the outcome measures used; therefore, all increases or decreases in scores have been reported.

RESULTS

Four participants met the criteria for inclusion in this study. The age of participants ranged from 52 to 63 years (mean 57 years). The number of days since stroke at entry to the study ranged from 82 to 444 days (mean 241 days). All four participants (two men and two women) had right sided infarcts. One of the participants was unable to attend the three month assessment.

Participant A

Participant A had a superior cerebral artery infarct, was 62 years old and was 219 days post stroke. On entry to the circuit training group she achieved maximum scores in CMSA arm subsection and the MAS upper arm and hand subsections. After the eight week circuit training improvement occurred specifically in body structures and function (elbow flexor force and CMSA hand subsection) and activity (MAS advanced hand subsection). She demonstrated an increase in the SA-SIP30 score which indicates an increase in the perceived impact the disability has on her life. She did not demonstrate any increased muscle tone or pain at any point.

Participant A was lost to the three month follow up as a result of a non-related medical condition resulting in admission to hospital. All outcomes for participant A are reported in Table 2.

Participant B

Participant B had an anterior cerebral artery infarct. He was 52 years old and 444 days post stroke. At eight weeks improvements were observed in the following body structures and function measures; force increased in internal shoulder rotators and wrist extensors; grip strength and CMSA hand subsection improved during the eight week circuit training group. However, a reduction in shoulder abduction force was noted, as well as a decrease in CMSA arm subsection. Activity measures remained the same. Participant B showed an increase in the SA-SIP30 score at eight weeks.

At the three month follow up the majority of the body structures and function outcome measures returned to baseline, with exception of wrist extensor and shoulder abduction power. These two scores remained at the eight week levels. However, an improvement was noted in activity and participation measures.

The spasticity angle increased in the biceps by 15[degrees] at the eight weeks assessment, suggesting an increase in muscle tone. Shoulder pain was noted at baseline using the CMSA pain subsection which remained the same at the eight week assessment. At three months muscle tone returned to baseline measures and shoulder pain improved. All results for participant B are displayed in Table 3.

Participant C

Participant C had a middle cerebral artery infarct, was 51 years old and was 82 days post stroke. Similarly to participant A, he also was high functioning at baseline assessment with maximum scores in CMSA arm subsection and MAS arm and hand subsections. At eight weeks body structures and function scores had improved. Force increased in shoulder extension, wrist flexion, wrist extension and wrist radial deviation. However, shoulder external rotation and elbow extension force reduced at the completion of the eight week circuit training group. An increase in MAS advanced hand subsection showed a maximum score at eight weeks. Perceived participation increased at eight week demonstrated by a reduction in the SA-SIP 30.

At three months the improvements in force were maintained, and both reductions seen at eight weeks returned to baseline levels. Grip strength and the CMSA hand subsection demonstrated improvements by the three month follow up assessment. Activity level remained maximal at three months, while his perceived participation reduced slightly. However, participation scores were improved from the baseline levels.

Participant C did not demonstrate any increased muscle tone according to the MTS or any shoulder pain according to the CMSA pain subsection at any of the three assessments. All results for participant C are shown in Table 4.

Participant D

Participant D also had a middle cerebral artery infarct, was 63 years old and was 218 days post stroke. At eight weeks a reduction was seen in shoulder abduction force. The CMSA arm score improved, while the MAS upper arm reduced. All other body structures and function and activity measures remained the same. However an improvement in perceived participation was shown.

Participant D's changes in muscle strength varied. At three months the reduction in shoulder abduction force returned to baseline levels, while elbow extension and wrist flexion force showed improvement. While unable to register any grip strength at baseline and at the eight week assessment, she demonstrated a two kilogram grip strength score at the three month assessment. A further increase in the CMSA arm score was noted.

An increase in activity was recorded with an improvement in the MAS upper arm and hand subsection scores at three months as well as a further reduction in SA-SIP30 score. This indicated a progressive reduction in the perception of the impact her disability had on her life. The spasticity angle was reduced by five degrees at the eight week assessment and that was maintained at the three month follow up, suggesting a reduction in muscle tone. The CMSA pain score remained unchanged at all three assessments. All results for participant D are shown in Table 5.

DISCUSSION

It is fully acknowledged that this case series focuses entirely on the experiences of four participants in an upper limb circuit training group. However, it is our belief the results raise three issues of interest with regard to improved understanding of upper limb management following a stroke event.

Firstly, for these four persons recovering from stroke the eight week upper limb circuit group appeared to have a positive effect on aspects of their upper limb performance. This is in concordance with previous reports that upper limb function improves with additional task related practice (Blennerhasset and Dite 2004). Unfortunately due to the limitations of this study (discussed in the 'strength and limitations' section) we are unable to draw firm conclusions. More in-depth analysis of individuals' results is discussed below.

Secondly, in terms of pain the upper limb circuit training did not have a negative effect on self reported pain. This supports the findings of English et al (2008). In fact, at three months follow up, participant B reported a reduction in pain which coincided with an improvement in participation. Although this cannot be directly attributed to the circuit training group, there may be a relationship between pain and participation.

Thirdly, the identification of impacts across domains encompassed by the ICF framework that includes participation emphasises the importance of extending assessment of effectiveness beyond the typical physiotherapy focus on 'body structures and function' and 'activity'.

At an individual level, there was an overall positive effect following the eight week intervention in performance of the upper limb circuit group for participant A and C. These improvements were more specific to advanced hand activity scores and may be associated with two factors. Firstly, for these patients the time since stroke was relatively short. Secondly, both scored highly at baseline for arm and hand measures and may, therefore, have been more likely to achieve a higher upper limb function (Nakayama et al 1994). Nakayama et al studied the recovery rates of 421 patients with stroke and reported that 27% of patients with severe upper limb paralysis compared with 50% of patients with mild upper limb paralysis improved in upper limb function after twelve weeks. Of interest the SA-SIP30 score showed an expected improvement in levels of participation for participant C. This was further confirmed by the improvement in activities involving stereognosis, for example, being able to find keys in a pocket. Participant A did not show an improvement in perceived participation, despite her reported improved ability to peg out the laundry and cook meals. Multiple co-morbidities and overall health deterioration that lead to hospital admission and study withdrawal may have contributed to this discrepancy. However, it is not unusual for perceived participation to reduce despite an increase in activities (Sinnott and Dean 2005).

For participants B and D any impacts at eight weeks were less distinct. At study entry both participants had (i) body structures and function and activity measures lower than participant A and C, (ii) increased muscle tone, and (iii) shoulder pain. These findings are in concordance with a previous report that participants with more severe problems with body structures and function did not report improved functional abilities following an upper limb group intervention (Pang et al 2006). Our observations in addition to Pang et al's findings that patients with more severe impairments are less likely to improve their upper limb function is supported by Nakayama et al (1994). While participant D did not report improved functional abilities, the therapist observed an improved activity performance within the group. For example, by week eight she could pick up twenty objects from the rice bowl compared with one object in the six minute test period in week one. Interestingly she had a similar time frame post stroke as participant A. This was not the case for participant B who had the longest time since stroke and possibly therefore why we were unable to measure clear improvements in any of the three domains of the ICF at 8 weeks.

Strengths and Limitations

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

There was a ceiling effect in some of the outcome measures used. For example participants A and C scored maximum points in the CMSA arm; MAS arm; and MAS hand at entry to the study, therefore if they improved during the circuit group, they were unable to demonstrate this improvement using these measures.

Another point of note is that some outcome measures used were not responsive enough to detect change in these participants. Although improvements in body structures and function, activity and participation were noted by the participants and the treating physiotherapist, at times these improvements were not reflected in the outcomes measured. For example, small perceived changes in strength were not able to be recorded objectively due to the structure of the MRC scale.

The SA-SIP30 was chosen to reflect improvements in participation; however, some of the participants found the wording difficult to understand, and at times it did not reflect individualised patient's participation as mentioned previously.

If this study was to be repeated in the future recommended alternative outcome measures may be dynamometric muscle testing, use of a patient activity log and the Goal Attainment Scale, and qualitative interviewing for measurement of participation.

CONCLUSION

This case series suggests that following a stroke active participation in an upper limb circuit training group is feasible and has the potential to be effective in an outpatient setting. We determined that improvements were more easily identified in participants with higher scores at study entry, and fewer days since stroke event. Self-reported pain levels did not change subsequent to circuit training participation. The ICF helped to interpret the measurements.

Further investigation is required using more refined outcome measures with greater responsiveness to small changes in upper limb function and levels of participation. The benefits of assessing change over time in a larger less diverse group of participants would be of value.

KEY POINTS

* Upper limb circuit training groups in people with stroke may be an effective way of providing physiotherapy in an outpatient setting.

* Pain levels did not change during the course of the circuit training group.

* People with higher functional levels seem to receive more benefit from an upper limb circuit group than people with lower levels.

* Alternative outcome measures and larger sample of patients are recommended for future research.

ACKNOWLEDGMENTS

We would like to acknowledge the Brain Injury Rehabilitation Service and the Physiotherapy Department of Burwood Hospital, Christchurch for allowing the time and resources to complete the research. Also we would like to thank Anne Sinnott for her review and additional help with this article. Finally, we would like to thank the School of Physiotherapy, University of Otago and Burwood Academy of Independent Living, Christchurch for their help throughout the whole process.

ADDRESS FOR CORRESPONDENCE

Kelly Robinson Bsc (Hons) Physiotherapy, Spinal Physiotherapist, Burwood Spinal Unit, Burwood Hospital, Christchurch, New Zealand. Postal: Physiotherapy Department, Burwood Hospital, Private Bag 4708, Christchurch, New Zealand. Email: kelly. robinson@cdhb.govt.nz Phone: +64 3 383-6833. Fax: +64 3 383-6879.

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Kelly Robinson BSc (Hons) Physiotherapy

Spinal Physiotherapist, Burwood Spinal Unit, Burwood Hospital, Christchurch, New Zealand

Jo Mahon BSc (Hons) Physiotherapy

Neurophysiotherapist, Burwood Spinal Unit, Burwood Hospital, Christchurch, New Zealand

Leeanne Yeoman BPhty Physiotherapy

Neurophysiotherapist, Brain Injury Rehabilitation Service, Burwood Hospital, Christchurch, New Zealand

Jessie Janssen MSc

PhD candidate, University of Otago, Dunedin, New Zealand
Table 1: Overview of the different workstations, ranging
in difficulties, for the upper limb circuit group

NO.    WORK STATION                EXERCISE

                                   1

1      Reach and Grasp             Slide pillow case
                                   on table:
       +/- FES                     - back and forward
       +/- Slings                  - round in circles
2      Fine Motor Skills           Writing
3      Strength                    Play with putty
4      Sensory                     Weight bearing on
                                   Affected hand whilst
                                   reaching with the
                                   other hand to stack
                                   cones
5      Nintendo Wii                Bowling game
6      Fitness                     Arm bike
                                   Low resistance

NO.    EXERCISE                    EXERCISE

       2                           3

1      Reach for objects           Move a stack of
                                   cones from
       in one box                  left hand side
       and move them into          of the table to
       another                     the right, one
       box (change height          at a time
       if appropriate)
2      Play solitaire on           Move items in
       a large board               and out of a
3      Lift heavy objects          box with tweezers
       out of a box                Resist movements
                                   using Theraband
4      Retrieve all items
       from within
       a tub of rice
5      Baseball game               Tennis game
6      Arm bike                    Arm bike
       Medium resistance           High resistance

NO.    EXERCISE                    EXERCISE

       4                           5

1

2      Take pegs on and            Turn over pack
3      off a pole                  of cards, one
4                                  card at the time
5
6

Table 2: Results for participant A according to the ICF
framework.

Participant A                           Before              After

Body structures and function

Grip strength (kg)                       14                  14
MTS Spasticity angle (degrees)           0                   0
CMSA arm/7                               7                   7
CMSA hand/7                              6                   7
CMSA pain/7                              7                   7

Activities
MAS arm/6                                6                   6
MAS Hand/6                               6                   6
MAS Advanced hand/6                      2                   6

Participation
SA-SIP30 (%)                             32                  36

MTS = Modified Tardieu Scale, CMSA = Chedoke McMasters Stroke
Assessment, MAS = Motor Assessment Scale, SA-SIP30 = Stroke-Adapted
Sickness Impact Profile -30. An increase in the measures of 'body
Structures and function' and activity indicate an improvement in
those domains, where as an increase in the SA-SIP 30 indicates a
decrease in the domain of participation.

Table 3: Results for participant B according to the ICF
framework.

                                                         3 month
Participant B                    before      after       follow up

Body structures and function

Grip strength (kg)                14          16            14
MTS Spasticity angle
(degrees)                         85          100           80
CMSA arm/7                        5           4             5
CMSA hand/7                       5           6             5
CMSA pain/7                       4           4             6

Activities
MAS arm/6                         5           5             5
MAS Hand/6                        5           5             6
MAS Advanced hand/6               2           2             2

Participation
SA-SIP30 (%)                      43          45            34

MTS = Modified Tardieu Scale, CMSA = Chedoke McMasters Stroke
Assessment, MAS = Motor Assessment Scale, SA-SIP30 = Stroke- Adapted
Sickness Impact Profile -30. An increase in the measures of 'body
Structures and function' and activity indicate an improvement in
those domains, where as an increase in the SA-SIP 30 indicates a
decrease in the domain of participation.

Table 4: Results for participant C according to the ICF
framework.

                                                         3 months
Participant C                    Before        After     follow up

Body structures and function

Grip strength (kg)                8             8           20
MTS Spasticity angle
(degrees)                         0             0           0
CMSA arm/7                        7             7           7
CMSA hand/7                       6             6           7
CMSA pain/7                       7             7           7

Activities
MAS arm/6                         6             6           6
MAS Hand/6                        6             6           6
MAS Advanced hand/6               3             6           6

Participation
SA-SIP30 (%)                     13             7           10

MTS = Modified Tardieu Scale, CMSA = Chedoke McMasters Stroke
Assessment, MAS = Motor Assessment Scale, SA-SIP30 = Stroke-Adapted
Sickness Impact Profile -30. An increase in the measures of 'body
structures and function' and activity indicate an improvement in
those domains, where as an increase in the SA-SIP 30 indicates a
decrease in the domain of participation.

Table 5: Results for participant D according to the ICF
framework.

                                                        3 months
Participant D                     Before      After     follow up

Body structures and function

Grip strength (kg)                  0           0          2
MTS Spasticity angle
(degrees)                           90          85         85
CMSA arm/7                          3           4          5
CMSA hand/7                         4           4          4
CMSA pain/7                         6           6          6

Activities
MAS arm/6                           3           1          4
MAS Hand/6                          3           3          5
MAS Advanced hand/6                 1           1          1

Participation
SA-SIP30 (%)                        34          28         24

MTS = Modified Tardieu Scale, CMSA = Chedoke McMasters Stroke
Assessment, MAS = Motor Assessment Scale, SA-SIP30 = Stroke-Adapted
Sickness Impact Profile -30. An increase in the measures of 'body
Structures and function' and activity indicate an improvement in
those domains, where as an increase in the SA-SIP 30 indicates a
decrease in the domain of participation.
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