Role of corrected-assisted-synchronized-periodic therapy in post-stroke rehabilitation
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.241405
Source of Support: None, Conflict of Interest: None
Keywords: CASP therapy, conventional physiotherapy, rehabilitation, spasticity, stroke
Stroke is a leading cause of long-term disability worldwide. Post-stroke spasticity often predisposes stroke survivors to a highly compromised lifestyle that adversely affects functional, emotional, and social dimensions. It also predisposes them to physical trauma in the form of increased risk of falls that adversely affect activities of daily living. Thus, post-stroke spasticity is an important cause of physical dependence. The potential role of various forms of physiotherapy and exercise techniques have been clearly highlighted in the available literature on stroke survivors. However, the currently available exercise techniques have demonstrated varying degrees of beneficial effects in different aspects of motor, psychological, and functional outcomes among stroke survivors. We introduce a new exercise technique called Corrected-Assisted-Synchronized -Periodic (CASP) therapy. In the present paper, we evaluated its role in different aspects of stroke outcome in comparison to conventional forms of physiotherapy.
This was a prospective, parallel, quasi-randomized, double-blind controlled intervention trial of the newly proposed CASP therapy versus conventional physiotherapy for patients with post-stroke spasticity. The trial was conducted at a super-specialty tertiary care and research centre in India, after obtaining ethical clearance from the Institute's Ethics Committee. Patients were assessed for spasticity on the 0–4 graded Ashworth score, and for muscle power on the 0–10 graded Modified Medical Research Council (MRC) grading (each grade was labelled on 0–10 count). Functional assessment was done using the 0–6 grade modified Rankin scale (mRS) and the 0-100 grade Barthel index of activities of daily living.
All patients were first subjected to appropriate pharmacotherapy on an individual basis based on the neurologist's advice for maximum possible correction of spasticity prior to inclusion in the study. Each of the aforementioned parameters were recorded at three separate visits, i.e., at the time of inclusion of patients in the study, and 3 as well as 6 months after the intervention. Sixty-one consecutive patients, with post-stroke spasticity of grade ≥1 and the muscle power on the affected side of grade 0/10 to 8/10 were included for the study. All of them were mandatorily recruited after at least 6 weeks of new-onset stroke, either ischemic or hemorrhagic.
The days of the out-patient stroke clinics were randomly allocated to two groups. On days allocated to group 1, all the selected patients received conventional therapy, and on days allocated to group 2, all the selected patients received CASP therapy. To prevent cluster contamination and avoid bias, separate physiotherapists were recruited for each group. Each group along with the allotted physiotherapist was completely blinded to the other group. As the CASP therapy requires active as well as passive movements of the extremity, the passive movement was conducted by a close relative who was trained for this job.
Both the groups were followed up in separate stroke clinics every 3 months for 6 months.
The author (SP) was responsible for selection of patients and their allotment to group 1 or group 2 related physiotherapist depending upon to which group that particular day was allocated.
All patients were separately assessed by the author (RB) who was completely blinded to the whole procedure, at 0, 3 and 6 months. Ignoring the correlation between observations at different time points, independent comparisons were done at 3 and 6 months between the two groups using Mann Whitney U test.
The primary outcome measures were (1) improvement in power, (2) reduction in spasticity, and (3) improvement in overall functional outcome.
The inclusion criteria for the study included: Age ≥18 years; recruitement of patients in the study at least six weeks after the onset of first-ever stroke or following recurrent ischemic or hemorrhagic stroke; full alertness and orientation of the patient; the patient having an mRS scale of ≥2 but ≤5; the patients having post-stroke spasticity, assessed by the modified Ashworth's scale, of grade ≥1 in at least two or more joints in the affected extremity; and, a motor power of less than or equal to grade 8/10 in the affected extremity in at least two or more joints.
The exclusion criteria for the study included: Withdrawal of consent at the time of randomization; patients suffering from severe osteoporosis, i.e., a z-score ≤−2.5; patients affected with peripheral vascular disease; patients with any extrapyramidal movement disorders in the affected extremity; and, patients with any joint contracture in the affected extremity.
Stroke-related medical history and patients' characteristics, such as age, sex, education, handedness (i.e., dominant hand affected by stroke), stroke severity, motor impairment, cognition, comorbidity, muscle tone, and power  were recorded at the baseline.
Patients were randomly allocated into two groups based upon the type of physiotherapy. The experimental group was advised CASP therapy. This included positioning of the limbs to correct the deformity, followed by minimal assistance by the physiotherapist/trained family member over complete range of motion, along with active synchronized efforts from the patient over full range of motion. This activity was to be done daily at approximately 2.5 hour intervals with 30 minutes of active physiotherapy during each session, for at least six times a day. The regimen excluded the 8 hours of undisturbed sleep that the patient was recommended to get. For the upper extremity, the postion to be maintained was arm adducted, forearm supinated with the wrist in the neutral position; fingers and thumb were kept flexed near the trunk and extended while moving away from the trunk [Figure 1]. First, the assistant (physiotherapist/trained family member) was asked to perform a complete range of movement of the arm from the completely flexed elbow with the maximum possible extended shoulder position to completely extended elbow and maximum possible flexion of the shoulder joint in a horizontal plane as well as in a vertical plane. After 10 such complete range of passive efforts, the patient was instructed to apply active efforts to perform the same movements in synchrony with the ongoing passive movement. Once the patient started making active efforts, the assistant was asked to maintain a minimal support during the action but to apply force at the terminal aspects of the action for ensuring that the range of movements was complete [Figure 1]. The physiotherapy for the affected lower limb was based upon the ability of the patient to sit/stand. For those who were bed bound, ankle was forced to the dorsiflexed position, along with flexion at the knee and hip joint for deformity correction. The assistant was asked to help the patient in practicing movements over the complete range of motion from a fully extended lower limb to the maximum painless flexion at the knee and hip joint, while keeping the ankle dorsiflexed in both supine and lateral positions, using only the superiorly placed limb in the latter case. Patients who could sit and bear some weight were asked to repeatedly sit on the chair and stand with the assistance of the assistant/trained family member, keeping the normal limb slightly away from the chair. They were asked to use the maximum effort on the affected limb. Assistance was provided to get the completely erect, final position each time.
The conventional therapy consisted of repeated passive movements of the affected joints 2–3 times daily.
The first session of each type of physiotherapy was done at the first outpatient department visit by the trained hospital physiotherapist, as per the protocol. During the same session, the patient's family member was also trained to perform the same physiotherapy in the domiciliary settings. Trained family members were advised to maintain a diary in which each session was to be mentioned and to bring the diary on each outpatient department visit for assuring compliance.
Conventional pharmacotherapies for spasticity management such as baclofen or tizanidine were allowed in optimal dosage after appropriate titration at regular intervals in each group. Statistical analysis was carried out using the Statistical Package for the Social Sciences (SPSS) for Windows statistical package, version 16.0 (IBM, USA). The clinical relevance of changes in the primary outcome scores after treatment and at follow-up was evaluated.
Between June 2015 and May 2016, 61 eligible patients were enrolled for participation in the study, of whom 31 (50.8%) received CASP and 30 (49.1%) received conventional therapy. All patients in the two groups completed treatment. Both groups were assessed after 3 and 6 months. Demographic and clinical baseline characteristics of the patients are described in [Table 1]. For the pre-specified demographic and clinical data, no statistical difference was observed between the groups. All results were analysed during case analyses at the end of the study.
Assessment of stroke-affected extremity after 3 and 6 months showed improvement in the mRS score, Barthel index of activities of daily living, tone, and muscle power compared to the baseline in both the groups [Table 2] and [Figure 2]. However, the improvement was significantly greater in the CASP therapy group compared to the conventional therapy group. After the intervention phase, improvement was significant in all the above mentioned parameters both at 3 months as well as at 6 months [Table 2]. Barthel index of activities of daily living which could not reach statistical significance (P = 0.093) at 3 months of intervention improved significantly (P = 0.001) at 6 months [Table 2].
The requirement of anti-spasticity medication (baclofen and tizanidine) had a significantly more decrease in the CASP therapy group in comparison to the conventional group at 3 months as well as 6 months [Table 3].
This study demonstrates the role of CASP in post-stroke rehabilitation. In comparison to the conventional exercise programs, the CASP therapy was found to be significantly better in reducing post-stroke spasticity. It was also associated with an improvement in the muscle power of the affected limbs. Significant improvement in the functional scales such as the mRS and Barthel index of activities of daily living was also seen.
The role of correction of limb position during physiotherapy
Stroke causes deformities of the affected limbs due to the presence of an abnormal tone. Correction of the deformed limb to the natural position is an important part of physiotherapy, which has been widely ignored in the conventional exercise programmes. In fact, the present exercise program emphasizes on overcorrection of spasticity-related deformity in the form of assistance that is provided during the exercise. For example, the prone position of the forearm and flexed posture of wrist and fingers is over corrected to complete supination of the forearm and a little extended position of wrist and fingers, in which the physiotherapist keeps the upper extremity mildly supported during the assisted synchronized therapy.
The role of assistance and synchronization
Assistance from a trained family member/physiotherapist to synchronize voluntary efforts from the patient along with passive stretch over the complete range of motion has been emphasized in this therapy. The key feature of this element is to let the patient do his/her bit of little movement that he/she could do, and to apply force only at the end of the movement done by the patient to make it a complete movement in that direction. Further, the patient is repeatedly asked to mentally continue the movement when the physiotherapist/relative is doing his/her bit of final movement. This ensures two things: (1) the full range of movement is completed with the patient's mind working on it both at cognitive as well as psychological levels, as the patient observes the full range of movement occurring even when his/her fullest possible efforts could bring out a small range of movement only; and, (2) this full range of movement ensures that contractures do not develop, and that the contracture-related disability, which has a contributory effect on weakness and spasticity, is minimized.
The role of higher frequency of periodic physiotherapy
The mandatory periodic exercise at 2.5 hours is another important feature of this exercise program. Muscle spasticity is well known to reduce on repeated movements at the concerned joints. However, this spasticity returns after sometime, and this duration varies from individual to individual. This spasticity and related functional contractures are the major causes of pain because of which the patient resists physiotherapy. Repetition of physiotherapy at 2.5–3-hour intervals ensured that spasticity did not return so that there was no pain during the next session. It has been our observation that most patients did not experience severe pain and were often willing to undergo such mode of therapy on their own.
Improvement in brain functions after stroke is attributed to the resolution of brain edema, revival of brain cells in the penumbric zone, and neuroplasticity. [13,14] The former two mechanisms are expected to play a role in all stroke patients managed conservatively. However, neuroplasticity is expected to make a difference based on physiotherapeutic intervention. In view of this, several physiotherapies have been tried. Several therapies have been constituted where different sensory inputs are provided to the brain. These are expected to provide different results by stimulating and improving the function of the remaining brain cells in the affected area and surroundings. The stimulatory inputs to the surviving brain cells in the affected area, in the penumbric zone, and the inputs to the normal brain surrounding the affected area, however, may come from two sources. First, it could be sensory inputs from the periphery; and second, it could be the inputs provided by the inner thought processes involving a particular action. Most of the known physiotherapies concentrate on the first part, with passive sensory inputs primarily coming through joint sensations and through the mechanoreceptors present within the muscle tissue. The CASP therapy, in addition to this peripheral stimulation, also takes into account the stimulation of these brain cells in question through inner thought processes that especially get activated when the patient observes the limb movement partly being done passively. The complexity of the movement also has a bearing on the stimulation of brain cells. The complexity of the task has been shown to be directly proportional to the activation of neural networks by the recruitment of existing but inactive elements of the functional system.,,, As physiotherapeutic interventions are expected to modify neuroplasticity, the complex movements involving nearly all joints of an extremity, as is done in the CASP therapy, may provide more intense and widespread stimulation to the concerned brain cells as well as to some distant areas of the brain concerned with that particular movement. In this context, it is important to understand that strengthening these distant areas may presumably play a complimentary role in brain function.
One important aspect of this CASP therapy is that no complex equipment is required. A relatively simple demonstration of the technique to the relatives/caregivers is enough for successfully implementing the entire rehabilitation program.
As against our study, another collaborative multicenter study done from India has indicated no benefit of training physiotherapy to caregiver relatives. As our study is from the same socio-cultural background, benefits shown in our study may be attributed to the actual modified CASP intervention. Another study on keeping limbs in corrected position through trained nurses showed equivocal results. This may suggest benefit in correction of limb position, as observed in our study, by doing physiotherapy in a corrected position rather than just keeping the limbs in corrected position.
However, the need for multiple repetitions at frequent intervals should be emphasized, as has been observed in another study that suggests that the >3 hour therapy (including occupational and speech therapy) per day is better than the <3 hour therapy.
This study signifies that CASP therapy has a major role in post-stroke rehabilitation in limiting disability, reducing the post-stroke spasticity, and in providing an improvement in the major functional outcomes.
We acknowledge the art work in [Figure 1] done by Mr. Anil Kumar, who works in the Department of Art and Photography, in our Institute.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]