Effects of Spring Assisted Dynamic Hand

Orthosis Training on Functions and

Movement Smoothness of the

Hemiparetic Upper Extremity

Youngkeun Woo

The Graduate School

Yonsei University

Department of Rehabilitation Therapy

Effects of Spring Assisted Dynamic Hand

Orthosis Training on Functions and

Movement Smoothness of the

Hemiparetic Upper Extremity

A Dissertation

Submitted to the Department of Rehabilitation Therapy

and the Graduate School of Yonsei University

in partial fulfillment of the

requirements for the degree of

Doctor of Philosophy

Youngkeun Woo

June 2010

This certifies that the dissertation of

Youngkeun Woo is approved.

Thesis Supervisor: Hyeseon Jeon

Chunghwi Yi

Ohyun Kwon

Minye Jung

Younghee Lee

The Graduate School

Yonsei University

June 2010

Acknowledgements

I am so lucky to have a wonderful people who is helping, encouraging and

stimulating during my studying and writing dissertation. First of all, I would like to

acknowledge to my patients who participated in this study with their trust in me. This

dissertation would not have been possible without their participation, and excellent

supervisor Professor Hyeseon Jeon who always gave me guidance, encouragement,

and support during writing dissertation. I also express my thanks to my doctorial

committee, comprising Professor Chunghwi Yi, Professor Ohyun Kwon, Professor

Minye Jung, and Professor Younghee Lee who not only found many errors but also

guided to writing my dissertation. And, I would like to thanks to Professor Seongsoo

Hwang who always gave me a new vision for future, and my colleagues are Gyuhang

Cho and Seungsub Shin what are called a member of family who always stood by me.

I also would like to thanks to Sujin Hwang, Boram Choi and Professor Juwon Lee

who supported my dissertation from experiments to writing, I also thanks to Professor

Min Ju, Professor Seungju Yi, Professor Wonsik Lim, Professor Hyunju Lee, and

Professor Yeonju Kim for earn my Ph. D degree while continuing work at school. I

also especially thank to Subin Go and Dujong Kim who try to help and support

during the experiments.

Finally, I would like to specially thank to my parents, my wife and children who

always provided all sorts of support.

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Table of Contents

List of Figures ···························································································· iii

List of Tables ····························································································· iv

Abstract ······································································································· v

Introduction ································································································· 1

Method ········································································································ 8

1. Participants ·························································································· 8

2. Experimental Design ········································································· 10

3. Outcome Measures ············································································ 12

3.1 Clinical Assessments ··································································· 12

3.1.1 Action Research Arm Test ····················································· 12

3.1.2 Fugl-Meyer Assessment ························································· 13

3.1.3 Box and Block Test ································································ 13

3.1.4 Grip Strength ·········································································· 14

3.2 3-D Motion Analysis ··································································· 14

3.2.1 Reach-to-grasp Task ······························································ 14

3.2.2 Test Procedures and Data Collection ····································· 15

4. Intervention ······················································································· 18

4.1 Spring Assisted Dynamic Hand Orthosis ···································· 18

4.2 Activities for the Experimental Group ········································ 19

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5. Statistical Analysis ············································································ 23

Results ······································································································· 24

1. Pre-intervention Status Between Groups ·········································· 24

2. Clinical Assessment Score ································································ 26

3. Movement Smoothness ····································································· 28

3.1 Resultant Velocity ······································································· 28

3.2 Jerkiness Score ············································································ 32

Discussion ································································································· 34

Conclusion ································································································ 40

References ································································································· 41

Appendix ··································································································· 51

Appendix A. Modified Ashworth Scale ················································ 52

Abstract in Korean ···················································································· 53

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List of Figures

Figure 1. Flow chart of the experimental design ········································· 11

Figure 2. Spring assisted dynamic hand orthosis ········································ 19

Figure 3. Tasks for the training using a spring assisted dynamic hand orthosis

······································································································· 22

Figure 4. Post-intervention resultant velocity in the experimental group ··· 30

Figure 5. Post-intervention resultant velocity in the control group ············ 31

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List of Tables

Table 1. General characteristics of participants ·········································· 9

Table 2. Pre-intervention clinical assessments before intervention ·········· 24

Table 3. Pre-intervention resultant velocity before intervention ·············· 25

Table 4. Pre-intervention jerkiness score before intervention ··················· 25

Table 5. Clinical assessment score after intervention ······························· 27

Table 6. Resultant velocity after intervention ··········································· 29

Table 7. Jerkiness score after intervention ················································ 33

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ABSTRACT

Effects of Spring Assisted Dynamic Hand Orthosis

Training on Functions and Movement Smoothness of the

Hemiparetic Upper Extremity

Youngkeun Woo Dept. of Rehabilitation Therapy

(Physical Therapy Major)

The Graduate School

Yonsei University

The purpose of this study was to assess the efficacy of training using a spring

assisted dynamic hand orthosis on stroke patients with upper limb hemiparesis. Ten

stroke patients (5 for the experimental group and 5 for the control group) were

recruited from a local rehabilitation hospital in Wonju City, Republic of Korea.

Subjects in the experimental group participated in 4 weeks of training using spring

assisted dynamic hand orthosis for 1 hour per day, 5 times per week. Each subject in

the control group just wore the same orthosis for 1 hour per day without participating

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in upper extremity training. Resultant velocity and jerkiness score from 3-D motion

analysis during reach-to-grasp task at elbow and acromion heights with target, and

clinical assessment score were used to demonstrate the efficacy of spring assisted

dynamic hand orthosis training.

The results of this study, the upper extremity score of the Fugl-Meyer Assessment

and the Box and Block Test score were increased significantly in the experimental

group after spring assisted dynamic hand orthosis training. Second, the resultant

velocity of the wrist joint for the reach-to-grasp task decreased significantly, and the

resultant velocity of the shoulder joint while performing a reach-to-grasp task at

acromion height decreased significantly in the experimental group. Third, the

jerkiness score of the shoulder joint at the sagittal plane decreased significantly in the

experimental group, during the reach-to-grasp task at acromion height, and the

jerkiness score of the elbow joint in the sagittal and transverse planes during the

reach-to-grasp task sessions at acromion height decreased significantly in the

experimental group. At both heights, the jerkiness scores of the wrist joint at the

coronal and transverse planes during the reach-to-grasp task decreased significantly in

the experimental group. The results of this study indicate that spring assisted dynamic

hand orthosis training is effective in recovering the movement of the hemiparetic

upper extremity of patients after stroke.

Key Words: Hemiparesis, Jerkiness score, Resultant velocity, Spring assisted

dynamic hand orthosis, Upper extremity.

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Introduction

Stroke is a disease that affects the arteries leading to the brain damage. It is the third

leading cause of death in the United States (American Stroke Association 2010), and

second most common cause of death in the Republic of Korea (Korean Statistical

Information Service 2010). Clinically, stroke causes a variety of damage to body

structures and functions, including changes in the level of consciousness, and

impaired sensory, motor, cognitive, perceptual, and language functions (O’Sullivan,

and Schmitz 2007). Impaired motor function is one of the most serious disability

sequences in stroke patients: over 50% of stroke patients experience a degree of long-

term disability in their functional activities a secondary effect of residual motor

impairment (Duncan et al. 1992; Nakayama et al. 1994). Secondary complications in

the shoulder, such as pain and subluxation, can also hinder the patient’s ability to

move. These impairments in the upper extremity interfere with the movement

required for self care and for household and occupational tasks (Cauraugh, and

Summers 2005).

Learned nonuse phenomenon is one of the theoretical mechanisms that may explain

the development of motor impairment in the upper extremity. It has been proposed

that stroke survivors experience a conditioned suppression of movement in the

affected upper extremity (Taub 2006). The rationale for learned nonuse is that it

makes only limited demands on a patient, providing little incentive to make the

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greater effort required to use the affected limb. The patient can manage from day to

day with the help of staff and by using the non-affected limb.

Stroke recovery is complex and non-linear. In addition, progress may not reflect

only a single mechanism (Mirbagheri, and Rymer 2008). One longitudinal study

suggests that most cause of spontaneous recovery of impairment may reach maximum

recovery levels within a few weeks or months: any further functional changes occur

more slowly, eventually terminating within the first 6 months. However, there is no

other evidence to limit potential further improvements to this time frame (Demain et

al. 2006; Mirbagheri, and Rymer 2008; Skilbeck et al. 1983). In fact, several previous

studies reported that some physical interventions were effective improving upper

extremity functions even in chronic stroke patients (Alon et al. 2003; Caimmi et al.

2008; Cauraugh, and Summers 2005; Kahn et al. 2006).

There is some evidence to attribute the degree of functional recovery of the affected

upper limb following stroke to its continued use. Overcoming learned nonuse is

partially related to a process called “overcoming learned nonuse phenomenon.”

Learned nonuse is overturned by using the affected extremity in the activities of daily

living through increased motivation, positive reinforcement, and use-dependent

cortical reorganization (Taub et al. 2006). Human brain mapping has shown that

reorganizational processes in the brain contribute to the restoration of motor function

following stroke (Carr, and Shepherd 2003; Clarkson, and Carmichael 2009; Honey,

and Sporns 2008; Wang et al. 2010).

According to Merians et al. (2002), approximately 75% of stroke patients learn to

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walk again, but 55% to 75% have continuing problems with upper extremity function.

He also reports that most studies of functional recovery after stroke have

demonstrated that physical therapy can improve functional recovery. However, the

effectiveness of intervention has generally been less pronounced for the upper

extremity than for the lower extremity. The location of the lesion of the stroke is a

critical factor affecting functional recovery. The middle cerebral artery supplies the

primary motor and sensory cortices for the upper extremity. Therefore, middle

cerebral artery lesions cause more severe upper extremity functional deficit with less

motor impairment in the lower extremity, than do other brain lesions. Most stroke

patients’ infarct or hemorrhage occurs in the middle cerebral artery, affecting carotid

distribution. Poor upper extremity function is therefore inevitable in these stroke

survivors (Fisher 1997; Garrison 2004).

A variety of treatment approaches are currently being used for recovering

hemiparetic upper extremity function. The most common traditional treatment

approaches for the upper extremity in stroke patients are neurofacilitatory treatments,

such as proprioceptive neuromuscular facilitation (PNF), neurodevelopmental

treatment (NDT), and the Brunnstrom’s approach. These treatments focus on the

remediation of deficits of muscular activity. Multiple sensory inputs are combined

with muscle recruitment techniques to facilitate and strengthen movement patterns

and encourage movement into synergistic patterns during the early recovery stages, in

order to increase afferent and proprioceptive stimulation (Adler, Beckers, and Buck

2007; Bobath 1990; Sawner, and Lavigne 1992). However, no evidence was found for

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the success of applying traditional intervention in muscle strength, synergism, muscle

tone, walking ability, dexterity, or activities of daily living (Cameron et al. 1999; van

Peppen et al. 2004; Wolf et al. 2002).

Practicing real-world tasks is one of the most commonly accepted training strategies

for overcoming learned nonuse. Task-oriented functional training customizes

treatment by the repetitive practice of purposeful tasks by making use of the residual

functions of proximal and/or distal segments of the affected limb. This approach,

based on the motor learning principles of practice and intermittent feedback, is a

necessary element of task-oriented practice in order to facilitate real-world activities

(Dobkin 2004). In this approach, motor performance assessment is carried out in the

context of functional tasks; the therapist teaches effective motor strategies to patients

rather than specific joint movements (Carr, and Shepherd 2003). It has been shown

that task-oriented movement training, as a form of activity-dependent motor

rehabilitation, facilitates the recovery process for upper extremity function

(Greenwood et al. 2003; Hallett 2001).

Constraint-induced movement therapy (CIMT) is one of the relatively new treatment

options for maximizing the motor recovery of upper extremity in functional

rehabilitation for stroke victims. CIMT has been influenced by the task-oriented

approach and it consists of unaffected limb constraint, massed training of the affected

limb, and shaping of behavior to improve the amount of use in the affected limb

(Mark, and Taub 2004). The conceptual basic idea for CIMT is that learned nonuse of

the affected limb is often continued even after the completion of formal rehabilitation,

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because of other factors. The recovery process is slow, and includes high-effort

attempts to use the affected arm (Dobkin 2004). Several CIMT studies related to

stroke patients. Wolf et al. (2006) reported that the CIMT resulted in significant

clinically improvements in the results of the Wolf Motor Function Test, which

measures the functional ability of a chronic hemiparetic arm. Wu et al. (2007)

reported that CIMT is more effective for chronic stroke patients than is regular

interdisciplinary rehabilitation, and Dahl et al. (2008) reported a long-term effect of

CIMT, assessed by the Motor Activity Log Test and Functional Independent Measure

of the hemiparetic arm. Dursun et al. (2009) suggested that CIMT is an encouraging

treatment approach for improving upper extremity motor function in stroke patients.

Maintaining the affected upper limb in a preferred position using a splint is another

intervention option for upper extremity rehabilitation. Static splinting is accomplished

by positioning the wrist at a static extension angle, and maintaining the digits in

desirable positions (Butler et al. 2006). The expected benefits of the splint are the

prevention or reduction of contracture, with its resultant shortening of the wrist and

finger muscles, and the functional improvement of affected hand. However, according

to some clinical studies (Lannin et al. 2007), static wrist splinting after stroke was not

effective in preventing a loss of range of motion at the wrist joints. There was

insufficient evidence either to support or refute the effectiveness of hand splinting for

adults following stroke (Lannin 2003). The effectiveness of a static hand splint on

motor recovery in hemiplegic hand function is controversial (Umpherd 2007). In

addition, problems related to task-specific practice do not increase movement in the

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case of minimal distal movement in the hemiparetic upper extremity, so it is difficult

to apply intensive training (Page et al. 2009). CIMT also poses a problem when it

applied to patients with stroke. When selecting a training protocol, some upper

extremity movement would appear to be a critical component in determining the

patient’s functional level (Thielman, Dean, and Gentile 2004).

A commercial splinting system called SaeboFlex orthosis (Saebo, Inc., Charlotte,

NC, U.S.A.) in order to overcome the disadvantages of previous approaches as

described above. It is designed to permit quick training in opening and closing the

affected hand. It consists of a cover around the forearm support, which is attached to a

dorsal hand covering that anchors the pulley and spring attachments. The orthosis is

used to assist the patient who cannot voluntarily re-open his or her affected hands,

following functional grasping, owing to flexor synergy dominance in the upper

extremity, or spasticity in the hands and fingers. By supporting the weakened wrist,

hand, and fingers, it allows the patient to functionally integrate use of the affected

hand at home. It is a new treatment approach applied recently in patients suffering the

effects of a stroke (Butler et al. 2006; Farrell 2007). Using a spring assisted dynamic

hand orthosis in this study, it is a modified SaeboFlex orthosis, with finger

attachments, for a more realistic grasp during real world activities, therefore we assess

the efficacy of training using a spring assisted dynamic hand orthosis in hemiparetic

upper extremity after stroke.

The purpose of this experiment was to evaluate the effectiveness of training using a

spring assisted dynamic hand orthosis on smoothness of movement, clinical

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assessment score, and grip strength of the affected limb in hemiparetic patients. To

determine resultant velocity and jerkiness score for movement smoothness, the Box

and Block Test (BBT), Action Research Arm Test (ARAT), and Fugl-Meyer

Assessment (FMA) for functions of the hemiparetic upper extremity were conducted.

- 8 -

Method

1. Participants

For this study, 10 stroke patients (5 for the experimental group and 5 for the control

group) were recruited from a local rehabilitation hospital in Wonju City, Republic of

Korea. They had been involved in a physical therapy program as outpatients or

inpatients. Inclusion criteria were: (1) 18 years or older; (2) unilateral hemiparesis

more than 6 months post-stroke duration; (3) no current or previous orthopedic or

surgical histories affecting the hemiparetic upper extremity; (4) Mini-Mental State

Examination (MMSE) – Korean version - score ≥ 23 (to ensure that they fully

understood the study procedure); (5) patients should have at least some active

voluntary movement of the upper extremity (i.e., 10 degrees of shoulder

flexion/abduction, 10 degrees of elbow flexion/extension, and 30 degrees of

interphalangeal proximal joints / 20 degrees of interphalangeal distal joints of

volitional finger flexion when the hand is positioned in wrist and finger extension);

(6) no flaccidity of the affected limb; and (7) no severe contracture or spasticity of the

affected wrist or hand (Modified Ashworth Scale (MAS) for grading spasticity for the

hands of subjects are 3 or 4) (See Appendix A for detail description of MAS). This

project was approved by the Yonsei University Wonju College of Medicine

institutional review board; all patients agreed to participate in this study and signed an

informed consent form. The general characteristics of participants including sex, age,

- 9 -

height, weight, arm length, side of hemiparesis, MMSE score (Korean version),

Brunnstrom’s recovery stage, time elapsed since lesion occurred, and group were

reported in Table 1.

Table 1. General characteristics of participants

Subjects Experimental group Control group

1 2 3 4 5 1 2 3 4 5

Sexa F M M M F M M M M F

Age (yrs) 73 49 53 40 40 39 57 38 55 67

Height (㎝) 150 179 168 170 157 168 170 181 168 157

Weight (㎏) 64 105 69 70 75 70 67 77 65 57

Arm Length (㎝) 42 53 49 47 44 48 49 50 48 45

Side of Hemiparesisb L R R L L R R L R L

MMSE score 28 30 30 26 30 26 30 30 30 30

Brunnstrom’s recovery stage 4 2 2 3 4 3 2 2 4 3

Post stroke duration (months) 36 40 32 21 19 48 42 17 10 21

aF: Female, M : Male bL: Left side hemiparesis, R: Right side hemiparesis

- 10 -

2. Experimental Design

The pre- and post-test control group design, with a 4 week intervention, was used to

compare the experimental and control groups. All subjects were assessed before and

after the intervention. The outcome measures used were the Action Research Arm

Test (ARAT); Fugl-Meyer Assessment (FMA); Box and Block Test (BBT); kinematic

variables from three-dimensional (3-D) motion analysis, while the subjects performed

reach-to-grasp tasks, with specific targets; and grip strength. Subjects in the

experimental group participated in 4 weeks of using spring assisted dynamic hand

orthosis training for 1 hour per day, 5 times per week. Each subject in the control

group just wore the same orthosis for 1 hour per day without participating in upper

extremity training (Figure 1). In addition to the above mentioned experimental

interventions, both the experimental and control groups received 1 hour of regular

physical therapy daily.

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Figure 1. Flow chart of the experimental design

Recruiting subject (N=10)

Experimental group (n=5)

Control group (n=5)

Pre-intervention Assessments

Pre-intervention Assessments

Training using a Spring assisted Dynamic Hand Orthosis with 5 times per week for 4 weeks, and an hour per day.

Wearing using a Spring assisted Dynamic Hand Orthosis with 5 times per week for 4 weeks, and an hour per day.

Post-intervention Assessments

Post-intervention Assessments

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3. Outcome Measures

Rehabilitation outcomes of patients should be assessed at all 3 levels as described in

the International Classification of Functioning, Disability and Health (ICF) model

(Barak, and Duncan 2006): body functions and structures (impairment), activities

(limitation), and participation (restriction). The ICF is the World Health

Organization’s (WHO) framework for health and disability. In this study, all subjects

were evaluated by 3 clinical assessments, 3-D motion analysis, and the measurement

of grip strength. According to the ICF model as commonly related to upper extremity

function, FMA and grip strength belong to the level of body functions and structures.

The ARAT and BBT, belong to the activities and participation level (Barak, and

Duncan 2006; Carr, and Shepherd 2003; Salter et al. 2005).

3.1 Clinical Assessments

In this study, the outcome measures for clinical assessments were the ARAT, FMA,

BBT, and grip strength.

3.1.1 Action Research Arm Test

The ARAT is a relatively short and simple measure of upper extremity function for

stroke patients. The ARAT has 19 items and its maximum possible score is 57 points.

Each item is scored on a 4-point ordinal scale as follows: 0 = can perform no part of

the test, 1 = performs test partially, 2 = completes test but takes an abnormally long

- 13 -

time or has great difficulty, and 3 = performs test normally. There are 4 sub-

categories: (1) grasp, (2) grip, (3) pinch, and (4) gross movement (Lyle 1981). The

test-retest reliability (ICC) value of ARAT reported in an ARAT-related study of 50

patients with stroke was 0.98 (Hsieh et al. 1998).

3.1.2 Fugl-Meyer Assessment

The FMA is used as an adaptation of Brunnstrom’s heimplegia classification. The

FMA uses an ordinal-level scoring system in which each detail is rated: 0 = cannot be

performed, 1 = can be partly performed, or 2 = can be performed faultlessly. The total

score ranges from 0 to 100 for both the upper and lower extremities. In this study, we

used the upper extremity subtest, and the total score for the upper extremity was 66.

This assessment includes an evaluation of muscle tone, range of motion, tendon

reflexes, and the performance of proximal and distal voluntary movements of the

affected arm (Fugl-Meyer et al. 1975). Inter-rater reliability as reported in an FMA-

related study with 37 stroke patients was 0.99, and test-retest reliability was 0.97

(Platz et al. 2005).

3.1.3 Box and Block Test

The BBT is a test of manual dexterity and is used to evaluate physically handicapped

individuals. The test is made up of a box with a partition through the center-creating 2

equal areas. A number of small wooden blocks (2.54 ㎝) are placed on one side of the

partition (18 ㎝ height). The subject is required to use the affected hand to grasp 1

- 14 -

block at a time and transport it over the partition and release it into the other side. The

subject is given 60 seconds in which to complete the test, and the number of blocks

transported to the other side is counted. Inter-rater reliability reported in a BBT-related

study of 37 stroke patients was 0.99, and test-retest reliability was 0.96 (Platz et al.

2005).

3.1.4 Grip Strength

Grip strength was measured using a hydraulic hand dynamometer (Jamar Hydraulic

Hand Dynamometer, Lafayette Instrument Company, U.S.A.). The subjects were

tested while seated comfortably on a low-backed chair with the affected arm at 90

degrees of elbow flexion. Each subject’s grip strength was measured 3 times, and the

mean of the 3 trials was used for data analysis. Test-retest reliability of the grip

strength test was reported in a grip strength-related study of 62 stroke patients: 0.87

for spastic hemiparesis and 0.98 for nonspastic hemiparesis (Chen et al. 2009).

3.2 3-D Motion Analysis

3.2.1 Reach-to-Grasp Task

The patients performed 2 different reach-to-grasp tasks while seated in non-swivel,

stationary chairs. Their feet were flat on the floor with a knee angle of 90 degrees.

Their trunk was secured to the chair back with a harness in order to prevent lateral

and forward flexion and rotation, but still allow scapular motion. The hand to be

tested rested on a table on the ipsilateral side, such that the shoulder was at

- 15 -

approximately 0 degrees of flexion/extension and 0 degrees of internal rotation. The

elbow was at 90 degrees of flexion; the wrist rested palm down on the table with the

finger joints in slight flexion. The target used for the spherical grasping task was a

soft, 10 ㎝-diameter ball, and it was positioned for 2 different reach-to-grasp tasks:

elbow and acromion height. The first position for the reach-to-grasp task was directly

in front of the tested arm at 100% length and at elbow height, and the other position

was directly in front at shoulder joint (level with the acromion), also at a distance of

100% length. Participants were instructed to grasp at their preferred speed. In this

study, arm length was defined as the distance from the anterior axillary fold to the

distal wrist crease when the subject raised his or her arm as close to 90 degrees

elevation as possible and reached forward (without trunk movement) as far as

possible. For each reach-to-grasp task, participants were provided with 3 practice

trials prior to the actual reach-to-grasp tasks, and each task was repeated 5 times (for

calculation of the mean data) with a 3 second rest between trials.

3.2.2 Test Procedures and Data Collection

Selecting kinematic variables as outcome measures from the captured motion data

using a 3-D motion analysis system is a reliable quantitative method for evaluating

motor performance in people with stroke. The relative ICC was good to excellent for

most variables (Wagner, Rhodes, and Patten 2008). In this study, we assessed the

movement smoothness during the reach-to-grasp task as a dependent variable in order

to evaluate the effectiveness of intervention. Rohrer et al. (2002) reported that

- 16 -

smoothness measure has most often been based on minimizing jerkiness and is a

characteristic of unimpaired movement. It is the most striking feature of stroke

recovery. Therefore, resultant velocity reflects the velocity of 3-D movement, and

jerkiness scores reflect the jerkiness of movement at each plane.

Participants performed the reach-to-grasp task while seated in a chair.

Spatiotemporal parameters were collected using a 3-D motion analysis system and

workstation software pre- and post-test (VICON MX system, Oxford Metrics, U.K.).

Data collection was conducted at the Motion Analysis Research Laboratory in the

Yonsei University. A 6-infrared camera VICON MX system obtained kinematic data

at 60 Hz, which was processed by Nexus 1.4 software. A total of 28 spherical retro-

reflective surface markers were placed at bony landmarks directly on the skin,

according to the guidelines of the VICON “upper limb” model marker-set. Two

markers were placed on the spinal column (C7 and T10), and 2 markers on the

sternum (sternum notch and xiphoid process). Markers for the upper extremities were

placed on both side of the acromio-clavicular joints, and medial and lateral

epicondyles of the left and right humerus. Three markers were placed on the lateral

part of both upper arms, 2 markers on the wrist styloid processes in each arm, 1

marker on the lateral forearm of each arm, 1 marker on the head of the third

metacarpal bone of each hand, and 2 markers on each index finger and thumb.

We defined the start and end of movement after Hingtgen et al. (2006). Start and

end of movement was defined as elbow flexion (beginning) to elbow extension (end).

The dependent variables include the jerkiness score of each axis and resultant velocity

- 17 -

for movement smoothness at the wrist joint, elbow joint, and shoulder joint. The

jerkiness score of each axis at the joint characterizes the average rate of change of

acceleration during the reach-to-grasp movement toward the target (Rohrer et al.

2002). The resultant velocity for movement smoothness of each joint was also used as

a dependent variable for intervention effects. The resultant velocity (dv) for

movement smoothness combines the component velocities for each axis to determine

the resultant velocity. Resultant velocity is a powerful concept that makes it possible

to treat 2- or 3-dimensional motion as a combination of its component straight-line

motions. Resultant velocity is the distance obtained in the Euclidean space. The

Euclidean metric is that the distance between any 2 or 3 points in space: it is the

length of the straight segment that joins those. The resultant velocity is calculated

using the following formula (Mosier et al. 2005; Wagner, Rhodes, and Patten 2008):

In this formula, Xv represents the velocity of sagittal plane movement, Yv is the

velocity of coronal plane movement, and Zv is the velocity of transverse plane

movement at the shoulder, elbow, and wrist joints.

- 18 -

4. Intervention

Both groups used a spring-assisted dynamic hand orthosis. Each member of the

control group wore a spring assisted dynamic hand orthosis to control for a possible

placebo effect of wearing a splint. Members of the experimental group performed

training activities while each wore a spring assisted dynamic hand orthosis. The

advantage of using a spring assisted dynamic hand orthosis was that activities could

be performed even though patients wear the splint so training was considered to

involve activities.

4.1 Spring Assisted Dynamic Hand Orthosis

The spring assisted dynamic hand orthosis is a modified SaeboFlex orthosis, with

finger attachments, for a more realistic grasp during real world activities (Figure 2).

Each finger sleeve is attached to the springs by a high-tensile polymer line in order to

provide assistance with finger extension. Spring tensile strength can be adjusted for

the appropriate amount of finger extension assistance needed. The finger caps are

made of leather for a more accurate grasp, and the orthosis has no motor or electrical

parts. Dorsum of the hand and forearm shell was made of lightweight plastic for ease-

of-fit in the hemiparetic hand.

- 19 -

Figure 2. Spring assisted dynamic hand orthosis

4.2 Activities for the Experimental Group

Training activities for the experimental group consisted of 20 sessions (5 times per

week): typically 1 hour per session. Each session consisted of 9 task-oriented practice

sessions using the hemiparetic arm and one rest period. Practice tasks were conducted

with the patients wearing the spring assisted dynamic hand orthosis. Tasks for the

training program were as follows: (1) moving a soft ball from the side of the affected

foot to the table, while seated; (2) moving a soft ball diagonally from the less-affected

side to the affected side while standing; (3) moving a soft ball diagonally from the

affected side to the less-affected side while standing; (4) moving a soft ball from the

left to the right side on the table while standing; (5) moving a soft ball from a box,

situated at knee height on the affected side, to a table while standing; (6) moving a

Finger cap Dorsum of the hand shell

Forearm shell

High-tensile polymer line

Finger sleeve

- 20 -

soft ball through the target from the left to right side while standing; (7) grasping and

releasing a soft ball to straightly forward and backward transfer on the table while

standing; (8) grasping and releasing a soft ball to diagonally forward and backward

transfer on the table while standing; (9) moving a soft ball from a cup to a cup on the

table while standing. Each task was performed for about 5-6 minutes. The following

pictures show the starting and ending positions (Figure 3).

Task 1.

Task 2.

- 21 -

Task 3.

Task 4.

Task 5.

Task 6.

- 22 -

Task 7.

Task 8.

Task 9.

Starting position Ending position

Figure 3. Tasks for the training using a spring assisted dynamic hand orthosis

- 23 -

5. Statistical Analysis

The parameters used for data analysis were ARAT, FMA of upper extremity

function, BBT, and grip strength of clinical assessments, and a jerkiness score and

resultant velocity of movement smoothness for the shoulder, elbow, and wrist joints.

A Mann-Whitney U test was used to ensure the initial equivalence of groups, and a

Wilconxon signed ranks test used to identify the training effects after intervention. An

alpha level of p < 0.05 was considered to be statistically significant. All statistical

analyses were performed using the SPSS statistical package 15.0 (SPSS, Chicago, IL,

U.S.A.).

- 24 -

Results

1. Pre-intervention Status Between Groups

There were no significant differences in the clinical assessment scores, resultant

velocity, and jerkiness score before intervention between groups (p > 0.05). The

clinical assessment scores of the ARAT, FMA of upper extremity function, BBT, and

grip strength were not significantly different between groups (Table 2). There was no

significant difference in the resultant velocity between groups (Table 3), and there

was no significant difference between groups in jerkiness score (Table 4).

Table 2. Pre-intervention clinical assessments before intervention (N=10)

Tests Variables Experimental group (n=5)

Control group (n=5) p

Action Research Arm

Test

Grasp 7.00 ± 3.74a 6.80 ± 5.01 0.833 Grip 4.40 ± 3.78 4.80 ± 3.56 0.753 Pinch 5.60 ± 6.73 6.00 ± 5.65 1.000

Gross Movements 5.20 ± 2.38 4.60 ± 2.50 0.511 Total 22.20 ± 14.60 22.20 ± 16.36 1.000

Fugl-Meyer Assessment of Upper Extremity 33.00 ± 15.98 29.80 ± 14.87 0.673

Box and Block Test (number) Hemiparetic side 6.00 ± 9.27 6.00 ± 9.27 0.829

Grip Strength (㎏) Hemiparetic side 6.12 ± 3.45 6.12 ± 3.45 0.461

a Mean ± standard deviation

- 25 -

Table 3. Pre-intervention resultant velocity before intervention (N=10)

Joint Taska Experimental group (n=5)

Control group (n=5) p

Shoulder Joint

A 37.78 ± 9.75b 60.06 ± 44.06 0.465

B 68.94 ± 21.04 85.84 ± 68.06 0.602

Elbow Joint

A 52.50 ± 7.45 48.12 ± 21.27 0.917

B 68.09 ± 20.55 64.29 ± 25.88 0.754

Wrist Joint

A 30.04 ± 15.15 29.94 ± 16.60 0.917 B 35.05 ± 9.03 27.89 ± 21.75 0.251

a The target located at elbow height (A) and acromion height during reach-to-grasp task b Mean ± standard deviation Table 4. Pre-intervention jerkiness score (number of count) before intervention

(N=10)

Movement Characteristics Taska Experimental group (n=5)

Control group (n=5) p

Shoulder Joint

Sagittal plane A 61.20 ± 24.18b 70.00 ± 4.41 0.916 B 64.80 ± 26.82 69.20 ± 4.76 0.209

Coronal plane

A 63.00 ± 20.43 71.00 ± 6.96 0.675 B 65.80 ± 28.52 76.20 ± 8.70 0.344

Transverse plane

A 60.00 ± 26.10 68.80 ± 11.16 0.600 B 62.80 ± 25.79 69.60 ± 6.22 0.602

Elbow Joint

Sagittal plane A 61.40 ± 27.15 70.00 ± 6.74 0.916 B 67.40 ± 19.93 73.80 ± 2.68 0.596

Transverse plane

A 57.40 ± 19.55 69.80 ± 5.63 0.142 B 65.00 ± 12.08 72.60 ± 1.81 0.293

Wrist Joint

Sagittal plane A 60.80 ± 17.10 65.40 ± 9.91 0.917 B 56.40 ± 16.62 62.80 ± 11.51 0.530

Coronal plane

A 66.60 ± 20.00 64.20 ± 7.22 0.249 B 67.20 ± 15.41 62.40 ± 9.28 0.209

Transverse plane

A 66.60 ± 20.08 70.20 ± 11.20 0.674 B 69.80 ± 15.28 66.40 ± 10.54 0.402

a The target located at elbow height (A) and acromion height (B) during reach-to-grasp task b Mean ± standard deviation

- 26 -

2. Clinical Assessment Score

Table 5 shows the effects of intervention on hemiparetic extremity function in two

groups. In the experimental group, the FMA of upper extremity score increased

significantly from 33.00±15.98 pre-intervention to 35.60±15.50 post-intervention (p =

0.042), and the BBT score increased from 6.00±9.27 to 8.40±10.69 (p = 0.039).

However, in the control group, only the FMA of upper extremity score increased

significantly from 29.80±14.87 to 31.20±14.54 (p = 0.038).

- 27 -

Table 5. Clinical assessment score after intervention (N=10)

Tests Variables Experimental group (n=5) Control group (n=5)

Pre-intervention

Post-intervention p Pre-

intervention Post-

intervention p

Action Research Arm

Test

Grasp 7.00 ± 3.74a 8.00 ± 3.24 0.102 6.80 ± 5.01 7.60 ± 5.77 0.102 Grip 4.40 ± 3.78 5.80 ± 3.03 0.102 4.80 ± 3.56 5.00 ± 3.46 0.317 Pinch 5.60 ± 6.73 6.60 ± 6.54 0.102 6.00 ± 5.65 6.60 ± 6.02 0.083 Gross

Movements 5.20 ± 2.38 5.40 ± 2.30 0.317 4.60 ± 2.50 4.80 ± 2.48 0.317

Total 22.20 ± 14.60 25.80 ± 13.31 0.066 22.20 ± 16.36 24.00 ± 17.47 0.083

Fugl-Meyer Assessment of Upper Extremity 33.00 ± 15.98 35.60 ± 15.50 0.042 29.80 ± 14.87 31.20 ± 14.54 0.038

Box and Block Test (number)

Hemiparetic side 6.00 ± 9.27 8.40 ± 10.69 0.039 3.80 ± 5.21 3.80 ± 2.94 0.713

Grip Strength (㎏)

Hemiparetic side 6.12 ± 3.45 6.25 ± 3.08 1.000 4.33 ± 2.49 4.80 ± 2.58 0.102

a Mean ± standard deviation

- 28 -

3. Movement Smoothness

3.1 Resultant Velocity

Table 6 shows the changes in hemiparetic extremity function in two groups after

spring assisted dynamic hand orthosis training. The resultant velocity of the shoulder

joint, at the height of the acromion, during reach-to-grasp task sessions decreased

significantly in the experimental group from 68.94±21.04 to 51.26±13.49 (p = 0.043).

The resultant velocity of the wrist joint in the experimental group during the reach-to-

grasp task attempts at both elbow and acromion heights, decreased significantly

from 30.04±15.15 to 13.95±4.01 and from 35.05±9.03 to 15.69±4.14, respectively (p

= 0.043) (Figure 4). However, for all joints assessed in the control group, the resultant

velocity did not significantly decrease after intervention (p > 0.05) (Figure 5).

- 29 -

Table 6. Resultant velocity after intervention (N=10)

Joint Taska Experimental group (n=5) Control group (n=5)

Pre- intervention Post-intervention p Pre-

intervention Post-

intervention p

Shoulder Joint

A 37.78 ± 9.75b 38.22 ± 12.10 0.893 60.06 ± 44.06 48.51 ± 26.72 0.138 B 68.94 ± 21.04 51.26 ± 13.49 0.043 85.84 ± 68.06 71.53 ± 26.52 0.686

Elbow Joint

A 52.50 ± 7.45 40.16 ± 22.35 0.225 48.12 ± 21.27 45.63 ± 23.54 0.500 B 68.09 ± 20.55 50.96 ± 25.67 0.225 64.29 ± 25.88 54.16 ± 13.78 0.500

Wrist Joint

A 30.04 ± 15.15 13.95 ± 4.01 0.043 29.94 ± 16.60 29.48 ± 11.19 0.893 B 35.05 ± 9.03 15.69 ± 4.14 0.043 27.89 ± 21.75 27.88 ± 9.65 0.500

a The target located at elbow height (A) and acromion height (B) during reach-to-grasp task b Mean ± standard deviation

- 30 -

Normalized percent of cycle (%) Normalized percent of cycle (%)

Normalized percent of cycle (%) Normalized percent of cycle (%)

Normalized percent of cycle (%) Normalized percent of cycle (%)

a. Shoulder joint

b. Elbow joint

c. Wrist joint * The target located at elbow height (A) and acromion height (B) during reach-to-grasp task

Figure 4. Post-intervention resultant velocity in the experimental group

Task A* Task B

Res

ulta

nt v

eloc

ity

Res

ulta

nt v

eloc

ity

Res

ulta

nt v

eloc

ity

Res

ulta

nt v

eloc

ity

Res

ulta

nt v

eloc

ity

Res

ulta

nt v

eloc

ity

pre-intervention

post-intervention

- 31 -

Normalized percent of cycle (%)

Normalized percent of cycle (%)

Normalized percent of cycle (%)

Normalized percent of cycle (%)

Normalized percent of cycle (%)

Normalized percent of cycle (%)

a. Shoulder joint

b. Elbow joint

c. Wrist joint

* The target located at elbow height (A) and acromion height (B) during reach-to-grasp task

Figure 5. Post-intervention resultant velocity in the control group

Task A* Task B

pre-intervention

post-intervention

Res

ulta

nt v

eloc

ity

Res

ulta

nt v

eloc

ity

Res

ulta

nt v

eloc

ity

Res

ulta

nt v

eloc

ity

Res

ulta

nt v

eloc

ity

Res

ulta

nt v

eloc

ity

- 32 -

3.2 Jerkiness Score

Table 7 shows the changes in jerkiness score after the spring assisted dynamic hand

orthosis training of the hemiparetic extremity. In the experimental group, the jerkiness

score of sagittal plane movement at the shoulder joint decreased significantly, from

64.80±26.82 to 58.00±28.60, in the reach-to-grasp task at acromion height (p = 0.043),

and jerkiness score of the sagittal plane at the elbow joint significantly decreased

from 67.40±19.93 to 58.00±24.36, in the reach-to-grasp task at acromion height (p =

0.042). Jerkiness score of transverse plane movement at the elbow joint decreased

significantly, from 65.00±12.08 to 60.20±16.94, for the reach-to-grasp task at

acromion height in the experimental group (p = 0.042). The jerkiness score of the

coronal plane and transverse plane at the wrist joint significantly decreased in the

experimental group after intervention. The jerkiness score of the coronal plane

decreased from 66.60±20.00 to 59.60±23.45 in the reach-to-grasp task at elbow

height (p = 0.042), and from 67.20±15.41 to 57.00±16.55 at acromion height (p =

0.043). The jerkiness score of transverse plane movement at elbow height decreased

from 66.60±20.08 to 59.20±23.18 in the reach-to-grasp task (p = 0.041), and from

69.80±15.28 to 61.00±15.68 at acromion height (p = 0.042). However, in the control

group, the jerkiness score of sagittal plane movement at the wrist joint increased from

62.80±11.51 to 72.40±3.04, in the reach-to-grasp task at acromion height (p = 0.043).

- 33 -

Table 7. Jerkiness score (number) after intervention (N=10)

Movement Characteristics Taska

Experimental group (n=5) Control group (n=5) Pre-

intervention Post-

intervention p Pre- intervention

Post-intervention p

Shoulder Joint

Sagittal plane

A 61.20 ± 24.18b 58.20 ± 28.90 0.500 70.00 ± 4.41 63.80 ± 15.28 0.416B 64.80 ± 26.82 58.00 ± 28.60 0.043 69.20 ± 4.76 67.20 ± 8.19 0.343

Coronal plane

A 63.00 ± 20.43 57.00 ± 28.64 0.078 71.00 ± 6.96 72.00 ± 1.58 0.893B 65.80 ± 28.52 62.60 ± 27.95 0.197 76.20 ± 8.70 72.20 ± 4.08 0.345

Transverse plane

A 60.00 ± 26.10 62.20 ± 30.35 0.588 68.80 ± 11.16 74.00 ± 3.39 0.279B 62.80 ± 25.79 60.40 ± 30.94 0.588 69.60 ± 6.22 70.60 ± 7.89 0.588

Elbow Joint

Sagittal plane

A 61.40 ± 27.15 57.00 ± 27.00 0.109 70.00 ± 6.74 72.60 ± 3.20 0.684B 67.40 ± 19.93 58.00 ± 24.36 0.042 73.80 ± 2.68 70.40 ± 6.34 0.176

Transverse plane

A 57.40 ± 19.55 55.00 ± 23.57 0.686 69.80 ± 5.63 65.40 ± 7.23 0.416 B 65.00 ± 12.08 60.20 ± 16.94 0.042 72.60 ± 1.81 69.00 ± 5.70 0.176

Wrist Joint

Sagittal plane

A 60.80 ± 17.10 58.40 ± 26.03 0.715 65.40 ± 9.91 65.80 ± 7.56 1.000B 56.40 ± 16.62 52.60 ± 15.69 0.197 62.80 ± 11.51 72.40 ± 3.04 0.043

Coronal plane

A 66.60 ± 20.00 59.60 ± 23.45 0.042 64.20 ± 7.22 66.40 ± 6.14 0.500B 67.20 ± 15.41 57.00 ± 16.50 0.043 62.40 ± 9.28 65.50 ± 15.50 0.684

Transverse plane

A 66.60 ± 20.08 59.20 ± 23.18 0.041 70.20 ± 11.20 70.00 ± 6.16 0.893B 69.80 ± 15.28 61.00 ± 15.68 0.042 66.40 ± 10.54 69.20 ± 5.06 0.892

a The target located at elbow height (A) and acromion height (B) during reach-to-grasp task b Mean ± standard deviation

- 34 -

Discussion

The purpose of this study was to assess the efficacy of training using a spring

assisted dynamic hand orthosis on stroke patients with upper limb hemiparesis.

Clinical assessments, resultant velocity, and jerkiness scores were used to demonstrate

the efficacy of spring assisted dynamic hand orthosis training.

This dissertation reports several significant results after the intervention. First, the

FMA of the upper extremity score and the BBT score were increased significantly in

the experimental group after the intervention. Second, the resultant velocity of the

wrist joint for the reach-to-grasp tasks decreased significantly in the experimental

group, but not in the control group, and the resultant velocity of the shoulder joint at

acromion height decreased significantly in the experimental group but did not

decrease in the control group. Third, the jerkiness score of the shoulder joint at the

sagittal plane decreased significantly in the experimental group, but did not decrease

in the control group during the reach-to-grasp task at acromion height. The jerkiness

scores of the elbow joint in the sagittal and transverse planes decreased significantly

in the experimental group rather than in the control group during the reach-to-grasp

task sessions at acromion height. At both heights, the jerkiness score of the wrist joint

in the coronal and transverse planes during the reach-to-grasp task decreased

significantly only in the experimental group.

The ICF model provides a variety of information (impairment of body functions and

structures, and limitations of activities and participation) relating to upper extremity

- 35 -

function measures. The upper extremity movement generally varies depending on the

goal of the task and performer’s level of skills in performing fine motor tasks such as

grasping or manipulation. Fine motor skill plays an important role in gross motor

skills for reaching the target, and controlling sensorimotor processing via

coordination during movement (Carr, and Shepherd 2003; Shumway-Cook, and

Wollacott 2007). Among the clinical assessment scores in this study, FMA was for

identifying gross motor skill ability at body structures and functions level; the ARAT

and BBT were for identifying fine motor skill ability at activity level. However, the

ARAT score, measure of fine motor skill, did not differ after the intervention in either

the experimental group or the control group. The ARAT and BBT were both used for

measuring fine motor skill. The ARAT was used to test grasp and grip performance

for different objects during each session, while the BBT tested performance in

grasping similar objects. Although clinical assessment scores, before the intervention,

were not statistically significantly different (p < 0.05), between the experimental and

control groups, these results indicated that, after the intervention, the experimental

group hand better fine motor skill results.

A 3-D motion analysis system was use to demonstrate the training effect of

movement dysfunction as a replacement for assessment using a observation

(Kawamura et al. 2007). Commonly, the focus of the observation and evaluation

during 3-D motion analysis was how a performer’s upper extremity was coordinated

in space and time during movement, using the parameters of velocity, maximum

range of motion angles, inter-joint coordination, and jerkiness score for movement

- 36 -

smoothness (Caimmi et al. 2008; van Vliet, and Sheridan 2007; Wagner et al. 2008;

Wu et al. 2007). In our study, we used resultant velocity and jerkiness score as

kinematic parameters, for assessing movement smoothness at each joint of the upper

extremity during reach-to-grasp tasks.

The resultant velocity reflects the jerkiness of movement in all 3-D movement, while

the jerkiness score evaluated the jerky movement in 1 direction. After the intervention,

resultant velocity decreased in the wrist joint and shoulder joint. The resultant

velocity of the wrist joint decreased at both height levels during the reach-to-grasp

task. However, the resultant velocity of the shoulder joint decreased in reach-to-grasp

task at acromion height. This result indicates that the resultant velocity of the shoulder

joint, during the reach-to-grasp task, at elbow height did not change after the

intervention, because there was a need for some shoulder movement during the task.

In the experimental group, the resultant velocity for movement smoothness was

improved by the spring assisted dynamic hand orthosis training. The reach-to-grasp

task of the upper extremity has provided a relatively simple model for studies of how

movement is planned, produced, and coordinated (Refshauge, Ada, and Ellis 2005),

and increased movement smoothness was a result of learned coordination for

recovery from neural injury (Rohrer et al. 2002). Our results showed that the jerkiness

scores of movement in the coronal and transverse planes of the wrist during the reach-

to-grasp task at both heights significantly decreased. And also, jerkiness scores in the

sagittal and transverse planes of the elbow joint, and sagittal plane of the shoulder

joint, significantly decreased during the reach-to-grasp task at acromion height. As we

- 37 -

discussed earlier, there was limited need for shoulder movement during the reach-to-

grasp task at elbow height, therefore there was no significant change in the reach-to-

grasp task at elbow height after the intervention, despite a difference in the

experimental group. We confirmed that there was a decrease in the jerkiness of

movement in the reach-to-grasp task sessions at higher positions.

Generally, in the hemiparetic upper extremity, movement increased jerkiness during

the task (Caimmi et al. 2008; Rohrer et al. 2002). Therefore, the movement of upper

limbs became smoother, less jerky, and more direct as recovery occurred in stroke

patients (Trombly 1993). The measurement of upper extremity performance in

patients with stroke show jerkier, less accurate, less coordinated, and less direct

movement paths, and fewer are well timed during movement (Refshauge, Ada, and

Ellis 2005). Speed, smoothness, and directness have been shown to be characteristics

of optimal performance during the performance of upper limb tasks, and can be

accurately observed in stroke patients (Refshauge, Ada, and Ellis 2005).

In this study, movement smoothness improved, as measured by resultant velocity

and jerkiness score, after the spring assisted dynamic hand orthosis training. These

results suggest that movements became less jerky, more coordinated, and well timed

during tasks undertaken in laboratory situations. These results indicate that recovery

also continued in case of chronic stroke. Arm movements in stroke patients had

increased jerkiness, were longer, more segmented, more variable, and had larger

movement errors: elbow-shoulder coordination was disrupted and the range of active

joint motion was decreased significantly compared with healthy subjects (Cirstea et al.

- 38 -

2003; Levin 1996; Rohrer et al. 2002; Wu et al. 2000).

Most recommendations for treating upper extremities after neurological injury

involve the intervention that is repetitive, task-oriented training of the impaired

extremity for several hours a day, constraining patients to use the impaired extremity

during waking hours. Selecting a task on which to base training activities is important

as the movement is designed to transfer from the clinical setting to real-world

activities (Taub et al. 2006). The spring assisted dynamic hand orthosis in this

dissertation was designed to provide splinting and repetition, task-oriented training,

mimicking real-world activities for the hemiparetic upper extremity. Using the spring

assisted dynamic hand orthosis has advantages in assisting finger extension for

impaired grip opening caused by spasticity or flexor synergy. It allows the impaired

hand to perform functional activities during training, and is expected to facilitate use

of the impaired extremity during functional tasks, which will carry-over into the real

world activities of daily living. However, it must be kept in mind that the clinical

assessment scores and kinematic parameters of 3-D motion analysis were obtained

under the laboratory environment. Therefore, effects of spring assisted dynamic hand

orthosis training from this experiment have limited generalizability into real world.

Another limitation is that we did not use only brain mapping technique to identify

brain reorganization. Confirming brain reorganization would provide objective

information about outcomes for neurologic problems in the human brain. In addition,

participants were not blinded, as this would have been difficult or impossible. The

non-binding of participants raises the possibility of bias attributable to placebo effects,

- 39 -

and the subjective misreporting of outcomes. Our sample size of stroke patients was

quite small. We suggest that the use of spring assisted dynamic hand orthosis training

should be applied to a larger population and include other types of neurological

patients.

- 40 -

Conclusion

The results of this study indicate that the spring assisted dynamic hand orthosis

training is effective in recovering the movement of the hemiparetic upper extremity of

patients after stroke. The function of the upper extremity in clinical assessment scores

increased in the experimental group but not in the control group. Parameters, such as

resultant velocity for movement smoothness and jerkiness score, also improved in the

hemiparetic upper extremity. Therefore, the spring assisted dynamic hand orthosis

training is considered to be an effective treatment option for undertaking task-oriented

activities. Further research is recommended using a greater variety of evaluation tools

and a larger patient sample size.

- 41 -

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Appendix

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Appendix A. Modified Ashworth Scale

Grade Description

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 ROM when the affected parts are moved in flexion or extension

1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM

2 More marked increase in muscle tone through most of the ROM, but affected parts easily moved

3 Considerable increase in muscle tone, passive movement difficult

4 Affected parts rigid in flexion or extension

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국문 요약

스프링식 동적 손 보조기 훈련이 편마비 상지의

기능과 동작에 미치는 영향

연세대학교 대학원

재활학과(물리치료학 전공)

우 영 근

본 연구는 스프링식 동적 손 보조기 훈련이 뇌졸중 환자의 편마비

상지에 미치는 영향을 알아보고자 하였다. 연구는 대한민국 강원도 원주시

소재 재활병원에서부터 10명의 뇌졸중 환자(실험군 5명과 대조군 5명)가

본 실험에 참여하였다. 실험군에 참여한 대상자는 4주간의 스프링식 동적

손 보조기 훈련을 하루에 1시간씩 1주일에 5회씩 참여하였다. 대조군에

참여한 대상자는 훈련에 참여하지 않고 1시간씩 같은 보조기를 착용하였다.

임상적 평가지수, 합성 속도, 그리고 흔들림 점수가 스프링식 동적 손

보 조 기 의 훈 련 효 과 를 알 아 보 기 위 한 변 수 로 사 용 되 었 다 .

- 54 -

연구 결과, 스프링식 동적 손 보조기 훈련 후, 상지의 Fugl-Meyer

평가와 나무토막검사 점수가 실험군에서 통계적으로 증가하였다.

실험군에서 손목 관절의 합성 속도는 뻗고 잡기 과제 동안 감소하였으며,

어깨 관절의 합성 속도가 견봉 높이의 뻗고 잡기 과제 동안 감소하였다.

또한, 정중면에서 어깨관절의 흔들림 점수가 견봉 높이의 뻗고 잡기 과제

동안 감소하였으며, 정중면과 가로면에서 팔꿈치 관절의 흔들림 점수가

견봉 높이의 뻗고 잡기 과제 동안 감소하였다. 이마면과 가로면의 손목

관절의 흔들림 점수는 뻗고 잡기 과제의 높이와 상관 없이 감소하였다.

따라서, 스프링식 동적 손 보조기 훈련은 뇌졸중 환자의 편마비 상지의

움직임을 회복시켜주는데 효과적인 훈련으로 사용할 수 있을 것이다.

핵심되는 말: 상지, 스프링식 동적 손 보조기, 편마비, 합성 속도,

흔들림 점수.