Stroke

Indian Journal of Physiotherapy & Occupational Therapy. July-September 2014, Vol. 8, No. 3 59
A Comparative Study on Task Specific Strength Training
and Resistance Training to Improve Lower Limb Strength
and Function in Hemiparetic Patients
Ena Bhatia1
, Tarpan Shah2
, Hiral Gandhi2
, D Sathees Kumar3
1
Physiotherapist, 2
Asst. Prof., Shree Swaminaryan Physiotherapy College, Surat, Kadodara Char Rasta, NH No 8 & 6,
Surat, Gujarat, 3
Lecturer Gulf Medical University Ajman, Dubai
ABSTRACT
Study compared the effect and effectiveness of task specific strength training (TSST) and resistance
training (RT) on strength and function in hemiparetic lower limb.After satisfying the inclusion criteria
30 patients were randomly assigned to group 1 (TSST) and group 2 (RT). Pre and post test scores
were recorded using Timed up and go test (TUG) and hand held dynamometer (HHD) for lower
limb to check function and muscle strength.After 4 weeks of intervention function and muscle strength
were checked using TUG test and HHD for lower limb. The Results showed improvement in both
groups and also showed increase in the strength and function in both the groups with improvement
in TUG and HHD. So study concluded that both groups showed improvement in lower limb strength
and function after 4 weeks of intervention but when compared, group 1 with task specific strength
training showed better improvement than group 2 with resistance training.
Keywords: Task Specific Strength Training, Resistance Training, Strength
INTRODUCTION
Stroke is a leading cause of death and most common
cause of disability among adults and it is important
contribution to morbidity, mortality and disability in
developed as well as developing countries.1
Patient
suffering from stroke can have motor impairments like
abnormal muscle tone. The classic distribution of
spasticity is a unilateral presentation on the side of the
body contralateral to the lesion, which predominantly
affects the antigravity muscles. Abnormal reflexes
(hyperactive tendon reflexes) are a more common
manifestation subsequent to a stroke.2
the degree of
motor recovery after stroke varies widely and is
directly related to the degree of initial severity and
interval from stroke to initiation of voluntary
movement.3
Motor impairment is muscle weakness
and decreased endurance. The most common
distribution of weakness is contralateral Hemiparesis.
The distal muscles are typically affected to a greater
extent than proximal muscles.4
Muscle weakness in
lower limb is associated with reduced walking speed
and endurance. HHD can be used as a reliable tool for
assessment of muscle strength.5
To measure the
functional performance of lower limb TUG test is a
reliable outcome tool to measure the function of
hemiparetic lower limb.6
All the neuromuscular problems associated with
stroke are most commonly treated with conventional
physiotherapy.7
in stroke rehabilitation, gait training
is one of the essential functional components where
physiotherapist is involved. Among different
physiotherapy managements, resistance training is a
method of increasing the ability of muscles to generate
force. Stroke survivors have the capacity to safely
improve lower extremity musculoskeletal strength in
both the paretic and nonparetic limbs with a program
of resistance strength training, and these
improvements lead to reductions in self-reported
functional limitations and disability.8
RT refers to progressive increases in resistance to
a muscle, as training induces greater ability to produce
and sustain force. The key elements of progressive
resistance strength training are to provide sufficient
DOI Number: 10.5958/0973-5674.2014.00357.8
14. Tarpan Shah--59.pmd 7/8/2014, 9:57 AM
59

60 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2014, Vol. 8, No. 3
resistance, to progressively increase the amount of
resistance as strength increases, and to continue the
training programme for a sufficient duration (a
minimum of four weeks) for benefits to acquire9
Task-oriented training utilizes a training
programme that focuses on specific functional tasks
to engage the systems (musculoskeletal,
neuromuscular, etc.).Task specific resistance exercise
show increased muscle strength (increased force
generating capacity), increased skill (increased
coordination of muscle activation), increased
extensibility and decreased stiffness of muscle. Task-
specific practice promotes motor learning and it is
focused on improving the performance & endurance
of functional tasks involving the lower extremities.
10
this study was aims to compare the effect and
effectiveness of task specific strength training and
resistance training to improve strength and function
in hemiparetic lower limb following stroke.
MATERIALS AND METHODOLOGY
Ethical clearance was obtained from the Ethical
Committee of the Institute for the present study. This
was a Randomized Experimental study design, a total
of 30 Subjects both males and females in age group of
45-65 years having ischemic unilateral Hemiparesis
with minimental score >20,Brunstrom recovery stage
>3 and Hemisphreic stroke scale – gait component
3were randomly assigned into two groups. Patients
with perceptual dysfunction, sensory deficit, medically
unstable patients and any other medical and
orthopedic problem involving lower limb were
excluded from the study. Informed consent was taken
from subjects for voluntarily participation in the study.
The Study was performed in the Physiotherapy OPD,
K S Hegde charitable hospital. Patients underwent
routine conventional therapy before administering the
interventions. Subjects were divided in to two groups;
group 1 included 15 patients, they received task
specific strength training for lower limb for 45 min /
day, 3days/week, for 4 weeks. Group 2 included 15
patients; they received resistance training for lower
limb for 45mins/day, 3days/week for 4 weeks.
Experimental Procedure
As pretest Patients were assessed before
administering the intervention. Timed up and go test
was used to assess patient’s pre test lower limb
functional performance. Hand held dynamometer was
used to assess patient’s pre test lower limb muscle
strength. The pre test scores were noted down on the
first day before the treatment after complete
assessment of the patient. Both the patients groups
were underwent conventional therapy which includes
stretching, active movements and gait training.
Task specific strength training: 10
It is given to the
Group 1 patients for 45 min /day, 3days/week, for a
period of 4 weeks .The workstations are designed to
strengthen the muscles of lower limbs in a functionally
relevant way. The six workstations incorporated into
the circuit were:
• standing and reaching in different directions for
objects located beyond arm’s length to promote
loading of the lower limbs and activation of lower
limb muscles;
• sit-to-stand from various chair heights ;
• stepping forward and backward onto blocks of
various heights;
• stepping sideways onto blocks of various heights;
• forward step-up onto blocks of various heights;
• Heels raises and lower while maintaining in a
standing posture.
Subjects were encouraged to work as hard as
possible at each workstation and were also given
verbal feedback and instructions aimed at improving
performance. The amount and intensity of the exercise
at each station were graded according to each subject’s
functional level, which were given for 5 min in each
workstation with 2 minutes rest between the work
stations. Progressions were made by increasing the
number of repetitions completed within 5 min at a
workstation and increasing complexity of the exercise
performed at each workstation, such as the distance
reached in standing, reducing the height of the chair
during sit-to stand, and increasing the height of the
blocks. Resistance training9
it is given to Group 2
patients for 45mins/day, 3days/week for 4 weeks. Hip
flexors, extensors, abductors, adductors, knee flexors,
extensors, ankle plantar and Dorsiflexors were
strengthened. Each muscle was given four warm-up
repetitionsat 25% of the 1-repetition maximum (1RM)
with weight cuffs followedby 3 sets (8 to 10 repetitions
per set) at 70% of the 1RM. 2 minutes rest given in
between each set. Training intensity is adjusted
biweekly by reassessing the 1RM.
60

Post test: Patients were again assessed at the end
of 4 weeks of intervention using timed up and go test
and hand dynamometer to evaluate the improvement
in lower limb function and strength. Lower extremity
muscle strength was evaluated using a handheld
dynamometer.5
The dynamometer was positioned with
the help of suspension ropes and sling and subject was
made to exert a maximum force against it. The muscle
group strength measured including hip flexors, hip
extensors, abductors, adductors, knee flexors, knee
extensors, ankle Dorsiflexors and ankle plantar flexors.
The hip flexors, hip extensors, abductors, adductors
strength was obtained in the standing position. The
knee extensor strength was obtained in sitting position.
The knee flexors strength was obtained in the prone
position. The ankle plantar flexors and Dorsiflexors
strength was obtained in the supine position.
Statistical Analysis
Data were analyzed by using Wilcoxon signed rank
sum test which is a non- parametric test for the intra
group comparison of improvement in lower limb
function and strength of control and experimental
groups. And inter group comparison of group 1 and
group 2 to assess the improvement in strength and
function by using Mann- Whitney U test is a non-
parametric test.
Table 1: Shows the difference between pre and post test scores of patient assessed for timed up and go test in
group 1 who received task specific strength training.
Group 1 MEAN MEAN DIFF Std. Deviation Z value
PRE TEST SCORE 27.4 9.667 9.00635 3.426*P = <0.001
POST TEST SCORE 17.733 7.94145
*Statistically significantly different between the groups
Table 2: Shows the difference between pre and post test scores of patient assessed for timed up and go test in group
2 who received resistance training.
Group 2 MEAN MEAN DIFF Std. Deviation Z value
PRE 29.7333 5.4666 7.44951 3.422*p = <0.001
POST 24.2667 7.71332
Table 3: Shows the comparison between group 1 and group 2 after 4 weeks of intervention of patient assessed for
timed up and go test.
Group MEAN MEAN DIFF Std. Deviation Z value
Group 1 9.6667 4.2 6.46603 2.09*p = 0.037
Group 2 5.4667 1.59762
Table 4: Shows the difference between pre and post test scores of patient assessed for muscle
strength test in group 1.
Muscle Groups Pre Test Score Posttestscore Mean Diff Std.deviation z Value p Value
Hip Flexors 4.2667 6.3333 2.0666 0.910 3.248* <0.001
Hipextensors 4.6 6.2667 1.6667 0.976 3.354* <0.001
Hipabductors 3.3333 5.0667 1.7334 0.704 3.473* <0.001
Hip Adductors 5.8 7.5333 1.7333 1.014 2.877* 0.004
Knee Flexors 3.6 6.9333 3.333 0.640 3.314* 0.000
Knee Extensos 4.3333 6.1333 1.8 0.77460 3.402* <0.001
Ankleplantarflexos 0.8000 2.3333 1.5333 0.63994 2.530* 0.011
Ankle Dorsi Flexors 0.1333 1.3333 1.2 0.45774 2.000* 0.046
Table 5: Shows the difference between pre and post test scores of patient assessed for muscle strength in group 2.
Muscle Groups Pre Post Mean Diff Std. Deviation z Value p Value
Hip Flexors 4.4667 5.4000 0.933 1.033 2.491* 0.013
Hip Extensors 3.5333 4.3333 0.800 0.862 2.585* 0.01
Hip Abductors 3.3333 4.2667 0.933 0.704 3.071* 0.002
Hip Adductors 4.2667 4.8667 0.600 0.632 2.714* 0.007
61

62 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2014, Vol. 8, No. 3
Table 5: Shows the difference between pre and post test scores of patient assessed for muscle
strength in group 2. (Contd.)
Muscle Groups Pre Post Mean Diff Std. Deviation z Value p Value
Knee Flexors 3.8000 5.0000 1.200 0.775 3.145* <0.001
Knee Extensors 2.93333 3.8667 0.93333 0.70373 3.071* <0.001
Ankle Plantar Flexors 0.9333 1.4667 0.53333 0.63994 2.530* 0.011
Table 6: Shows the comparison of muscle strength by modified hand held dynamometer
between group 1 & group 2
Muscle Groups Mean Diff Std. Deviation z Value p Value
Group 1 Group 2 Group 1 Group 2
Hip Flexors 2.0667 0.9333 1.62422 .94122 2.159* 0.031
Hip Extensors 1.6667 0.8 .97590 0.86189 2.307* 0.021
Hip Abductors 1.7333 0.9333 0.70373 .70373 2.684* 0.007
Hip Adductors 1.7333 0.6 0.70373 1.09978 2.693* 0.007
Knee Flexors 2.333 1.4 1.44749 0.91026 1.96* 0.05
Knee Extensors 1.8 0.9333 0.77460 0.70373 2.87* 0.004
Ankleplantarflexors 1.5333 0.5333 1.35576 0.63994 2.214* 0.027
DISCUSSION
The focal neurological deficit resulting from a stroke
is a reflection of the size and location of the lesion and
the amount of collateral blood flow.7
Group 1 who
underwent task specific strength training while testing
muscle strength by hand held dynamometer had
shown the improvement in strength when compared
pre and post test scores and that values proved by
Wilcoxon signed rank test. scores were showing that
the task specific strength training is effective in
improving lower limb muscle strength and functional
abilities of hemiparetic patients. This statement was
supported by Yea-Ru Yang Ray-Yau who had found
improvement in lower extremity strength and
reductions in functional limitations with task specific
strength training programme due to improved motor
unit recruitment and motor learning (the development
of neuromotor patterns of co-ordination between
agonist and antagonist muscles through practice of a
skill)10
and also Paul D Vreede had demonstrated
improvement in strength and functional abilities by
task oriented training because the exercises of
functional task exercise program resembled daily task.
The participants may have been stimulated to become
more active in their free time and these exercise were
easily transferable to daily life situations.11
scores were showing that the resistance training is
effective in improving lower limb muscle strength and
functional abilities of hemiparetic patients. This is
supported by Ouellette MM has demonstrated the
improvement in strength and function as the slow
velocity of movement given with resistance training
intervention leads to improvements in force
production and have driven changes in power. The
power generated by the hip flexors and the ankle
plantar flexors of the paretic lower limb has been
shown to be a strong predictor of walking speed in
individuals after stroke.9
Also Milner- Brown et al has
found that strength improved due to the neural
coordination between agonists and antagonists and by
the synchronization of motor unit activity.12
The results were suggesting that it is possible for
task-oriented progressive resistance strength training
to induce increase in muscle strength that can be
transferred to improved functional performance. It is
supported by Carr and Shepherd who has indicated
that transfer is unlikely to occur unless subjects are
also practicing the task to be learned. Critical to the
regaining of effective performance is the development
of flexibility of performance, which is achieved by
practicing the action under a variety of different task
contexts. Repetitive practice of the action to be learned
can therefore have dual benefits, enabling the patient
to practice the action as well as increasing muscle
strength.13
Timed Up and Go test shown the results that were
easy to collect the score and it reflect the overall
functional abilities of lower limb performance in
hemiparetic subjects. This is already proven by Ng SS,
Hui-Chan CW , he proved that timed up and go test is
62

reliable, and correlated well with plantar flexor
strength, gait performance, and walking endurance in
subjects with chronic stroke.6
Hand held dynamometer
as a tool is easy to administer and has been found to
be reliable for assessing muscle strength.6
CONCLUSION
Task specific strength training group showed
improvement in hemi paretic lower limb strength and
function at the end of 4 weeks. Resistance training
group showed improvement in hemi paretic lower
limb strength and function at the end of 4 weeks. When
both the groups were compared for improvement in
hemi paretic lower limb strength and function at the
end of 4 weeks of intervention, it was observed that
Task specific strength training showed significant
improvement compared to Resistance training.
ACKNOWLEDGEMENT
We present sincere gratitude to Dr .Chandrakant
modi and Dr.T Ramesh, Shree Swaminarayan
Physiotherapy College Surat, Dr.Shailaja Modithaya,
Dr Harsha H N and Dr.Amrit Mirajkar Dept of
Physiology, K S Hegde Medical Academy Mangalore
for their Guidance and Support and Encouragement
throughout the course of study.
Conflict of Interest: Nil
Source of Funding: Nil
REFERENCES
1. K. Park, Preventive and social medicine, chapter
6-epidemiology of chronic non- communicable
diseases and conditions:stroke,16th
edition ,
2000,page 280-283.
2. Susan B.O’Sullivan, Thomas J. Schmitx, Physical
rehabilitation assessment and treatment, chapter
18 – stroke,5th
edition, 2005, page 721-723,773.
3. Hilde M. Feys, Willy j de Weerdt, Beat E Selz.
Effect of therapeutic for the hemiplegic upper
extremities to reverse the effect of learned nonuse
among chronic stroke and head injured patients.
Exp Neurol. 1989; 104:125-132.
4. Christopher M. Fredericks, Lisa k. Saladin,
Pathophysiology of the motor systems,
principals and clinical presentations, chapter 21-
stroke, 1996, 1st
edition, page 487-498.
5. Bohanon RW .Test- retest ,reliability of hand held
dynamometry during a single session of strength
assessment .phys ther 1986;66:206-209.
6. Ng SS, Hui-Chan CW .The timed up & go test:
its reliability and association with lower-limb
impairments and loco motor capacities in people
with chronic stroke.Arch Phys Med Rehabil 2005
Aug; 86(8):1641-1647
7. Darcy Ann Umphred, Neurological
Rehabilitation, chapter 22- hemiplegia resulting
from vascular insult or disease, 1990, 2nd
edition,
page 619.
8. Wolf S, Lecraw D, Barton L, Janna B. Forced use
of hemiplegic upper extremities to reverse the
effect of learned nonuse among chronic stroke
and head injured patients. Exp Neurol. 1989; 104:
125-132.
9. Ouellette MM, Le Brasseur NK, Bean JF, et al.
High-intensity resistance training improves
muscle strength, self-reported function, and
disability in long-term stroke survivors.
Stroke.2004; 35:1404–1409.
10. Yea-RuYang Ray-Yau WangKuei-Han Lin: Task
oriented progressive resistance strength training
improves muscle strength and functional
performance in individuals with stroke, Clin
Rehabil, 2006;Vol. 20, No. 10, 860-870.
11. Paul L Vreede, BSc, Monique M.
Samson,MD,PhD, Nico L. U.van Meeteren, PT,
PhD, wz Sijmen A. Duursma, MD, PhD and
Harald J. J. Verhaar, MD, PhDFunctional-Task
Exercise Versus Resistance Strength Exercise to
Improve Daily Function in Older Women: A
Randomized, Controlled Trial 2005.
12. Milner – Brown, H.S., Stein, R.B. and Lee, R.G.
(1975) Synchronization of human motorunits:
possible role of exercise and supraspinal reflexes.
Electroencephalography and clinical
Neurophysiology, pg-245.
13. Carr JH, Shepherd RB. Stroke rehabilitation:
guidelines for exercise and training to optimize
motor skill. Butterworth-Heinemann, 2003.
63

Stroke

More Related Content

What's hot

Similar to Stroke

More from Shrimad Rajchandra College of Physiotherapy,Shree Swaminarayan Physiotherapy College

Recently uploaded

Stroke