"AN EXPERIMENTAL STUDY ON THE EFFECTS OF VIRTUAL

REALITY VERSUS CONVENTIONAL TRAINING FOR

REHABILITATING UPPER LIMB FUNCTIONS IN
CEREBROVASCULAR ACCIDENT PATIENTS."

REGISTER NO: 741910488

SUBMITTED TO
THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY,
CHENNAI,
AS PARTIAL FULFILLMENT OF THE
BACHELOR OF PHYSIOTHERAPY DEGREE.
NOVEMBER 2023
 CERTIFICATE

Certified that this is the bonafide work of MISS. SHYREETI

DAVEENA CHRISTOPHER of Excel College of Physiotherapy,
Komarapalayam, Namakkal, submitted in partial fulfillment of the
requirements for the Bachelor of physiotherapy degree course from The
Tamilnadu Dr. M.G.R. Medical University under the registration
number741910488 for the NOVEMBER 2023 examination.

Place: Namakkal Principal:

Date:
 A PROJECT WORK ON

"AN EXPERIMENTAL STUDY ON THE EFFECTS OF VIRTUAL

REALITY VERSUS CONVENTIONAL TRAINING FOR
REHABILITATING UPPER LIMB FUNCTIONS IN
CEREBROVASCULAR ACCIDENT PATIENTS."

Under the guidance of,

Principal: ……………………………….
PROFESSOR DR. A. AYYAPPAN MPT.,
Principal,
Excel College of Physiotherapy,
Komarapalayam, Namakkal –637303.

Guide: ……………………………………
PROFESSOR DR. A. AYYAPPAN MPT.,
Principal,
Excel College of Physiotherapy,
Komarapalayam, Namakkal –637303.

SUBMITTED TO
THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY,
CHENNAI,
AS PARTIAL FULFILLMENT OF THE
BACHELOR OF PHYSIOTHERAPY DEGREE.
NOVEMBER 2023
 A PROJECT WORK ON

"AN EXPERIMENTAL STUDY ON THE EFFECTS OF VIRTUAL

REALITY VERSUS CONVENTIONAL TRAINING FOR
REHABILITATING UPPER LIMB FUNCTIONS IN
CEREBROVASCULAR ACCIDENT PATIENTS."

Has been submitted in partial fulfillment for the requirement of the

BACHELOR OF PHYSIOTHERAPY DEGREE.

NOVEMBER 2023

Internal Examiner External Examiner

 ACKNOWLEDGMENT

With immense pleasure and love, I owe my first and foremost

thanks to THE GOD THE CREATOR, the merciful and the passionate,
for blessed me with this opportunity to step into this world of Health Care
Academia. The showers of blessings through God’s accompaniment in
the academic journey has always been my source of life-affirmation,
strength, inspiration and has steered me in all endeavors leading to the
completion of this project.

With great respect, I would like to express my sincere thanks to

Prof. Dr. A. K. NATESAN, the Chairman, of Excel Group Institutions,
for providing me with a delightful academic environment and the
necessary infrastructure to cultivate knowledge and wisdom.

With sincere gratitude, goes to DR. MADHAN KARTHICK, the

Vice-chairman of Excel Group institutions, for all his support in every
aspect to build my clinical education and knowledge.

With deep respect, I would like to thank MR. N.

SENGOTTAIYAN, Technical Director, Excel group Institutions, for his
support towards my journey of academics.

My earnest gratitude and honor go to PROF. DR. A. AYYAPPAN

MPT., the Principal of Excel College of Physiotherapy. His unwavering
support, steadfast encouragement, and dedicated guidance have been
instrumental in my journey as a student. Not only has he served as my
Principal but has also taken on the role of the guide for this thesis project.
 His passion for instilling a professional attitude in medical
academia, coupled with his dedication and discipline, has been evident
throughout this journey. His affable accompaniment has made the
successful completion of this project an unforgettable learning experience.
I owe lot to him, indeed!

I am of course indebted to thank all THE FACULTY MEMBERS

and NON-TEACHING and SUPPORT STAFF of Excel College of
Physiotherapy for their invaluable contribution in cultivating education
and special skills in me which stands significant for my career.

My deep humble sense of gratefulness to MY PARENTS for their

love and trust in me. I am grateful for their vision to building a career for
a girl-child and it got realized through their sweat of blood. “I am,
because they are.” I wish to carve my love and thanks to my SISTER, for
her enduring love. You three have been the biggest source and support
throughout my life.

I know my CHARMING FRIENDS will never let me thank them

as they are part of me and my life. They are my extended family and the
well-wishers. Indeed, it is my proudest moment of improvement in my
life to have them with me for where I am heading to. So the word thanks
might not express my emotions, hence I bow them at this moment of
completing my degree for their unconditional support and gracious
contributions and care for my life here at the Excel.

Last not the least, THANK YOU everyone who is part of this
academic journey of my life.
 CONTENTS
S. NO TITLE PAGE NO
ABSTRACT
INTRODUCTION
1.1 BACKGROUND
1.2 CLASSIFICATION
1 1.3 EPIDEMIOLOGY
1.4 VIRTUAL REALITY
1.5 OPERATIONAL DEFINITION
2 REVIEW OF LITRATURE
AIMS AND OBJECTIVES
3.1 AIMS
3 3.2 OBJECTIVES
3.3 STATEMENT OF THE PROBLEM
MATERIALS AND METHODOLOGY
4.1 MATERIALS
4.2 METHODOLOGY
4.3 SAMPLING TECHNIQUE
4.4 SAMPLING SIZE
4.5 STUDY SETTING
4.6 STUDY DURATION
4.7 STUDY CRITERIA
4 4.8 HYPOTHESIS
4.9 OUTCOME MEASURES
4.10 VARIABLES
DEPENDENT
INDEPENDENT
4.11 TREATMENT TECHNIQUE
4.11.1 VIRTUAL REALITY
411.2 CONVENTIONAL TRAINING
5 STATASTICAL TOOLS
6 DATA PRESENTATION
7 DATA ANALYSIS AND GRAPHICAL
PRESENTATIONS
8 RESULTS AND DISSCUSSIONS
9 SUMMARY AND CONCLUSION
10 LIMITATION AND RECOMMENDATION
11 BIBLIOGRAPHY
12 REFERENCE
13 APPENDIX
PARAMETER
14 14.1 FUNCTIONAL INDEPENDENCE MEASURE
14.2 MODIFIED BARTHEL INDEX
CASE STUDY 1
15 CASE STUDY 2
CASE STUDY 3
 ABSTRACT

Background: In recent years, efforts have been made to implement virtual reality
(VR) to support the delivery of poststroke upper extremity motor rehabilitation
exercises. Therefore, it is important to review and analyze the existing research
evidence of its effectiveness.

Objective: This study examined the effectiveness of using VR and conventional

training for upper extremity motor rehabilitation in patients with stroke.

Methods: Changes in outcomes related to impairments in upper extremity functions

and structures, activity limitations, and participation restrictions in life situations from
baseline to after intervention, after intervention to follow-up assessment, and baseline
to follow-up assessment were examined. Standardized mean differences (SMDs) were
calculated using a random-effects model. Subgroup analyses were performed to
determine whether the differences in treatment outcomes depended on age, stroke
recovery stage, VR program type, therapy delivery format, similarities in intervention
duration between study groups, intervention duration in VR groups, and trial length.

Results: A total of 50 trials were analyzed. Compared with the control groups that
used either conventional therapy or no therapy, the intervention groups that used VR
to support exercise therapy showed significant improvements in upper extremity
motor function.

Conclusions: VR-supported upper extremity exercise therapy can be effective in

improving motor rehabilitation results. Our review showed that of the 12
rehabilitation outcomes examined during the course of VR-based therapy, significant
improvements were detected in 2 (upper extremity motor function and range of
motion), and both significant and nonsignificant improvements were observed in
another 2 (muscle strength and independence in day-to-day activities), depending on
the measurement tools or methods used
 CHAPTER 1

1.1 BACKGROUND

DISABILITY
It is defined as the “Functional loss due to permanent physical impairment
resulting from congenital condition, disease or trauma”. It excluded illness/injury of
recent origin (morbidity) resulting into temporary loss of ability to see, hear, speak or
move

Disability is part of being human. Almost everyone will temporarily or permanently

experience disability at some point in their life. An estimated 1.3 billion people –
about 16% of the global population – currently experience significant disability. This
number is increasing due in part to population ageing and an increase in the
prevalence of noncommunicable diseases.

Disability results from the interaction between individuals with a health condition,
such as cerebral palsy, Down syndrome and depression, with personal and
environmental factors including negative attitudes, inaccessible transportation and
public buildings, and limited social support.

A person’s environment has a huge effect on the experience and extent of disability.
Inaccessible environments create barriers that often hinder the full and effective
participation of persons with disabilities in society on an equal basis with others.
Progress on improving social participation can be made by addressing these barriers
and facilitating persons with disabilities in their day to day lives.

World Health Organization’s (WHO) International Classification of Functioning,

Disability and Health (ICF), uses ‘disability’ as an umbrella term for any or all of the
following components:
• Impairments - problems in body function or structure
• Activity limitations - difficulties in executing activities
• Participation restrictions - problems an individual may experience in involvement in
life situations.

1
TYPES OF DISABILITIES :

PRIMARY DISABILITIES :

Primary disabilities are characteristics or behaviours that reflect differences in

brain structure and function, such as mental retardation, attention deficits and sensory
integration dysfunction.
A primary disability is a functional deficit that is a result of permanent brain
injury. A primary disability affects how a student learns
Disabilities that are direct consequences of a disease or condition are called
primary disability
- Paraplegia following spinal cord injury,
- Inability to walk after fracture

SECONDARY DISABILITIES:
Secondary disabilities are disabilities that the individual is not born with. These
disabilities and behaviours develop over time because of a poor fit between the person
and the environment.secondary disability means a disability that is, or results from,
the aggravation, acceleration, exacerbation, deterioration or recurrence of a prior
disability
Disabilities that did not exist at the onset of primary disability but develop
subsequently are called secondary disability. E.g. Joint contractures in poliomyelitis.
Disability has been described as significantly restricted ability, relative to an
individual or group norm and this term is often used to refer to individual functioning
including physical or sensory impairment, cognitive impairment or mental disorder

STROKE THE MOST COMMON CAUSE OF DISABILITY :

Stroke is the second leading cause of death and a major cause of disability
worldwide. Its incidence is increasing because the population ages. In addition, more
young people are affected by stroke in low- and middle-income countries. Ischemic
stroke is more frequent but hemorrhagic stroke is responsible for more deaths and
disability-adjusted life-years lost. Incidence and mortality of stroke differ between
countries, geographical regions, and ethnic groups. In high-income countries mainly,
improvements in prevention, acute treatment, and neurorehabilitation have led to a
substantial decrease in the burden of stroke over the past 30 years. This article
2
reviews the epidemiological and clinical data concerning stroke incidence and burden
around the globe.
Stroke is an important cause of disability and use of health services. Knowledge
of the prevalence of a condition, that is the proportion of the population affected by a
given disease at a given time, is essential for planning purposes. Many estimates of
the prevalence of stroke have been published from a wide range of countries but
international comparisons are fraught with difficulties.

Some disabilities that can result from a stroke which includes:

● Paralysis or Problems controlling movement
● Cognitive deficits
● Speech problems
● Swallowing problems
● Emotional deficits
● Pain
● Vision problems
● Continence problems

3
STROKE:

In the 1970s the World Health Organisation defined "stroke" as a "neurological

deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by
death within 24 hours",although the word "stroke" is centuries old. This definition
was supposed to reflect the reversibility of tissue damage and was devised for the
purpose, with the time frame of 24 hours being chosen arbitrarily.

The 24-hour limit divides stroke from transient ischemic attack, which is a
related syndrome of stroke symptoms that resolve completely within 24 hours With
the availability of treatments that can reduce stroke severity when given early, many
now prefer alternative terminology, such as "brain attack" and "acute ischemic
cerebrovascular syndrome" (modelled after heart attack and acute coronary syndrome,
respectively), to reflect the urgency of stroke symptoms and the need to act swiftly.

A stroke is a medical condition in which poor blood flow to the brain causes
cell death. There are two main types of stroke

1. ISCHEMIC : Due to lack of blood flow.

2. HEMORRHAGIC: due to bleeding Both cause parts of the brain to stop
functioning properly.

Signs and symptoms of a stroke may include an inability to move or feel on one
side of the body, problems with understanding or speaking, dizziness, or loss of vision
to one side .Signs and symptoms often appear soon after the stroke has occurred.

If symptoms last less than one or two hours, the stroke is a transient ischemic
attack (TIA), also called a mini-stroke. A hemorrhagic stroke may also be associated
with a severe headache . The symptoms of a stroke can be permanent.Long-term
complications may include pneumonia and loss of bladder control
The United States has an estimated 3 million stroke survivors today, which is
double the number of survivors 25 years ago. The economic impact of stroke in 2007
was estimated at $62.7 billion, markedly increased from the estimate in 2001 of $30
billion, of which $17 billion were direct medical costs and $13 billion were indirect
costs from lost productivity. Fortunately, modern medical interventions (mostly risk
factor modifications) have decreased stroke mortality rates by approximately 7% per
year in industrialised nations since 1970. The advances continue but with increased
cost of care for more advanced treatments.
4
 The biggest risk for stroke is high blood pressure. Other risk factors include high
blood cholesterol , tobacco, smoking , obesity, diabetes mellitus, a previous TIA, end
stage kidney disease and atrial fibrillation . An ischemic stroke is typically caused by
blockage of a blood vessel, though there are also less common causes. A hemorrhagic
stroke is caused by either bleeding directly into the brain or into the space between
the brains membranes Bleeding may occur due to a ruptured brain aneurysm
Diagnosis is typically based on a physical team and supported by medical imaging
such as a CT scan or MRI scan.

A CT scan can rule out bleeding, but may not necessarily rule out ischemia,
which early on typically does not show up on a CT scan.Other tests such as an
electrocardiogram (ECG) and blood tests are done to determine risk factors and rule
out other possible causes. Low blood sugar may cause similar symptoms.

Prevention includes decreasing risk factors, surgery to open up the arteries to the
brain in those with problematic carotid narrowing , and warfarin in people with atrial
fibrillation . Aspirin or stains may be recommended by physicians for prevention.

A stroke or TIA often requires emergency care. An ischemic stroke, if detected

within three to four-and-a-half hours, may be treatable with a medication that can
break down the clot .Some hemorrhagic strokes benefit from surgery. Treatment to
attempt recovery of lost function is called stroke rehabilitation

5
1.2CLASSIFICATION :

Strokes can be classified into two major categories:

1. Ischemic
2. Hemorrhagic

Ischemic strokes are caused by interruption of blood supply to the brain, while
hemorrhagic strokes result from the rupture of a blood vessel or an abnormal vascular
structure. About 87% of strokes are ischemic, the rest being hemorrhagic. Bleeding
can develop inside areas of ischemia, a condition known as “hemorrhagic
transformation" It is unknown how many hemorrhagic strokes actually start as
ischemic strokes.

Ischemic:
In an ischemic stroke, blood supply to part of the brain is decreased, leading to
dysfunction of the brain tissue in that area. There are four reasons why this might
happen:

1. Thrombosis (obstruction of a blood vessel by a blood clot

forming locally)
2. Embolism (obstruction due to an embolus from elsewhere in
the body)
3. Systemic hypoperfusion (general decrease in blood supply, e.g.,
in shock)
4. Cerebral venous sinus thrombosis

6
 A stroke without an obvious explanation is termed a cryptogenic stroke
(idiopathic) ; this constitutes 30–40% of all ischemic strokes.

There are various classification systems for acute ischemic stroke. The Oxford
Community Stroke Project classification (OCSP, also known as the Bamford or
Oxford classification) relies primarily on the initial symptoms; based on the extent of
the symptoms, the stroke episode is classified as total anterior circulation infarct
(TACI), partial anterior circulation infarct (PACI), lacunar infarct (LACI) or
posterior circulation infarct (POCI). These four entities predict the extent of the stroke,
the area of the brain that is affected, the underlying cause, and the prognosis.The
TOAST (Trial of org 10172 in Acute Stroke Treatment) classification is based on
clinical symptoms as well as results of further investigations; on this basis, a stroke is
classified as being due to : thrombosis or embolism due to atherosclerosis of a large
artery, an embolism originating in the heart, complete blockage of a small blood
vessel, other determined cause, undetermined cause

7
 HEMORRHAGIC:

There are two main types of hemorrhagic stroke.

● Intracerebral haemorrhage , which is bleeding within the brain
itself (when an artery in the brain bursts, flooding the surrounding tissue
with blood), due to either intraparenchymal haemorrhage or
intraventricular haemorrhage
● Subarachnoid haemorrhage which is bleeding that occurs
outside of the brain tissue but still within the skull, and precisely between
the arachnoid mater and pia mater.

The above two main types of hemorrhagic stroke are also two different forms of
intracranial haemorrhage , which is the accumulation of blood anywhere within the
cranial vault but the other forms of intracranial haemorrhage, such as epidural
hematoma (bleeding between the skull and the dura mater, which is the thick
outermost layer of the meninges that surround the brain) and subdural hematoma
(bleeding in the subdural space), are not considered "hemorrhagic
strokes".Hemorrhagic strokes may occur on the background of alterations to the blood
vessels in the brain, such as cerebral amyloid angiopathy , cerebral arteriovenous
malformation and an intracranial aneurysm, which can cause intraparenchymal or
subarachnoid haemorrhage.

In addition to neurological impairment, hemorrhagic strokes usually cause

specific symptoms (for instance, subarachnoid haemorrhage classically causes a
severe headache known as a thunderclap headache or reveal evidence of a previous
head injury

8
1.3EPIDEMIOLOGY:

The epidemiology of “all strokes'' lumped together is one matter, whereas the
epidemiology of the various stroke types and subtypes may be quite another. Ideally,
all require study. But, until the quiet recent past, most epidemiological studies and
clinical trials were based mainly on all strokes, sometimes with separate analysis of
the rather distinct clinical syndrome of spontaneous subarachnoid haemorrhage.

Stroke is a major global public health problem . According to the global burden
of diseases (GBD) study in 1990, stroke was the second leading cause of death
worldwide . subsequent efforts to update the GBD study reported nearly 5.87 million
stroke deaths globally in 2010, as compared to 4.66 million in 1990.

This indicated a 26 percent increase in global stroke deaths during the past two
decades . With the rising proportion of mortality, stroke still remains the second
leading cause of death worldwide .

According to the estimates from the GBD study in 2001, over 85% of the global
burden of stroke was borne by low-and middle-income countries. Given the lack of
reliable reporting mechanisms and disease or death registration system in LMICs , the
epidemiological findings from the GBD study for most of the LMICs, are likely to be
underestimated .

9
 A global systematic review of population-based stroke studies has documented
that the incidence rate of stroke in LMICs has increased from
56/100,000 person-years during 1970-1979 to 117/100,000 person-years during
the period 2000-2008. This study has also reported a decrease in the stroke incidence
from 163 per 100,000 person-years in 1970-1979 to 94 per 100,000 person-years
during 2000-2008 in high-income countries (HICs) indicating approximately 42 per
cent decrease in stroke incidence in HICs and more than double increase in stroke
incidence in LMICs, during the past four decades.

India has been experiencing significant demographic, economic and

epidemiological transition during the past two decades. These have resulted in an
increase in life expectancy and consequently an increase in the ageing population.
Reliable morbidity and mortality estimates for stroke in India are very limited.

In addition, available research information on the epidemiology of stroke in India

suffers from various methodological flaws such as small and variable sample sizes,
inconsistent diagnostic criteria, different case definitions and survey strategies.

Most of these studies are cross-sectional, and the primary objectives of these
studies are also diverse. Given the paucity of data and lack of reliable reporting
mechanisms, understanding the epidemiology of stroke in India is challenging.
Hence, we conducted a systematic review of epidemiological studies of stroke in
India with an objective to investigate the incidence and prevalence of stroke in India
and understand the true magnitude of the problem.

The annual incidence rate of stroke in India is 13/100,000 population with

15.2/100, 000 in males and 10.8/100,000 in females [Abraham Jet al. 1972 sunder rao
PSS 1971]. In 2012 213, an overall 3126 patients in India were identified with an
annual incidence rate of 140/100,000. Stroke in the leading cause of serious long term
disabilities in the United States. Each year, approximately 795,000 people suffer from
stroke TUS centres for Disease Control and prevention]
10
 According to the 2010 Global Burden of Disease Study,Stroke categorised
under cardiovascular and Circulatory Diseases, is the second leading cause of death
globally and the third leading cause of premature death and disability as measured in
Disability Adjusted Life Years (DALY). Cerebrovascular disease is the largest
neurologic contributor and accounts for 4.1% of total global DALY.
Generally, ischaemic strokes account for about 80% of stroke cases while
haemorrhagic stroke accounts for 20% but the actual proportions of stroke types
depend on the population. Data from the first INTERSTROKE study involving 22
countries showed that the proportions of ischaemic and haemorrhagic stroke in Africa
were about 66% and 34%, respectively, compared to about 91% of ischaemic stroke
and 9% of haemorrhagic stroke in high-income countries
Stroke remains the third leading cause of mortality in the United States after
cardiovascular disease and cancer, accounting for 10% to 12% of all deaths. Globally,
stroke is the second leading cause of mortality in developed nations with 4,5 million
deaths every year. An estimated 550,000 strokes occur each year, resulting in 150,000
deaths and more than 300,000 individuals with significant disability.

The United States has an estimated 3 million stroke survivors today, which is
double the number of survivors 25 years ago. The economic impact of stroke in 2007
was estimated at $62.7 billion, markedly increased from the estimate in 2001 of $30
billion, of which $17 billion were direct medical costs and $13 billion were indirect
costs from lost productivity. Fortunately, modern medical interventions (mostly risk
factor modifications) have decreased stroke mortality rates by approximately 7% per
year in industrialised nations since 1970. The advances continue but with increased
cost of care for more advanced treatments.

The syndromes that lead to stroke comprise two broad categories: ischemic and
hemorrhagic stroke. Ischemic strokes account for approximately 80% of strokes, and
hemorrhagic strokes account for the remaining 20%.

11
MORTALITY BY AGE AND SEX:
In a study conducted by khaw , the study illustrated a table showing the mortality
rates for stroke by age and sex in the United kingdom. Rates rise sharply with
increasing age. In marked contrast with coronary heart disease , in which there is a 5:1
male: female ratio at younger ages , there is a consistent sex differential in stroke
mortality rates

Age-specific stroke: The incidence of stroke increases with age, doubling after
the age of 55 years. However, in an alarming trend, strokes in people aged 20–

12
54 years increased from 12.9% to 18.6% of all cases globally between 1990
and 2016. Nevertheless, age-standardised attributable death rates decreased by
36.2% over the same period

Gender-specific stroke: The occurrence of stroke in men and women also

depends on age. It is higher at younger ages in women, whereas incidence
increases slightly with older age in men. The higher risk for stroke in women is
due to factors related to pregnancy, such as preeclampsia, contraceptive use
and hormonal therapy, as well as migraine with aura. Atrial fibrillation
increases stroke risk in women over 75 years by 20%. Based on the National
Institutes of Health Stroke Scale

RISK FACTORS OF STROKE:

The risk of stroke increases with age and doubles over the age of 55 years in both
men and women. Risk is increased further when an individual has an existing medical
condition like hypertension, coronary artery disease or hyperlipidemia. Nearly 60% of
strokes are in patients with a history of transient ischemic attack (TIA). Some of the
risk factors for stroke are modifiable, and some are non-modifiable

NON MODIFIABLE RISK FACTORS INCLUDE:

● Age
● Sex
● race/ethnicity
● TIA
● Genetics

MODIFIABLE RISK FACTORS INCLUDE:

● Hypertension
● Smoking , alcohol and drug abuse
● Physical inactivity
● Hyperlipidaemia
● Diet
● Diabetes melitus
13
 ● Atrial fibrillation
● Genetics

PATHOPHYSIOLOGY :

It is important to understand the neurovascular anatomy to study the clinical

manifestation of the stroke. The blood flow to the brain is managed by two internal
carotids anteriorly and two vertebral arteries posteriorly (the circle of Willis).

Ischemic stroke: Ischemic stroke is caused by deficient blood and oxygen supply
to the brain; hemorrhagic stroke is caused by bleeding or leaky blood
vessels.Ischemic occlusions contribute to around 85% of casualties in stroke patients,
with the remainder due to intracerebral bleeding. Ischemic occlusion generates
thrombotic and embolic conditions in the brain. In thrombosis, the blood flow is
affected by narrowing of vessels due to atherosclerosis. The build-up of plaque will
eventually constrict the vascular chamber and form clots, causing thrombotic stroke.
In an embolic stroke, decreased blood flow to the brain region causes an embolism;
the blood flow to the brain reduces, causing severe stress and untimely cell death
(necrosis). Necrosis is followed by disruption of the plasma membrane, organelle
swelling and leaking of cellular contents into extracellular space , and loss of neuronal
function. Other key events contributing to stroke pathology are inflammation, energy
failure, loss of homeostasis, acidosis, increased intracellular calcium levels,
excitotoxicity, free radical-mediated toxicity, cytokine-mediated cytotoxicity,
complement activation, impairment of the blood–brain barrier, activation of glial cells,
oxidative stress and infiltration of leukocytes

Hemorrhagic stroke : Hemorrhagic stroke accounts for approximately 10–15% of

all strokes and has a high mortality rate. In this condition, stress in the brain tissue and
internal injury cause blood vessels to rupture. It produces toxic effects in the vascular
14
system, resulting in infarction It is classified into intracerebral and subarachnoid
haemorrhage. In ICH, blood vessels rupture and cause abnormal accumulation of
blood within the brain. The main reasons for ICH are hypertension, disrupted
vasculature, excessive use of anticoagulants and thrombolytic agents. In subarachnoid
haemorrhage, blood accumulates in the subarachnoid space of the brain due to a head
injury or cerebral aneurysm

PROBLEM LIST OF STROKE:

Common problem lists include:

 Tonal abnormalities
 Muscular weakness
 Synergistic pattern
 Tightness and contracture
 Gait abnormalities
 Postural abnormalities
 Functional disability
Other problems include:
➢ Impaired cognition

➢ Communication deficits
➢ Decreased sensory awareness
➢ Perceptual deficits

➢ Impaired motor dysfunction

➢ Tonal alteration
➢ Muscle weakness

➢ Abnormal synergies
➢ Tightness

➢ Imbalance
➢ Incoordination

15
EARLY WARNING SIGNS OF STROKE INCLUDE :

 Face drooping
 Arm weakness & Temporary loss of basic muscle movement
 Speech difficulty & dysarthria
 Head ache & Dizziness
 Sudden confusion
 Aphasia

In a retrospective study problem orientated physiotherapy records were

examined on 156 consecutive stroke patients admitted to medical wards and referred
to the physiotherapy depart- ment. The purpose of the study was to identify from the
problem lists those problems physio- therapists are dealing with in stroke care. There
were 1338 problems recorded, and these were divided into 16 clinically meaningful
subgroups. Three of the sixteen subgroups accounted for 60.2 percent of all the
problems recorded, namely lack of voluntary movement and mobility in general
(25.7%), imbalance in muscle tone (19.5%), and problems in maintaining balance
(15.0%). On discharge only 34.1 per cent of all problems were reported to be resolved.
There was wide variation in the success rate claimed with different problems.

16
MANAGEMENT :

Physiotherapy management
The past decade has seen an exponential growth in the number of randomised
control trials (RCT) in relation to physiotherapy interventions utilised in Stroke.
Veerbeek et al (2014) highlight that the number of RCTs on "Stroke Interventions"
has almost quadrupled in the past 10 years, with strong evidence seen in 30 out of 53
interventions for beneficial effects on one or more outcomes. The main changes lie in
the increased number of interventions to which ‘strong evidence’ could be assigned
and an increase in the number of outcomes for which the findings are statistically
significant.

OTHER CONCERVATIVE MANAGEMENT

● Circuit class
● Hydrotherapy
● Electrotherapy
● Spasticity management
● Stretch
● Botulinum toxin
17
 ● Contracture management
● Fatigue management
● Positioning
● Early mobilization
● Balance training
● Sitting
● Cardiorespiratory training
● Strength trainig
● Circuit class
● Hydrotherapy
● Electrotherapy
● Spasticity management
● Stretch
● Contracture management & Fatigue management

In lower limb management

● Standing
● Gait and mobility
● Treadmill training
● Electromechanical assisted
● Rhythmic cueing
● virtual reality
● Overground walking
● Community walking
● Orthotics
For upper limb management
 Bilateral arm training
 Constrained indeed movement therapy
 Electrical stimulation
 robot assisted arm training
 Virtual reality
 Mirror therapy
 Mental practice

18
  Splinting

1.4 VIRTUAL REALITY

Upper limb motor impairment following stroke is a common condition that

impacts significantly the independence and quality of life of stroke survivors. In
recent years, scholars have massively turned to virtual reality (VR) to develop more
effective rehabilitation approaches. VR systems are promising tools that can help
patients engage in intensive, repetitive and task-oriented practice using new
technologies to promote neuroplasticity and recovery.
Multiple studies have found significant improvements in upper limb function for
patients using VR in therapy, but the heterogeneity of methods and tools employed
make the assessment of VR efficacy difficult.
In an effort to assist these individuals with motor recovery, virtual reality
(VR) systems were developed. VR is defined as a “computer-based technology
that allows users to interact with a multisensory simulated environment and
receive ‘real-time’ feedback on performance”.The interactive games are
designed to provide the patient with real-life scenarios and activities relevant to
daily living. The software is able to provide key concepts required for motor
learning including frequency, intensity, repetition and task-oriented training
while enabling the user to feel involved in their rehabilitation.These systems
19
have many settings that allow accommodation for patient needs, abilities and
goals through the manipulation of the degree of difficulty, focus on the
extremity of choice as well as options for game tasks.

1.5 OPERATIONAL DEFINITIONS:

STROKE
"Rapidly developed clinical signs of focal or global disturbance of cerebral
function, lasting more than 24 hours or leading to death with no apparent cause other
than of vascular origin". 1970-WHO

20
HEMIPLEGIA
"a paralysis of one side of the body is the classic sign of neuro vascular disease
of the brain It is one of the manifestation of neuromuscular disease and it occurs with
stroke involving cerebral hemisphere or brain or brainstem".

VIRTUAL REALITY
computer-based technology that allows users to interact with a multisensory
simulated environment and receive ‘real-time’ feedback on performance”. The
interactive games are designed to provide the patient with real-life scenarios and
activities relevant to daily living.

CONVENTIONAL TRAINING
Conventional physiotherapy is defined as the treatment of movement disorders caused
by impairments of joints and the muscles that move the joints. It is a health care
profession concerned with human function and movement and maximizing physical
potential. The three main components of conventional physiotherapy are mobilization,
strengthening, and stretching. Depending on the supposed origin of the disorder, the
physiotherapist will opt for the corresponding treatment approach

FUNCTIONAL ACTIVITIES
Activities of daily living (ADLs or ADL) is a term used in healthcare to refer to
people's daily self-care activities

THE FUNCTIONAL INDEPENDENCE MEASURE:

The Functional Independence Measure (FIM) is one widely accepted outcome
measure developed to assess the skills acquired during inpatient rehabilitation

MODIFIED BARTHEL INDEX:

Modified Barthel ADL index Measure of physical disability used widely to
assess behaviour relating to activities of daily living for stroke patients or patients

21
with other disabling conditions. It measures what patients do in practice. Assessment
is made by anyone who knows the patient well.

NEED FOR THE STUDY

There are many different intervention for improving upper limb functions in
hemiplegic patients. This study is designed to find out the effectiveness of virtual
reality versus conventional training on improving upper limb function in hemiplegic
patients. There is little evidence for the effectiveness of virtual reality versus
convention training on improving upper limb function. So it is necessary to study the
effectiveness of virtual reality versus conventional training on improving upper limb
function.

22
 CHAPTER 2

REVIEW OF LITERATURE

1. In 2011, a meta-analysis completed by Saposnik and Levin looked at the effects of

VR as adjunctive therapy in neurorehabilitation for arm motor recovery post
stroke.Among the twelve studies analyzed, 5 were randomized controlled trials and 7
were observational studies.These studies looked at patients suffering from both
acute/subacute and chronic stroke effects and ranging in age from 26 to 88
years.Outcome measurements used in these studies included the Fugl-Meyer
Assessment, Wolf Motor Function Test (WMFT), and Functional Independence
Measure (FIM). Favouring the VR group, the results displayed a significant benefit
for arm strength, improvement in arm motor impairment and arm motor function
through the selected outcomes.

2. A more recent systematic review was conducted by Laver et al (2017) included 72

studies with objectives to identify the efficacy of VR interventions in stroke
patients.This particular review had a primary focus on upper limb function and
activity and a secondary focus on gait, balance, global motor function, cognitive
function, activity limitation, participation restriction, quality of life, and adverse
events.Studies included in this review were randomized and quasi-randomized trials,
which compared the efficacy of VR based interventions to a control group receiving
standard-care approaches or no intervention. The results of this review identified a
significant difference favouring the intervention between groups for upper limb
function when the intervention group received VR in combination with usual
care.This review also identified a significant difference between groups favouring VR
for activities of daily living (ADLs), which were addressed using outcomes such as
the Functional Independence Measure (FIM), Barthel Index, and on-road driving test.

The other outcomes tested were not statistically significant based on the results of this
review. As this topic remains relatively novel in the realm of stroke rehabilitation,
current research concludes that future investigations will be required to provide
higher-quality evidence to identify the effects of VR interventions on various
components of stroke rehabilitation.

23
3. More recently, A Case Series by Irene Cortés-Pérez et al (2020) "Immersive
Virtual Reality in Stroke Patients as a New Approach for Reducing Postural
Disabilities and Falls Risk", in this study, Three chronic ischemic stroke patients were
selected. One patient who received 25 sessions of immersive VR intervention for two
months was compared with another patient who received equivalent CT and a third
patient with no intervention. Balance, gait, risk of falling, and vestibular and visual
implications in the equilibrium were assessed. After the interventions, the two patients
receiving any of the treatments showed an improvement in balance compared to the
untreated patient. In comparison to CT, our results suggest a higher effect of
immersive VR in the improvement of balance and a reduction of falls risk due to the
active upright work during the VR intervention.The research shows positive outcomes
in improving upper limb function with the use of standard physiotherapy and Virtual
Games (VR) as compared to receiving only standard physiotherapy among stroke
survivors.
4. S. Viñas-Diz a, M. Sobrido-Prieto et al ., 2016
Strong scientific evidence supports the beneficial effects of VR on upper limb motor
recovery in stroke patients. Further studies are needed to fully determine which
changes are generated in cortical reorganisation, what type of VR system is the most
appropriate, whether benefits are maintained in the long term, and which frequencies
and intensities of treatment are the most suitable.
5. Owen O’Neil MRes, BSc a, Manuel Murie Fernandez MD, PhD b, Jürgen
Herzog MD c, Marta Beorchia MSc d, Valerio Gower MSc e, Furio Gramatica
MSc f, Klaus Starrost MSc g, Lorenz Kiwull MD 2018
This narrative article offers insights to clinicians with an interest in how VR can be
used for motor rehabilitation in a clinical context. The settings described include 3
different service delivery models for methods of integrating VR for motor impairment
in neurologic rehabilitation.
These settings included an inpatient application for Parkinson disease, a Kiosk model
for pediatrics, and a telerehabilitation approach for home rehabilitation. Overall, the
clinics found good responses from

24
6. Erika Pedreira da Fonseca PT, MSc * †, Nildo Manoel Ribeiro da Silva PT,
PhD ‡, Elen Beatriz Pinto PT, PhD 2017
The results of this study showed that after a stroke, patients undergoing treatment that
included virtual reality and patients receiving conventional therapy showed an
improvement in balance during gait and a reduction in the occurrence of falls. The
differences in gait balance after intervention in the control group and the reduction in
the occurrence of falls in the treatment group were significant. However, the
intergroup analysis showed no difference between the two outcomes.
7. Jiayin Chen ; Calvin Kalun ; Tianrong Chen 2022
Our findings contribute further evidence to the literature, showing that VR-supported
exercise therapy is effective in improving motor function, especially gross motor
function. One possible explanation for our findings is that VR promotes motor
learning. First, VR can promote access to therapeutic exercises; it can be used to
simulate real-life environments, which allows for real-time interactions and provides a
means for individuals to practice therapeutic tasks that may not be feasible to perform
in the real world because of resource limitations or safety concerns Second, virtual
environments can provide visual, auditory, or haptic feedback that can facilitate motor
skill learning.
8. Steven Truijen et al. Neurol Sci. 2022
In the last decade, there is a growing interest in the use of virtual reality for
rehabilitation in clinical and home settings. The aim of this systematic review is to do
a summary of the current evidence on the effect of home-based virtual reality training
and telerehabilitation on postural balance in individuals with central neurological
disorders.
9. Christine Glenny & Paul Stolee
The purpose of this review was to accumulate and synthesize past research focusing
on the reliability and validity of the FIM and the MDS for use with older adults. To
our knowledge, there have been no publications to date that have systematically
reviewed and compared evidence of the psychometric properties of both tools. It is
important for functional status outcome measures to be validated for use with older
adults because this group of individuals represents a substantial proportion of the
25
population being assessed with these instruments. Also, it is unlikely that the
measurement properties of assessment tools will be consistent between the older and
younger populations

10. Hongyan Yang et al. Medicine (Baltimore). 2021.

In patients with ischemic stroke, activities of daily living were used as an outcome
indicator, and correct assessment is very important. We sought to examine the
reliability and validity of the modified Barthel Index as an evaluation tool of activities
of daily living in ischemic stroke patients by applying the Rasch analysis.We used a
prospectively collected cohort of ischemic stroke patients in the department of
neurology. Rasch analysis was used for evaluating the reliability and validity of the
modified Barthel Index.A total of 231 patients were included in the analysis. The
average of modified Barthel Index was 36.2 ± 17.8. The modified Barthel Index had
high reliability of 0.88. There were no extremely mismatched items, and considered
unidimensional, but the Point-Measure of bowels and bladder were 0.27, extremely
lower than other items. The scale was stable in different sex and age, but had notable
differential item functioning in muscle strength of the limbs. Rating categories were
not functioning adequately in items. The item difficulty and patient ability were not
matched, with a difference of 1.17 logics. 29.4% patients, no easy items could match
their ability.The modified Barthel Index had high reliability but a relatively bad
matching degree between item difficulty and patient ability. It still needs further
improvement to reflect the activities of daily living in ischemic stroke patients.

11. Fang Liu et al. J Stroke Cerebrovasc Dis. 2020 Sep.

Modified Rankin Scale and Barthel Index are the most common scales for assessing
stroke outcomes in clinical practice and trials. Concordance between the Barthel
Index scores and the modified Rankin Scale grades is important to define favorable
outcome in clinical practice and stroke trials consistently. The purpose of this study
was to examine the relationship between the scores of Barthel Index and 3-item
Barthel Index Short Form with the modified Rankin Scale grades of acute stroke
patients.

26
12. Yuto Kameyama et al. J Stroke Cerebrovasc Dis. 2022
There is no unified view of the relationship between sarcopenia and the activities of
daily living (ADL) in stroke patients. This study aimed to determine whether
sarcopenia affects the ADL in elderly patients with stroke.

13. Sherief Ghozy et al. J Neurointerv Surg. 2022

Most studies define the technical success of endovascular thrombectomy (EVT) as a
Thrombolysis in Cerebral Infarction (TICI) revascularization grade of 2b or higher.
However, growing evidence suggests that TICI 3 is the best angiographic predictor of
improved functional outcomes. To assess the association between successful TICI
revascularization grades and functional independence at 90 days, we performed a
systematic review and network meta-analysis of thrombectomy studies that reported
TICI scores and functional outcomes, measured by the modified Rankin Scale, using
the semi-automated AutoLit software platform. Forty studies with 8691 patients were
included in the quantitative synthesis. Across TICI, modified TICI (mTICI), and
expanded TICI (eTICI), the highest rate of good functional outcomes was observed in
patients with TICI 3 recanalization, followed by those with TICI 2c and TICI 2b
recanalization, respectively. Rates of good functional outcomes were similar among
patients with either TICI 2c or TICI 3 grades. On further sensitivity analysis of the
eTICI scale, the rates of good functional outcomes were equivalent between eTICI
2b50 and eTICI 2b67 (OR 0.81, 95% CI 0.52 to 1.25). We conclude that near
complete or complete revascularization (TICI 2c/3) is associated with higher rates of
functional outcomes after EVT.

27
28
 CHAPTER 3
AIMS AND OBJECTIVES

3.1 AIM OF THE STUDY

The aim of the study is to find the effectiveness of virtual reality versus
conventional training on improving upper limb functional activities in post stroke
patients.

3.2 OBJECTIVES OF THE STUDY

To find out the effectiveness of virtual reality on improving upper limb
functional activities in post stroke patients.
To find out the effectiveness of conventional training on improving upper limb
functional activities in post stroke patients.
To find out the effectiveness of virtual reality versus conventional training on
improving upper limb functional activities in post stroke patients.

3.3 STATEMENT OF THE PROBLEM

The study proposes to evaluate the effectiveness of virtual reality versus
conventional training on improving upper limb functional activities in post stroke
patients.

29
 CHAPTER 4

MATERIALS AND METHODOLOGY

4.1 MATERIALS

 Couch
 Xbox
 Display screen
 Jockey
 Pillows
 Mirror box
 Stool
 Weighing machine
 Inch tape.
 Chair
 Table
 blanket
 Plastic cups - 2
 Peg board
 Books
 Sponge balls
 Towel
 Drawer
 200g jar of coffee
 push-button telephone
 pencil
 2.3L plastic pitcher with lid
 250 ml plastic cup
 wash cloth
 wash basin (24.5 cm. in diameter, height 8 cm.)

30
  Pull-on vest with 5 buttons
 bath towel (65cm X 100cm)
 75ml toothpaste with screw lid, >50% full
 Toothbrush
 dinner plate (Melamine or heavy plastic, 25 cm. in diameter)
 medium resistance putty
 knife and fork & Handkerchief
 built up handles the length of the utensil handle
 Metal zipper in polar fleece poncho
 Container (50 x 37 × 27em)
 A plastic grocery bag holding 2kg weight
 Reflex hammer & Swiss ball

4.2. STUDY DESIGN

Quasi experimental study

4.3. SAMPLING TECHNIQUE

Purposive random sampling

4.4. SAMPLE SIZE

50 subjects which fulfil the inclusion criteria were taken.

GROUP A (experimental group): 25 participants
GROUP B (control group): 25 participants

4.5. STUDY SETTING

The study was conducted in Arogya Rehabilitation Center, Erode

4.6. STUDY DURATION

6 Months

31
4.7. TREATMENT DURATION

45 minutes per session, 2 session per day, 6 days per week, total duration of
treatment about 24 weeks.

4.8. STUDY CRITERIA

INCLUSION

 Both male and female

 Ischemic stroke
 Age: 40 - 60 years
 Had stroke on 1st time
 Hemiplegic stroke
 6 months of stroke occurrence

EXCLUSION

 Demyelinating and degenerative diseases of the brain

 Myelopathy
 Myopathy
 Paraneoplastic neurological syndromes
 Traumatic head injury
 Intracranial tumours
 Charcot's atrophy
 Recent fracture
 Arthritis
 Acute cardio respiratory diseases
 Hearing deficit
 Visual deficit

32
4.9. HYPOTHESIS

4.9.1 NULL HYPOTHESIS

There is no significant difference in the effectiveness of virtual reality

versus conventional training on improving upper limb functional activities in
stroke patients.

4.9.2 ALTERNATE HYPOTHESIS

There is a significant difference in the effectiveness of virtual reality

versus conventional training on improving upper limb functional activities in
stroke patients.

4.10. OUTCOME MEASURES

 FIM scale
 Modified barthel index scale

4.11. VARIABLES

4.11.1 DEPENDENT VARIABLE

Functional activities of upper limb

4.11.2 INDEPENDENT VARIABLE:

Virtual reality
Conventional training

33
4.12 TREATMENT TECHNIQUES
PROCEDURE
The selected patients received clear explanation about the treatment procedure
prior to the study.
The written informed consent form was received before the intervention begun.
The participants received interventions with a target of 6 training sessions per
week for 6 months of up to 45 minutes duration and 2 sessions per day .
The pre and post test values were taken by using Functional independence
measure and Modified Barthel index
Designated research therapists provided both the VR training and the CT as an
addition to standard rehabilitation. The amount of physical therapy provided was
registered for each patient.
Informing the patients :
Before the first session, the patients were sufficiently instructed about the
background and aims of Virtual reality and about conventional training respectively,
as well as the respective side effects of the treatment and they were made aware of the
importance of continuous, frequent training and self management.
GROUP A:
Patients from group A (experimental group) received VR training with the
YouGrabber system. It consists of sensors attached to the ceiling, an infrared camera,
and software in combination with a television developed for rehabilitation purposes. It
comprises several games that the therapist can adapt to the patient's actual motor
abilities. The different therapy modes include reaching and grasping exercises,
selective finger movements, supination/pronation, whole-arm movements, unimanual
or bimanual training, and virtually enhanced movements, i.e., movements that can be
visually increased on the screen. Game parameters that could be adjusted were
prioritized among others, speed of objects, intervals between objects, and dispersion
to the left and right of object positions.

34
GAMES ADMINISTERED :
 Rowing game
 Fruit crush
 Wall painting
 Fruit ninja

35
GROUP B:
Patients randomized to the control group participated in CT under supervision of a
therapist to match the therapy time provided in the experimental group. Conventional
arm training was based on a set of standardized exercises along with mirror box
therapy, task oriented approach and motor relearning program with an emphasis on
task-related practice. It included exercises for different gross movements and
dexterity using a variety of grips and selective finger movements.

Exercises such as :

 Activities in mirror box

 Flexion extension of wrist and fingers
 Supination & pronation of forearm
 Opposition exercises
 Peg board exercises
 Opening the bottle cap
 Opening a closed container
 Opening a tooth paste tube
 Brushing
 Combing
 Buttoning and unbuttoning shirt
 Folding tissues or towels
 Attempting to draw figures on a paper
 Turning the pages of a book
 Alternative ball passing activities
 Zipping and unzipping activities
 Picking objects with spoon or fork
 Drinking water from cup
 Holding bags with handles
 Assembling paper cup pyramid and putting it back one into other

36
37
 CHAPTER 5
STATISTICAL TOOLS

Formula : paired t’ test

∑ 2 −(̅)2
S=
−1

∑
̅=

̅
t=

d= difference between pre and post test

̅= mean difference

n= total number of subjects

S= standard deviation

38
 CHAPTER 6
DATA PRESENTATION
FUNCTIONAL INDEPENDENCE MEASURE :MAX SCORE-126
(GROUP A : EXPERIMENTAL GROUP)
MEAN
PRE-TEST POST-TEST MEAN
Sr. No DIFFERENCE
VALUE VALUE DIFFRENCE
SQUARE
1 56 63 7 49
2 28 34 6 36
3 29 34 5 25
4 33 39 6 36
5 36 42 6 36
6 79 86 7 49
7 53 58 5 25
8 34 39 5 25
9 43 49 6 36
10 30 36 6 36
11 73 78 5 25
12 62 68 6 36
13 78 85 7 49
14 27 33 6 36
15 32 38 6 36
16 67 76 9 81
17 57 65 8 64
18 51 57 6 36
19 47 56 9 81
20 45 52 7 49
21 40 45 5 25
22 72 78 6 36

39
 23 35 42 7 49
24 47 53 6 36
25 62 67 5 25
TOTAL VALUE 157 1017
GROUP B (CONTROL GROUP)
S.NO PRE-TEST POST-TEST MEAN MEAN
VALUES VALUES DIFFRENCE DIFFERENCE
SQUARE
1 73 75 2 4
2 62 65 3 9
3 78 81 3 9
4 27 30 3 9
5 32 35 3 9
6 67 71 4 16
7 57 60 3 9
8 51 54 3 9
9 47 49 2 4
10 45 50 5 25
11 56 60 4 16
12 28 32 4 16
13 29 31 2 4
14 33 36 3 9
15 36 39 3 9
16 79 81 2 4
17 53 57 4 16
18 34 37 3 9
19 43 48 5 25
20 27 30 3 9
21 32 35 3 9
22 67 71 4 16
23 57 60 3 9

24 51 54 3 9

40
 25 30 34 4 16
TOTAL 81 279

MODIFIED BARTHEL INDEX – MAX SCORE:100

GROUP A (EXPERIMENTAL GROUP)

MEAN
V Sr. POST-TEST MEAN
PRE-TEST VALUE DIFFERENCE
No VALUE DIFFRENCE
SQUARE
1 82 90 8 64
2 54 61 7 49
3 28 33 5 25
4 24 32 8 64
5 54 60 6 36
6 24 29 5 25
7 28 35 7 49
8 31 39 8 64
9 75 82 7 49
10 31 39 8 64
11 67 74 7 49
12 27 34 7 49
13 53 58 5 25
14 82 88 6 36
15 74 79 5 25
16 65 71 6 36
17 53 58 5 25
18 27 33 6 36
19 68 73 5 25
20 67 75 8 64

41
21 54 61 7 49
22 32 39 7 49
23 33 41 8 64
24 42 49 7 49
25 23 28 5 25
TOTAL VALUE 163 1095

MODIFIED BARTHEL INDEX

GROUP B : CONTROL GROUP
MEAN
Sr. PRE-TEST MEAN
POST-TEST VALUE DIFFERENCE
No VALUE DIFFRENCE
SQUARE
1 67 71 4 16
2 31 35 4 16
3 75 79 4 16
4 31 34 3 9
5 28 33 5 25
6 24 27 3 9
7 54 57 3 9
8 24 27 3 9
9 28 31 3 9
10 54 55 1 1
11 82 85 3 9
12 67 70 3 9
13 68 70 2 4
14 27 30 3 9
15 53 57 4 16
16 65 68 3 9
17 74 77 3 9
18 82 90 8 64
19 53 55 2 4
20 27 30 3 9

42
 21 56 60 4 16
22 36 38 2 4
23 41 45 4 16
24 63 65 2 4
25 32 35 3 9
TOTAL VALUE 82 310

CHAPTER 7
DATA ANALYSIS & INTERPRETETION
7.1 GROUP A (EXPERIMENTAL GROUP)

OUTCOME PRE & MEAN MEAN STANDARD CALCULATED

MEASURE POST DIFFRENCE DEVIATION “T” VALUE
TEST
VALUE
FUNCTIONAL Pre 48.64 6.28 1.127 27.86
INDEPENDENCE Test
MEASURE Post test 54.92

MODIFIED Pre test 47.92 6.52 0.5 66

BARTHEL
Post test 54.44
INDEX

43
 7.2 GROUP B (CONTROL GROUP)

OUTCOME PRE & MEAN MEAN STANDARD CALCULATED

MEASURE POST DIFFRENCE DEVIATION “T” VALUE
TEST
VALUE
FUNCTIONAL Pre 47.76 3.24 0.830 19.51
INDEPENDENCE Test
MEASURE Post test 51

MODIFIED Pre test 49.68 3.28 1.307 12.54

BARTHEL
Post test 52.96
INDEX

44
45
 CHAPTER 8
RESULTS AND DISSCUSSION
8.1 : Functional Independence Measure Scale
The calculated 't value for the experimental group is 27.86 whereas for the
control group the calculated ‘t value is 19.51 . Since the calculated value between
both the groups exhibits a clear difference that is the control group has less value
than the experimental group Hence, Null hypothesis is rejected and alternate
hypothesis accepted.
8.2 : Modified Barthel Index scale
The calculated 't value for the experimental group is 66 whereas for the control
group the calculated ‘t value is 12.59. Since the calculated value between both the
groups exhibits a clear difference that is the control group has less value than the
experimental group Hence, Null hypothesis is rejected and alternate hypothesis
accepted.
DISCUSSION
The aim of the study was to find the effectiveness of Virtual reality versus
conventional training among post stroke patients on improving upper limb functional
activities has been proved. Patient showed changes in their upper limb functions
considerably during the study period.
In this study, functional independence of the patient was measured by functional
independence measure and modified barthel index scale. This study showed that
"There was statistical significant difference in the post test mean and the pre test
mean."
The gamification of VR rehabilitation interventions is believed to motivate
patients to actively participate with pleasure thus increasing the tasks performed and
augmenting their recovery. When participants are more interested, they are more
concentrated and more persistent in completing their tasks. Certain benefits in
psychological outcomes should always be acknowledged as a positive component,
especially in neurological patients who often are faced with a long recovery
(Qian..et.al..2020). Our results are in agreement with those of previous systematic
reviews or narrative ones that have examined semi-immersive VR interventions (Yates
et al., 2016; Porras et al., 2018; Rutkowski et al., 2020) and with a scoping review that
assessed the application of HMD in adult physical rehabilitation (Saldana et al., 2020). The
authors did state that the use of HMD as a low-cost, portable tool seems to have additional

46
benefits, but the generalization of the findings is yet to be discussed due to the relatively low
level of evidence and the small number of participants (Saldana et al., 2020). Another key
aspect noted also by Porras et al. (2018) is the additional benefits of incorporating VR in
conventional rehabilitation, such as motivation and engagement.

47
 CHAPTER 9

SUMMARY AND CONCLUSION

On average, VR or gaming interventions produced a maximum improvement of

the possible improvement that could be achieved . Dose and severity of motor
impairment did not significantly influence rehabilitation outcomes. Treatment gains
were significantly larger overall when the computerized training involved a gaming
component with just visual feedback. VR or gaming interventions showed a
significant treatment advantage over active control treatments.
Overall, VR- or gaming-based upper extremity rehabilitation post stroke appears
to be more effective than conventional methods. Further in-depth study of variables
affecting improvement, such as individual motor presentation, treatment dose, and the
relationship between them are needed.

48
 CHAPTER 10

LIMITATIONS AND RECOMMENDATIONS

10.1. LIMITATIONS:
 As only small sample size is included in this study, the result
cannot be generalised
 Patients with age 25-50 years were only taken for the study.

10.2. RECOMMENDATION
 Other conditions such as cerebral palsy with lack of upperlimb
motor control also be treated by using virtual reality and
conventional training
 The Study was carried out for a short duration, long term study is
recommended for further exploration.

49
50
 CHAPTER 11

BIBLIOGRAPHY

1. Therapeutic Exercise Foundations and Techniques, 6th Edition Carolyn Kisner

PT, MS & Lynn Allen Colby PT, MS
2. Textbook of Rehabilitation S Sunder MBBS Dip Phys Med
3. Textbook of therapeutic exercise S.LAKSHMI NARAYANAN PT
4. Physical medicine and rehabilitation - Susan O Sullivan
5. Darcy Umphred's neurological rehabilitation
6. Cash textbook of Neuro physiotherapy
7. Glady Samuel PT in Neuro rehabilitation
8. Bickerstaff neurology
9. Dr. Hassan Elwan neurology
10. Lindsay neurology and Neuro surgery illust

51
 CHAPTER 12

REFERENCE

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Rehabil. 1 (1), 12. doi:10.1186/1743-0003-1-12

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59
 CHAPTER 13

APPENDICES

APPENDIX - 1: INFORMED CONSENT FORM

Myself , consent the researcher for my voluntary participation in the

study on "THE EFFECTIVENESS OF VIRTUAL REALITY VERSUS
CONVENTIONAL TRAINING ON IMPROVING UPPER LIMB FUNCTION
FOR POST STROKE PATIENTS “.

The Researcher has briefed me in detail about the treatment approach as well as
explained the risks of participation and has answered the questions related to the
research to my satisfaction.

SIGNATURE OF PARTICIPANT:

SIGNATURE OF RESEARCHER:

SIGNATURE OF WITNESS:

60
 APPENDIX - 2
ASSESSMENT CHART
Name:
Age/Sex :
RegNo:
D.O.Adm :
D.O.Ass:
Pathology :Isch/hem
Affected Side: R/L
Outcome Measures:

SCALE PRETEST POST TEST

MODIFIED BARTHEL
INDEX
FUNCTIONAL
INDEPENDENCE
MEASURE

Group:
Duration of Treatment:
Intervention:
Date:

61
 CHAPTER 14
PARAMETERS
MODIFIED BARTHEL INDEX
INDEX ITEM SCORE DESCRIPTION
0 Unable to participate in a transfer. Two attendants are required to transfer
the
patient with or without a mechanical device.

3 Able to participate but maximum assistance of one other person is require in

all
aspects of the transfer.

8 The transfer requires the assistance of one other person. Assistance may be
CHAIR/BED required in any aspect of the transfer.
TRANSFERS
12 The presence of another person is required either as a confidence measure, or
to
provide supervision for safety.

15 The patient can safely approach the bed walking or in a

wheelchair, lock brakes, lift footrests, or position walking aid, move safely to
bed,
lie down, come to a sitting position on the side of the bed, change the
position
of
the wheelchair, transfer back into it safely and/or grasp aid and stand. The
patient
must be independent in all phases of this activity.

0 Dependent in ambulation.

3 Constant presence of one or more assistant is required during ambulation.

Assistance is required with reaching aids and/or their manipulation. One

person is
8 required to offer assistance.

The patient is independent in ambulation but unable to walk 50 metres

without
12 help, or supervision is needed for confidence or safety in hazardous
situations.
AMBULATION
The patient must be able to wear braces if required, lock and unlock these
braces
assume standing position, sit down, and place the necessary aids into position
for
15 use. The patient must be able to crutches, canes, or a walkarette, and walk 50
metres without help or supervision.

0 Dependent in wheelchair ambulation.

1 Patient can propel self short distances on flat surface, but assistance is
required for
AMBULATION all other steps of wheelchair management.
/WHEELCHAI
R

62
 3 Presence of one person is necessary and constant assistance is required to
manipulate chair to table, bed, etc.
* (If unable to
walk)
4 The patient can propel self for a reasonable duration over regularly
encountered
Only use this terrain. Minimal assistance may still be required in “tight corners” or to
item if the negotiate
patient is a kerb 100mm high.
rated “0” for
Ambulation,
and then
only if the 5 To propel wheelchair independently, the patient must be able to go around
patient has corners,
been trained turn around, manoeuvre the chair to a table, bed, toilet, etc. The patient must
in be
wheelchair able to push a chair at least 50 metres and negotiate a kerb.
management.

INDEX ITEM SCORE DESCRIPTION

0 The patient is unable to climb stairs.

2 Assistance is required in all aspects of chair climbing, including assistance

with
walking aids.

5 The patient is able to ascend/descend but is unable to carry walking aids and
needs
supervision and assistance.
STAIR
CLIMBING
8 Generally no assistance is required. At times supervision is required for
safety due
to morning stiffness, shortness of breath, etc.

10 The patient is able to go up and down a flight of stairs safely without help or
supervision. The patient is able to use hand rails, cane or crutches when
needed
and is able to carry these devices as he/she ascends or descends.

0 Fully dependent in toileting.

2 Assistance required in all aspects of toileting.

5 Assistance may be required with management of clothing, transferring, or

washing hands.

TOILET 8 Supervision may be required for safety with normal toilet. A commode may
TRANSFERS be
used at night but assistance is required for emptying and cleaning.

10 The patient is able to get on/off the toilet, fasten clothing and use toilet paper
without help. If necessary, the patient may use a bed pan or commode or
urinal at
night, but must be able to empty it and clean it.

0 The patient is bowel incontinent.

63
 2 The patient needs help to assume appropriate position, and with bowel
movement
facilitatory techniques.

5 The patient can assume appropriate position, but cannot use facilitatory
techniques
or clean self without assistance and has frequent accidents. Assistance is
required
BOWEL with incontinence aids such as pad, etc.
CONTROL
8 The patient may require supervision with the use of suppository or enema
and has
occasional accidents.

10 The patient can control bowels and has no accidents, can use suppository, or
take
an enema when necessary.

0 The patient is dependent in bladder management, is incontinent, or has

indwelling
catheter.

2 The patient is incontinent but is able to assist with the application of an

internal or
external device.

BLADDER 5 The patient is generally dry by day, but not at night and needs some
CONTROL assistance
with the devices.

8 The patient is generally dry by day and night, but may have an occasional
accident
or need minimal assistance with internal or external devices.

10 The patient is able to control bladder day and night, and/or is independent
with
internal or external devices.

INDEX ITEM SCORE DESCRIPTION

0 Total dependence in bathing self.

1 Assistance is required in all aspects of bathing, but patient is able to make

some
contribution.

3 Assistance is required with either transfer to shower/bath or with washing or

drying; including inability to complete a task because of condition or
disease, etc.
BATHING
Supervision is required for safety in adjusting the water temperature, or in
4 the transfer.

The patient may use a bathtub, a shower, or take a complete sponge bath.
The
5 patient must be able to do all the steps of whichever method is employed
without
another person being present.

0 The patient is dependent in all aspects of dressing and is unable to

participate in
the activity.

2 The patient is able to participate to some degree, but is dependent in all

aspects of
64
65
 dressing.

DRESSING 5 Assistance is needed in putting on, and/or removing any clothing.

8 Only minimal assistance is required with fastening clothing such as buttons,

zips,
bra, shoes, etc.

10 The patient is able to put on, remove, corset, braces, as prescribed.

0 The patient is unable to attend to personal hygiene and is dependent in all

aspects.
Assistance is required in all steps of personal hygiene, but patient able to
make
1 some contribution.

PERSONAL Some assistance is required in one or more steps of personal hygiene.

HYGIENE
3
(Grooming) Patient is able to conduct his/her own personal hygiene but requires minimal
4 assistance before and/or after the operation.

The patient can wash his/her hands and face, comb hair, clean teeth and
shave. A
5 male patient may use any kind of razor but must insert the blade, or plug in
the
razor without help, as well as retrieve it from the drawer or cabinet. A
female
patient must apply her own make-up, if used, but need not braid or style her
hair.

0 Dependent in all aspects and needs to be fed, nasogastric needs to be

administered.
Can manipulate an eating device, usually a spoon, but someone must
2 provide active assistance during the meal.

Able to feed self with supervision. Assistance is required with associated

tasks
5 such as putting milk/sugar into tea, salt, pepper, spreading butter, turning a
plate or
other “set up” activities.
FEEDING
Independence in feeding with prepared tray, except may need meat cut, milk
8 carton opened or jar lid etc. The presence of another person is not required.

The patient can feed self from a tray or table when someone puts the food
within
reach. The patient must put on an assistive device if needed, cut food, and if
10 desired use salt and pepper, spread butter, etc.

SCORE INTERPRETATION
00 - 20 Total Dependence

21 - 60 Severe Dependence

61 - 90 Moderate Dependence

91 - 99 Slight Dependence

- 100 Independence

66
 SCORE PREDICTION
Less Than 40 Unlikely to go home
● Dependent in Mobility
● Dependent in Self Care

60 Pivotal score where patients move from dependency to assisted independence.

60 - 80 If living alone will probably need a number of community services to cope.

More Than 85 Likely to be discharged to community living

● Independent in transfers and able to walk or use wheelchair independently.

FUNCTIONAL INDEPENDENCE MEASURE SCALE

Each item is scored on a 7 point ordinal scale, ranging from a score of 1 to a score of 7.
The higher the score, the more independent the patient is in performing the task
associated with that item.

FIM levels

No Helper

 7. Complete Independence (Timely, Safety)

 6. Modified Independence (Device)

65
Helper - Modified Dependence

 5. Supervision (Subject = 100%)

 4. Minimal Assistance (Subject = 75% or more)
 3. Moderate Assistance (Subject = 50% or more)

Helper - Complete Dependence

 2. Maximal Assistance (Subject = 25% or more)

 1. Total Assistance or not Testable (Subject less than 25%)

Leave no blanks. Enter 1 if not testable due to risk.

The total score for the FIM

 motor subscale (the sum of the individual motor subscale items) will be a value
between 13 and 91.
 cognition subscale (the sum of the individual cognition subscale items) will be a
value between 5 and 35.

The total score for the FIM instrument (the sum of the motor and cognition subscale
scores) will be a value between 18 and 126.

66
 CHAPTER 15
CASE STUDY 1

SUBJECTIVE:
NAME: Nandhini
AGE : 29
SEX : Female
OCCUPATION: Finance manager
DATE OF ASSESSMENT: 15/05/2023
CLINICAL DIAGNOSIS :Haemarrhagic stroke
HAND DOMINANCE: Right
CHIEF COMPLAINTS: Patient is unable to move her right hand and leg.
Also she felt some abnormality in her face while seeing the mirror.
HISTORY TAKING :
HISTORY OF PRESENT ILLNESS:
The onset of illness occured before a couple of years during her first labour.
On May of 2019 she give birth to baby girl under C section. And after 3 days she got an
episode of seizure at night during her dinner. Then she was taken to a near by hospital and
got some IV. Then they referred her to Senthil Neuro where she diagnosed with stroke as
MRI and CT was taken immediately .Then she underwent craniotomy and remained
unconscious for 10 days after which she prescribed drugs for 6 months then she continued her
treatment along with physiotherapy in Arogya rehabilitation.
DRUG HISTORY: For seizures and Hypertension
SURGICAL HISTORY: C section, uterus cyst removal, craniotomy
FAMILY HISTORY: No any relevant history of previous stroke in family
PAIN HISTORY: Shoulder, Sudden, aching
OBJECTIVE
ON OBSERVATION: Enters into Dept. with her mothers support
BODY BUILT: Monomorphic
FACIAL EXPRESSION :Grimacy
ATTITUDE OF LIMBS: Left upper limb Adducted and patient hold it by using contralateral
upper limb.
POSTURE: Faulty, shoulder drooped

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ON EXAMINATION
SPECIAL SENSES

 Vision- normal
 Hearing- normal
 Speech- slow and clumsy

HIGHER CORTICAL FUNCTION

COGNITION
Attention Intact
Concentration Intact
Orientation Intact
Memory Intact
Judgement Intact
Problem solving Intact
Decision making Intact

PERCEPTION
Apraxia Intact
Figure ground perception Intact
Spatial orientation Intact
Left right discrimination intact

CRANIAL NERVE ASSESSMENT: INTACT

MOTOR ASSESSMENT (MUSCLE TONE):
SHOULDER
MOVEMENT Right Left
Flexion Unable to assess (pain)
Extension Unable to assess
Internal rotation NORMAL SYNERGY
External rotation Unable to assess
Abduction Unable to assess
Adduction SYNERGY

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ELBOW
MOVEMENT RIGHT LEFT
Flexion
Normal 1+
Extension

WRIST
MOVEMENT RIGHT LEFT
Flexion
Normal 1+
Extension

HIP
MOVEMENT RIGHT LEFT
Flexion
Normal 1+
Extension

KNEE
MOVEMENT RIGHT LEFT
Flexion Normal 1
Extension Normal 1+

VOLUNTARY MUSCLE CONTROL

MOVEMENT RIGHT LEFT
Shoulder flexion Normal Poor
Shoulder extension Poor
Elbow flexion Fair 1+
Elbow extension Fair 1+
Supination Poor +
Pronation Poor+
Wrist flexion Poor+
Weist extension Poor
Finger flexion Poor ++
Finger extension Poor

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MUSCLE STRENGTH:
MOVEMENT RIGHT LEFT
Shoulder flexion Normal 4-
Shoulder extension 4-
Shoulder abduction 3+
Shoulder adduction 4-
Elbow flexion 3+
Elbow extension 3+
Supination 3+
Pronation 3+
Wrist flexion 2
Weist extension 2
Finger flexion 1
Finger extension 1

REFLEX INTEGRITY
Superficial: normal
Deep tendon: 4+
SENSORY FUNCTION
Intact (superficial & deep)
FUNCTIONAL MOBILITY
Barhel index:33
Functional independence measure :47

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 CASE STUDY 2

SUBJECTIVE
NAME: Mrs. Saraswathi
AGE: 57
SEX : F
OCCUPATION: House wife
DATE OF ASSESSMENT: 24/03/2023
CLINICAL DIAGNOSIS: Parkinsonism with depression
HAND DOMINANCE: Right
CHIEF COMPLAINTS: patient not able to do anything because of tiredness.
She always feels cold and shivering
FELT NEED :As per the patient she wants her childern to with her and no need to improve
anything.
HISTORY TAKING :
HISTORY OF PRESENT ILLNESS: since 2018, Mrs saraswathi was having tremor on left
side in upper and lower limbs and intolerance to cold. In 2018, they went to PSG Combatore
and consulted Dr.Subramaniyam. There she was diagnosed with Stroke and started
medication. Last year during Covid lock down period they came back to erode and
discontinued the drugs for 3 months as she was unable to go to hospital for follow up. On 215
July 2020 they went to Srinivasa Speciality and she was admitted for 1day. They restarted
and also referred to psychiatrist as she was showing symptoms of depression. Now she is
under medication for both the diagnosis.
PAST HISTORY :Bells palsy after Hysterectomy after 2015.
During 2014-15 had join pain and diagnosed RA.
DRUG HISTORY: syndopaplus 1-1/2-1 & Nurokind 3 Tab 0-0-1
FAMILY HISTORY: No similar history of illness
Patient’s Husband passed away
OBJECTIVE
ON OBSERVATION
BODY BUILT -Ectomorphic
FACIAL EXPRESSION - Mask like face

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ATTITUDE OF LIMBS - Normal
POSTURE -forward stooped posture
Voluntary movements - slow
ON EXAMINATION
SPECIAL SENSES
Vision - Intact
Speech - Intact, Hypophonia
Hearing - Intact
HIGHER CORTICAL FUNCTION
COGNITION
Attention Good
Concentration Fair
Orientation Fair
Memory Fair
Judgement Fair
Problem solving Poor
Decision making Affected

PERCEPTION
Apraxia Fair
Figure ground perception
Spatial orientation
Right left discrimination

CRANIAL NERVE ASSESSMENT

all cranial nerves intact
MOTOR ASSESSMENT
MUSCEL POWER
SHOULDER
MOVEMENT RIGHT LEFT
Flexion 4 4
Extension 3+ 3+
Abduction 3+ 3+

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Adduction 4 4
ELBOW
MOVEMENT RIGHT LEFT
Flexion 4 4
Extension 4 4
Supination 4 4
Pronation 4 4

WRIST
MOVEMENT RIGHT LEFT
Flexion 4 4
Extension 4 4

HIP
MOVEMENT RIGHT LEFT
Flexion 4 4
Extension 4 4
Internal rotation 4 4
External rotation 4 4
Abduction 4 4
Adduction 4 4

KNEE
MOVEMENT LEFT RIGHT
Flexion 4 4
Extension 4 4

ANKLE
MOVEMENT LEFT RIGHT
Dorsi flexion 4 4
Plantar flexion 4 4

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PAIN: present on both shoulder and lower back after doing repeated movements

TREMMOR: absent

RIGIDITY: absent

BRADYKINESIA: There is reduction in speed of voluntary movements

POSTURAL INSTABILITY: present (always has a fear of fall)

SENSORY FUNCTION: intact

COORDINATION TEST
Grass motor Good
Fine motor Fair
Hand to eye Fair
Bilateral Fair

FUNCTIONAL MOBILITY
Modified barthel score :57
Functional independence measure:
77

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 CASE STUDY 3:

SUBJECTIVE
NAME: Santhosh
AGE: 25
SEX : male
OCCUPATION: student
DATE OF ASSESSMENT: 31.01.2023
CLINICAL DIAGNOSIS: haemorrhagic stroke
HAND DOMINANCE: right
CHIEF COMPLAINTS: patient is unable to attend his college classes , unable to move their
right side arm and leg , unable to move independently
HISTORY TAKING :
HISTORY OF PRESENT ILLNESS: with no earlier symptoms , 2 months ago the patient
was attending his regular in person classes where the patient suddenly fainted , he was
immediately take to a clinic in komarapalayam where they administered him with IV
assuming he fainted because of not having his breakfast . once the patient gained his
consciousness he complained of not being able to move his limbs and also exhibited a slurred
speech, the patient was immediately shifted to Vijaya hitec hospital erode where all the
necessary scans and tests were carried out after which the patient was diagnosed with stroke.
On 2nd of December 2022 the patient underwent a craniotomy after a normal recovery the
patient was then referred to Arogya rehabilitation centre for physiotherapy
PAST HISTORY : nill
DRUG HISTORY:
FAMILY HISTORY:

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OBJECTIVE
ON OBSERVATION
BODY BUILT – mesomorphic
FACIAL EXPRESSION – slight drooping
ATTITUDE OF LIMBS - Normal
POSTURE -forward stooped posture
Voluntary movements - slow
ON EXAMINATION
SPECIAL SENSES
Vision - Intact
Speech - Intact, Hypophonia
Hearing - Intact
HIGHER CORTICAL FUNCTION
COGNITION
Attention Good
Concentration Fair
Orientation Fair
Memory Fair
Judgement Fair
Problem solving Fair
Decision making Poor

PERCEPTION
Apraxia Fair
Figure ground perception
Spatial orientation
Right left discrimination

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CRANIAL NERVE ASSESSMENT
all cranial nerves intact
MOTOR ASSESSMENT
MUSCEL POWER
SHOULDER
MOVEMENT RIGHT LEFT
Flexion 4 4
Extension 3+ 3
Abduction 3 3+
Adduction 4 4

ELBOW
MOVEMENT RIGHT LEFT
Flexion 4 4
Extension 2 2
Supination 3 3
Pronation 4 4

WRIST
MOVEMENT RIGHT LEFT
Flexion 2 2
Extension 2 2

HIP
MOVEMENT RIGHT LEFT
Flexion 4 4
Extension 4 4
Internal rotation 4 4
External rotation 4 4
Abduction 4 4
Adduction 4 4

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KNEE
MOVEMENT LEFT RIGHT
Flexion 4 4
Extension 4 4

ANKLE
MOVEMENT LEFT RIGHT
Dorsi flexion 4 4
Plantar flexion 4 4

PAIN: present on both shoulder and lower back after doing repeated movements

TREMMOR: absent

RIGIDITY: absent

BRADYKINESIA: There is reduction in speed of voluntary movements

POSTURAL INSTABILITY: present

SENSORY FUNCTION: intact

COORDINATION TEST
Grass motor Good
Fine motor Fair
Hand to eye Fair
Bilateral Fair

FUNCTIONAL MOBILITY
Modified barthel score :52
Functional independence measure:
74

78