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Table of Contents    
Year : 2018  |  Volume : 66  |  Issue : 6  |  Page : 1859-1860

Role of corrected-assisted-synchronized-periodic therapy in post-stroke rehabilitation: Additional facts

Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication28-Nov-2018

Correspondence Address:
Dr. Sunil Pradhan
Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.246296

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How to cite this article:
Pradhan S, Bansal R. Role of corrected-assisted-synchronized-periodic therapy in post-stroke rehabilitation: Additional facts. Neurol India 2018;66:1859-60

How to cite this URL:
Pradhan S, Bansal R. Role of corrected-assisted-synchronized-periodic therapy in post-stroke rehabilitation: Additional facts. Neurol India [serial online] 2018 [cited 2022 May 17];66:1859-60. Available from: https://www.neurologyindia.com/text.asp?2018/66/6/1859/246296

We hereby wish to respond to the valuable comments given on our paper on “Role of CASP therapy in post-stroke rehabilitation”[1] by Drs. Srivastava and Vishnu,[2] and by Dr. KN Arya.[3] Drs. Srivastava and Vishnu[2] have mentioned, and rightly so, that uni-model targeting in stroke pathophysiology is not very effective, and in this context, even the uni-model physiotherapy programs have also not been found to be very effective. The main advantage of corrected-assisted-synchronized-periodic therapy (CASP) is, in fact, in conducting a multi-modal physiotherapeutic approach toward post-stroke rehabilitation. For example, it addresses the key elements of the existing physiotherapeutic approaches such as: (1) Constraint induced movement therapy (CIMT), as the normal half of body is not allowed to be used in CASP therapy; and, (2) Mirror therapy, as the caregivers’ assistance during patient's efforts makes the patient believe that his limb is actually working to the fullest extent. We restricted our end point to clinical assessment as that is obviously the main objective in any clinical setting, and the more complex neuroimaging and biochemical biomarkers of functional improvement have yet to show their real worth. Meanwhile, we are using some of the newer neuroimaging techniques to objectivize the clinical improvement but that is part of another larger project that is currently underway.

We had a very unique way of designating clusters. All patients of stroke attending the Monday outpatient department (OPD) formed one cluster, and those patients attending our Friday OPD formed another cluster. As this is not the conventional way, the term ‘cluster’ is used, and since our statistical analysis was at an individual level, we did not use the term ‘cluster’ and instead called it a “quasi-randomized trial”. The aim of this type of ‘clustering’ was to keep the two patient-groups completely separate from each other ( first blinding), with one author knowing the group assigned and another one assessing all patients in a separate non-OPD location on a separate week-day with no knowledge of the patient's clinical details (second blinding). We, however, agree that with the patient's full awareness of what they were being subjected to as physiotherapy, double blinding always remains an issue of concern.

Drs. Srivastava and Vishnu[2] quoted a paper[4] where more than 3-hour physiotherapy per day was found to be superior to less than 3-hour duration of physiotherapy per day, as far as improvement in the power is concerned. If we add-up 6 sessions of half an hour each at 3 hourly intervals, as has been done in our CASP therapy, it becomes 3 hours per day, and this duration may have contributed to the improvement in power. However, the previous study used one or a maximum of two sessions per day, and therefore, no comparison can be drawn with our 6 times/day schedule meant to reduce spasticity, functional contractures and related pain during physiotherapy.

Drs. Srivastava and Vishnu[2] mentioned that a similar exercise régime has been described in stroke recovery guide of the National Stroke Association.[5] We have gone through the entire content of the voluminous guide and did not find any component of CASP therapy in it. This guide emphasizes the use of the opposite healthy arm to perform or assist the paralyzed limb, which is seldom practised now-a-days due to better results with CIMT. Also, there is no mention of over-correction of deformities by an assistant during therapy. The guide also does not combine active and passive movements, where passive assistance is given only at the end of active movements to complete the full range of movement.

In stroke rehabilitation, the emphasis currently is on improving motor control rather than muscle power, and if power is to be improved, then the progressive resistance exercise is better than passive stretching, as has been pointed out by Dr. Arya.[3] In this context, we would like to reiterate that CASP therapy is meant for that early phase of illness when there is too little voluntary movement to institute any resistance or to conduct any additional occupational therapy to improve motor control, but at the same time, CASP discourages individual muscle activity and encourages overall full movement of the arm, thus indulging in coordinated muscle activity. As finger movements are the last to appear in stroke, CASP therapy requires full extension of fingers at the end-of-arm extension, and the complete closure of the fist during the flexed position of the arm.

Shoulder dislocation has always been a concern for stroke physiotherapists and has been found to be more common during the acute flaccid state of hemiplegia. Most of our patients had already developed spasticity when we recruited them in our study. However, two important precautions are in-built in CASP therapy to prevent shoulder dislocation — (1) One hand of the assistance provider is always below the elbow that continually provides a constant mild upward thrust; and, (2) only forward movement (flexion at shoulder) is allowed, as most dislocations occur during shoulder abduction.

Similarly, during lower limb therapy, the foot is placed in full dorsiflexion during leg flexion, and in full plantar flexion during leg extension; this may be a preparatory exercise for providing an ankle foot orthosis at some later stage when the patient starts walking.

We also encountered the clinical situation when post-stroke pain combined with spasticity led to shoulder and elbow contractures in several of our patients who were recruited at a late stage after the occurrence of stroke. It was perhaps the increased frequency of therapy (3 hourly in CASP) that helped these patients because they complained of more pain and stiffness during the first morning session than in the subsequent sessions in the afternoon and evening.

We conclude by emphasizing that CASP therapy may prove to be a boon for stroke patients in families who belong to the middle-class and poor strata, residing in suburban and rural Indian townships, who do not have access to facilities for institutionalized physiotherapy or for mechanised/robotic therapy, but at the same time, who do have a strong family back-up with close relatives ready to spend time, either alone or turn-by-turn, in helping to rehabilitate the stroke victims. Providing motivation to caregiver relatives/friends while teaching CASP therapy is the key to the success of this rehabilitation program. Further, this is not a substitute for progressive resistance therapy that is performed to improve the patient's power; or, for occupational therapies to improve the patient's fine motor control. These rehabilitative therapies may be concurrently or consecutively employed when the patient has achieved sufficient functionality to perform them.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Pradhan S, Bansal R. Role of corrected-assisted-synchronized-periodic therapy in post-stroke rehabilitation. Neurol India 2018;66:1345-50.  Back to cited text no. 1
[PUBMED]  [Full text]  
Srivastava MV, Vishnu VY. Exercise after stroke: The essential endurance. Neurol India 2018;66:1306-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
Arya KN. Evolution of motor therapies in stroke rehabilitation: An eternal path. Neurol India 2018;66:1303-5.  Back to cited text no. 3
[PUBMED]  [Full text]  
Wang H, Camicia M, Terdiman J, Mannava MK, Sidney S, Sandel ME. Daily treatment time and functional gains of stroke patients during inpatient rehabilitation. PM R. 2013;5:122-8.  Back to cited text no. 4
National Stroke Association. Hope — A stroke recovery guide. www.stroke.org. 2010: pp 51-64. Available from: https://www.stroke.org/sites/default/files/resources/NSA-Hope-Guide.pdf. [Last accessed on 2018 Nov 04].  Back to cited text no. 5


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