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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 4  |  Issue : 2  |  Page : 185-188

Effect of stretching and proprioceptive loading in hand function among patients with cerebellar tremor


1 Department of Physiotherapy, Global Hospitals and Health City; Department of Physiotherapy, Sree Balaji College of Physiotherapy, Chennai, Tamil Nadu, India
2 Department of Physiotherapy, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
3 Department of Physiotherapy, Sree Balaji College of Physiotherapy, Chennai, Tamil Nadu, India

Date of Web Publication20-Dec-2016

Correspondence Address:
Hariharasudhan Ravichandran
Department of Physiotherapy, Global Hospitals and Health City, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-4848.196210

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  Abstract 

Background and Objective: Tremor, the most common form of abnormal involuntary movement, affects the performance of activities of daily living. Evidence on effective form of physiotherapy techniques which can help manage intentional tremor and improve hand function among cerebellar dysfunction patients in inconclusive. Hence, this study aims to establish the effectiveness of stretching and proprioceptive loading among cerebellar patients with intentional tremors. The objective of this study is to compare the efficacy of stretching and proprioceptive loading among patients with cerebellar intention tremor. Materials and Methods: A total of thirty patients with intention tremor due to cerebellar lesion were recruited for this study. They were randomized into two groups, Group I received stretching exercise and Group II received proprioceptive loading exercise. Pre- and post-test outcome measures were taken at the end of duration of 3 weeks intervention. Outcome measures were Fahn's tremor rating scale and nine hole peg test. Results: Statistical analyses were done by McNemar test, Wilcoxon's signed rank test, and Mann–Whitney test. Post-test scores of both groups were compared and found that Group II treated with proprioceptive loading exercise had higher significant result than the group treated with strengthening exercise program. Conclusion: Proprioceptive loading exercise has demonstrated signifi cant effect on reducing cerebellar tremor and improving muscle coordination in reaching activities.

Keywords: Cerebellar tremor, coordination, proprioception, stretching


How to cite this article:
Ravichandran H, Janakiraman B, Sundaram S. Effect of stretching and proprioceptive loading in hand function among patients with cerebellar tremor. Arch Med Health Sci 2016;4:185-8

How to cite this URL:
Ravichandran H, Janakiraman B, Sundaram S. Effect of stretching and proprioceptive loading in hand function among patients with cerebellar tremor. Arch Med Health Sci [serial online] 2016 [cited 2017 Aug 22];4:185-8. Available from: http://www.amhsjournal.org/text.asp?2016/4/2/185/196210


  Introduction Top


Cerebellar tremor, also known as kinetic, action, or intention tremor, is a dyskinetic disorder characterized by a broad, coarse, and low frequency (<5 Hz) tremor. Tremor is a condition where goal-directed movements produce shaking in the moving body parts, most noticeably in the hand. It is more obvious when performing delicate fine movements than broad sweeping ones. The amplitude of cerebellar tremor increases as an extremity approaches the endpoint of deliberate and visually guided movement. A cerebellar tremor is usually perpendicular to the direction of movement. It is the result of dysfunction of the cerebellum, particularly on the same side in the lateral zone, which controls visually guided movements.[1]

Cerebellar or intention tremor is often caused by the damage or degeneration in the cerebellum. This damage or degeneration to cerebellum is often caused by neurodegenerative diseases, trauma, tumor, stroke, toxicity, vascular diseases, space-occupying lesions, hereditary, or acquired cerebellar degenerations, particularly spinocerebellar ataxia. The most common site for cerebellar lesions that leads to the intentional tremor is superior cerebellar peduncle and dentate nucleus, through which cerebellum is linked to the rest of the brain.[2] Intention tremors can also be caused as a result of damage to the brainstem or thalamus. Both of these structures are involved in the transmission of information between the cerebellum and the cerebral cortex, as well as between the cerebellum and the spinal cord, and then on to the motor neurons. When these become damaged, the relay system between the cerebellum and the muscle which it is trying to act upon is compromised, resulting in the development of a tremor.[3] Cerebellar tremor is a largely underestimated cause of disability, probably because it is usually the part of a wider clinical picture where strength is often preserved, but movement control is affected.[2] Unfortunately, the treatment of cerebellar tremor is still not clear.[4]

Intention tremors that are caused by normal, everyday activities, such as stress, anxiety, fear, anger, caffeine, and fatigue, do not seem to result from damage to any part of the brain. These tremors instead seem to be a temporary worsening of a small tremor that is present in every human being. These tremors generally go away with time.[5]

Electrophysiological studies can be useful in determining frequency of the tremor, and accelerometric studies quantify tremor amplitude. Magnetic resonance imaging is used to locate the damage to and degradation of the cerebellum that may be causing the intention tremor.[6]

Cerebellar tremor results in difficulty execution of fine movements such as reaching or grasping objects. Treating cerebellar tremor effectively is one of the major areas of concern to improve the functional independence. The tremor may disappear for a while after a treatment has been administered and then return. Intention tremors are known to be very difficult to treat with pharmacotherapy and drugs. There is no established pharmacological treatment for an intention tremor, several drugs have been found to have positive effects on intention tremors and are used as treatment by many neuro consultants. Isoniazid, buspirone hydrochloride, glutethimide, carbamazepine, clonazepam, buspirone, topiramate, zofran, propranolol, and primidone have all seen moderate results in treating intention tremor and can be prescribed treatments. Physiotherapy has not much focused on research in the management of tremors. Very few widely accepted physiotherapy techniques in tremor management are relaxation exercises, biofeedback, stretching exercises, and strengthening exercises. There is, as yet, no satisfactory treatment for intention tremor.[2] Hence, there is a need for a study to fill the research gap in tremor management. The extent of research on such techniques is scarce. This study aims to compare the effect of stretching and proprioceptive loading in hand functions among patients with cerebellar tremor.


  Materials and Methods Top


Population and sampling

The local institutional review board approved the study and a detailed explanation of the study was given to each patient and written consent was obtained. A total of thirty patients with cerebellar intentional tremor with the age group of 40–60 years attending, outpatient department of Madha Medical College and Hospital, Chennai, India, between November 2015 and January 2016 were recruited. Both male and female patients fulfilling inclusion criteria were randomly allocated into two groups, Groups I and II randomly. To be included, the patients should be diagnosed by hospital neurologist as cerebellar ataxic subject, tremor rating score of 1–4 according to finger-to-nose test (FNT), upper limb muscle power more than 4. We excluded patients who had Fredrick's ataxia, upper extremity muscle power ≤3, disoriented patients, dementia, Tabes dorsalis, Wilson's disease, spasticity, and rigidity. Group I with 15 patients received conventional physiotherapy treatment which included Frenkel exercise along with manual stretching in comparison Group II consist of 15 patients was treated with same Frenkel exercise with proprioceptive loading of hand with a weight cuff (500–750 g).

Informed consent was obtained in written or thumb impression from the patients prior to the treatment session. Baseline screening was carried out using outcome measures; Fahn's tremor rating scale and nine hole peg test (9HPT).

FNT was performed to clinically assess and grade according to Fahn's tremor rating scale. Scoring was given after repeating the test 3 times on the same subject. To assess the hand co-ordination, 9HPT was asked to perform using dominant hand. Patients were asked to place the pegs in 50 s. Number of pegs placed appropriately in the peg board by the patients in 50 s was taken for evaluation. Both Fahn's tremor rating scale and 9HPT were repeated again after 3 weeks of training to represent the posttest data.

Both groups were treated for 30 min in each session with rest time of 5 min every 15 min within sessions to avoid fatigue. All patients received 5 days of treatment in a week with no dropouts for 3 weeks. Group I patients were given stretching exercises for biceps, triceps, pronators, long finger flexors, and extensors. Each muscle/muscle groups was stretched for 15 repetitions per se ssion with a hold count of 15 s between each repetition. Group II patients were taught to do Frenkel exercise with weight cuffs on their wrist [Figure 1].
Figure 1: Subject with performing Frenkel exercise with proprioceptive loading.

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  Results Top


Data were coded and entered using EpiInfo version 3.5.1 (Centers for Disease Control and Prevention, USA) and exported to Statistical Package for Social Sciences (SPSS) version 16 (SPSS Inc. Chicago). Postintervention analyses were performed using Mann–Whitney U-test. Data were described as mean and standard deviation according to its normality.

Demographics

A total of 30 (100%) individuals who were included in this study were randomly divided into Groups I and II. Mean age with a standard deviation of Groups I and II was 49.87 ± 7.01 and 50.80 ± 6.83. A total of 18 males and 12 females participated in this study. There is no significant difference between the age distribution of Groups I and II [Table 1].
Table 1: Descriptive statistics

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Fahn's tremor rating scale

In Group I, the mean and standard deviation of Fahn's tremor rating scale before the intervention was 3.27 ± 0.704 and has diminished to 2.40 ± 0.986 after intervention. The percentage of change was 26.61 [Table 2]. Pretest mean and standard deviation of Group II was 3.33 ± 0.816 and that of postintervention was 1.73 ± 0.799 with a percentage change of 48.05 [Table 3].
Table 2: Within group comparison of finger to nose test and nine hole peg test among Group I

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Table 3: Within group comparison of finger to nose test and nine hole peg test among Group II

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Mann–Whitney U-test was used to compare the post-test scores of Fahn's tremor rating scale. Mann–Whitney scores for Fahn's tremor rating scale was 69.50, P = 0.061, which is considered to be near significant (P > 0.05) [Table 4].
Table 4: Comparison of posttest scores of Fahn's tremor rating scale among both groups (Mann-Whitney U-test)

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Nine hole peg test

Mean and standard deviation of Group I for 9HPT before the intervention was 3.53 ± 1.187 and has diminished to 4.60 ± 1.298 after intervention. The percentage of change was 30.31 [Table 2]. Pretest mean and standard deviation of Group II was 3.80 ± 1.474 and that of postintervention was 6.20 ± 1.320 with a percentage change of 63.16 [Table 3].

Mann–Whitney scores of 9HPT were 45.50, P = 0.004, which is considered to be highly significant [Table 5]. This implies that additional proprioceptive loading with Frenkel exercise has shown significant improvement in upper extremity coordination to improve functional activities.
Table 5: Comparison of posttest scores of nine hole peg test among both groups (Mann-Whitney U-test)

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  Discussion Top


The effects of load and force on tremor have received considerable attention by the research community. This study analyzed the effects of proprioceptive loading response on upper extremity tremor among patients with cerebellar dysfunction, and the results were analyzed using the parameters of Fahn's tremor rating scale and 9HPT.

The major finding of our present study is the clear reduction of overall tremor, amplitude, and frequency during the post-test analysis among patients treated with proprioceptive loading exercise program. This method of intervention requires a weight cuff of about 500–750 g and it is portable and easily applicable.

Frenkel's exercise was included in both groups, as this was well supported by many practitioners. Gardiner indicated that Frenkel's exercise aimed at establishing voluntary control of movement by the use of any part of the sensory mechanism which remained intact.[7] This view was well supported by the fact that exercise based on Frenkel's principles is used to train smooth movement and precision, which helps to carry out the normal activities of daily living.

In Group II, proprioceptive loading while performing Frenkel's exercise showed greater result than the other group. This was similar to the result of McGruder et al., who showed that application of weight to wrist joint reduces the intention tremor with some improvement in the functional activities on static brain lesions patients. Their study also reported that the size of benefit seems to be sensitive to the amount of weight used.[8] In this study, we used 600 g of weight load around wrist joint to elicit proprioceptive loading response. This was supported by Rocon et al., in their study robotic exoskeleton force was used to achieve proprioceptive loading and attenuated mild and severe tremors.[9]

In another group, patients treated with stretching exercises. This is validated by the fact that cerebellar tremor is thought to be moderated through increased long latency stretch reflexes. The results of studies manipulating the sensory input suggest that cerebellar tremor is partially driven by stretch elicited peripheral feedback. At the same time, several peripheral structures may be affected by additional proprioceptive loading and therefore account for the reduction of intention tremor. Feys et al. regard the intention tremor as a result of oscillations of the peripheral feedback circuit. Also proprioceptive loading significantly contributed to the decrease in the overall tremor frequency.[10]

Another study results of Feys et al. state that muscle spindles are an essential part of the loop reflex. Although muscle spindle activity and spinal reflexes are considered to be normal in patients with cerebellar dysfunction, decreasing the stretch sensitivity of the muscle spindles and thus also the long latency stretch reflexes, by means of additional proprioceptive loading, may have had an important effect on tremor and improvement in muscle coordination.[11]

Tremor reduction may be related to the changed mechanical properties of the wrist joint and muscles as a result of sustained additional proprioceptive loading. Changes in mechanical properties of muscles may have contributed to the reduction of tremor amplitude, the degree of muscle stiffness is probably related to the additional proprioceptive loading, and therefore may explain the dose-related response of tremor reduction and improvement in muscular coordination in our present study. Thus, we concluded that proprioceptive loading reduced tremor among cerebellar intention tremor patients.

This study proved that proprioceptive loading is effective in cerebellar tremor. The demerits are small sample size and need for long-term follow-up. In future, studies conducting a randomized controlled trial on orthoses comparing weighted bracelets are beneficial in clinical practice.


  Conclusion Top


Cerebellar tremor patients face difficulty in performing their activities of daily living. This study aimed at determining efficacy between stretching exercise and proprioceptive loading among patients with cerebellar tremor. Statistical analysis showed that the reduction of overall tremor amplitude and frequency is evident following intervention with proprioceptive loading. It is concluded that proprioceptive loading is effective in cerebellar tremor patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We would like to thank Dr. Clement Joseph for their support in carrying out this research and also other technical staffs of Global health city for their effort in paper works. We are also grateful to all the patients who gave their consent to participate in this research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Seeberger L. Cerebellar Tremor-Definition and Treatment. Englewood: The Colorado Neurological Institute Review. Fall; 2005.  Back to cited text no. 1
    
2.
Bhidayasiri R. Differential diagnosis of common tremor syndromes. Postgrad Med J 2005;81:756-62.  Back to cited text no. 2
    
3.
Dale P, George JA, David F, William CH, Anthony SL, James OM, et al. Neuroscience. 4th ed. Sunderland, USA: Sinauer Associates, Inc.; 2008.  Back to cited text no. 3
    
4.
Thompson AJ. Symptomatic management and rehabilitation in multiple sclerosis. J Neurol Neurosurg Psychiatry 2001;71 Suppl 2:ii22-7.  Back to cited text no. 4
    
5.
Daniel H. Tremor. U.S. National Library of Medicine. Available from: https://medlineplus.gov/tremor.html. [Last updated on 2015 Jun 15].  Back to cited text no. 5
    
6.
Chou KL. Diagnosis and management of the patient with tremor. Med Health R I 2004;87:135-8.  Back to cited text no. 6
    
7.
Gardiner D. The Principles of Exercise Therapy. 4th ed. New Delhi: CBS Publishers and Distributors; 1985. p. 240.  Back to cited text no. 7
    
8.
McGruder J, Cors D, Tiernan AM, Tomlin G. Weighted wrist cuffs for tremor reduction during eating in adults with static brain lesions. Am J Occup Ther 2003;57:507-16.  Back to cited text no. 8
    
9.
Rocon E, Gallego JÁ, Belda-Lois JM, Benito-León J, Luis Pons J. Biomechanical loading as an alternative treatment for tremor: A review of two approaches. Tremor Other Hyperkinet Mov (N Y) 2012;2. pii: 02-77-495-1.  Back to cited text no. 9
    
10.
Feys P, Helsen W, Liu X, Mooren D, Albrecht H, Nuttin B, et al. Effects of peripheral cooling on intention tremor in multiple sclerosis. J Neurol Neurosurg Psychiatry 2005;76:373-9.  Back to cited text no. 10
    
11.
Feys P, Helsen W, Ilsbroukx S, Meurrens T. Is MS Intention tremor amplitude related to changed peripheral reflexes? ISRN Neurol 2011;2011:192414.  Back to cited text no. 11
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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