Effect of Cognitive Behavioral Therapy on Functional Outcomes in Patients with Stroke

Upper extremity impairment is a commonmotor de icit after a stroke, and 30– 60%of stroke sufferers have disability and inability to use their affected upper extremity in their daily lives. Stroke survivors with cognitive dysfunctions are most likely to be dependent in activities of daily living. Further deterioration is possible as a result of limitation in activities. Psychiatric problems are also common among stroke survivors. This may delay recovery process and further impair cognitive function due to adaptations to unhealthy lifestyles or noncompliance to rehabilitation. Cognitive behavioral training (CBT) increase blood supply to 20% of different brain areas, and facilitation of internancial neurons activity. Cognitive behavioral training (CBT) act as Incentive therapy focuses on active participation, self-esteem, motivational features such as score keeping, and competition. The ultimate objective of physiotherapy is for patients to return to full independence and their former occupations.The purpose of this studywas to investigate the effect of cognitive behavioral training on functional outcomes in stroke patients.Forty stroke patients from both sexes participated in this study 20 patients for each group. Random distribution for patients to 2 groups; Group (A) exposed cognitive behavioral therapy for 60 min and selected physical therapy program for 30 min, every other day for 24 sessions, total duration of session (90min). Control group (B) received the same selected physical therapy program for 60 min, every other day for 24 sessions total duration of session (60 min). Changing in affected upper extremity motor impairment were measured (Dash scale, Wolf scale and Jammar hand dynamometer). The result of our study was improvement of motor functions were signi icantly greater in the study group than the control group (p = 0.0001).


INTRODUCTION
Stroke characterized as neurological de icit attributed to acute focal injury of central nervous system through vascular cause as cerebral infarction, intracerebral, and subarachnoid hemorrhage (Sacco et al., 2013). Stroke is the second leading cause of death worldwide and is the major cause of morbidity, particularly in middle aged and elderly population (Lee et al., 2014), de icit mostly post stroke is hemiparesis of contralateral upper limb, with more 80% of stroke patients experi-encing acutely and more 40% chronically (Cramer et al., 1997). Impairments as disabilities of common activities such as reaching, holding onto objects for a review on precision grip de icits (Bleyenheuft and Thonnard, 2010).
The incidence of cognitive de icit increases three times after stroke. Some of the patients recover completely from physical disability after the stroke but are often unable to cope with activities of daily life because of cognitive impairment (Desmond et al., 2002). Originally it was designed to treat depression and, now using for several mental health. Computerized cognitive training involves structured practices on standardized and cognitively challenging tasks (Kueider et al., 2012;Jak et al., 2013).
In this study, we assessed the effects of cognitive behavioral training on functional outcomes in stroke patients

PATIENTS AND METHODS
Forty patients presented clinically with cerebrovascular stroke (CVS) were participated in this study. The patients were selected from inpatients units of Neurology, Medicine faculty, Cairo University, and the outpatient's clinic from the Faculty of Physical Therapy, Cairo University.
Forty stroke patients were diagnosed by a neurologist based on careful clinical assessment and radiological studies (computed axial tomography and /or magnetic resonance imaging) for brain. Ages ranged from 45 to 65 years. The Patients were (mild cognitive impairment) assessed by mini mental state examination (MMSE) score between (18-23). The patients were medically stable with mild degree of spasticity (grade 1 and 1+ according to Modi ied Ashworth Scale). Their duration of illness ranged from six months to 24 months. All patients' level of education was the same. Exclusion criteria were as follow; Hemiparesis due to any cause other than vascular insult. Hemiparesis due to vertebrobasilar stroke. History of visual, auditory and other neurological disorders affecting their cognitive training (e.g.blindness, deafness). Medications that may affect cognition.
Moderate and severe cognitive impaired patients. Illiterate patients. Uncooperative patients. Any previous cognitive training. Any other orthopedic abnormalities as severe osteoarthritis, osteoporosis and recent or old malunion fractures of upper limbs.
Ethical committee of faculty of physical therapy and informed consent for all participants were approved. Random distribution for patients to 2 equal groups, Study group (I) cognitive behavioral therapy and selected physical therapy program, Control group (II) performed selected physical therapy program only.
The following measures for motor function assessment used. The JAMAR Hand Dynamometer displays grip force up to 200 EP or 90 kg. DASH assessment disorders and measure disability of upper extremities and monitor changes or functional over time. Wolf Motor Function Test is quantitative index of upper extremity motor and instructive for assessing motor status of high function chronic patients had stroke and traumatic brain injury. Mindful Attention Awareness Scale (MAAS) has demonstrated high test-retest reliability, discriminant and convergent validity, known-groups validity, and criterion validity.
Patients with (CVS) stroke received cognitive training via Rehacom system for eight weeks, three sessions per week, day after day. The duration of session was 60 minutes with 10 minutes in between the two procedures, the two procedures are applied at each session for example application of attention concentration training with igural memory, application of reaction behavior training with logical thinking.
Rehacom was done at cognition laboratory at Physical Therapy Faculty, training of igural memory, attention concentration, reaction behavior and logical thinking. The investigator made appropriate adjustment of the Rehacom before the patient sat in front of Rehacom. Every patient assumed acomfortable sitting position on achair with suitable height infront of the screen. The device and the procedure were explained in details for each patient before starting training to be aware about the training procedure. Each patient trained on use device.
Patients were answering the tasks by pressing the simple keys of the custom panel. Attention concentration training consists of 24 levels of dif iculties. Figural memory training consists of 9 levels of dificulties. Reaction behavior training consists of 16 levels of dif iculties. Logical thinking training consists of 23 levels of dif iculties.
In the training session, every patient was starting training from level one and when the patient successfully inished the level, the training then progresses to the level of dif iculty. The patients received selected physical therapy program including (range of motion exercise (active assisted, and active resisted exercises), positioning, passive, active stretching exercises and home routine exercises).

Demographic data
Study group 20 patients with stroke. Mean ± SD age and illness for 57.5 ± 6.61 years and 12.6 ± 4.3 months respectively. (Table 1).Control group 20 patients with stroke. Mean ± SD age and illness for 54.65 ± 7.38 years and 12.9 ± 5.2 months respectively. No signi icant differences in age and illness duration and sex distribution were observed. (Tables 1 and 2) The sex distribution in the study group revealed that there were 2 (10%) females and 18 (90%) males. The sex distribution in the control group revealed that there were 3 (15%) females and 17 (85%) males. There was no signi icant difference in between both groups (p = 0.63). (Table 2).

Motor assessments
Study group gained greater improvement than control group

Relationship between MAAS, Dash scale, Wolf scale, and hand grip force
The correlation between MAAS and Dash scale was strong negative signi icant correlations (r = -0.97, p = 0.0001). (Table 7).

DISCUSSION
In the current study, a highly signi icant difference was observed between study group A and control group B regarding the level of functional outcomes in affected upper extremity, also a signi icant difference was detected between both groups A&B in cognitive functions post treatment.
This indicates that the cognitive behavioral therapy has a positive effect on the functional outcomes of upper limb in stroke patients. The results of the current study agreed with previous studies (Kerr et al., 2011;Gordon et al., 2004;Ploughman et al., 2015Ploughman et al., , 2007Moftah and Jadavji, 2019).
The present study indings agreed with (Flavia et al., 2010) who demonstrated that cognitive reha-bilitation is very important for stroke patients to improving capability to perform daily activities and could also compensated to impaired nervous system. Computer-assisted cognitive rehabilitation gives instant and direct feedback to patient performance.
These improvements were achieved through computer-based cognitive training program. This may be explained visual and auditory feedback activates unused or underused synapses as such; continued training might establish new sensory engrams and help to perform tasks without feedback. biofeedback could be neural plasticity by engaging auxiliary sensory inputs (Huang et al., 2006).
In addition, the training conducted in form of wii game (motivation and interest) which lead to the reactivation for brain neurotransmitters. This was re lected by improvement of the patient's level of alertness, visual attention during treatment program by providing continuous visual stimuli through the dynamic screen along with auditory stimuli that lead to improvement of level of functional performance of stroke patients during activities of daily living (Kim et al., 2011).
The computer-based training has effects on the neural level. Function and structural changing in brain post computer-based cognitive training, they found, white matter connectivity measures changed during the training period (Nordvik et al., 2012). The current study indings were in agreement with (Björkdahl et al., 2013) who demonstrated that cognitive training enhance function of daily life and reduce effect of fatigue in daily living activities.
Also there is long term effect of cognitive training on functional and cognitive performance of stroke patients that was sustained after termination of the program by three months.
The present study indings agreed with (Kerr et al., 2011) Behavioral training can facilitate functional outcome and support post-stroke plasticity.
The current study indings agreed with (Gordon et al., 2004;Ploughman et al., 2015) who demonstrated that cognitive motor rehabilitation after stroke may be a catalyst to promote neuroplasticity in the brain and functional recovery.
The current study indings agreed with (Ploughman et al., 2007). Exercise improves attention and cognitive function, which may enhance re-learning of motor skills after stroke The current study indings were in agreement with (Nan et al., 2019)Neurofeedback training inducing many brain plasticity and associate with improving of emotional state, cognitive, and motor functions.
Current study indings disagreed with (Brown et al., 1999;Maylor et al., 2001), who demonstrated that Cognitive-motor interventions are interventions which combine cognitive with physical rehabilitation task, or perform dual-task. Interventions give negative effect on postural or functional outcomes and perform concurrent cognitive task in stroke patients.
The present study results agreed with (Harley et al., 2006) who found that dual task training elicits cognitive performance and postural stability needed for accurate motor function of upper extremities.
The current study can be explained by (Haggard et al., 2000) who found that dual task in stroke patients were signi icantly correlated with activities of daily living measured by Barthel ADL index.
Our inding of current study demonstrated signi icantly increase in value for hand grip force of post treatment compared with that of control group. That indicated that cognitive training has a signi icant effect on hand grip strength.

CONCLUSIONS
Based on the scores and indings of this study, it was concluded that the cognitive behavioral training had a signi icant effect on functional outcomes in stroke patients.
There were a signi icant improvement of the study group(A) more than in control group (B) post treatment, Therefore the cognitive behavioral training combined with selected physical therapy program is recommended with physical therapy rehabilitation to improve functional outcomes in upper limbs for stroke patients.

ACKNOWLEDGEMENT
I would like to express my deepest appreciation and gratitude to myparents and my family, also dr. Abdul allimatteya, dr. Ehab shaker and dr. Moataztalaatelsemary.for suggesting the point of research, there efforts, continuous guidance, useful suggestions and support throughout the study. they provided all required facilities to enable me to carry this work forward beside and overall encouragement and advice.

Funding Support
None