Effectiveness of Task Oriented Physiotherapy along with Conventional Physiotherapy for Patients with Stroke

Background: Stroke is a disorder where brain is damaged either by blockage in the blood vessels or rupture of the blood vessels. It is the approximately number five leading cause of death. It is also the leading cause of longer period disability as well as preventable cause of disability. Objectives: To determine and compare balance, functional status and mobility before and after application of task oriented physiotherapy along with conventional physiotherapy among patients with Stroke. Methodology: Classic experimental study design was used in this study. 30 patients with stroke were randomly assigned into two groups among them 15 patients were assigned into experimental group received task oriented physiotherapy with conventional physiotherapy and another 15 into control group received only conventional physiotherapy. Total treatment sessions were twenty-four comprising of 3 sessions per week for 8 weeks. Single blinding procedure was used during data collection. Outcome measurement tools: Berg balance scale (BBS) was used to measure balance, functional independence measurement (FIM) was used to measure functional status and timed up and go test (TUG) to measure mobility. Analysis of data: Inferential statistics such as for between group analysis of BBS and FIM used Mann-Whitney U test, and within group analysis of BBS and FIM used Wilcoxon test. Besides Independent t test used for between group analysis and Paired t test was done for within group analysis of TUG by using SPSS version 22. Results: It was found that balance, functional status and mobility improved both between and within group results except standing unsupported one foot in front. Conclusion: This research showed that task oriented physiotherapy along with conventional physiotherapy was more effective than only conventional physiotherapy for patients with stroke.


LIST OF TABLES
Wilcox on sign rank test for individual variable of FIM 55 Table-10 Test statistics of FIM in each variable between group 56 Table-11 Mean difference of TUG test in the Control group 57 Table-12 Mean difference of TUG test in the Experimental group 59

Background
Stroke is the disorder where brain is damaged either by blockage in the blood vessels or rupture of the blood vessels of the brain. There are so many risk factors of stroke including modifiable and non-modifiable factors. The risk factors predominantly are high cholesterol, diabetes, smoking, atrial fibrillation and lack of physical activity.
The early and common signs include asymmetry in face, one side weakness, one side altered sensation and difficulties in speech (Jin, 2014).
American Stroke Association (2016) stated that, it is the approximately five number leading cause of death. It is also the leading cause of longer period disability as well as preventable cause of disability. African American people are more affected by stroke. As stroke affects the central nervous system especially when the brainstem, the vestibular system is more likely to affected and can cause dizziness, vertigo eventually imbalance. Among the stroke survivors about 40 percent approximately experienced falling over ground in 1 year of stroke. Women stroke patients have some experience in difficulties to maintaining their balance during dressing were several times a day (American Heart and Stroke Association, 2015).
It is the approximately 3 rd most leading cause of death globally where in UK it is the most important health problem. About 23% of people die within 30 days where 60-70% from the remaining dies within 3 years. The morbid portion have prolong stay in hospital, reduced quality of life due to extendedtime disability therefore it is also the secondary reason of disability and impairment in UK. This causes a big compromise in the economic sector (Parmer, Sumaria & Hashi, 2011). The brain is an exciting area in neurology as it is complex in anatomy and in function. With the advance of age in addition to decay, the brain become more prone to get many complicated life frightening diseases, so it needs a proper timely connection. Stroke is a critical condition, which causes death and disability in the world as well in Bangladesh.
Stroke treatment involves a multidisciplinary team. The team includes Physiatrist, Rehabilitation Nurses, and Physiotherapists, Speech therapist, Social Worker, Psychologist and Vocational councilor. Bangladesh is the most densely populated developing country in the world. Stroke isthe third most common cause of death and adult disability in Bangladesh (Islam et al.,2012).
There are so many impairments found in acute and chronic stroke patients including lower limb weakness which is second most affected part (72%), urinary incontinence, dysphasia, impaired consciousness, and cognitive impairment etc (Lwarence et al., 2001). Recently Lwarence, 2018 again examined that proper nursing and rehabilitation is needed to recovery of stroke impairments and disability in acute phase.
Stroke is the major cause for disability in worldwide and it is increasing day by day with high risk factors including modifiable and non-modifiable. So, it is a great concern about the burden of the society now days. Physiotherapy is playing a vital role for rehabilitation of the stroke patients and other neurological, musculoskeletal patients among the worldwide.
Physiotherapy is such a major component of medical science for rehabilitation of stroke patient (Daviason & Waters, 2000). It is used to assist patients for progress as much of their innovative body purpose as achievable (Gale, 2005).
Tsaih 2018 demonstrated that task oriented electro myographic biofeedback enhance the strength and balance of chronic stroke patients. Task related TA exercise enhanced affected TA muscle power in persistent stroke patients. Knox, Rewards & Rechard (2018), demonstrated that six hours" task training improve walking capacity of chronic stroke patients.
There are various approaches are used to treatment of stroke patients. Such as Task There is general opinion that physiotherapy improves the function of stroke patients. But the benefits seem to be normally and statistically small and limited (Dobkin & Dorsch, 2013).
Another study conducted by Tyson et al, (2006) stated that balance and mobility limitations are more common in chronic stroke patients. So, balance and mobility limitations can be improved by exercise (Mikle, Alen & Macko, 2006). Task oriented training or task oriented physiotherapy hasthe capacity in case of improve balance and mobility (Yang et al, 2006). In Bangladesh, most of the patient come at later stage and their improvement are not satisfactory. It is thought, if we can identify the specific factors, then we can give concentration on those specific factors for the better outcome of the people who are suffering stroke and they will get maximum benefit from physiotherapy treatment (Islam, 2013).
Several studies have been explored the value of task specific physiotherapy program to get better the equilibrium ability of the stroke survivors. Balance problem is a major problem of stroke survivors. A study by Kim, Lee, Bae, Yu & Kim (2012) on 20 stroke patients found a significant improvement on chest control, stability and walk ability after a comprehensive series of task oriented training program. Task oriented circuit training on balance and gait ability has been proved significantly effective to improve balance and gait (Kim, Jung & Lee, 2017).
Stability training by force platform with visual feedback technique (FPVF) showed a significant development of sense of balance in persistent stroke patient (Srivastava, Taly, Gupta, Kumar & Murali, 2009). Functional rehabilitation strategies had been proven to be effective in the improvement of postural balance of the stroke patients (Cordun & Marinescu, 2014).
Many of the studies have been explored the effectiveness of physiotherapy to improve the balance ability of the stroke survivors. Balance training by biofeedback has been proved significantly effective to improve postural control (Yavuzer, Eser, Karakus, Karaoglan, & Stam, 2006). Functional rehabilitation strategies had been established to be effective in the improvement of postural stability of the stroke patients (Cordun & Marinescu, 2014).
A systematic review was conducted by Van-Duijnhoven et al., (2016) to find out the Effects of exercise therapy on balance performance in chronic stroke. 43 randomized control trials were included from 2000 to 2015. Similar area interest has been created and the aim is to explore the studies conducted after the year of 2000 to 2017.
The lack of evidence based practice is evident in several areas of physiotherapy practitioners in Bangladesh. Lack of time, resource, busy schedule, ignorance, poor skill, lack of knowledge about electronic search strategies etc. are the possible causes which have been identified from the personal communication by the investigator with the physiotherapy practitioners. Therefore, the study can help the practitioners in Evidence based practice and encourage the other to continue further investigation.
In case of achieving independent sit to stand additional exercise is effective for improvement of balance for stroke patients and the result found significant difference. (Barreca, Sigouin, Lambert, Ansely, 2004).
Another study conducted by Blennerhassett and Dite (2004) found that extra taskrelated perform improves mobility and upper limb function early after stroke. The tasks became increasingly more complicated and feedback was reduced over the training course. No significant between-group variation was found for knee flexion peak at any time of evaluation (Jonsdottir, Cattaneo, Recalcati, Regola, Rabuffetti, Ferrarin, & Casiraghi, 2010). Ischemicstroke is more common in younger people and 85% to 90% due to ischemic and 15% to 10% is caused by hemorrhage age in western world. In Asia constitute a largepercentage (Hossain et al 2011). Pellicer, Lusar, Casanovas, & Ferrer (2017), demonstrated that study found effects on multimodal exercise on walking capacity and found improvement on functional ability of stoke patients.

Justification of the study
Stroke is themost important reason for death and mostprimary causes of grown-up disability with impairment in the world. One of the main purposesof the rehabilitative process is to help patients achieve as high a level of functional independence as possible within the limits of their impairments. Task related training (TRT) or task oriented physiotherapy is a treatmenttechnique that involves the performance of repeated work;aim oriented, purposefulactivities in a normalsetting.And it tries to improve balance and functional level with mobility to do ADLs properly and reduce impairment related to balance functional status and mobility.

Functional independence measurement scale (FIM)
The FIM instrument refers to a scale that is used to measure one's ability to function with independence. The FIM is used worldwide in medical rehabilitation units. The FIM score ranges from 1 to 7, with 1 (Total Assistance) being the lowest possible score and 7 (Complete Independence) being the maximum possible score.

Aim
To evaluate the effectiveness of task oriented physiotherapy along with conventional physiotherapy for the patients with stroke.
1.5Objectives of the study 1.5.1 General objective To determine and compare the effectiveness of task oriented physiotherapy along with conventional physiotherapy for patients with stroke.

Specific objective
To find out the socio demographic status and medical information of participants.
To find out the effectiveness of the Task oriented physiotherapy between and within group along with conventional physiotherapy to improve balance for patients with stroke.
To identify the effectiveness of task oriented physiotherapy between and within group along with conventional physiotherapy to improve functional status for the patients with stroke.
To find out the effectiveness of task oriented physiotherapy between and within group along with conventional physiotherapy to improve mobility for the patients with stroke.

Null hypothesis ((H0)
Task oriented physiotherapy along with conventional physiotherapy is no more effective than conventional therapy for the treatment of patients with stroke.
H o : µ 1 -µ 2 =0 or µ 1 =µ 2, where the experimental group and control group initial and final mean difference is same.

1.7Alternative hypothesis
Task oriented physiotherapy along with conventional physiotherapy is more effective than only conventional therapy for the treatment of patients with stroke H a : µ 1 -µ 2 ≠ or µ 1 ≠ µ 2, where the experimental group and control group initial and final mean difference is not same.

CHAPTER II LITERATURE REVIEW
Stroke is a common neurological condition in worldwide and it is increasing day by day. There are so many causes behind this problem and so many treatment procedures to solve this problem. Stroke patients face many difficulties including hand function, balance problem, gait problem, and movement difficulties. A common neurological insufficiency characterized by the sudden development of a clinical sign of focal disturbance secondary to a vascular event and persists more than 24 hours may know as stroke (Gayer & Gomes, 2009). Now a day"s stroke is the major familiar cause of impairment in (ADLs) activities of daily living and it is increasing worldwide (Hsieh & Sheu, 2001).
Stroke definition according to the World Health Organization (WHO) ""A clinical syndrome consisting of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than a vascular origin".
According to Sym and Kim (2015) stated that there are so many causes that stroke patients have so many difficulties in their body function including upper extremity task, lower extremity task, balance problem, postural problem, and gait problem. They found there is no significant in two groups. On the ramp, there is gait training with stroke patient enhanced active balance ability and a high-quality result for other neurological condition.
Stroke is caused by the stoppage of blood supply to the brain when there is clot or bursting of the blood vessels. Suddenly feeling weakness paresthesia pain or lack of sensation of the face area, upper limb or leg, the majority have frequently on one side of the body, uncertainty, problem facing in speaking or understanding speech, There are so many or huge number of nerve cell is dependable for controlling a variety of parts and processes within the body. If the cells are not organized or stopped function properly, the body parts they are responsible for controlling also cannot functioning properly (Ryan, 2006). TIA is most common and concerning a mini stroke is diagnosed by transient ischemic attacks (TIA), or mild-strokes, that for the moment break off blood supply to the brain. While TIAs source related symptoms (such as visualization problem, or provisional weak point in a limb), sometimes weakness spread all over the body including limb face as quickly as a few minutes (Bruno, 2004).
There is no standardized classification of stroke subtypes. Stroke or cerebra vascular accident (CVA) can be classified according to pathological type or temporal factors or their course of progression and each type has different causes (Bierman, 1993).
Ischemic stroke is the mainly familiar type of stroke. Ischemic stroke occurs when a brain artery is blocked for any reason. Approximately 80% of all strokes are Ischemic stroke. Brain cells cannot work if any artery is blocked for any unknown reason. The brain cell become dies if the artery is blocked for few minutes continuously (NINDS, 2004). When blood clot occurs or thrombus forms within the brain itself the stroke that means common type of stroke occurs. It may disturb the smooth blood flow through artery by the affected vessels. The term atherosclerosis of brain artery may cause by fatty deposit inside the blood vessels. The term Cerebral thrombosis which is occurs sudden at night or early in the morning and more common as TIA. By early diagnosis of TIA need urgent treatment and is very important for stroke prevention (Stroke Forum 2006). The word such French word "lacuna" meaning "gap" or "cavity". A lacunars stroke is one type of stroke when thrombosis occurs in smallvessel involves one of the brains, yet deeper penetrating arteries commonly lacunar strokes produces purely motor deficits purely sensory deficits or a combination of motor and sensory deficits (Bierman, 1993).
Embolic stroke is caused by an embolus. Most often cerebral embolism resulting for embolus forms in a blood vessel but away from the brain it occurs. Then it travels through the blood in artery or in the brain and may block the blood flow to the brain from artery. When arterial fibrillation occurs, it may form blood clot and it is the common cause of emboli. The duration of embolism without including any warning may develop rapidly, between 10-20 seconds (Avillion, 2002).
A hemorrhagic stroke is also common for stroke survivors and it occurs when artery of brain rupture and blood spread out the normal brain tissue and stopped the blood delivery to the brain and totally stopped the normal function of the brain.
Approximately 20% account for this type of all strokes. Hemorrhagic can occur in many ways. The most common causes are including bleeding aneurysm, a fragile or skinny spot on an artery wall; when arterial walls rupture open (NINDS 2004). In intra cerebral stroke, blood spreads into the subarachnoid space between the brain and cranium. As fluid builds up, force into the brain increases, impairing its function.
Hypertension is a recurrent source of these types of strokes, but Vessel with preexisting defects, such as an aneurysm, are also at risk of rupture. There are so many evidences to enhance the upper limb recovery by practicing repetitive task approaches (Higgins et al., 2006). Therapeutic intervention by using this approach enhances the target towards task training. This method influences active participation of repetitive task to the participants to enhance activity (Shumway-Cook & Woollacott, 2001). One study showed the application of task oriented approach including CIMT that means constraint induced movement therapy using the protocol of task practice; behavioral therapy severe only limb training with constrained to the unaffected extremity (Morris, Taub & Mark, 2006).
Effects of CIMT have been studied in individuals with acute sub-acute and chronic stroke including different severe condition of upper extremity motor impairment.
Therapy including many types of repeated work like task specific movement affected limb or single joints and gradually complex joint or multi joints.
Frence et al., (2010)  The study by Farqalit & Shahnawaz (2013), found the Asymmetrical foot positioning during sitting to standing training is more effective than symmetrical positioning. The experimental group had STS training by positioning the affected foot behind the normal foot where the control group had the similar training with symmetrical foot position, 5 days a week for total 4 weeks. The training promotes weight bearing on the injured leg, make the function more efficient and thus prevent fall on ground (Camargos, Rodrigues &Teixeira, 2009). Weight-bearing asymmetry of hemiplegic patient decrease by performing repetitive task with the affected foot placed behind the unaffected foot. This foot placement cause to bear more weight on the affected side.
The similar strategy used in task-specific training for improving STS in patients with sub-acute stroke (Brunt, Greenberg, Wankadia, Trimble & Shechtman, 2002).
The study by Cha, Shin and Kim (2017) found Bad Ragaz ring method along with comprehensive rehabilitation therapy is more effective than comprehensive rehabilitation therapy alone. This is a form of Aquatic therapy designed to improve balance and walking abilities. The physical characteristics such as viscosity, buoyancy, density, specific gravity, and hydrostatic pressure promote equal resistance to all muscle groups and increase sensory input. In addition, the hydrodynamic elements of water, including met centric effects and inertia, are essential for the maintenance and restoration of balance (Lambeck & Stanat, 2000). Jung, Kim, Chung & Hwang (2014) found Weight shifting training along with conventional therapy is beneficial than the conventional therapy alone. After stroke trunk muscle strength and weight-shift ability may be decreased. It is evident that reaching exercises in seated position improve sitting balance and gait speed in chronic hemiplegic patients (Dean et al. 2007). Yang, Kim & Lee, 2016 found Real-time Auditory Stimulation Feedback is an effective means on Balance and Gait ability of stroke patient. It is a software base intervention when patients make heel strike and foot flat on ground the software recorded the pressure and provided real-time auditory stimulation for the patients. Ordahan et al. (2015) found exercise administered with balance trainer is effective to improve balance and postural control in stroke patients. This is a biofeedback system which is used in the development of standing balance and postural control. Sharma and Kaur (2017) identified Core stabilization along with pelvic PNF was more effective for improving trunk impairment, balance and gait of chronic stroke patient.
The core muscles -transverse abdominis, multifidus, Para spinals, quadrates lumborum, and obliques were trained. The muscles of the trunk and pelvis are measured as core musculature that is dependable for maintaining balance (Kibler, Press & Sciascia, 2006).
Kyo and hayon 2015 stated that ramp gait exercise with PNF improves stroke patients dynamic balance ability and good outcome of a ramp gait. PNF is an important approach to therapeutic exercise that assemble functionally improve pattern of movement with techniques of neuromuscular facilitation to promote motor response neuromuscular control and function (Kisner & Colby, 2007). "Hallmarks of this approach to therapeutic exercise are the use of diagonal patterns and the application of sensory cues specifically proprioceptive, coetaneous, visual and auditory stimuli-to elicit motor response" (Kisner & Colby, 2007). Scapular PNF technique organizes functional patterns for performing the exercise and can be used to stretch or strengthen muscles selectively. These techniques also help the muscle to relearn the normal time of ingathering and amount of activation to maintain the balance between different groups of muscles. One of the technique exploited in PNF is hold relax technique. This hold relax technique is very effective, simple, and pain free technique which has dynamic to work up relaxation improve flexibility and reduce pain. The proprioceptive neuromuscular facilitation technique also elevates the trunk stability of stroke patients. Good trunk stability is essential for balance and upper extremity use during daily living activities. Proprioceptive Neuro Muscular facilitation stimulates proprioceptors within the muscle and tendon thereby improving function and increasing muscle strength, reduces pain (Klein et al., 2002).
Muscles such as abdominal and multifidus are usually contract prior to the prime movers of the lower limb which is called the feed forward mechanism to stabilize the spine (Hodges and Richardson, 1997). Kall et al. 2017 found that long-term engagement in multimodal rehabilitation programs is effective for stroke patients.
Multi modal therapy provides sensory-motor stimulation, the 3-dimensional movements of the horse mimic the normal individual gait pattern, is revealed to be effective for the stoke patient.
Llorens, Gomez, Alcaniz, Colomer and Noe, (2015) found Virtual reality based therapy combined with conventional therapy is effective to improve balance of stroke patient. This is a skill based rehab program which is effective and motivation tools.
Lee, Lee & Lee (2013)found that gait training with Body Weight Support Treadmill Training improves gait and balance in chronic stroke patient. This is used for the patients who have difficulties in full weight bearing on their lower limbs. The remarked activities increase the function and walking capacity (Visintin, Barbeau, Korner-Bitensky, & Mayo, 1998). Cho, Kim & Lee (2012) found that balance and gait can improve by gait training with motor imagery training of chronic stroke patients significantly better than gait training alone. The motor imaginary practice improves learning ability. It is showed in some studies that the same parts of the brain are activated like the actual performance (Butler& Page, 2006). The studies that have been discussed above explored and presented some new effective treatment strategies to improve balance of chronic stroke patient and that was the aim of the current study.
Another study showed that task training with group therapy is a safe treatment and it is better when compared with another task training including individual task training of equal based dose. It is safe training program for self-reported mobility for the unable to walk independently stroke patients (Caroline, Jacqline, Ricarda, Brandel, Kawkel & Hammelsheim, 2015).
Lee, Lee & Lee (2013)found that Intensive gait training with Body Weight Support Treadmill Training improves gait and balance in chronic stroke patient. This is used for the patients who have difficulties in full weight bearing on their lower limbs.
Although another study said that initially it is not advised for poor walkers as intervention, also BWSTT may not reflect the task-related environment of overground training for motor learning (Dobkin, 2012).
Villager, Chandrasekhar & Welsh (2011) stated that Functional task-oriented training recently applied to patients with stroke is more effective than the conventional therapy. Recent studies have shown that task oriented training helps to enhance the functions of the upper extremity, but mostly in terms of balance with other body parts and balance while walking. Others have claimed that such training also helps patients take care of themselves Task-oriented mirror therapy is conventional, movementoriented mirror therapy with addition of functional tasks (Arya, Verma, Garg, Sharma & Agarwal 2012). Achievement of positive effects of both the conventional and taskoriented therapies leads to optimum results of rehabilitation.
Another study proved that effects on static and dynamic balance of task oriented training are more effective for chronic stroke patients in water or on land. They provide strengthening exercise program for individuals with chronic stroke patients to improve the muscular weakness and inhibited the improvement to functions. Finally, they got the result that in water exercise effectively improve on the balance of chronic stroke patients (Lee, Ko & Cho 2010).
Fayes et al, 1998 stated that specific intervention during acute phase after stroke improved motor recovery that was proved after 1 year of taking intervention. It is proved that task specific intervention is important for stroke patients and it is beneficial for the enhancement of upper limb motor recovery in later phase. Arm function recovery is poor in stroke patients found several studies but it helps to minimize the upper limb problem.
Recently a study was conducted by Liu et al (2018) stated that cognitive behavioral therapy and task oriented balance training helps to reduce fear of falling in chronic stroke patients. There are two major challenges for stroke patients like fear of falling and balance problem. So, they proved that combination of this therapy reduce the fear of falling and balance problem. They use as intervention including stepping up and down, heel raising exercise, semi squatting, standing on a dura, obstacles walking.
Intervention was given twice a week for 8 weeks. Finally, the result founded that this is very effective, also cost effective to reduce the fear of falling and balance problem besides improve the quality of life of stroke patients. another study by using The Brief

Self-Efficacy Scale Interdisciplinary Comprehensive Arm Rehabilitation Evaluation
(ICARE) measure the participant"s confidence when using the weaker arm.
Intervention system was fixed and this encouraged specific practice in the home or societysetting (Winstein et al., 2013).
Recently another study was conducted by Liu et al (2019) stated that cognitive behavioral therapy and task oriented training reduce the fear of falling and balance problem. This study provides important new information about the efficacy of an 8-week,16-session Cognitive Behavioral Therapy with Task Oriented Training intervention that seems to reduce the fear of falling and fear-avoidance behavior and improve balance and independent daily living, with benefits maintained for 12 months after completing the intervention. Cognitive Behavioral Therapy seems to be a possible adjuvant therapy to supplement the treatment effects of usual physiotherapy in cognitively intact people with a history of stroke.

CHAPTER III METHODOLOGY
This thesis evaluated the effectiveness of task oriented physiotherapy along with conventional physiotherapy for the patients with stroke. To identify the effectiveness of this treatment regime, berg balance scale, functional independent measurement scale and time up and go test were used as measurement tools for measuring balance, functional status and mobility.

Study design
The study was a quantitative evaluation of classic experimental research design.
Classic experimental research finding out the causal relationship between independent and dependent variables and infer the findings for generalization (Depoy and Giltin, 2015). In fact, the study was an experiment between different subject designs. Task oriented physiotherapy along with conventional physiotherapy applied to the treatment group and only conventional physiotherapy techniques applied to the control group. It was a single blinded study where the participant was blinded. A pretest before intervention and posttest after 24 sessions of intervention was administered with each subject of both groups to compare the functional improvement effects before and after the treatment.

3.2Study Area
The study was conducted from outpatient, neurology physiotherapy unit of center for rehabilitation of the paralysed (CRP), Savar, and Dhaka 1343.

3.3Study Site
This study was done in Centre for the rehabilitation of the paralysed (CRP), Chapain, and Savar, Dhaka 1343.

Study period
The duration of the study was 10 Month. This study was conducted from August 2018 to April 2019.

Study Population
The patient of the Hospital treated in Neurology Unit Outpatient of Physiotherapy Department. Patients was Diagnosed as Stroke or stroke.

3.6Sample size
The patients who came to neurology unit of physiotherapy department, CRP, Savar from October 1 to December 30, 2018 and who met the inclusion criteria was selected for the study. And total 30 participants met the criteria was included in the study.
Who did not meet the criteria was excluded. So, sample size for this thesis was 30.
Among them 15 participants were in trial group and 15 participants in control group.

3.7Sampling Technique
30 participants with stroke who met the inclusion criteria selected conveniently from outpatient neurological unit of physiotherapy department of CRP, Savar and Dhaka.
All the participants had equal probability of assessing to any of two groups and 15 patients were randomly assigned to experimental group comprising of treatment approaches of task oriented physiotherapy along with conventional physiotherapy and 15 participants to control group treated by usual conventional therapy for this study.
Single blinding procedure was followed in this study. The participants were assigned into experimental group and control group by using computed generated random number from 1 to 30. An initial randomization was done by computer to identify the participants of experimental and control group and the first participants came out in the experimental group.

3.8Inclusion criteria
Subject selection from CRP: Subject was selected from outpatient Neurology unit, Physiotherapy Department, CRP at Savar, Dhaka.
Male and female both were included: Both male and female who had stroke were included because Sherrington, et al. (2016) showed that prevalence of male and female both are at high risk.

Patients diagnose as stroke:
This type of stroke patients were included because physiotherapy favors most in terms of ischemic or hemorrhagic stroke based on MRI or CT scan (Winstein et al, 2016).
Ability to walk 10 meters: The researcher included this type of patients because this type of patients has shown effectiveness in previous study (Kim, Lee, Bae & Kim 2012) Age range between 35 to 80years: This age range was selected because most of the people suffering from stroke around the age range showed most vulnerable (Timmermans et al, 2014).
Suffering from stroke at least 6 months: Duration of stroke within 6 months after stroke (Kim, Jung & Lee 2017)
Participants who were unwilling to participate.

Data collection Tools
The interviewer was asked from the structured questionnaire which was designed to collect information on related. However, the questionnaire was comprised of five sections of items.

3.10.1Berg Balance Scale (BBS)
The Berg balance scale is used to objectively determine a patient's ability (or inability) to safely balance during a series of predetermined tasks. It is a 14-item list with each item 18 consisting of a five-point ordinal scale ranging from 0 to 4, with 0 indicating the lowest level of function and 4 the highest level of function and takes approximately 20 minutes to complete.

3.10.2Functional Independent Measurement (FIM)
The Functional Independence Measure (FIM) is an assessment tool that aims to evaluate the functional status of patients throughout the rehabilitation process following a stroke, traumatic brain injury, spinal cord injury or cancer. FIM is comprised of 18 items, grouped into 2 subscales -motor and cognition. 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. 1 -Total assistance with helper, 2 -Maximal assistance with helper, 3 -Moderate assistance with helper, 3 -Moderate assistance with helper, 5 -Supervision or setup with helper, 5 -Supervision or setup with helper, 7 -Complete independence with no helper.
The total score for the FIM motor subscale (the sum of the individual motor subscale items) will be a value between 13 and 91.
The total score for the FIM 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.

3.10.3Timed Up and Go Test
Patients wear their regular footwear and can use a walking aid, if needed. Begin by having the patient sit back in a standard arm chair and identify a line 3 meters, or 10 feet away, on the floor.

Data collection procedure
The data collection procedure was conducted through assessing the patient, initial recording, treatment and final recording. After screening the patient at department, the patients were assessed by a graduate physiotherapist by the structured and close ended questionnaire with face to face interview. Twenty-four sessions of treatment were provided for every subject. Thirty subjects were chosen for data collection according to the inclusion criteria. The researcher divided all participants into two groups and coded (n=15) for control group and (n=15) for experimental group. Experimental group received conventional physiotherapy with task oriented physiotherapy and control group received only conventional physiotherapy.
Pretest was performed before beginning the treatment and the balance were noted with BBS, FIM, and TUG score on questionnaire form. The same procedure was performed to take post-test at the end of twenty-four session of treatment. Researcher gave the assessment form to each subject before starting treatment and after six sessions of treatment and instructed to put tick mark on the subjective part and objective part like BBS, FIM and TUG questionnaire according to their balance, functional status and mobility performance. The data collector collected the data both in experimental and control group in front of the qualified physiotherapist to reduce the biasness.

3.12Intervention regimen
Step up Balance board exercise

Kicking a ball Stand and walk
Obstacle course Walk and carry

Questionnaire
The questionnaire was developing under the advice and permission of the supervisor following certain guidelines. There were seven close ended questions with socio demographic information and six another question for medical information, fourteen questions for measuring berg balance scale, nineteen questions for measuring functional independence measurement scale, and lastly one question for measuring time up and go test. First seven questions were formulated to identify the socio demographic status of the stroke patients. Six another question for medical information. Another Fourteen questions for balance, nineteen questions for functional status and one question for mobility. All questions were related to balance, functions and mobility of stroke patients.

14 Data analysis
Statistical analysis was performed by using statistical package for social science (SPSS) version 22.

3.14.1Statistical test
Statistical analysis refers to the well-defined organization and interpretations of the data by systemic and mathematical procedure and rules (DePoy and Gitlin, 2015).
Mann-Whitney U-test was used for between group"s analysis of balance and functional status. Within group analysis of balance and functional status was analyzed by Wilcoxon signed rank test (Hicks, 2009). Unrelated test and paired t test for between and within group analysis of mobility.

3.14.2Level of Significance
To find out the significance of the study, the "p" value was calculated. The p values refer to the probability of the results for experimental study. The word probability refers to the accuracy of the findings. The level of significant was set at 95% (p<0.05). A p value is called level of significance for an experiment and a p value of <0.05 was accepted as significant result for health service research. If the p value is equal or smaller than the significant level, the results are said to be significant (DePoy and Gitlin, 2015).

3.14.3Treatment Regime
Three physiotherapists who were expert in treatment of neurological patient were involved in treatment of patients. All the physiotherapists have the experience of more than three years in the aspect of neurological physiotherapy. Among them, four were male and two was female physiotherapist. Protocol for conventional physiotherapy was obtained from head of physiotherapy department, Centre for the rehabilitation of the paralysed (CRP) (Appendix-F). An in-service training was arranged to share the information with practical demonstration regarding task oriented physiotherapy including patient position, number of task, dose, rest interval and repetition of task (Appendix-G) with conventional physiotherapy.

3.15Quality control and assurance
The investigator had enough knowledge in the designed study, hence the study area and underneath issues had been keenly explored by him. The format of the questionnaire was purely structural, thus it enabled a definitive answer. The questionnaire was developed according to the literature search. Follow the international accepted questionnaire and peer reviewed for reliable questionnaire. The investigator tried to avoid selection bias due to strictly maintained inclusion and exclusion criteria. The study was avoided conflict the selection of participants.

Ethical consideration
The      Among the all 30 participants ischemic type was 83% and hemorrhagic type was 17%. In control group, ischemic type was (n=11) 73.3% and hemorrhagic type was (n=4) 26.7%. On the other hand, in experimental group, ischemic type was (n=14) 93%, hemorrhagic type was (n=1) 6.7%. Among the all 30 participants using assistive device were 90% (n=27) and not using assistive device were 10% (n=3). In control group, using assistive device participants were 87% (n=13) and not using assistive device participants 13% (n=2). In experimental group, using assistive device participants were 93% (n=14) and not using assistive device participants 7% (n=1) Among the all 30 participants history of fall experience were 7% (n=2) and no history of fall experience were 93% (n=28). In control group, history of fall experience was 0% (n=0) and no history of fall experience 100% (n=15). In experimental group, history of fall experience was 13% (n=2) and no history of fall experience 87%

Total 30
The result showed that the calculated value of U is 43 for berg balance scale. From the calculated value (U=43), it was clear that U value between experimental and control groups had an associated probability. The level of significance is .003 which is less than 0.05. Therefore, the result is significant for one tailed hypothesis. Since the p value is less than 0.05, the result is significant and the null hypothesis (no relationship) is now rejected and the alternative hypothesis is accepted. So, it can conclude that task oriented physiotherapy along with conventional physiotherapy is more effective than only conventional therapy between group analysis of individual variables to improve balance for the patients with stroke in terms of balance.  Table 4 showed U score of each individual variable between control and experimental group of BBS is significant difference in all variables.  Transfer .008

Mann Whitney U test
Standing unsupported with eye closed .007 Standing unsupported with feet together .045 Reaching forward .008 Pick up object from the floor .008 Turning to look behind .048 Turn 360 degrees .009 Place alternate foot on step .004 Standing unsupported one foot in front .019 Standing on one leg .003 Table proved that between groups analysis in each components of BBS showed significant improvement occurred in all variables. It indicated that task oriented physiotherapy along with conventional physiotherapy found effective treatment for patient with stroke in terms of improving balance capacity.

Total 30
The result showed that Mann Whitney U test score for FIM is 37. And observed p value is .002 which is less than 0.05. So, we conclude that there is a significant difference between the distribution ranks in the FIM that is the exists significant difference in recalling the item between control post FIM and experimental post of FIM. So, the test is significant for functional status and the null hypothesis is rejected and alternative hypothesis is accepted. Patients who were taken task oriented physiotherapy along with conventional therapy showed effectiveness in functional status rather than patients who were only taken between group of individual tasks.

Pre-test
Post-test   The result showed Unrelated/independent t test in between group at 5% level of significant described that the calculated t value is 2.614 and for df= 28, the calculated t value is smaller that has an associated probability level of .16%. This means that the probability of random error being responsible for the outcome of this experiment is in 0.16. As the usual cut-off point for claiming support for the experimental hypothesis was 16% and it could be said that the result was significant. Thus, task oriented physiotherapy along with conventional therapy for the patients with stroke was more effective than conventional physiotherapy alone for the patients with stroke. This study found that in timed up and go test observed t value was 5.580

Within group analysis
(4.867±3.378) in the control group at two tailed paired t test while this same variable for experimental group observed value was 11.033 (6.93±2.434). 5% level of significant at 14(fourteen) degrees of freedom standard t value was 10.500. The observed t value in experimental was more than the standard t value, so null hypothesis was rejected and alternative hypothesis was accepted, that indicated that task oriented physiotherapy is effective for the patients with stroke. The observed t value in control group was less than standard t value that means null hypothesis was accepted and alternative hypothesis was rejected in the between group. Table showed that within group analysis of TUG test the improvement of Time up and go test was highly significant and in fact in control group (p= 0.000) and trial group (p= 0.000).

DISCUSSION
The purpose of the study was to find out the effects of task oriented physiotherapy along with conventional physiotherapy for stroke rehabilitation. The result of the study shown that combined task oriented physiotherapy training was found more beneficial in comparison to only conventional physiotherapy alone to improve the balance, functional status and mobility performance in ambulant stroke subjects. The baseline characteristics of all the subjects were similar in both experimental and control group. The study showed significant difference in both group and following 8 weeks" task oriented physiotherapy intervention session there was a significant improvement in balance and functional status.
The result showed that among the stroke patients about 43% were male and 57% were female, where all the female participants were housewife. In contrast an epidemiological study in Bangladesh showed that 74% were male patients and 26% were female patients (Islam et al., 2012). So, it could be male are more affected than female in stroke but in our study, female participants were more than male.
Result showed that among 30 participants, 2 participants was illiterate in the control group and no participants was in experimental group, 10 participants of control group was in primary level and 12 participants was in experimental group. Higher secondary was no participant in control group whereas 2 participants in experimental group.
There were 2 participants was in honors level in control group and 1 participant was in experimental group. In Masters Level 1 participants was from control group and no participant from experimental group. In compare a study by Hossain et al. (2011) in Bangladesh found that approximately received schooling patients were 31%, collage education received were 19%, university going or like similar institution patients were 13%and patients who were not attend school or others was 37%. Among the 30 participants weight are grouped into 3 categories such 50-60kg (n=13) 43% among them in control were 7 and experimental were 6 participants, 61-70 kg (n=11) 37% in experimental were 6, control were 5 participants and 71-80kg (n= 6) 20% in experimental were3 and control were 3 participants.
The result found that 43% (n=13) were between 51-60 kg, 37% (n=11) were between61-70 kg and 20% (n=6) were between 71-80 kg and the mean weight for the control group was 63.07 kg and for the experimental group was 62.73 kg.
The study also showed that the stroke was Ischemic type in 83% of the participants Where hemorrhagic type in 17%. In control group, ischemic was (n=11) 73.3% and hemorrhagic was (n=4) 26.7%. In experimental group, ischemic type was (n=14) 93%, hemorrhagic type was (n=1) 6.7%. In an epidemiological study, it was found that the greater part (61·18%) patients suffered from an Ischemic and others had intracerebral hemorrhage (29·40%), subarachnoid hemorrhage (8·24%), or aneurysm (1·18%) (Islam et al., 2012). In this study, it was found that Ischemic and In terms of BMI, majority of the participants in the experimental group were normal weight (50%) followed by overweight (35.72%), obese 14.28% and in contrast control group had similar 42.85% normal weight and overweight participants separately and 14.3% obese participants. In another study showed that 56.8% participants BMI was less than 25 and 34.3% participants BMI was more than 25 (Choo et al., 2009).
In the study 10 % participant were not used assistive device and 90 % participants were used assistive device. In contrast another study showed that 9% participants were using walker, 45% participant were using cane and 46% participant were not used any assistive device (Salbach et al., 2006).
The mean difference indicates that balance more improved in Experimental group than Control group. Pre-test mean difference was 15 and post-test mean difference was 17.86. Statistically the study was analyzed by Mann Whitney U test where the U value was 43. The critical value of U at (p≤. 05) was 28. Therefore, the result was significant at (p≤ .05) at one-tailed hypothesis. Most of the variables indicated that the result was significant, although some variables indicated not significant result. So, the overall result was statistically significant.
In this study the mean pretest BBS score was 41.06 with a mean after 8-week rehabilitation of 59.06. This balance gain is highly significant (p<0.001). In compare a study the admission mean BBS was 35.75 ± 11.55. All the patients were chronic (Srivastava et al., 2010). In this study in pretest score of BBS was 15(50%) were wheelchair bound, 12(40%) were walking with assistance and 3(10%) were independent. After 8-weeek intervention study found there were no wheelchair bound, 12(33.3%) were walking with assistance and 18(60%) were independent.
Rehabilitation decreases the disability and improves balance. Another study showed that among stroke patients taken physiotherapy session on average 13.6 days average number of therapy session per day was 1.5 and average time of per session was 38.1 minutes (Jette et al., 2005).
The result showed for TUG test calculated by Unrelated/independent t test in between group at 5% level of significant described that the calculated t value is 2.614 and paired t test for TUG test observed t value was 5.580 (4.867±3.378) in the control group at two tailed paired t test while this same variable for experimental group observed value was 11.033 (6.93±2.434). 5% level of significant at 14(fourteen) degrees of freedom standard t value was 10.500. This indicated that task oriented physiotherapy treatment approach was more effective for improving functional status for the patients with stroke. In this study mobility improved significantly. In comparison with another study proved that high intensity task oriented training can improve mobility early after stroke (Outermense et al, 2010).
The present study determined the effects of task oriented physiotherapy along with conventional physiotherapy for improving balance, mobility and functional status of patients with cerebro vascular disease or as well as stroke. Some studies have found that task oriented physiotherapy is effective for stroke patients. In comparison with one study conducted by Liu et al, 2019 stated that task oriented training and cognitive behavior therapy is decreased the fear of falling of the stroke survivors.
In contrast another study found the effects of Oculomotor and Gaze Stability Exercise on Balance after Stroke (Pimenta, Correia, Alves, &Virella, 2017).
In this study sample size was 30 in comparison to another study conducted by Blennerhassett and Dite (2004) found that extra task-related practice can change the performance of patients to improve mobility and upper limb function early after stroke, a randomized controlled trial. The sample size was thirty diagnosed as subacute stroke into two group one group was mobility group n=15 and upper limb group (control) n=15. It was a movement science approach like task oriented training. They received standard rehabilitation program of extra training including five times per one-hour session per day for total four weeks. Mobility group were receiving training like stationary bikes, treadmills and task training including sit to stand, step up, obstacle course walking, standing balance stretching strengthening exercise. After 6 months" outcome were measured. Outcome measurement tools were the Jebsen Taylor Hand Function Test, Motor assessment scale, 6MWT, TUG test. Only significance was found for the 6MWT and the TUG in favor of the Mobility Group.
In this study intervention duration was 3 times per day for 45 min per day for total 8 weeks. In contrast another study conducted by Knox, Stewart and Richard (2018), showed six hour of task oriented training improve walking competency in post stroke patients. Their intervention period was 12 weeks which support our study intervention period approximately 8 weeks. Another study also stated that task oriented motor rehabilitation therapy improves performance in motor tasks (Amky, Baumgartner, Bracko, Luft& Wegener, 2017). In comparison a study conducted by Dean Richerd and Mallouin, 2000 found that Task-related circuit training program improves performance of locomotor tasks for the patients with chronic stroke: A randomized, controlled pilot trial. The sample size was nine and in experimental group was 5(n=5) who were participated in task oriented training based on exercise circuit. On the other hand, control group 4 participants (n=4) was received circuit training intervention.
Total 10 exercises mainly focused to improve functional abilities. The duration of exercise was one hour per day, 3 times per week for 4 weeks. Participants were encouraged to do more complex tasks with more repetitions. Outcomes were measured at base guideline and after 4 weeks and at 2 months. Measurement tools were 6MWT, 10MWT, TUG test. Significant group difference was found in walking speed, walking endurance and ability to balance. No other between group difference whereon instead off sit to stand. Stand, but only at the 4-week time point.
In this study no follow up session was conducted but in contrast other study they had follow up session of 6 months. Participants were 20 patients with chronic stroke.
Task-oriented training with biofeedback (n=10) and or usual rehabilitation care (UC) (n=10). Duration of treatment was 3 times per for 45 min, total 6 weeks" sessions. The outcome of the study was taken at baseline and after 6 weeks. And 6 months follows up. It involved gait-training using feedback from an acoustic signal to indicate the amount of muscle contraction used during walking. The result of the study was no significant between-group difference was found for knee flexion peak at any time of assessment (Jonsdottir, Cattaneo, Recalcati, Regola, Rabuffetti, Ferrarin, & Casiraghi, 2010).
There are so many evidences to support upper extremity training by via functional task approach (Higgins et al., 2006). Therapeutic intervention by using this approach enhances the goal towards task practice in training. This approach influences active participation of repetitive task to the participants to enhance activity (Shumway-Cook & Woollacott, 2001). One study showed the application of task oriented approach including CIMT that means constraint induced movement therapy using the protocol of task practice; behavioral therapy severe single limb training with constrained to the unaffected limb (Morris, Taub & Mark, 2006).
Effects of CIMT have been studied in individuals with acute sub-acute and chronic stroke including different severe condition of upper extremity motor impairment. A Cochrane review by Sirtori and colleagues (2009) found total 19 studies including 619 participants and they concluded that CIMT resulted in "moderate reduction in disability," but six-month benefit is not clear. Again, they conduct another randomized control trail for a Cochrane review in 2010 including total 674 participants. (Corbetta, Sirtori, Moja, & Gatti, 2010). They concluded that CIMT resulted in "modest improvement in arm motor function" and that it has "no evidence of benefit on disability." Shweta and Shuvarna stated that task oriented rehabilitation after stroke is effective and relevant for stroke practice. The probable mechanism for effectiveness of task related training may be assumed that to an improvement of presynaptic inhibition of the hyperactive stretch reflexes in spastic muscles, decrease in the co contraction of spastic antagonists, and disinhibition of downward controlled instructions to the motor neurons of paretic influence.
Another study stated that task oriented training with cognitive behavior therapy de crease the fear of falling in chronic stroke patients (Liu, Yf, Chung & Ng, 2019). It can support our study which is mobility improvement and decrease the risk of falling in stroke patients.
Another study was conducted by Outermans, Peppen, Wittink, Takken, &Kwakkel, found the Effects of a high-intensity task-oriented training on gait performance early after stroke: a pilot study. The sample size was 44 patients diagnosed by sub-acute stroke and they were randomized into two group. One is high-intensity task-oriented training for mobility (n=23) or low intensity standard therapy (n=21). Training period was 3 times per week for total 4 weeks with 45 min per sessions. They included 10 standard tasks mainly focusing on improving walking competency using functional mobility tasks. Outcome measure was Berg Balance Scale (BBS), 6-Minute Walk Test (6 MWT), Functional Reach Test (FRT). Outcome measure was collected at baseline and 4 week later. In the high intensity group, more repetitions were added; in the low intensity group, the motor control challenge of each task was enhanced. No significant between-group differences were found for the BBS or the FRT.
In compare to our study another study was found and they had Twenty-seven patients diagnosed as acute stroke were randomly assigned into three groups. In experimental group, they received intensive gait-focused task-oriented training and in control group they received physical therapy containing old general approaches for 5 weeks. All groups received conventional hospital care. Outcomes measurement were assessed pre-intervention, post-intervention including Fugl-Meyer Assessment, Berg Balance Scale, Barthel Index, 6-meter walk test, electro goniometer. After completion of 6 weeks" intervention they found non-significant between-group difference. There were no other significant between-group differences.
Therapy for the hemi paretic arm might begin with single-joint attempts at movement before proceeding gradually to more complex, multi-joint actions, then task-specific practice such as reaching to grasp a coffee cup, a process known as shaping.
Facilitation of skilled motor practice for the upper extremity can take several forms, including shaping plus constraint induced movement therapy (CIMT). This technique includes 6 hours a day of progressive task-related practice with restraint of the unaffected limb all day for 2 weeks. Increased use and faster skilled movements of the affected limb may result and persist for up to two years (Wolf et al., 2008). However, the intervention has shown efficacy only in patients who can partially extend the wrist and fingers, meaning they have fair motor control and at least modest corticospinal tract sparing. Extensive restraint may not be as critical to gains as the high intensity of practice with a therapist; gains have been seen with just 2 hours of daily practice and without restraining the unaffected hand all day (Smania et al. 2012).
A study conducted by Salbach, Mayo, Hanley, Richard, Cote, (2004) found that taskorientated intervention enhances walking distance and speed in the first-year post stroke: a randomized controlled trial. The sample size was 91 patients diagnosed as stroke. They were randomized into two group like intervention group 44 patients who received task-oriented mobility training including different category functional tasks for lower extremities and improve walking balance, distance and speed, and besides to a control group including 47 patients that received upper extremity task-oriented training such as writing or typing on a keyboard. Duration of training was 3 times a week for 6 weeks. Outcomes were assessed at baseline and immediately following intervention after 6 weeks and measurement tools was Six-minute Walk Test, Berg Balance Scale, Timed Up and Go test. The study found at post-intervention there was a significant between-group difference in favor of the intervention group for the following outcomes.
However, in contrast another randomized controlled clinical study with 60 participants the researchers did not find a significant difference between post-stroke gait training using treadmill with partial body weight support and on ground motor relearning gait training (Nilsson, Carlsson, Danielsson, Fugl-Meyer, Hellstrom, Kristensen, et al., 2001). Both groups were significantly improved on Functional Independence Measure (FIM), walking velocity, Functional Ambulation Classification (FAC) and Berg's Balance Scale.
There are so many studies found for upper extremity and only few studies found for lower extremities. Although the lower extremity showed good prognosis instead of upper extremity. Some studies demonstrated that approximately 80% stroke patients survive the acute phase with walking ability and 30% to 66% have facing arm disability (Kwakkel, Kollen &Wagenaar, 1990). The upper extremity recovery procedure is almost slower than the lower extremity recovery process (Kwakkel, Wagenaar, Kollen, & Lankhorst, 1996).
Ghazal& Amjad (2016) stated that task oriented training improves the balance as well as balance outcome of stroke patients with diabetes. It also played an important role to reducing fall risk in diabetic population. Another study found the effects of activity repetition training who were doing Salat prayer compare with task oriented training program. They found effectiveness and proved improve in functional outcome (Ghous, Malik, Amjad, & Kanwal, 2017 (3), 76-80.

CHAPTERVI LIMITATIONS
The study has several limitations. The sample size was very small, so the result is difficult to generalize among whole population. Researcher has taken help from one assessor for data collection purpose, it may vary result. Data was collected one clinical setting CRP Savar, it can influence the result. Sometimes treatment sessions were interrupted due to public holiday mistaken in appointment schedule may interrupt the result. 6% participants were illiterate; it may give data error way.
Therefore, the duration of the effect after the experimental intervention is unknown.
Also, further research is needed to confirm the effectiveness of task oriented physiotherapy along with conventional physiotherapy for patients with stroke. The rehabilitation period was small only 8 weeks for total 24 sessions of intervention for the two groups that experimental group and control group. Similar studies with longer intervention time are required for conclusive results. However, the present study is meaningful because it suggests that simple task oriented physiotherapy routine can improve balance, functional status and mobility of patients with stroke. Owing to limitations of the present study further studies are needed.

CHAPTER VI CONCLUSION & RECOMMENDATION
Physiotherapy is a modern scientific treatment approach which is evidenced based.
So, people are more concern about their disease and management. and advance data analysis methods to provide information about the performance of specific and the quality of use. Further study should be done in more specific treatment or placebo treatment in control group compared with task oriented physiotherapy treatment approach for stroke patients. There were no upper extremity measurement tools, no follow up sessions. As will be discussed above the upper extremity related articles used in this study may have been inadequate, and future studies should use measure more specific and sensitive to the intervention. In addition, no follow-up session was conducted. I would like to ask you some questions regarding thesis and I will meet you for two times including pre-intervention and post intervention session. I am assuring you that management provided to you would not cause any harm. Moreover, treatment would be provided by physiotherapist. The information will be kept confidential and will be used only for thesis purpose.
You have the right to withdraw your participation at any time. Besides If you feel uncomfortable to give answer to any question you can escape that question.
Questionnaire will take 20 to 30 minutes to fill up. Please give me the correct answers of the questions and allow the data collector to examine your health condition. Questionnaires were developing to measure Balance by Berg Balance Scale (BBS), Functional Independency measure by Functional Independence Measurement Scale (FIM), and to measure mobility by Time Up and Go Test (TUG). Please use a black pen to fill up the answer. Each question should be answer by tick (√) marking. I am also requesting you to provide tick (√) mark on the specific one answer that most closely relates to you.