RESEARCH PROPOSAL
EVALUATION OF THE DEGREE OF IMPAIRMENT IN TRUNK, UPPER LIMB AND LOWER LIMB AMONG SUBJECTS WITH STROKE AND ITS RELATION TO FUNCTIONAL OUTCOME.
MPT (NEUROLOGICAL AND PSYCHO-SOMATIC DISORDERS)
Ms. LIKHI. M
DEPARTMENT OF PHYSIOTHERAPY
FATHER MULLER MEDICAL COLLEGE
MANGALORE-575002
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
KARNATAKA, BANGALORE
ANNEXURE II
PROFORMA FOR REGISTERATION OF SUBJECTS FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / Ms. LIKHI. MDEPARTMENT OF PHYSIOTHERAPY
FATHER MULLER MEDICAL COLLEGE
MANGALORE-575002
2. / NAME OF THE INSTITUTION / FATHER MULLER MEDICAL COLLEGE
MANGALORE
( PHYSIOTHERAPY COURSE)
3. / COURSE OF THE STUDY / MASTER OF PHYSIOTHERAPY.
(PHYSIOTHERAPY IN NEUROLOGICAL AND PSYCHO-SOMATIC DISORDERS. )
4. / DATE OF ADMISSION TO THE COURSE / 31-05-2008
5. / TITLE OF THE TOPIC / EVALUATION OF THE DEGREE OF IMPAIRMENT IN TRUNK, UPPER LIMB AND LOWER LIMB AMONG SUBJECTS WITH STROKE AND ITS RELATION TO FUNCTIONAL OUTCOME.
6.
7.
8. / BRIEF RESUME OF THE INTENDED WORK.
6.1 NEED FOR THE STUDY:
Stroke essentially continues to have a great impact on public health,as a major cause of long-term disability1.Nevertheless,with the initiation of early inpatient
rehabilitation programs, it has become possible to lessen the residual impairments and disabilities2.
Trunk impairment has been found to be an important predictor of functional outcome after stroke3.Equally significant is the upper and lower extremity status,
since it greatly affects the overall function4, 5, 6.
Attainment of optimum functional independence is the ultimate goal of any rehabilitation program and hence this study attempts to determine,whether the functional independence is governed by the degree of impairment of the trunk,upper limb or lower limb?
The level of trunk activity is quantified by the Trunk Impairment Scale (TIS),
which is a validated tool for evaluating the trunk function at the impairment level post-stroke7,8.The severity of impairment of the upper and lower extremity is measured by a standardized tool; the Simplified Stroke Rehabilitation Assessment of Movement (S-STREAM) instrument subscale for the upper limb and lower limb9,10. Independence in activities of daily living (ADLs) and functional tasks is measured using Functional Independence Measure (FIM), which demonstrates excellent reliability,validity and sensitivity11.
This study aims at quantifying the extent of impairment of the trunk,upper extremity and lower extremity separately and correlating it with the functional outcome.
The findings of the study would contribute to the existing knowledge of the degree of variability in impairment after stroke,with respect to different segments of the body and the extent to which it has an impact on the functional independence, which would help us to establish a realistic goal and plan of management for a successful stroke rehabilitation.
RESEARCH QUESTION:
Is there any correlation between the degree of impairment of trunk, upper limb and lower limb and the functional independence in stroke patients?
HYPOTHESIS:
There will be a correlation between the degree of impairment of trunk, upper limb and lower limb and the functional outcome in stroke patients.
NULL HYPOTHESIS:
There will be no correlation between the degree of impairment of trunk, upper limb and lower limb and the functional outcome in stroke patients.
6.2 REVIEW OF LITERATURE:
Over the time, there have been several literatures, which emphasize on the general relationship that exists between the early functional recovery after stroke and its impact on long-term functional independence.
The parameters that influence an early functional recovery depend on the extent of impairment and disabilities, ensuing the event of stroke1,2.
Verheyden and co-researchers3 have emphasized on the importance of trunk
performance in predicting the functional outcome in a prospective study of 102 post-stroke patients.
Recovery of arm and leg by itself has been depicted as independent factors affecting the functional outcome, in a prospective study conducted by Tom Skyhoj Olsen4,
who included 75 hemiplegic patients.
Another study done by Verheyden and co-researchers8, reinforced the Trunk Impairment Scale (TIS) to be a standardized scale to evaluate the trunk function in stroke patients.
In the study done by Fujiwara et al7; Trunk Impairment Scale was shown to be reliable , valid and responsive for the use of stroke outcome research.
Hsueh and colleagues9, in a study of 351 patients with first stroke occurrence,
used the Simplified Stroke Rehabilitation Assessment Of Movement
(S-STREAM) instrument to assess motor function and concluded it to be useful in
clinical practice and research.
Hsieh and co-workers10, in a study of 388 stroke patients concluded all the subscales of S-STREAM to have good discriminative, predictive and evaluative properties and recommended its use in the evaluation of motor and mobility function in patients who have experienced stroke.
Kenneth and colleagues11, concluded Functional Independence Measure (FIM) to have an acceptable reliability across a wide variety of setters, raters and patients, after reviewing 11 studies, published from the year 1993 to 1995.
Margret and co researchers12 also emphasized on the reliability of FIM, for the
purpose of quantifying disability and the associated impact on quality of daily living activities in post- stroke patients.
6.3 OBJECTIVES OF THE STUDY:
1. To assess the degree of impairment of trunk, upper limb and lower limb in post-stroke patients.
2. To correlate the above data with their functional performance by using FIM.
MATERIALS AND METHODS:
7.1 SOURCE OF DATA :-
Subjects with stroke admitted in hospitals in Father Muller Medical College Hospital, Mangalore.
7.2 METHOD OF COLLECTION OF DATA :
STUDY DESIGN:-
Descriptive cross- sectional study.
SAMPLE PROCEDURE:-
Thirty subjects with stroke, both the genders; who consecutively get admitted in the inpatient unit, satisfying the inclusion criteria would be recruited for the study using purposive sampling technique.
Informed consent will be taken from all the subjects. Explanation and instructions regarding the procedure to be followed will be given to the subjects.
Thorough neurological assessment including Higher Mental function (using Mini
Mental State examination) will be done. The severity of stroke will be graded using the Canadian Neurological scale (CNS).
The degree of impairment of trunk, upper limb and lower limb would be assessed separately using TIS, S-STREAM subscale for upper and lower extremity respectively; and functional outcome measured by FIM.
The collected data will be analyzed by using appropriate statistical tools.
INCLUSION CRITERIA:
· Subjects within 50-80 years.
· Subjects in the first 5 weeks of admission, after the onset of stroke.
· Unihemispheric ischaemic stroke, according to clinical and radiological
data.
· Those with a history of first time stroke.
· Subjects with a score of 4.0 to 7.0 according to Canadian Neurological scale.
EXCLUSION CRITERIA :
· Haemodynamically unstable patients.
· Subjects with impaired cognitive status, psychiatric or perceptual problems.
· Subjects with visual or auditory impairments.
· Subjects with any musculoskeletal dysfunction.
· Any vestibular dysfunction.
· Any other neurological deficits.
OUTCOME MEASURES :
· Trunk Impairment Scale (TIS).
· Simplified Stroke Rehabilitation Assessment Of Movement (S-STREAM) subscale for upper and lower extremities.
· Functional Independence Measure (FIM).
STATISTICAL ANALYSIS :
The collected data will be analyzed by using Karl Pearson’s correlation coefficient and Mann Whiteney U test will be used to compare the impairments between the
categories.
7.3 Does the study require any investigation or intervention to be conducted on patients or animals?
No
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes
LIST OF REFERENCES :
1. Paciaroni M, Arnold P, Van Melle G, Bogousslavsky J. Severe disability at hospital discharge in ischaemic stroke survivors. European Neurology 2000; 43(1): 30-34.
2. Horgan N F, Finn A M. Motor recovery following stroke: A basis for evaluation. Disability and rehabilitation 1999; 19(2): 64-70.
3. Verheyden G, Nieuwboer A, De Wit L, Feys H, Schuback B, Baert I, Jenni W, Schupp W,Thijs V, De Weerdt W. Trunk Performance after stroke: An eye-catching predictor of functional outcome. Journal Of Neurology, Neurosurgery & Psychiatry 2007; 78: 694-698.
4. Olsen T S. Arm and Leg Paresis as outcome predictors in Stroke Rehabilitation. Stroke 1990; 21: 247-251.
5. Kwakkel G, Kollen B. Predicting improvement in the Upper Paretic limb after stroke: a longitudinal perspective study. Restorative Neurology and Neuroscience 2007; 25: 5-6.
6. Parry R H, Lincoln N B, Vass C D. Effect of severity of arm impairment on response to additional physiotherapy early after stroke. Clin Rehabil. 1999; 13(3): 187-198.
7. Fujiwara T, Liu M, TsujiT, Souoda S, Mizunok, Akaboshi K, Hasek, Masakado Y, Chino N. Development of a new measure to assess Trunk Impairment After Stroke. (Trunk Impairment Scale : Its Psychometric Properties.) American journal of Physical Medicine and Rehabilitation. 2004; 83: 681- 688.
8. Verheyden G , Nieuboer A, Feys H, Thijs V, Vaes K, Weerdt W. Discriminant ability of the Trunk Impairment Scale: A Comparison between stroke patients and healthy individuals. Disability and rehabilitation 2005; 27:1023-1028.
9. Hsueh I P, Wang W C,Wang C H, Sheu C F, Lo S K, Lin J H, Hsieh C L. A Simplified Stroke Rehabilitation Assessment of Movement Instrument. Physical Therapy 2006; 86: 936-943.
10. Hsieh Y W, Lin J H,Wang C H, Sheu C F, Hsueh I P, Hsieh C L. Discriminative, predictive and evaluative properties of the simplified stroke rehabilitation assessment of movement instrument in patients with stroke. J Rehabil Med 2007; 39: 454–460.
11. Otteubachu K J, Hsu Y, Carl V. Grauger, Fielder R C. The reliability Of the Functional Independence Measure: A Quantitative review. Archives Of Physical Medicine and Rehabilitation 1996; 77: 1226-32.
12. Stineman M G, Jette A, Fielder R, Granger C. Impairment- Specific dimensions Within the Functional Independence. Archives Of Physical Medicine and Rehabilitation 1997; 78: 636-643.
9. / SIGNATURE OF THE CANDIDATE
10. / REMARKS OF THE GUIDE
11. / NAME AND DESIGNATION OF
11.1 GUIDE
11.2 SIGNATURE
11.3 CO-GUIDE
11.4 SIGNATURE
11.5 HEAD OF THE DEPARTMENT
11.6 SIGNATURE
/ MR. JIDESH V.V
ASSISTANT PROFESSOR
DEPT OF PHYSIOTHERAPY
DR. PETER GEORGE
ASSISTANT PROFESSOR
DEPT OF MEDICINE
MR.NARASIMMAN S. ASSOCIATE PROFESSOR DEPT OF PHYSIOTHERAPY
12 / 12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL
12.2 SIGNATURE
CONSENT FORM
I, ______hereby agree to provide my fullest consent and co-operation as a subject for the dissertation work of Ms.Likhi.M titled
“Evaluation of the degree of impairment in trunk, upper limb and lower limb among subjects with stroke and its relation to functional outcome” as a part of her post- graduation in physiotherapy.
The possible benefits and risk of the study as well as the procedure and duration of the study have been explained to me. The questions and queries I have posed have been answered to my satisfaction and I am aware that my identity will be kept confidential. I am also aware that I can discontinue the study at anytime I wish to do so.
Place:
Date: Signature
PROFORMA
SUBJECT PROFILE
AgeGender
Height
Weight
Type of stroke
Side of stroke
MMSE score
Canadian Neurologic Scale Score
OUTCOME MEASURES
1. Trunk Impairment Scale
ITEMS / SCORE1. Perception of Trunk Verticality
2. Trunk Rotation Muscle Strength on the Affected Side
3. Trunk Rotation Muscle Strength on the Unaffected Side
4. Righting Reflex on the Affected Side
5 .Righting Reflex on the Unaffected Side.
6. Stroke Impairment Assessment Set Abdominal Muscle Strength.
2. SIMPLIFIED STROKE REHABILITATION ASSESSMENT OF MOVEMENT (S-STREAM) SUBSCALE FOR UPPER LIMB .
ITEMS / SCORE1.Elbow extension while supine.
2.Scapular protraction.
3.Making a fist.
4.Raising arm to fullest elevation.
5.Total extension of fingers.
3. SIMPLIFIED STROKE REHABILITATION ASSESSMENT OF MOVEMENT (S-STREAM) SUBSCALE FOR LOWER LIMB .
ITEMS / SCORE1.Knee extension while sitting.
2.Hip flexion while sitting.
3.Knee flexion while sitting.
4.Plantar flexion while sitting.
5.Dorsiflexion while standing.
4.FUNCTIONAL INDEPENDENCE MEASURE (FIM).
ITEMS1.SELF-CARE
A.Eating
B.Grooming
C.Bathing
D.Dressing-Upper
E.Dressing-Lower
F.Toileting
2.SPHINCTER CONTROL
G.Bladder
H.Bowel
3.TRANSFERS
I.Bed,Chair,Wheelchair
J.Toilet
K.Tub,Shower
4.LOCOMOTION
L.Walk/Wheelchair
M.Stairs
5.COMMUNICATION
N.Comprehension
O.Expression
6.SOCIAL COGNITION
P.Social interaction
Q.Problem Solving
R.Memory
DATE: PHYSIOTHERAPIST